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Importance of periodic health check up for Indian women.

INTRODUCTION: Constitution of India provides equal rights to women, however due lack of acceptance from the male dominant society, Indian women are not as privileged as men and are not treated equal and their priorities for health remains low and intrinsically linked to their status in society. In the past, work on women's health was primarily focused on the health problems during pregnancy and childbirth. However gender-based approach to health care has broadened the understanding of women's health problems and helped to identify ways to address them for women of all ages. (1)

As the life expectancy of females in India has increased from 23.96 years in 1901 to 66.90 in 2011, that has lead to increase in health problems of aging and rise of non-communicable diseases amongst women which represents one of the major health challenges. Till recent past, control and prevention of communicable diseases was emphasized. Attention has now shifted to control and prevention of non-communicable diseases including stroke, hypertension and coronary artery disease at the national level. Rising affluence has modified the dietary pattern characterized by increased consumption of diets rich in fat, sugar and calories; change in life style, increasing stress of modern life has led to rapid rise of non-communicable diseases amongst women.

Women's body changes throughout her life time, from fetal development to post menopause hence there is increasing need for age related regular health check up by screening for health. Cardiovascular diseases are now known to be a major cause of death among women.

However, this is not well recognized, leading to delays in treatment-seeking and diagnosis among women. The identification of gender differences in cardiovascular disease has made it possible to develop more effective health promotion and prevention strategies that have improved women's health in many countries.

MATERIAL & METHODS: The present study was undertaken to survey the health status for certain defined non communicable diseases of women living in a military station in the state of Jammu and Kashmir. Total 1384 married women of between the age of 20 yrs to 55 yrs of army personnel participated in the study out of 1730 women ( n= 1384, 77.57%) present in the garrison.. The study duration was from 06 Jun to 11 Jun 2011. List of all houses in the garrison was obtained and listed for study. Army being controlled population, hence the health check was carried out in a planned manner by calling and doing health check- up for 40-45 women in a day at a military hospital The study was conducted in four phases.

Phase I: Health Awareness Campaign: A health education campaign for women was organized in the area of study in May 2011. Women in different locations were collected in their respective five strategic locations on different days and made aware of the health risks they are exposed to and as to why their health examination, at least once a year is mandatory. A Family Health Record Card documenting details of various examinations to be carried out was designed.

Phase II: Conduct of Programme: Health examination was conducted at a military hospital near Jammu. All women underwent basic anthropometric measurements (height, weight, BMI) followed by general medical examination including measurement of blood pressure. They were tested for haemoglobin and routine tests of urine sample. Women above the age of 35years were tested for random blood sugar, serum cholesterol, breast examination for lump and PAP smear.

Phase three consisted of reporting and in Phase four follow up was done for treatment of cases found positive for any ailment. The BMI was computed and the body weight status of each individual was classified in accordance with the WHO classification; overweight was defined as BMI of 25.0-29.9 kg/[mt.sup.2] and obesity as [greater than or equal to]30 kg/[mt.sup.2]. (2)

Women were labeled as "pre-hypertensive" those with BP ranging from 120-139 mmHg systolic and/or 80-89 mmHg diastolic. Blood pressure > 140/90 mm of Hg was labeled as case of hypertension. This new designation is intended to identify those individuals in whom early intervention by adoption of healthy lifestyles could reduce BP, decrease the rate of progression of BP to hypertensive levels with age, or prevent hypertension entirely. (3)

Anemia was graded as Mild anaemia (10.0-10.9 grams/decilitre for pregnant women and 10.0-11.9 g/dl for non-pregnant women, Moderate anaemia (7.0-9.9g/dl), and Severe anaemia (< 7.0 g/dl) (4) Serum Cholesterol was labeled as borderline high (200-239mg/dl); High > 240 mg/dl (5) and hyperglycemia was based on Blood Sugar Random > 200mg/dl. (6)

SAMPLING: All the 1384 out of 1730 women present in the military camp area participated in the study. These women belonged to different states of India and are rotated every two years due to the posting system leading to mixture of army soldiers and their families from all over India. Demographic data for those aged 22 years and over are shown in Table 1.

RESULTS: Total 1384 women from different parts of India participated in the survey. Age profile of participants as per Table 2 shows that the age of youngest participants were 22 years and oldest was 56 years.

Education is a fundamental means to bring any desired change in society, which is an accepted fact throughout the world. The literacy rate before independence was 2.6% and as per 2011 Census the male literacy rate is 82.14 while female literacy rate is 65.46. In the sample population only 0.79 percent women were literate and majority 68.21% have been to high school, 17.27% were graduates. Detail of education qualifications is given in Table No. 3.

The range of age was 22 years to 54 Years with mean of 29.8, Mean income of the families was Rupees 27, 053. The weight range was 36 Kilograms to 108 Kilograms. Systolic blood pressure range measured from 106 mm of Hg to 170 mm of Hg whereas diastolic blood pressure mean was 78.5 with range of 66 mm of Hg to 116 mm of Hg. Values of hemoglobin ranged from 7.2 mg/dl to 14.4 mg/dl with mean of 8.2 mg /dl. Serum cholesterol ranged from 132 Mg /dl to 246 mg/dl with mean of 164.3 mg/dl whereas Blood Sugar (random) values mean was 66.6 mg% with a range of 56.4-146.8mg%

Obesity is increasing at an alarming rate and research on obesity in India has found prevalence to be higher among women. In the present study total 19.59% (n=270) women were found either overweight or obese. On further analysis the prevalence of overweight amongst participants having BMI of 25 to 30 was 14.02 percent and 5.49 percent women were found obese with BMI more than 30 as given in table No. 5.

Pre hypertension (BP > 120 and/or >80 mmHg) prevalence was detected in 12.13 percent of women whereas prevalence of hypertension using revised criteria (BP > 140 and/or >90 mmHg) was 13.65 percent. Prevalence of anaemia (<12g/dl for non-pregnant & <11g/dl for pregnant women) was observed in 38.70 percent women. 304 (21%) women more than 35 years of age underwent additional clinical examination for presence of breast lump and investigations for serum cholesterol, random Blood Sugar and PAP smear to detect cervical cancer.

Borderline high serum cholesterol (200-239mg/dl) was detected in 15.46% females; however 2.96% participants had serum cholesterol values more than 240 mg%. While undertaking random blood sugar values it was observed that 6.25% had blood sugar values more than 200 mg/dl. On clinical examination of breasts, 11 (3.61%) women had palpable lumps. PAP smear could be undertaken for 287 women as 17 women were not conforming the criteria for PAP smear due to menstrual periods.6.20% participants' PAP smear showed Non-specific inflammation and only 0.69 % were having epithelial abnormalities in the microscopic examination vide table 6.

DISCUSSION: OBESITY: In present study overweight amongst participants (BMI > 25) was 14.02% and 5.49% women (BMI > 25) were found obese. The studies conducted by National family health survey (NFHS-2) in 1998-1999 and NFHS-3 in 2005-2006 indicates that prevalence of obesity among Indian women has increased from 10.6% to 12.6% (increased by 24.52%). Prevalence of obesity was more amongst women residing in cities (23.5%), having high qualification (23.8%), and belonging to Sikh community (31.6%) and households in the highest wealth quintile (30.5%). Highest percentage of obese women is found in Punjab (29.9%). (4)

In a study conducted by Anuradha et al the prevalence of overweight (BMI [greater than or equal to] 23) was 27.7% (95% confidence interval [CI] 24.3-32.2) and the prevalence of obesity (BMI [greater than or equal to] 25) was 19.8% (95% CI 16.5-23.6)7 The present group of participants were conglomeration of women representing many Indian states and union territories with major contribution from wealthy states like Punjab, Haryana, Kerala thus the percentage of women with overweight / obesity is above National average.

ANAEMIA: Anaemia is the most common nutritional deficiency disorder in the world and it was observed in 37.04 percent of women participants of the present survey which is lower than national surveys. In NFHS II 52 percent of women had some degree of anaemia. (8)

Thirty-five percent of women are mildly anaemic, 15 percent are moderately anaemic, and 2 percent are severely anaemic. The National Family Health Survey III conducted in 2005-06 brought out that more than half of women in India (55.3%) are anaemic. On further analysis it is documented that 38.6% women were mild anaemic (Hb 10 -11.9 Gm/dl) 15% moderately anaemic (Hb 7.00-9.9 Gm/dl) and 1.8% severely anaemic ((Hb <7 Gm/dl). WHO has estimated that prevalence of anaemia in developed and developing countries in pregnant women is 14 per cent in developed and 51 per cent in developing countries and 65-75 per cent in India.9

HYPERTENSION: Present study using revised criteria has shown that prevalence of pre hypertension among participants was 12.13% and 13.65% women were hypertensive As per the study of Sushil K. Bansal et al the hypertension, was present in 30.9% (95% CI 25.6 to 36.0) of males and 27.8% (95% CI 23.4 to 32.2) of females. (10)

Whereas the studies by Gupta R shown a high prevalence of hypertension among urban adults: men 30%, women 33% in Jaipur (1995), men 44%, women 45% in Mumbai (1999), men 31%, women 36% in Thiruvananthapuram (2000), 14% in Chennai (2001), and men 36%, women 37% in Jaipur (2002). Among the rural populations, hypertension prevalence is men 24%, women 17% in Rajasthan (1994). Hypertension diagnosed by multiple examinations has been reported in 27% male and 28% female executives in Mumbai (2000) and 4.5% rural subjects in Haryana (1999). (11)

DIABETES: Hyperglycemia was recorded among 6.25percent women. The NFHS III report States that according to self-reports, over two percent of women and men age 35-49 are suffering from diabetes. The number of women who have diabetes ranges from 282 per 100, 000 women in Rajasthan to 2, 549 per 100, 000 women in Kerala. In five other states (Tamil Nadu, Goa, Tripura, West Bengal, and Delhi) the number with diabetes is relatively high (above 1, 500 per 100, 000 women). None of the states in the Central Region have prevalence levels above 1, 000 per 100, 000 women. Rajasthan, Uttar Pradesh, Assam, and Maharashtra all have diabetes prevalence levels below 500 per 100, 000 women. (4)

CANCERS: Cancer has become one of the ten leading causes of death in India. Breast cancer is the most common diagnosed malignancy in India, it ranks second to cervical cancer. (12) In this study 304 women were examined for breast lump and 11 women (3.61%) had breast lump. PAP smear was undertaken for 287 women and 6.20% were positive for inflammatory reaction and 0.69% showed epithelial changes.

Report published by Registrar General of India states cervical cancer is the leading cause of cancer death in women in both rural and urban areas. The cervical cancer death rate of 16 per 100 000 reported suggests that a 30-year old Indian woman has about 0-7% risk of dying from cervical cancer before 70 years of age in the absence of other diseases. By contrast, the risk of dying during pregnancy for Indian women aged 15-49 years is about 0-6%. (13)

LIPIDS: Borderline high serum cholesterol (200-239mg/dl) was detected in 15.46% females; however 2.96% participants had serum cholesterol values more than 240 mg%. 18 K Goswami et al in his study in Kolkota observed mean Cholesterol value amongst females 189.8 [+ or -] 38.2 SD. (14)

CONCLUSION: Present study brings outs fact that presence of many non-communicable diseases amongst women go undetected unless a system of routine health check-up for is implemented. Advice on common conditions amongst Indian women like anaemia, easily detectable cancers and life style diseases bring immense benefit to community.

Timely detection and prevention of dangerous conditions like carcinomas of breast and cervix, and debilitating conditions like obesity, hypertension, diabetes mellitus and IHD is a cost effective measure of health care delivery. Delay in diagnosis and treatment of these preventable will lead to increased healthcare costs further leading to worsening the poverty as families have to pay for more long-term healthcare services, medications, and rehabilitation.

Gender equality is more appropriate concept to use in context of health. Policies and programmes should aim at achieving gender equality in health through appropriate investments and designs to be able to meet health needs of women and men to overcome the effect of discrimination. (15)

It is recommended that a comprehensive health policy be considered by policy makers to include appropriate intervention strategies for regular health screening of Indian women for common and preventable cancers and lifestyle diseases and to achieve the same the health care personnel must be actively involved in providing health education regarding life style modification and importance of screening for common cancers.

DOI: 10.14260/jemds/2014/2983

REFERENCES:

(1.) What is a gender-based approach to public health? Online Q & A 7 March 2007 http://www.who.int/features/qa/56/en/index. html 29 Dec 2013.

(2.) WHO Expert committee. Physical status: The use and interpretation of anthropometry. WHO Technical Report Series 894, 1995. p. 47.

(3.) Chobanion AV, Bakris GL, Black HR. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure- The JNC 7 report. JAMA. 2003; 289: 2560-2572

(4.) International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3) India, 2005-06: (1)

(5.) Executive Summary of the Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults] JAMA. 2001 May 16; 285 (19): 2486-97

(6.) Fonseca V, Inzucchi SE, Ferrannini E. Redefining the Diagnosis of Diabetes Using Glycated Hemoglobin Diabetes Care July 2009 32: 1344-1345; doi: 10.2337/dc09-9034.

(7.) Anuradha R. Dr. Ravivarman G. Dr. Timsi Jain: The Prevalence of Overweight and Obesity among Women in an Urban Slum of Chennai Journal of Clinical and Diagnostic Research. 2011 October, Vol-5 (5): 957-960

(8.) International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-2), 1998-09: India: Key Findings Mumbai: IIPS. Pp 19

(9.) DeMayer EM, Tegman A. Prevalence of anaemia in the World. World Health Organ Qlty 1998; 38: 302-16

(10.) Sushil K. Bansal et al the prevalence of hypertension and hypertension risk factors in a rural Indian community: A prospective door-to-door study: J Cardiovascular Dis Res. 2012 Apr-Jun; 3 (2): 117-123

(11.) Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertension. 2004 Feb; 18 (2): 73-8.

(12.) Kamath R, Mahajan KS, Ashok L, Sanal T S. A study on risk factors of breast cancer among patients attending the tertiary care hospital, in Udupi district. Indian J Community Med, 2013 [cited 2013 Dec 26]; 38: 95-9.)

(13.) Registrar General of India. Special bulletin on maternal mortality in India 2007-2009. http://www.censusindia.gov.in/vital_statistics/

(14.) Goswami K, Bandyopadhyay A. Lipid profile in middle class Bengali population of Kolkota. Indian J Clin Biochem. 2003; 18 (2): 127-30

(15.) Sen G, Ostlin P, Unequal, unfair, ineffective and inefficient. Gender-inequity in health: why it exists and how we can change it. Final report to the WHO commission on Social Determinants of Health, September 2007, Geneva, World Health Organisation, 2007.

AUTHORS:

[1.] Avtar Singh Bansal

[2.] M. P. Cariappa

[3.] R. K. Gupta

[4.] Rajshree Gupta

PARTICULARS OF CONTRIBUTORS:

[1.] Professor, Department of Community Medicine, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab.

[2.] Reader, Department of Community Medicine, AFMC, Pune.

[3.] Professor, Department of Community Medicine, ACMS, Delhi.

[4.] Project Manager, Med Education, Department of Community Medicine, AD Instruments, New Delhi.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Avtar Singh Bansal, Professor, Department of Community Medicine, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab.

Email: avtarsinghbansal @gmail.com

Date of Submission: 02/07/2014.

Date of Peer Review: 03/07/2014.

Date of Acceptance: 07/07/2014.

Date of Publishing: 12/07/2014.
Table 1: Demographic profile of participants

PUNJAB           198
HARYANA          134
RAJASTHAN        109
KERLA             98
TAMIL NADU        96
KARNATAKA         88
HIMACHAL          81
MIJAR             79
UP                75
ODISHA            71
BENGAL            69
UTTRAKHAND        63
NORTH EAST        60
JHARKHAND         45
J&K               34
MAHARASHTRA       33
ANDHRA PRADESH    32
MP                21
GUJRAT             4
DELHI              3

Note: Table made from bar graph.

Table 2: Age distribution of participants

Series1, Total, 1384
Series1, 22-30 Years, 879
Series1, 31-40 Years, 341
Series1, 41-50, 132
Series1, > 50 Years, 32

Note: Table made from bar graph.

Table 3: Educational profile of participants

Education        Numbers   Percent

Literate           11       0.79
Primary School     145      10.48
High School        944      68.21
Graduate           239      17.27
Post Graduate      45       03.25
Total             1384     100.00

Table 4: Investigation and other Parameters

Parameter                             Range        Mean

Age (years)                           22-54        29.8
Monthly income (Rs)               20,000-90,000   27, 053
Weight (Kg)                         36-108 kg     53.4 kg
Blood Pressure Systolic (mmHg)       106-170       126.6
Blood Pressure Diastolic (mmHg)      66-116        78.5
Haemoglobin (g/dl)                  7.2-14.4        8.2
Serum Cholesterol (mg/l)             132-246       164.3
Blood Sugar (R)                    56.4-146.8      86.6

Table 5: Overweight and obesity amongst women

BMI         25-29   Percentage   > 30   Percentage

Age Group
20-30        47        3.40       17       1.23
31-40        76        5.49       31       2.24
41-50        53        3.83       22       1.73
>50          18        1.30       4        0.29
Total        194      14.02       76       5.49

Table 6: Results of the Study

Parameters                                     Results

                                         n     Positive     %

Overweight (BMI 25-30kg/m2)             1384     194      14.02
Obese (BMI > 30 kg/m2)                  1384      76      5.49
Pre-hypertension                        1384     168      12.13
Hypertension                            1384     189      13.65
Anaemia (<12g/dl for non-pregnant       1384     536      38.70
  & <11g/dl for pregnant women)
Cholesterol borderline high             304       47      15.46
  (200-239mg/dl)
Cholesterol high (>240 mg/dl)           304       9       2.96
Hyperglycemia (>200mg/dl)               304       19      6.25
Breast Lump                             304       11      3.61
PAP Smear (Non-specific inflammation)   287       16      6.20
PAP Smear (Epithelial abnormalities)    287       2       0.69
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Title Annotation:ORIGINAL ARTICLE
Author:Bansal, Avtar Singh; Cariappa, M.P.; Gupta, R.K.; Gupta, Rajshree
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Jul 14, 2014
Words:3238
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