Sexual Orientation Change Efforts Among LGBT+ People of Kerala: Prevalence, Correlates, and Mental Health Aspects

Sexual Orientation Change Efforts (SOCE) have been reported worldwide and have adverse psychiatric consequences. However, no data are available for India or Kerala. We assessed the prevalence of SOCE, its characteristics, and mental health aspects among LGBT+ individuals in Kerala. This cross-sectional survey used snowball sampling. An online questionnaire collected sociodemographic information and history and characteristics of SOCE. Religiosity and SOCE-associated distress were evaluated using 6-point Likert scales. Patient Health Questionnaire (PHQ-9) screened for depressive symptoms; its ninth question assessed death wishes and self-harm thoughts. Generalized Anxiety Disorder Assessment (GAD-7) screened for anxiety symptoms. Participants' (n = 130) mean age was 26.80 ± 7.12 years. Most common biological sex (63.1%) and gender identity (50.8%) were male, and sexual orientation was gay(42.3%). Prevalence of SOCE was 45.4%. In SOCE group, 39% reported very severe distress. SOCE was most commonly self-prompted (47.5%), performed through psychotherapy (28.8%), and performed by doctors (28.8%). SOCE group had significantly higher religiosity scores (t = 2.61, p = .01). Among cisgender men, 48.48% had SOCE history, against 28.57% among cisgender women (χ2 = 3.19, p = .07). SOCE is highly prevalent among the LGBT+ community in Kerala, with high associated distress. Multi-level approaches are necessary to mitigate this problem.

Spatio-temporal classification of land use and land cover and its changes in Kerala using remote sensing and machine learning approach

Land use and land cover (LULC) analysis gives important information on how the region has evolved over time. Kerala, a land with an extensive and dynamic history of land-use changes, has, until now, lacked comprehensive investigations into this history. So the current study focuses on Kerala, one of the ecologically diverse states in India with complex topography, through Landsat images taken from 1990 to 2020 using two different machine learning classifications, random forest (RF) and classification and regression trees (CART) on Google Earth Engine (GEE) platform. RF and CART are versatile machine learning algorithms frequently employed for classification and regression, offering effective tools for predictive modelling across diverse domains due to their flexibility and data-handling capabilities. Normalised Difference Vegetation Index (NDVI), Normalised Differences Built-up Index (NDBI), Modified Normalised Difference Water Index (MNDWI), and Bare soil index (BSI) are integral indices utilised to enhance the precision of land use and land cover classification in satellite imagery, playing a crucial role by providing valuable insights into specific landscape attributes that may be challenging to identify using individual spectral bands alone. The results showed that the performance of RF is better than that of CART in all the years. Thus, RF algorithm outputs are used to infer the change in the LULC for three decades. The changes in the NDVI values point out the loss of vegetation for the urban area expansion during the study period. The increasing value of NDBI and BSI in the state indicates growth in high-density built-up areas and barren land. The slight reduction in the value of MNDWI indicates the shrinking water bodies in the state. The results of LULC showed the urban expansion (158.2%) and loss of agricultural area (15.52%) in the region during the study period. It was noted the area of the barren class, as well as the water class, decreased steadily from 1990 to 2020. The results of the current study will provide insight into the land-use planners, government, and non-governmental organizations (NGOs) for the necessary sustainable land-use practices.

Emerging nitrate contamination in groundwater: Changing phase in a fast-growing state of India

The consumption of nitrate-contaminated groundwater is often associated with potential health risks, particularly in children. This study aimed to assess the hydrochemistry and nitrate contamination in groundwater of Kerala state, India for the years 2010 and 2018 and evaluate the potential human health risks due to nitrate exposure in adults, and children through oral ingestion and dermal contact pathways. Nitrate-contaminated zones were identified by spatial mapping of nitrate concentration based on groundwater quality data of 324 wells. Groundwater is typically acidic to slightly alkaline, and the electrical conductivity (EC) varied from 33 to 1180 μS/cm in 2010 and 34.6-2500 mg/L in 2018 indicating a noticeable increase over the years. Most samples fall within low salt enrichment category. The nitrate concentration in groundwater varied from 0 to 173 mg/L with a mean of 15.4 mg/L during 2010 and 0 to 244 with a mean of 20.3 mg/L during 2018. Though nitrate concentrations show uneven spatial distributions due to both natural and anthropogenic sources, the spatial clustering of higher concentrations remains almost same in both periods. In 2010, non-carcinogenic risk, as measured by Health Index Total (HITotal) values in groundwater for the investigated region, ranged from 0.005 to 4.170 (mean of 0.349) for males, 0.005 to 4.928 (mean of 0.413) for females, and 0.008 to 7.243 (mean of 0.607) for children, while in 2018, the corresponding values varied from 0.001 to 5.881 (mean of 0.501) for males, 0.002 to 6.950 (mean of 0.592) for females, and 0.003 to 10.215 (mean of 0.870) for children, indicating a substantial increase in risk, for females and children. Greater health risk is observed in children during both the periods. The findings emphasize the need for proper water quality management, especially in regions with higher vulnerability to nitrate pollution, to safeguard human health and well-being.

The Politics and Aesthetics of Male Homosexuality in Malayalam Cinema: Contextualizing the Film Ka Bodyscapes (2016)

Focusing on the Malayalam film Ka Bodyscapes (2016), this article attempts to historically trace and critically engage with the representations of gay sexuality in Malayalam cinema from the South Indian state of Kerala. It interrogates how Ka Bodyscapes brought to the forefront hitherto unexplored visual dynamics of the gay male body and homoeroticism on screen while troubling the heterosexual dynamics of the Malayalam film industry. By situating this film within the history of representation of male homosexuality in Malayalam cinema and the changing regimes of queer politics and feminist interventions in Kerala in the last decade, the article argues how the film's radical visual representation of gay sexuality at the intersection of caste and religion problematizes the heterosexual family/state, thereby challenging the patriarchal masculinity that marginalizes women and sexual minorities in Kerala.

Predicting stroke in Asian patients with atrial fibrillation using machine learning: A report from the KERALA-AF registry, with external validation in the APHRS-AF registry

Atrial fibrillation (AF) is a significant risk factor for stroke. Based on the higher stroke associated with AF in the South Asian population, we constructed a one-year stroke prediction model using machine learning (ML) methods in KERALA-AF South Asian cohort. External validation was performed in the prospective APHRS-AF registry. We studied 2101 patients and 83 were to patients with stroke in KERALA-AF registry. The random forest showed the best predictive performance in the internal validation with receiver operator characteristic curve (AUC) and G-mean of 0.821 and 0.427, respectively. In the external validation, the light gradient boosting machine showed the best predictive performance with AUC and G-mean of 0.670 and 0.083, respectively. We report the first demonstration of ML's applicability in an Indian prospective cohort, although the more modest prediction on external validation in a separate multinational Asian registry suggests the need for ethnic-specific ML models.

Prevalence of tuberculosis in homes for the aged and orphanages of a district in Kerala, India

BACKGROUND

India accounts for one fourth of the TB burden globally. One of the objectives of the National Strategic Plan is to achieve 90% notification rate of all TB cases. Screening of high risk groups is one of the important components towards achieving this objective. Inmates of homes for the aged and orphanages are at higher risk of having TB infection and disease. Hence this study was conducted with the objective of identifying the prevalence of TB among inmates of homes for the aged and orphanages.

METHODS

A cross sectional study was done in homes for the aged and orphanages of Kollam district of Kerala in India. Sample size was estimated as 466. Cluster sampling using probability proportionate to size was used. There were 32 homes for the aged, from which 5 were selected. Out of 43 orphanages 8 were selected. Inmates were screened using a questionnaire. Those with any of the symptoms suggestive of TB were examined by a pulmonologist in a camp conducted at the institute. Those who needed further evaluation were brought to Government Medical College, Kollam/other nearest government health setting. All those who were detected to be having tuberculosis, were guided and given the care as per the NTEP treatment protocol. Permission was taken from the Collector of Kollam district. Informed written consent from the study subjects/legally accepted representative and assent were taken.

RESULTS

533 inmates were assessed from homes for the aged. The mean age was 56.70 (SD - 17.40). Five new TB patients were identified during the study. Of this three patients had extra-pulmonary and two were pulmonary TB. Eight patients were receiving treatment for TB at the time of study already, seven of which were pulmonary and one was extra-pulmonary. So the prevalence of TB in homes for the aged was 13/533 ie 2.43% (95%CI - 1.36 to 4.03%) or 2430/lakh. A higher percentage of inmates with tuberculosis were females, stayed in dormitory, had only primary education, had history of contact with TB and were undernourished compared to inmates without tuberculosis. We screened 478 children in orphanages of Kollam district. There were no children less than 5 years. Most of the children were in the age group of 10-15 years (62.1%). Nine children (1.9%) had history of contact with TB. One child had a previous history of TB. There was only one child who was suspected to have Tuberculosis, She was evaluated by a pediatrician and Tuberculosis was ruled out.

CONCLUSION

The prevalence of TB in inmates of homes for the aged is much higher than the general population. This highlights the need for a more active case detection in such institutions, especially in the context of the country marching towards TB elimination. The absence of tuberculosis among children in orphanages is a positive indicator that the community is moving in the direction of TB elimination.

Surveillance of Nipah virus in Pteropus medius of Kerala state, India, 2023

Introduction

Since 2018, the Indian state of Kerala has reported four Nipah virus (NiV) disease outbreaks, raising concerns about NiV spillover from bats to the human population. Considering this, a cross-sectional study was undertaken in the Pteropus medius bat population around the Nipah virus-affected regions of Kozhikode, Kerala, India, during February, July, and September 2023.

Methods

Throat swabs, rectal swabs, and organ samples were collected from bats to test for NiV using the real-time reverse transcriptase polymerase chain reaction (RT-PCR), while serum samples were screened for anti-Nipah IgG antibodies through ELISA.

Results

An overall seroprevalence of 20.9% was observed in 272 P. medius bats tested. The throat and rectal swab samples of 321 bats were negative for NiV RNA. However, 4 of 44 P. medius bats tested positive for NiV in their liver/spleen samples. The partial N gene retrieved showed more than 99% similarity with the earlier reported NiV genome from Kerala state, India.

Discussion

The findings of the study caution that there is a spillover risk in the region and necessary precautions should be taken.

A structural equation modeling examining the influence of body mass index on the lipid profile of type II diabetes patients

Background: High Body Mass Index (BMI) has a two times greater risk of developing type II diabetes compared to low BMI. The results showed that general obesity had a risk of 2.24 times while abdominal obesity had a risk of 2.44 times for the occurrence of diabetes. Aim: Based on the background described, the researcher was interested in examining the influence of BMI on the lipid profile of type II diabetes patients. Methods: A considerably large sample of 500 type II diabetes patients who attended the outpatient department of Endocrinology wing of NIMS Medicity (NICER-Noorul Islam Centre for Endocrinology Research), Kerala, India were selected to the macrosample pool following purposive random sampling method. Height and weight of the patients were taken following standard methods and BMI of the patients was computed. Biochemical investigations such as their lipid profile along with Fasting, Post Prandial Blood Glucose values and HbA1C were obtained from patients' medical records. Finally, the hypothesized model was developed and tested by Structural Equation Modeling (SEM) technique using SPSS AMOS 22.0. Results: The results show that height and weight highly influenced the BMI, among which weight, as shown by Standardized Regression Weights (SRW) Estimate- 1.102, Statistically Significant) influenced more than height (SRW Estimate:-0.683, Statistically Significant), weight had a positive influence, whereas height had a negative influence in selected Type II Diabetes patients. The model could not establish any relationship between BMI and lipid profile (SRW Estimate:-0.037, Statistically not Significant). Conclusion: The findings suggest that in diabetes patients increase in BMI alone does not lead to any alterations in their lipid profile.

The role(s) of community health workers in primary health care reform in Kerala, before and during the COVID 19 pandemic: a qualitative study

Background

Accredited Social Health Activists (ASHA) are Community Health Workers (CHWs) employed by the National Health Mission of the Government of India to link the population to health facilities and improve maternal and child health outcomes in the country. The government of Kerala launched primary health reform measures in 2016 whereby Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The COVID-19 pandemic in 2020 impacted essential health service delivery, including primary care services. The CHWs network of Kerala played a crucial role in implementing the primary care reforms and COVID-19 management efforts that followed. We carried out a study to understand the perspectives of the CHWs in Kerala about their role in the recent primary healthcare reforms and during the COVID-19 pandemic management efforts.

Methods

We conducted in-depth interviews (IDI) with 16 ASHAs from 8 primary care facilities in Kerala from July to October 2021. We further conducted Focus Group Discussions (FGDs) (N = 34) with population subgroups in these eight facility catchment areas and asked their opinion about the ASHAs working in their community. We obtained written informed consent from all the participants, and interview transcripts were thematically analysed by a team of four researchers using ATLAS.ti 9 software.

Results

Our study participants were women aged about 45 years with over 10 years of work experience as CHWs. Their job responsibilities as a frontline health worker helped them build trust in the community and local self-governments. CHWs were assigned roles of outpatient crowd management, and registration duties in FHCs. The COVID-19 pandemic increased their job roles manifold. Community members positively mentioned the home visits, delivery of medicines, and emotional support offered by the CHWs during the pandemic. The CHWs noted that the honorarium of INR 6,000 (US$73) was inconsistent and very low for the volume of work done.

Conclusion

The CHWs in Kerala play a crucial role in primary care reforms and COVID-19 management. Despite their strong work ethic and close relationship with local self-governments, low and irregular wages remain the biggest challenge.

Work Ability, Anxiety, and Depression among Long-Term Breast Cancer Survivors of Northern Kerala, India; A Historical Cohort Study

BACKGROUND

Increasing number of breast cancer cases, and improved survival due to advancements in early detection, and treatment resulted in an increase in women living beyond a cancer diagnosis. Survivors have to face long-term physical effects as well as psychosocial issues post-treatment. This study aims to study survivourship in terms of work ability, anxiety and depression.

METHODS

Retrospective cohort study on female breast cancer survivors from Hospital Based Cancer Registry (HBCR) of a Tertiary Cancer Centre (TCC). Data from 2016 (n=534) were collected from the medical records, and a follow-up survey (n=209) was conducted in 2022 to study their survivorship issues.

RESULTS

In 2022, the mean age of the cohort (n=209) was 55.45 ± 9.36. The mean work ability score was 40.7±5.73 (95% CI 39.92 to 41.48).  In the multivariate binary logistic regression model, those who were married (OR 7.15, 95%CI 2.61 to 19.55), disease-free (OR 15.27, 95% CI 2.36 to 98.7), employed (OR 9.09, 95%CI 1.12 to 73.5), having no fatigue (OR 2.6, 95% CI 1.05 to 6.48), no pain (OR 3.11, 95% CI 1.16 to 8.35), and no depression (OR 6.58, 95% CI 1.82-23.8) were found to have optimal work ability. Anxiety (OR 4.93, 95% CI 1.76 to 13.76), and sub-optimal work ability (OR 4.22, 95% CI 1.39 to 12.77) were predictors of depression among survivors. Disease status and fatigue were associated with all three dimensions of survivorship in our study.

CONCLUSION

Understanding survivorship will help improve health outcomes in this population. In our study, work ability, anxiety, depression, and their associated factors were found to be interrelated. Interventions in these areas can go a long way in improving breast cancer survivorship.

Mental health morbidities in Kerala, India: Insights from National Mental Health Survey, 2015-2016

Background

The National Mental Health Survey was borne out of the felt need for a comprehensive epidemiological survey on mental health to understand the magnitude of psychiatric morbidities in India to aid in mental health policymaking, service planning, and delivery. Kerala was one of the 12 surveyed states, representing southern India.

Aims

To estimate the prevalence and pattern of various mental illnesses and substance use disorders in a representative sample from Kerala state.

Settings and Design

A household survey using a multi-stage, stratified, random cluster sampling technique, with selection based on probability proportionate to size at each stage.

Materials and Methods

The community-based survey was carried out by trained field staff on individuals from systematically selected households from three randomly selected districts of Kerala. The instruments used in the survey included M.I.N.I adult version 6.0, a modified version of the Fagerström Nicotine Dependence Scale and questionnaires to screen for epilepsy, intellectual disability, and autism spectrum disorders.

Results

A total of 2479 respondents aged >18 years were interviewed. The lifetime and current prevalence of mental morbidity (excluding tobacco use disorders) was 14.14% and 11.36%, respectively. Neurotic/stress-related disorders and depressive disorders were 5.43% and 2.49%, respectively, while severe mental disorders were prevalent in 0.44% of the sample. The prevalence of high risk for suicide was 2.23%.

Conclusions

The survey revealed high rates of common mental illnesses and suicide risk in the state when compared to national estimates.

Interaction of climate change and marine pollution in Southern India: Implications for coastal zone management practices and policies

Climate change and marine litter are inextricably linked, and their interaction manifests differently depending on the specific environmental and biological characteristics, and other human activities taking place. The negative impacts resulting from those synergistic interactions are threatening coastal and marine ecosystems and the many goods and services they provide. This is particularly pervasive in the coastal zone of the Indian subcontinent. India is already experiencing severe climate change impacts, which are projected to worsen in the future. At the same time, the country is gripped by a litter crisis that is overwhelming authorities and communities and hindering the country's sustainable development goals. The coastal environment and communities of the southern states of Kerala and Tamil Nadu are particularly vulnerable to the impacts of climate change. While these state governments and authorities are stepping up efforts to improve the management of their coastal zones, the scale and severity of these issues are mounting. Here we review the combined effects of climate change and marine litter pollution in Southern India, focusing on the Gulf of Mannar Reserve in Tamil Nadu and the Malabar Coast in Kerala. Finally, we discuss effective management options that could help improve resilience and sustainability.

Right Versus Wrong: A Qualitative Appraisal With Respect to Pandemic Trajectories of Transgender Population in Kerala, India

The transgender population generally faces rights violations and discrimination in their day-to-day lives, which was exacerbated during the recent pandemic. This necessitates close scrutiny from an ethics perspective. Following directives from a 2014 Supreme Court judgement, Kerala became the first Indian state to implement a comprehensive policy to enforce the constitutional rights of transgender people. Despite such positive actions, a basic social tendency not to respect gender diversity has led to discrimination and marginalization. This was very evident during the pandemic. In this empirical work, we have documented the lives of the transgender community during the pandemic wherein they share experiences related to livelihood, interaction with the healthcare system, and acceptance in society vis-à-vis the pandemic. Simply providing third-gender status will not help the gender-marginalized community to grow to their fullest potential and have a better lifestyle on par with others in mainstream society.

Monitoring the Family Health Centres in Kerala, India: Findings from a facility survey

Introduction

Kerala, a south Indian state, has often been cited globally as a model for better health outcomes at low cost but faces unique challenges in achieving Universal Health Coverage (UHC). To propel the efforts in achieving UHC, the Government of Kerala announced the "Aardram" health reform initiative, emphasising improving the quality of primary care service delivery. The reforms started in 2017, and in the first stage, 170 of 848 Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The facilities were provided with additional doctors, nurses, and paramedical staff; the working hours were extended, and the range of services offered increased. In support of these processes, we carried out a facility assessment to assess differences between upgraded FHCs and existing PHCs.

Materials and Methods

We conducted a facility-based cross-sectional assessment in eight primary care facilities of Kerala, FHC (N=4) and PHCs (N=4) from June to October 2019. A structured questionnaire covering utilisation and coverage of selected priority services for various populations and health outcome data was filled out by health staff to report data for the financial year 2018-19. Data were analysed in Microsoft Excel spreadsheets for easy analysis and replication by state stakeholders.

Results

Coverage indicators such as full antenatal care and full immunization coverage were not appreciably different in FHCs as compared to PHCs. However, key reform-related differences were observed. On average, FHCs had 0.8 medical officers and one staff nurse per 10,000 population, whereas PHCs had 0.7 medical officers and less than 0.4 staff nurses per 10,000 population, even as the size of populations served by these human resources varied greatly across both types of facilities. The number of outpatient department visits per 10,000 population annually was 11,343 persons in FHCs and 9,580 persons in PHCs. FHCs also provided additional services such as screening for depression and chronic obstructive pulmonary disorders.

Conclusion

Aardram primary healthcare reforms are still in their early days and appear to be associated with improved service coverage at the institutional level. However, some patterns are uneven: reforms should be carefully documented, and population-level impacts monitored over time.

Breast screening practices of 35-65 years old women - A cross-sectional survey in Alappuzha, Kerala, India

BACKGROUND

Enhancing cancer literacy, promoting early detection, and avoiding treatment delays are essential for reducing breast cancer mortality and ensuring a good quality of life among women in less developed countries. The present paper describes the breast screening practices of women in the Alappuzha district of Kerala state, India.

MATERIALS AND METHODS

A multi-stage cluster sampling method was used to select study participants. Data were collected using a structured questionnaire, entered using Kobo Toolbox, and analyzed using IBM SPSS Statistics-25 for Windows. The proportions of women who practiced breast examinations were estimated with 95% confidence intervals. The Chi-square test was used to test the associations, and binary logistic regression was used to estimate odds ratios.

RESULTS

Among 320 women, 55% were less than 50 years old, 45% had higher secondary education or above, and six were already diagnosed with breast cancer (1.9%, 95% CI: 0.4%-3.4%). Of the 314 women, 73.2% were practicing breast self-examination (95% CI: 68.4%-78.1%), and 25.2% ever attended clinical breast examination (95% CI: 20.4%-30.0%). Working/retired/self-employed women with higher secondary education and above had almost 10 times higher odds (OR = 10, 95% CI: 3.35-29.86) of practicing breast self-examination (BSE) compared to homemakers or women working under rural employment schemes with a low level of education.

CONCLUSION

A higher percentage of women practicing BSE and clinical breast examination (CBE) in the present study indicates that women in this population are more concerned about breast cancer. Women should be educated more on the symptoms and risk factors, the proper ways of practicing BSE, and the importance of consulting a health practitioner for CBE. Also, it is crucial to ensure that awareness and screening programs reach marginalized women.

Examining the Triple Burden of Malnutrition: Insights from a Community-Based Comprehensive Nutrition Survey among Indigenous Tribal Children (0-19 Years) in the Western Ghats Hills of India

This article presents findings from a community-based cross-sectional study conducted in Attappadi, Kerala, India, aimed at assessing the prevalence of the triple burden of malnutrition among indigenous children aged 0-19 years. Historically, the indigenous population in Attappadi has faced significant developmental challenges, including high rates of malnutrition, infant mortality, and neonatal mortality. This study revealed alarming rates of undernutrition among children aged 0-59 months, with 40.9% experiencing stunting, 27.4% wasting, and 48.3% being underweight. Adolescent girls also suffered from undernutrition, with 21% classified as underweight and 43.3% experiencing stunting. Surprisingly, overweight or obesity was identified as a nutritional problem, affecting 1.4% of children aged 0-59 months, 4.2% of children aged 5-9 years, and 10.5% of adolescent girls. Additionally, a distressing proportion of young children aged 12-59 months (91.2%) were anaemic, with 50% diagnosed specifically with iron deficiency anaemia (IDA). Nearly all adolescent girls (96.6%) were reportedly suffering from anaemia. Deficiencies in vitamin B12, vitamin D, folate, and vitamin-A were prevalent among 35%, 20%, 16%, and 12% of children aged 12-59 months, respectively. The study underscores the urgent need for comprehensive interventions to address this triple burden of malnutrition. Recommendations include promoting culturally appropriate local food-based solutions, establishing participatory and community-led systems for health and nutrition information dissemination, and strengthening the nutrition surveillance system through village-level health and nutrition workers. By adopting a holistic approach, these interventions can help improve the nutritional status and well-being of the indigenous tribal children in Attappadi.

Checklist of digenean fauna infecting fishes of Kerala region, India

A checklist of digenetic trematodes of fishes (both freshwater, brackish and marine) from Kerala is prepared on the basis of scientific articles published during the period from 1970 to 2022. To date, 94 species (72 adults and 22 metacercariae) belonging to 26 families and 62 genera were documented. The largest Family reported here is Hemiuridae under which ten genera and 23 species have been documented. For each parasite species, information is provided on the host(s), developmental stage(s), site(s) of infection, geographical locality (-ies) and the published source(s). Available illustrations have also been presented. 'Keys to the Trematoda' Volumes 1 to 3 are followed for presenting taxonomic status. The checklist forms the first complete listing of digenetic trematodes infecting marine, brackish and freshwater fishes of Kerala, India. The current effort meets the demand for a checklist on diverse trematode fauna parasitizing fishes of Kerala which will be helpful to future researchers working on fish parasites.

Framework and Overview of a State-Wide College Mental Health Program in Kerala, India

Background

Mental health issues are common among college students, and structured services have been proven to enhance outcomes. Despite increased enrolment for higher education in India, college mental health services remain sparse. JEEVANI is the first structured state-wide college mental health service in India. This paper describes its framework and provides an overview of its functioning during the initial five months.

Methods

In 2019-2020, the Directorate of Collegiate Education, Government of Kerala, implemented the program in 66 colleges catering to approximately 60,000 students. Qualified counsellors were trained to identify issues and provide interventions and early referrals, using a stepped-care approach. They conducted awareness programs to promote mental health and reduce stigma.

Results

The services were accessed by 2,315 students during the assessment period (October 2019 to February 2020). The beneficiaries were predominantly females (54.1%). Over a third (38.8%) belonged to the lower socio-economic strata, and 2.5% had significant vulnerabilities. Although no syndromal diagnoses were made, anxiety and depression were the most common presentations. The counsellors provided 3,758 individual sessions and facilitated support for students who reported academic difficulties or interpersonal issues. Severe mental illness was detected in 54 students, and referrals for specialist mental health input were initiated in 68.

Conclusion

Describing the framework, sharing the technical material, and providing an overview of its functioning from a resource-constrained setting in India may encourage higher education institutions in low- and middle-income countries to consider similar projects.

Does early-life migration experience determine health and health-risk behavior in later life? Evidence from elderly returns migrants in Kerala, India

Becoming elderly is an intrinsic part of life, and the burden of disease increases with age. However, the early life migration experience and occupational hazards at the destination can lead to serious health problems later in life. This study aims to understand the association between early life migration and the health and risky behavior of elderly return migrants using data from the Kerala Migration Survey in 2018. The results of bivariate and multivariate analyses show that the majority of migrants return due to retirement and ill health at the average age of 51 and suffer from poor health and multiple diseases. More than half (55%) of elderly returnees reported poor health, and among them, 70% have at least one chronic disease. The early life migration experience and injuries at the destination are the main determinants of poor self-rated health and chronic disease. Furthermore, elderly return migrants have high-risk health behaviours such as smoking and alcohol consumption, as well as less access to health schemes. Despite some shortcomings, this study identifies the most vulnerable groups among the elderly and their health characteristics. This will help to promote healthy aging in Kerala, India, or areas with increasing numbers of elderly and return migrants around the world.

Epidemiology of Motoric Cognitive Risk Syndrome in the Kerala Einstein Study: Protocol for a Prospective Cohort Study

BACKGROUND

The southern India state of Kerala has among the highest proportion of older adults in its population in the country. An increase in chronic age-related diseases such as dementia is expected in the older Kerala population. Identifying older individuals early in the course of cognitive decline offers the best hope of introducing preventive measures early and planning management. However, the epidemiology and pathogenesis of predementia syndromes at the early stages of cognitive decline in older adults are not well established in India.

OBJECTIVE

The Kerala Einstein Study (KES) is a community-based cohort study that was established in 2008 and is based in the Kozhikode district in Kerala state. KES aims to establish risk factors and brain substrates of motoric cognitive risk syndrome (MCR), a predementia syndrome characterized by the presence of slow gait and subjective cognitive concerns in individuals without dementia or disability. This protocol describes the study design and procedures for this KES project.

METHODS

KES is proposing to enroll a sample of 1000 adults ≥60 years old from urban and rural areas in the Kozhikode district of Kerala state: 200 recruited in the previous phase of KES and 800 new participants to be recruited in this project. MCR is the cognitive phenotype of primary interest. The associations between previously established risk factors for dementia as well as novel risk factors (apathy and traumatic brain injury) and MCR will be examined in KES. Risk factor profiles for MCR will be compared between urban and rural residents as well as with individuals who meet the criteria for mild cognitive impairment (MCI). Cognitive and physical function, medical history and medications, sociodemographic characteristics, lifestyle patterns, and activities of daily living will be evaluated. Participants will also undergo magnetic resonance imaging and electrocardiogram investigations. Longitudinal follow-up is planned in a subset of participants as a prelude to future longitudinal studies.

RESULTS

KES (2R01AG039330-07) was funded by the US National Institutes of Health in September 2019 and received approval from the Indian Medical Council of Research to start the study in June 2021. We had recruited 433 new participants from urban and rural sites in Kozhikode as of May 2023: 41.1% (178/433) women, 67.7% (293/433) rural residents, and 13.4% (58/433) MCR cases. Enrollment is actively ongoing at all the KES recruitment sites.

CONCLUSIONS

KES will provide new insights into risk factors and brain substrates associated with MCR in India and will help guide future development of regionally specific preventive interventions for dementia.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49933.

The Sociodemographic Profile of Community-Dwelling Older Adults With Serious Mental Illness in Kerala - A Cross-Sectional Study

Background

Older adults with serious mental illness (OASMI) have to manage the twin challenges of old age and mental illness. Understanding their characteristics will help policymakers and researchers plan tailored interventions. The profile of OASMI is not described in any publication from India, and this paper addresses that gap. The information from this study will serve as a baseline for the planned periodic follow-up of the study participants.

Methods

This study employed a cross- sectional design among a sample of OASMI identified through multistage cluster sampling from three districts in Kerala. We interviewed them in their households and collected sociodemographic data using a pretested tool.

Results

Among the 917 OASMI participants, 66% were females, 18% were the 'oldest-old' (≥80 years), 94.1% were unemployed, 51.7% were socially backward, 68.5% were financially weak, 10.1% were living alone, 59.4% were living without partners, and 63.7% had caregivers.

Conclusion

Compared to the general population of older adults in Kerala, the OASMI have poorer socioeconomic status and higher rates of social isolation, and males are dying earlier. The profile of the OASMI depicts their multiple vulnerabilities and the need to address those.

A peer support program results in greater health benefits for peer leaders than other participants: evidence from the Kerala diabetes prevention program

BACKGROUND

Peer support programs are promising approaches to diabetes prevention. However, there is still limited evidence on the health benefits of peer support programs for lay peer leaders.

PURPOSE

To examine whether a peer support program designed for diabetes prevention resulted in greater improvements in health behaviors and outcomes for peer leaders as compared to other participants.

METHODS

51 lay peer leaders and 437 participants from the Kerala Diabetes Prevention Program were included. Data were collected at baseline, 12 months, and 24 months. We compared behavioral, clinical, biochemical, and health-related quality of life parameters between peer leaders and their peers at the three time-points.

RESULTS

After 12 months, peer leaders showed significant improvements in leisure time physical activity (+ 17.7% vs. + 3.4%, P = 0.001) and health-related quality of life (0.0 vs. + 0.1, P = 0.004); and a significant reduction in alcohol use (-13.6% vs. -6.6%, P = 0.012) and 2-hour plasma glucose (-4.1 vs. + 9.9, P = 0.006), as compared to participants. After 24 months, relative to baseline, peer leaders had significant improvements in fruit and vegetable intake (+ 34.5% vs. + 26.5%, P = 0.017) and leisure time physical activity (+ 7.9% vs. -0.9%, P = 0.009); and a greater reduction in alcohol use (-13.6% vs. -4.9%, P = 0.008), and waist-to-hip ratio (-0.04 vs. -0.02, P = 0.014), as compared to participants. However, only the changes in fruit and vegetable intake and waist-to-hip ratio were maintained between 12 and 24 months.

CONCLUSION

Being a peer leader in a diabetes prevention program was associated with greater health benefits during and after the intervention period. Further studies are needed to examine the long-term sustainability of these benefits.

Molecular characterization and phylogenetic analysis of porcine circovirus 2 from Kerala, India

Porcine circovirus type 2 (PCV2), the causative agent of porcine circovirus-associated diseases (PCVADs), has a worldwide distribution, and is considered as one of the most important emerging viral pathogens of economic importance. In Kerala, a total of 62 tissue samples were collected during post mortem from pigs suspected to have died of PCV2 infection. The animals exhibited symptoms like respiratory illness, gradual wasting, rough hair coat, polypnoea, dyspnoea, pallor, diarrhoea, icterus, etc. PCV2 was detected in 36 (58.06%) samples by PCR. Phylogenetic analyses of complete ORF2, and complete genome sequences were carried out and genotypes 2d, 2 h and 2b were detected. The genotype predominant in Kerala was 2d. It was observed that genotypes 2 h and 2b have been recently introduced into North Kerala as it was not detected in the region prior to 2016. Close relationship of Kerala sequences with sequences from Tamil Nadu, Uttar Pradesh and Mizoram were noticed in the phylogenetic tree and also at the amino acid level. A unique K243N mutation was observed in one of the samples. It was also noticed that the most variable amino acid position in ORF2 was 169 where the occurrence of three possible amino acids were observed. The results of the study indicate that multiple genotypes of PCV2 are prevalent in pigs in Kerala and that the percent positivity is higher than that recorded in the State previously.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13337-023-00814-1.

Molecular characterization of Amblyomma geoemydae using CO1 mitochondrial gene to validate phenotypic taxonomical evaluation

Animal ectoparasites are linked to the spread of serious medical and veterinary important pathogens. Our research intends to close the knowledge gap concerning the numerous ectoparasites that inhabit animals in Wayanad. Ectoparasites in animals brought to the veterinary dispensaries in Wayanad were retrieved and identified morphologically and molecularly. Using a high-quality stereomicroscope, the taxonomic features of the four following species were examined and identified: Haemaphysalis bispinosa, Rhipicephalus annulatus, R. microplus, and Amblyomma geoemydae. The important disease vector A. geoemydae was reported for the first time in Kerala. The important phenotypic characters of the highlighted species A. geoemydae are the edge of the basis capituli is circular without cornua, and the hypostomal dental formula is 2/2. The taxonomically identified four species were subjected to CO1 gene sequence analysis. The evolutionary relationship was inspected through the neighbour-joining method, and the phylogenetic tree was built through the Maximum Likelihood method. The present study has also estimated the diversity index of R. microplus, R. annulatus, H. bispinosa, and A. geoemydae. Among them, R. microplus 0.36638 have reported with the maximum diversity index score. The significance of the study is the presence of Lyme disease vector A. geoemydae, in the Wayanad District of Kerala, and it is the first report of the species from where an outbreak of Lyme disease occurred in 2013.

Isolation and identification of Streptococcus agalactiae in cage-cultured green chromide Etroplus suratensis in Kerala, India

Streptococcus agalactiae is one of the main aetiological agents in large-scale mortalities of tilapia, having caused major economic losses to the aquaculture industry in recent years. This study describes the isolation and identification of the bacteria from cage-cultured Etroplus suratensis that experienced moderate to severe mortalities in Kerala, India. Gram-positive, catalase-negative S. agalactiae was identified from brain, eye and liver of the fish by antigen grouping and 16S rDNA sequencing. Multiplex PCR confirmed that the isolate belonged to capsular serotype Ia. Antibiotic susceptibility tests showed that the isolate was resistant to methicillin, vancomycin, tetracycline, kanamycin, streptomycin, ampicillin, oxacillin and amikacin. Histological sections of the infected E. suratensis brain revealed infiltration of inflammatory cells, vacuolation and meningitis. This report is the first description of S. agalactiae as a primary pathogen causing mortalities in E. suratensis culture in Kerala.

Ensemble of fuzzy-analytical hierarchy process in landslide susceptibility modeling from a humid tropical region of Western Ghats, Southern India

The western flanks of the Western Ghats are one of the major landslide hotspots in India. Recent rainfall triggered landslide incidents in this humid tropical region necessitating the accurate and reliable landslide susceptibility mapping (LSM) of selected parts of Western Ghats for hazard mitigation. In this study, a GIS-coupled fuzzy Multi-Criteria Decision Making (MCDM) technique is used to evaluate the landslide-susceptible zones in a highland segment of the Southern Western Ghats. Fuzzy numbers specified the relative weights of nine landslide influencing factors that were established and delineated using the ArcGIS, and the pairwise comparison of these fuzzy numbers in the Analytical hierarchy process (AHP) system resulted in standardized causative factor weights. Thereafter, the normalized weights are assigned to corresponding thematic layers, and finally, a landslide susceptibility map is generated. The model is validated using the area under the curve values (AUC) and F1 scores. The result reveals that about 27% of the study area is classified as highly susceptible zones followed by 24% area in moderately susceptible zone, 33% in low susceptible, and 16% in a very low susceptible area. Also, the study shows that the plateau scarps in the Western Ghats are highly susceptible to the occurrence of landslides. Moreover, the predictive accuracy estimated by the AUC scores (79%) and F1 scores (85%) shows that the LSM map is trustworthy for future hazard mitigation and land use planning in the study area.

Proportion of papillary thyroid microcarcinoma in Kerala, India, over a decade: a retrospective cohort study

Background

Overdiagnosis is a phenomenon where an indolent cancer is diagnosed that otherwise would not have caused harm to the patient during their lifetime. The rising incidence of papillary thyroid cancer (PTC) in various regions of the world is attributed to overdiagnosis. In such regions, the rates of papillary thyroid microcarcinoma (PTMC) are also rising. We aimed to study whether a similar pattern of rising PTMC is found in Kerala, a state in India, where there has been a doubling of thyroid cancer incidence over a decade.

Methods

We conducted a retrospective cohort study in two large government medical colleges, which are tertiary referral facilities in the state of Kerala. We collected data on the PTC diagnosis in Kozhikode and Thrissur Government Medical colleges from 2010 to 2020. We analysed our data by age, gender and tumor size.

Results

The incidence of PTC at Kozhikode and Thrissur Government Medical colleges nearly doubled from 2010 to 2020. The overall proportion of PTMC in these specimens was 18.9%. The proportion of PTMC only marginally increased from 14.7 to 17.9 during the period. Of the total incidence of microcarcinomas, 64% were reported in individuals less than 45 years of age.

Conclusion

The rise in the number of PTCs diagnosed in the government-run public healthcare centres in Kerala state in India is unlikely to be due to overdiagnosis since there was no disproportionate rise in rates of PTMCs. The patients that these hospitals cater to may be less likely to show healthcare-seeking behavior or ease of healthcare access which is closely associated with the problem of overdiagnosis.

Prevalence, awareness, treatment, control and correlates of prevalence and control of hypertension among older adults in Kerala: A Mixed Methods Study

INTRODUCTION

We conducted this study among older adults with the following objectives: (1) To find out the prevalence, awareness, treatment and control of hypertension, (2) To understand the factors associated with hypertension prevalence and control.

METHODS

A mixed-methods study employing a sequential exploratory design was conducted with a survey of 300 participants aged >=60 years, and 15 in-depth interviews. Blood Pressure (BP) and waist circumference were measured using standard protocol. Survey data were analysed using univariate and multivariate procedures. In-depth interviews were analysed employing thematic analysis.

RESULTS

Hypertension prevalence was 72.3% (95% CI= 67.1-77.2), 68.2% (CI=61.8-74.2) were aware, 65.4% (CI=59.0-71.6) were treated and 24% (CI=18.6-29.9) achieved adequate control. Inadequate physical activity [(adjusted odds ratio (AOR)]=2.34; CI=1.19-4.59), current alcohol use (AOR=2.28; CI=1.06-4.91) and self-reported diabetes (AOR=2.02; CI=1.15-3.52) were associated with hypertension prevalence. Those who reported diabetes (AOR=2.72, CI =1.34-5.55), with education level up to high school (AOR = 2.58, CI = 1.11-6.00) and who were in the age group 60-70 years (AOR=2.14, CI= 1.09-4.20) were more likely to have controlled hypertension compared to their counterparts. From the in-depth interviews it was found that availability and accessibility of services, family support, financial wellbeing, habits and beliefs and conducive environment played a role in hypertension diagnosis and management.

DISCUSSION

Prevalence of hypertension was high in this population along with poor control. Efforts are required to improve hypertension control focussing on older adults with low education and those who are aged 70 years and above.

The long-term effects of Kerala Diabetes Prevention Program on diabetes incidence and cardiometabolic risk: a study protocol

INTRODUCTION

India currently has more than 74.2 million people with Type 2 Diabetes Mellitus (T2DM). This is predicted to increase to 124.9 million by 2045. In combination with controlling blood glucose levels among those with T2DM, preventing the onset of diabetes among those at high risk of developing it is essential. Although many diabetes prevention interventions have been implemented in resource-limited settings in recent years, there is limited evidence about their long-term effectiveness, cost-effectiveness, and sustainability. Moreover, evidence on the impact of a diabetes prevention program on cardiovascular risk over time is limited.

OBJECTIVES

The overall aim of this study is to evaluate the long-term cardiometabolic effects of the Kerala Diabetes Prevention Program (K-DPP). Specific aims are 1) to measure the long-term effectiveness of K-DPP on diabetes incidence and cardiometabolic risk after nine years from participant recruitment; 2) to assess retinal microvasculature, microalbuminuria, and ECG abnormalities and their association with cardiometabolic risk factors over nine years of the intervention; 3) to evaluate the long-term cost-effectiveness and return on investment of the K-DPP; and 4) to assess the sustainability of community engagement, peer-support, and other related community activities after nine years.

METHODS

The nine-year follow-up study aims to reach all 1007 study participants (500 intervention and 507 control) from 60 randomized polling areas recruited to the original trial. Data are being collected in two phases. In phase 1 (Survey), we are admintsering a structured questionnaire, undertake physical measurements, and collect blood and urine samples for biochemical analysis. In phase II, we are inviting participants to undergo retinal imaging, body composition measurements, and ECG. All data collection is being conducted by trained Nurses. The primary outcome is the incidence of T2DM. Secondary outcomes include behavioral, psychosocial, clinical, biochemical, and retinal vasculature measures. Data analysis strategies include a comparison of outcome indicators with baseline, and follow-up measurements conducted at 12 and 24 months. Analysis of the long-term cost-effectiveness of the intervention is planned.

DISCUSSION

Findings from this follow-up study will contribute to improved policy and practice regarding the long-term effects of lifestyle interventions for diabetes prevention in India and other resource-limited settings.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry-(updated from the original trial)ACTRN12611000262909; India: CTRI/2021/10/037191.

The role of local governments in the implementation of evidence-based nutrition interventions in Kerala

OBJECTIVE

To study the involvement and influence of local participatory governments consisting of Panchayat Raj institutions (PRIs) in implementing evidence-based interventions for eliminating maternal and child undernutrition in the state of Kerala, India.

METHODS

In-depth interviews were carried out among stakeholders in six selected local governments using a semi-structured questionnaire. Transcribed interviews were coded and thematically analysed.

RESULTS

PRIs facilitated nutrition interventions through additional resource mobilisation, nutrition monitoring and surveillance, acting as a more approachable point of governance, utilising general acceptance to mobilise volunteers to tackle local challenges, enabling formal and informal platforms for community participation and spaces of co-creation. Changes in the attitude of different stakeholders, timely policy backing and support, and interconnections at the local level aided the process. Gaps exist in awareness creation, dietary diversification, feeding behaviours, maternal mental health, infrastructure development, monitoring of anthropometric indicators and planning for nutrition interventions during emergencies.

CONCLUSION

Results illustrate complex linkages PRIs have within the health system and how these linkages help in the implementation of interventions. The study explored previously identified pathways from the literature and identified additional pathways through which local participatory governance contributes to the successful implementation of nutrition interventions.

Combatting emerging infectious diseases from Nipah to COVID-19 in Kerala, India

BACKGROUND

The state of Kerala, India, has experienced several unprecedented events in the past few years. The current study was an attempt to explore perceptions of stakeholders on how the decentralised system helped during the Nipah virus (NiV) outbreaks and COVID-19 pandemic in Kerala.

METHODS

This study used a qualitative descriptive approach built on the advocacy paradigm. The stakeholders who were involved in decision-making and the representatives of local self-government who had real-time experience and had handled the challenges were identified using purposive sampling. Seven key informant interviews (KIIs) and nine in-depth interviews (IDIs) were conducted.

RESULTS

Findings indicate that decentralisation had enabled the state to effectively deal with the outbreaks and the pandemic. The survey revealed four major themes: decision-making, engagement level, people-centric action, and difficulties. Two to four categories have emerged for each theme.

CONCLUSION

The study results highlight the importance of human resources and service delivery as balancing factors during public health emergencies in any developing nation with limited resources. Given that very few nations have the healthcare infrastructure and resources necessary to cater to the healthcare needs of the whole population, decentralisation should be reinforced.

Decentralisation, health and Sustainable Development Goal 3

SETTING

Kerala State, India, implemented decentralising reforms of healthcare institutions 25 years ago through transfer of administrative control and a sizeable share of the financial allocation.

OBJECTIVE

To describe the main impacts of decentralisation in Kerala on local policy formulation, programme implementation and service delivery for sustainable health systems.

DESIGN

This was part of a broader qualitative study on decentralisation and health in Kerala. We conducted 25 in-depth interviews and reviewed 31 government orders or policy documents, five related transcripts and five thematic reports from the main study.

RESULTS

Liaising between health system and local governments has improved over time. A shift from welfare-centric projects to infrastructure, human resources and services was evident. Considerable heterogeneity existed due to varying degrees of involvement, capacity, resources and needs of the community. State-level discourse and recent augmentation efforts for moving towards the UN Sustainable Development Goals (SDGs) strongly uphold the role of local governments in planning, financing and implementation.

CONCLUSION

The 25-year history of decentralised healthcare administration in Kerala indicates both successes and failures. Central support without disempowering the local governments can be a viable option to allow flexible decision-making consistent with broader system goals.

Morphological and molecular characterization of Rhipicephalus microplus and Rhipicephalus annulatus from selected states of southern India

Ticks of the genus Rhipicephalus infesting cattle are the primary animal pests responsible for the annual economic loss of billions of dollars. Due to the morphological resemblance among the members of the Rhipicephalus (Boophilus) genus, species identification is very difficult. In this study, the adult R. annulatus and R. microplus ticks from two south Indian states viz., Kerala and Karnataka were subjected to morphological and molecular characterization. The R. microplus isolates from south India differed morphologically from true R. microplus clade A ticks. The ventral spur on the first pedipalp observed in male R. microplus was similar to that of R. australis. The phylogenetic analysis revealed that the R. microplus from these states clustered with R. microplus clade C. The mitochondrial cytochrome c oxidase I (COI) was identified as the preferred molecular marker compared to the internal transcribed spacer 2 (ITS2). The interspecific divergence between R. microplus and R. annulatus isolates from South India was 7.9 per cent based on COI. Moreover, based on COI, the R. microplus isolates revealed higher intraspecific divergence (2.9%) than R. annulatus (1%). The ITS2 sequences failed to differentiate R. microplus and R. annulatus.

Non-communicable disease management: Access to healthcare during COVID-19 pandemic in rural Kerala, India

Background

Globally, data on the coronavirus disease (COVID-19) pandemic showed a higher risk of infection and complications in people with non-communicable diseases (NCDs). In India, the prevalence of NCDs and their risk factors vary significantly between states. Compared to other states, Kerala has the highest prevalence of non-communicable diseases in the country, along with the highest proportion of the elderly population. The study evaluates the disease management patterns and changes in healthcare behaviors among adults with NCDs in Kerala during the COVID-19 pandemic.

Methods

A cross-sectional study was conducted among 410 adult NCD patients in rural Thiruvananthapuram district, Kerala. Using a semi-structured interview schedule, the present study gathered information on socio-demographic characteristics, disease patterns, healthcare utilization, and behavioral change during the pandemic.

Results

Mean age of the participants was 62 years (range: 37-88; women: 64%). The most prevalent NCD was hypertension (74%) and diabetes (65%) followed by chronic respiratory disease (12%), cardiovascular disease (11%), and cancer (2%). Nearly 76% had difficulty in obtaining consultation/medical follow-up. Around 10% relied on telecommunication and 32% reported increased stress during the pandemic. Those with low socio-economic status and with a single NCD were more vulnerable to the challenges faced during the pandemic.

Conclusion

A higher proportion of adults with NCDs faced difficulties in healthcare access and had negative healthcare behaviors during the pandemic. The findings highlight the need to ensure better healthcare for people living with NCDs during the times of pandemic.

Ecological risk assessment and phytomanagement of trace metals in the sediments of mangroves associated with the Ramsar sites of Kerala, southern India

The study investigated trace metal accumulation in the sediments of three major mangrove ecosystems associated with the Ramsar sites of Kerala state, the ecological risks they pose, and the absorption, accumulation, and translocation of metals in five dominant mangrove species, as these systems are heavily impacted by anthropogenic interventions. The trace metal concentrations (mg kg^-1) in the sediment of different mangrove habitats of Kerala ranged from 20 to 295 for Cu, 65 to 350 for Zn, 72 to 151 for Pb, 11 to 210 for Ni, 42 to 228 for Mn, 0 to 6 for Cd,124 to 565 for Cr, and 0 to 2.9 for Ag. An overall enrichment of metals was recorded in sediment, exceeding the prescribed effects range median (ERM) of consensus-based sediment quality guidelines (SQGs) for Cu and Cr concentrations at Munroe Island and Ni at Vypin, indicating a detrimental risk to biota in the sediments. Principal component analysis and a higher geoaccumulation index indicated the contribution of trace metals from industries, agricultural runoff, and urban waste disposal. The ecological risk index suggested that cadmium poses a very high risk to the mangrove ecosystem at Vypin. Furthermore, the bioconcentration factor for various trace metals in Avicennia marina and Lumnitzera racemosa in Ayiramthengu was > 2, suggesting that these species can accumulate trace metals, particularly Cr, Cd, and Pb. Further, our findings suggest that A. marina may be considered as an efficient metal trap for Cd in aerial parts, as indicated by the significant translocation factor (> 1) combined with the bioconcentration factor. Therefore, the study revealed that Munroe island and Vypin had a considerable level of contamination for toxic metals and Avicennia marina could be a promising candidate species for the phytoremediation of these trace metals in the coastal settings of Kerala state.

Of primary health care reforms and pandemic responses: understanding perspectives of health system actors in Kerala before and during COVID-19

BACKGROUND

In 2016, the Government of the southern Indian state of Kerala launched the Aardram mission, a set of reforms in the state's health sector with the support of Local Self Governments (LSG). Primary Health Centres (PHCs) were slated for transformation into Family Health Centres (FHCs), with extended hours of operation as well as improved quality and range of services. With the COVID-19 pandemic emerging soon after their introduction, we studied the outcomes of the transformation from PHC to FHC and how they related to primary healthcare service delivery during COVID-19.

METHODS

A qualitative study was conducted using In-depth interviews with 80 health system actors (male n = 32, female n = 48) aged between 30-63 years in eight primary care facilities of four districts in Kerala from July to October 2021. Participants included LSG members, medical and public health staff, as well as community leaders. Questions about the need for primary healthcare reforms, their implementation, challenges, achievements, and the impact of COVID-19 on service delivery were asked. Written informed consent was obtained and interview transcripts - transliterated into English-were thematically analysed by a team of four researchers using ATLAS.ti 9 software.

RESULTS

LSG members and health staff felt that the PHC was an institution that guarantees preventive, promotive, and curative care to the poorest section of society and can help in reducing the high cost of care. Post-transformation to FHCs, improved timings, additional human resources, new services, fully functioning laboratories, and well stocked pharmacies were observed and linked to improved service utilization and reduced cost of care. Challenges of geographical access remained, along with concerns about the lack of attention to public health functions, and sustainability in low-revenue LSGs. COVID-19 pandemic restrictions disrupted promotive services, awareness sessions and outreach activities; newly introduced services were stopped, and outpatient numbers were reduced drastically. Essential health delivery and COVID-19 management increased the workload of health workers and LSG members, as the emphasis was placed on managing the COVID-19 pandemic and delivering essential health services.

CONCLUSION

Most of the health system actors expressed their belief in and commitment to primary health care reforms and noted positive impacts on the clinical side with remaining challenges of access, outreach, and sustainability. COVID-19 reduced service coverage and utilisation, but motivated greater efforts on the part of both health workers and community representatives. Primary health care is a shared priority now, with a need for greater focus on systems strengthening, collaboration, and primary prevention.

Protective Role of Social Networks for the Well-Being of Persons with Disabilities: Results from a State-Wide Cross-Sectional Survey in Kerala, India

The current study presents the findings from a cross-sectional survey on social factors associated with the well-being of persons with disabilities (PWDs) in Kerala, India. We conducted a community-based survey across three geographical zones, North, Central, and South of Kerala state, between April and September 2021. We randomly selected two districts from each zone using a stratified sample method, followed by one local self-government from each of these six districts. Community health professionals identified individuals with disabilities, and researchers collected information on their social networks, service accessibility, well-being, and mental health. Overall, 244 (54.2%) participants had a physical disability, while 107 (23.78%) had an intellectual disability. The mean well-being score was 12.9 (S.D = 4.9, range = 5-20). Overall, 216 (48%) had poor social networks, 247 (55%) had issues regarding service accessibility, and 147 (33%) had depressive symptoms. Among the PWDs with issues with service access, 55% had limited social networks. A regression analysis revealed that social networks (b = 2.30, p = 0.000) and service accessibility (b = -2.09, p = 0.000) were associated with well-being. Social networks are more important than financial assistance because they facilitate better access to psycho-socioeconomic resources, a prerequisite for well-being.

Weather integrated multiple machine learning models for prediction of dengue prevalence in India

Dengue is a rapidly spreading viral disease transmitted to humans by Aedes mosquitoes. Due to global urbanization and climate change, the number of dengue cases are gradually increasing in recent decades. Hence, an early prediction of dengue continues to be a major concern for public health in countries with high prevalence of dengue. Creating a robust forecast model for the accurate prediction of dengue is a complex task and can be done through various data modelling approaches. In the present study, we have applied vector auto regression, generalized boosted models, support vector regression, and long short-term memory (LSTM) to predict the dengue prevalence in Kerala state of the Indian subcontinent. We consider the number of dengue cases as the target variable and weather variables viz., relative humidity, soil moisture, mean temperature, precipitation, and NINO3.4 as independent variables. Various analytical models have been applied on both datasets and predicted the dengue cases. Among all the models, the LSTM model was outperformed with superior prediction capability (RMSE: 0.345 and R²:0.86) than the other models. However, other models are able to capture the trend of dengue cases but failed in predicting the outbreak periods when compared to LSTM. The findings of this study will be helpful for public health agencies and policymakers to draw appropriate control measures before the onset of dengue. The proposed LSTM model for dengue prediction can be followed by other states of India as well.

Evaluation of daily average temperature trends in Kerala, India, using MERRA-2 reanalysis data: a climate change perspective

Modern-Era Retrospective Analysis for Research and Applications, version 2 (MERRA-2) data for a period of 40 years (1980-2019) was used to detect the trend characteristics of daily average temperature in the state of Kerala, India. Data extracted from a total of fifty locations in the state were statistically processed using Mann-Kendall (MK) and Spearman's Rho (SR) tests to detect the trend, Pettitt test to identify the single change point, and Theil-Sen's method for the calculation of the rate of change. The MERRA-2 product is validated for the study region according to statistical indicators. The daily average temperature in the state during the period of study varies between 16.56 and 32.64 °C. The spatial pattern of daily average maximum temperature shows higher temperature domains in the central and southern parts of the state. Trend characteristics of daily average temperature assessed through MK and SR tests show a significant increasing trend in all stations, with maximum values in stations located in the northern part of the state. Change point detected through the Pettitt test divided the sampling stations into three groups based on the change in daily average temperature characteristics in the years 2002 (north zone), 2009 (south zone), and 2012 (central zone), indicating nonunique spatial variability in temperature characteristics in the state. The rate of change in the daily average temperature assessed indicates an increase at the rate of an average of 0.013 °C.year^-1. During the whole study period, the daily average temperature showed an overall increase of 0.54 °C, and for the 100-year futuristic prediction, the daily average temperature in the state shows an average increase of 1.35 °C. Among the stations, a higher rate of increase in daily average temperature is shown by stations located in the eastern part of the Pathanamthitta, Idukki, and Kollam districts. Though the rise in daily average temperature is not much higher, its spatial characteristics require more attention because, in recent times, the study area has faced repeated, severe, and long drought conditions along with sunburn incidents. As an agrarian state, a change in the temperature domain will adversely affect the overall agricultural production and will evoke not only a food crisis but also economic as well as water resources issues. The result obtained can be used as holistic basic information for understanding the impending effect of climate change in the state to frame better mitigation as well as management strategies.

The local roots of 'health for all': Primary health care in practices, 1950s-2000s

We look at Universal Health Coverage (UHC) through a historical investigation of the "health for all by 2000" policy adopted by the WHO in 1978. Within contemporary debates on access to care, Alma Ata is usually considered as a brief moment of well-intentioned utopia, which buckled to global health's agenda of performance metrics and targeted diseases. Such visions of primary health care (PHC) are shared references in the debates about UHC. Aiming at a less geopolitical and more local approach of the strategy's roots than the existing historiography, the paper draws from historical and ethnographic work on health policies and practices in Tanzania, Oman and Kerala (India), in which PHC was not only envisioned, but constructed as the backbone of local health systems, often prior to Alma Ata. All three states were praised for their PHC achievements. Studying them allows for emphasizing the importance of national trajectories in PHC, as well as revealing shared core issues such as the importance of access and affordability, of the focus on rural centers and the mass training of non-medical personnel, and of the articulation of vertical programs and horizontal system building. It also reveals very different trajectories in terms of duration, priorities, outcomes and international visibility.

Effectiveness of an oral health education intervention among 6-12-year-old children: A cluster randomized controlled trial

OBJECTIVES

Literature on the effectiveness of theory-based oral health education on the oral hygiene of children is limited. We aimed to determine the effectiveness of an health behaviour theory-based school oral health education intervention on 1) oral hygiene and 2) oral health-related knowledge, attitude and practices among 6-12-year-old children in Kerala, India.

METHODS

Cluster randomized controlled trial. Sixteen class divisions (clusters) were randomized into intervention and control groups of 225 and 228 children respectively. Primary and secondary outcomes were plaque score as measured using the simplified oral hygiene index (OHI-S) and oral health-related knowledge, attitude and practices respectively. The intervention group received structured oral health education classes for three months and materials including pamphlets. Children in the control group were not given the classes or materials.

RESULTS

Post-intervention OHI-S scores in the intervention group and control groups were 1.65 and 2.17 respectively (difference = -0.52, 95%CI -0.86, -0.18). All the secondary outcomes improved in the intervention group compared to the control group.

CONCLUSIONS

The intervention improved the oral hygiene status, oral health-related knowledge, attitude and practices of the children. Longer term follow-up and economic appraisal are needed to help policymakers plan and develop OHEI based on health behaviour theories.

Knowledge about tuberculosis among tribal population in Kerala in the backdrop of TB elimination goal by 2025

INTRODUCTION

Kerala is one among the States in India with least prevalence of tuberculosis and is reportedly aiming to be the first State to reach the target of 'Zero TB' by 2025. But knowledge about TB among the vulnerable groups plays a critical role in controlling the spread and achieving the target of eliminating TB.

MATERIALS AND METHODS

Drawing on a collaborative research program in India to estimate the burden of TB among tribal population, the level of knowledge and its possible links between life style of tribals, their customs and practices is examined Multi stage cluster sampling technique was adopted and 3 wards were selected in three districts in Kerala: Wayanad, Idukki and Palakkad which encompasses major share of the tribal population by probability proportional to size sampling method to draw a sample of 2600 individuals.

RESULTS

Awareness about TB among Tribal population in Kerala is impressive. However, in-depth knowledge on how TB is caused and spread, the symptoms, place of treatment and the cost are not so appreciable. Misconceptions and also lack of knowledge still prevail on who is prone to TB, how TB is spread and the causative agent. The IEC activities have had its effect in sensitizing the tribal population on how to identify the symptoms of TB. The average knowledge score was 5.06 points (72.2 percent, SD: 1.81) out of a total possible score of 7 points. The individual mean knowledge score is 0.65 overall considering all the knowledge domains where the maximum value is 1 and minimum is 0. The mean knowledge score among the Malayarayan Christians and Hindus is relatively higher but poor among Kattunayaka and Irular tribes. Mean knowledge score decreases significantly with increasing age. Gender differential in mean knowledge score is absent but greater educational attainment is associated with higher knowledge scores. However knowledge is not translated to practice of all preventive aspects of TB.

CONCLUSION

Knowledge deficit poses challenges in the efforts to eliminate TB in Kerala because the State is progressing towards zero TB target. Hence spreading awareness on these vital aspects need better focus among the tribal population.

Knowledge, Attitude and Practices Regarding Menstrual Cup Among Females in an Urban Setting of South Kerala

Objective

This study aims to assess the knowledge, attitude, and practices regarding menstrual cups use and the factors associated with it among females of the reproductive age group in an urban setting of South Kerala.

Materials and methods

We conducted a cross-sectional study from December 2021 to January 2022 among females of the reproductive age group. Data was entered in MS Excel and was analyzed using Statistical Package for Social Sciences version 26.0. The significance of association was tested using the Chi-square test. Binary logistic regression was done to predict the factors associated with knowledge levels regarding menstrual cup.

Results

The mean age of study participants was 25.68(SD 6.64) years. Lack of knowledge (22.6%) and fear of insertion (56.2%) were the major reasons for not trying a menstrual cup. Out of the 350 study participants, 258(73.7%) had good knowledge scores and 92(26.3%) had poor knowledge scores. Discomfort and leakage were the most important problems reported by participants. A statistically significant association was found between younger age, educational status, socioeconomic, status, marital status of females in the reproductive age group, and knowledge about the menstrual cup.

Conclusion

Most of the participants (93.4%) were aware of menstrual cups. Even though two third of the participants had good knowledge regarding menstrual cups, only 15.1% have tried to use a menstrual cup. Fear of insertion was the most common concern for not trying a menstrual cup. Discomfort and leakage were the most important problems reported by participants. Younger age and higher educational qualifications were found to be independently associated with knowledge levels regarding menstrual cups.

History Cancer Care in Kerala

The history of cancer care of Kerala spread back to colonial era, where the first hospitals with cancer care facilities were started and run by the London Missionary Society. Later, many government hospitals started cancer care and establishment of the Regional Cancer Centre in 1981 elevated the status of Kerala in the cancer care map of India. The history of modern cancer care in Kerala dates back to the nineteenth century. In Travancore, where the capital of Kerala was later located, modern medicine was first made available in 1811 to the royal family followed by their officials, prisoners and the general public respectively.

New Genus and Two New Species of Semiterrestrial Crabs (Decapoda: Brachyura: Gecarcinucidae) from the Southern Western Ghats, India

One new genus and two new species of semiterrestrial freshwater crabs are described from the Southern Western Ghats mountain range in India: Pavizham gavi gen., sp. nov. and Rajathelphusa brunnea sp. nov. The carapace of Pavizham n. gen. is superficially similar to Baratha and Snaha described from the same region, but it can be distinguished from Baratha in having no visible postorbital cristae, complete sutures between male thoracic sternites 2 and 3, the possession of a triangular male pleon and the elongate terminal segment of the male first gonopod; and from Snaha by the presence of a long flagellum on the exopod of the third maxilliped, a complete suture separating male thoracic sternites 2 and 3, and its triangular male pleon. Rajathelphusa brunnea sp. nov. can easily be distinguished from congeners in possessing a distinctly more slender and elongate male first gonopod.

Bargaining with patriarchy through the life course: obstacles faced (and overcome) by women leaders in Kerala's health sector

BACKGROUND

The COVID-19 pandemic has helped shine the spotlight on the role of women's leadership in tackling the world's health and health system challenges. The proportion of women occupying senior leadership positions in the health sector is less compared to males, even as they constitute a vast majority of the work force. The South Indian state of Kerala is an exception to this trend, a phenomenon that we sought to understand and contextualise. We undertook a study to understand the personal and professional journeys of some women leaders in the Kerala health sector to determine the antecedents of their leadership positions, the challenges that came their way in leadership, and strategies adopted to overcome these challenges. We also investigated into how these experiences shaped their styles and approaches to leadership.

METHODS

We conducted a qualitative study involving semi-structured in-depth interviews with women leaders. Sixteen women leaders were identified from public records and through peer nomination and interviewed in their language of preference following written informed consent procedures. Interviews focused on participants' professional and personal trajectories, work-life balance, style of leadership, challenges, enablers, lessons learned in their path, and their vision for the health system. The interviews conducted in Malayalam were transliterated into English and thematically analysed using Atlas.Ti8 software by three researchers.

RESULTS

Our study participants were aged 40 to around 80 years, from 8 out of 14 districts of the state. Women leaders in Kerala's health sector faced challenges through the life-course: during their early school education, in professional service as well as in their roles as leaders. There were myriad experiences - including gender stereotyping and discrimination at the intersection of gender and other social identities. Women developed manifold ways of overcoming them and evolve unique - and again myriad-leadership styles.

CONCLUSIONS

Women leaders in Kerala have faced shared challenges through their life-course to climb up the ranks of leadership; each leader has adopted unique ways of overcoming them and developed similarly unique leadership styles. At each life stage there were bargains with patriarchy - involving family members (often as allies), against formal and informal institutional rules, managers, peers and subordinates., which in turn suggests a feminist consciousness on the part of Kerala women leaders as well as the society in which they are seeking to lead.

Household secondary attack rate in SARS-CoV-2 infection during the second wave of the COVID-19 pandemic in South India

Background

Coronavirus disease 2019 (COVID-19) has become a major public health problem since its inception disrupting public life and crippling health systems. The mutated variant of the causative virus, Delta, has been notorious in causing rapid upsurge in cases compared to the Alpha variant. The current study tries to find out the household secondary attack rate (HSAR) of COVID-19 and factors associated with it during the second wave of cases in Kerala.

Methodology

A retrospective cohort study was performed among 313 household contacts of 76 COVID-19 patients who had been admitted in Government Medical College, Thrissur, in the southern state of India, Kerala. Data from the participants were collected via phone using a semi-structured interview schedule, and analysis was performed with SPSS software.

Results

The HSAR among household contacts was 59.1% (53.4-64.6%). The risk of acquiring COVID infection among household contacts was higher among contacts of symptomatic index cases with a P value of 0.001 and an odds ratio of 11 (3.7-32.4). index cases were having a home isolation P value of 0.001 and an odds ratio of 3.2 (2-5.1), with delay in COVID-19 testing for index cases with a P value of 0.006. Regarding characteristics of household contacts, higher age groups (p = 0.048), groups living in the same room with an index case P value of 0.021 and an odds ratio of [1.71 (1-2.8)], groups having physical contact with an index case P value of 0.001 and an odds ratio of [3.7 (2.1-7)], groups with touched or cleaned linen/articles with an index case P value of 0.02 and an odds ratio of [1.8 (1-3.1)], and groups having co-morbidities, especially diabetes mellitus (p = 0.0020), were significantly associated with chances of acquiring infection. However, the history of previous COVID positivity in household contacts was a protective factor against the infection P value of 0.009 with an odds ratio of [0.09 (0.01-0.78)].

Conclusion

The study concludes that the second wave of COVID-19 in Kerala was primarily caused by a high SAR, especially among household contacts, and this could have been the reason for the difficulty in control measures during the wave.

Prevalence of Tuberculosis Infection among Adults of Thiruvananthapuram District of Kerala as Measured by Interferon Gamma Release Assay - A Cross-Sectional Study

Background

To achieve the goals of the end tuberculosis (TB) strategy, strategies for management of TB infection (TBI) have to be expanded. The first step to devise policies is to understand the distribution and determinants of TBI in the community. The objectives of the study were to estimate the prevalence of TBI using Interferon Gamma Release Assay (IGRA) and its determinants among the adult population of Thiruvananthapuram district, Kerala.

Materials and Methods

A community-based, cross-sectional study using the stratified cluster sampling was carried out among the adults. TBI was detected using IGRA conducted on whole blood sample. Data on determinants were collected using a structured questionnaire by the face-to-face interview. The prevalence of TBI was estimated. Univariate and multivariate analysis was conducted to identify the determinants.

Results

Age standardized prevalence of TBI among 396 adults was 20.5% (95% confidence interval [CI] 16.52-24.48). On adjusting for the possible confounders, increasing age (adjusted odds ratio [OR] 1.028; 95% CI 1.008-1.048; P = 0.005), history of contact with active TB disease (adjusted OR 7.61; 95% CI 4.43-13.05; P < 0.001), childhood contact (adjusted OR 8.20; 95% CI 3.14-21.41; P < 0.001), and household contact (adjusted OR 10.12; 95% CI 5.39-18.98; P < 0.001) were found to be the determinants of TBI in this population.

Conclusion

The present study observed that nearly one-fifth of the adult population in the Thiruvananthapuram district has TBI. For the programmatic management, factors such as increasing age and contact history may be considered for the elimination of TBI in the state.