Life Style and Behavioural Factors are Associated with Stroke Recurrence Among Survivors of First Episode of Stroke: A Case Control Study.

BACKGROUND: Secondary stroke prevention treatment is associated with an 80% reduction in risk of recurrent stroke. But one out of every four strokes are recurrent. Adherence to pharmacological therapy and strict control of risk factors are essential for prevention of recurrent strokes. METHODS: Pair matched incident case control study was done to find out the factors associated with stroke recurrence after first ever stroke. Incident cases of recurrent strokes and age and post stroke period matched controls were recruited prospectively. The estimated sample size for the study was 70 matched pairs. Data collected from medical records and by visiting their homes. Analysis was done using R statistical software. RESULTS: Bivariate analysis showed cardio embolic stroke subtype, poor lipid control, unhealthy diet, physical inactivity, medication nonadherence, presence of depression, memory problems no discharge advice at index admission and low income were associated increased risk of recurrence. Higher mean NIHSS score and a greater number of days of hospitalisation during index stroke had less risk of recurrence. Conditional logistic regression analysis revealed non adherence to medication (OR 7.46, 1.67-33.28) and not receiving discharge advice at index admission (OR 10.79, 2.38-49.02) were associated with increased risk of recurrence whereas lacunar stroke (OR 0.08, 0.01-0.59) and a greater number of days of hospitalization during index stroke (OR 0.82, 0.67-0.99) were associated with less risk of recurrence. CONCLUSION: Individualised patient education regarding stroke, recurrence risk, medication adherence, healthy lifestyle and risk factor control can reduce stroke recurrence risk.

Using open-source data to explore distribution of built environment characteristics across Kerala, India.

BACKGROUND: Built environment characteristics in the neighborhood are of utmost priority for a healthy lifestyle in the fast-urbanizing countries. These characteristics are closely linked to the disease burden and challenges in low- and middle-income countries (LMICs), which have been unexplored using open-source data. The present technology offers online resources and open source software that enable researchers to explore built environment characteristics with health and allied phenomena. OBJECTIVES: This article intends to delineate methods to capture available and accessible objective built environment variables for a state in India and determine their distribution across the state. METHODS: Built environment variables such as population density and residential density were collated from the Census of India. Safety from crime and traffic were captured as crime rates and pedestrian accident rates, respectively, acquired from State Crime Records Bureau. Greenness, built-up density, and land slope were gathered from open-source satellite imagery repository. Road intersection density was derived from OpenStreetMap. Processing and analysis differed for each dataset depending on its source and nature. RESULTS: Each variable showed a distinct pattern across the state. Population and residential density were found to be closely related to each other across both districts and subdistricts. They were both positively related to crime rates, pedestrian accident rates, built-up density, and intersection density, whereas negatively related to land slope and greenness across the subdistricts. CONCLUSION: Delineating the distribution of built environment variables using available and open-source data in resource-poor settings is a first in public health research among LMICs. Cost-effectiveness and reproducible nature of open-source solutions could equip researchers in resource-poor settings to identify built environment characteristics and patterns across regions.

Incidence of type 2 diabetes mellitus and prediabetes in Kerala, India: results from a 10-year prospective cohort.

BACKGROUND: Kerala, the southern state of India, has experienced sudden rise in the prevalence estimates of diabetes. A cohort study on the incidence of type 2 diabetes mellitus (T2DM) in Kerala state thus aptly bridges the lacuna of incidence estimate of T2DM from a population at risk. METHODS: A 10-year prospective cohort study was carried out in two urban wards of central Kerala. The individuals who participated in the baseline survey in 2007 were again invited for a follow-up study in 2017. The data was analyzed using IBM SPSS Statistics for windows (version 21.0). Logistic regression analysis was used to estimate odds ratios and 95% confidence intervals. Findings are based on the 10-year follow-up data from 869 participants from the cohort. RESULTS: The overall follow-up and response rate of the study was 68.9 and 86.9% respectively. During the follow-up period, 190 people (21.9%) developed T2DM. The incidence rate of T2DM and impaired fasting glucose (IFG) were 24.5 per 1000 person years and 45.01 per 1000 person years respectively. Nearly 60% of participants with baseline IFG were converted to T2DM group in the follow-up period. Age > 45 years, family history of T2DM, BMI ≥ 25 kg/m2 and presence of central obesity emerged as important risk factors for incident T2DM. CONCLUSION: High incidence of prediabetes over diabetes observed in this study shows an epidemic trend of T2DM in Kerala, India. It requires an immediate public health action.

Fruit, vegetable, and legume intake, and cardiovascular disease and deaths in 18 countries (PURE): a prospective cohort study.

BACKGROUND: The association between intake of fruits, vegetables, and legumes with cardiovascular disease and deaths has been investigated extensively in Europe, the USA, Japan, and China, but little or no data are available from the Middle East, South America, Africa, or south Asia. METHODS: We did a prospective cohort study (Prospective Urban Rural Epidemiology [PURE] in 135 335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and high-income countries in seven geographical regions: North America and Europe, South America, the Middle East, south Asia, China, southeast Asia, and Africa. We documented their diet using country-specific food frequency questionnaires at baseline. Standardised questionnaires were used to collect information about demographic factors, socioeconomic status (education, income, and employment), lifestyle (smoking, physical activity, and alcohol intake), health history and medication use, and family history of cardiovascular disease. The follow-up period varied based on the date when recruitment began at each site or country. The main clinical outcomes were major cardiovascular disease (defined as death from cardiovascular causes and non-fatal myocardial infarction, stroke, and heart failure), fatal and non-fatal myocardial infarction, fatal and non-fatal strokes, cardiovascular mortality, non-cardiovascular mortality, and total mortality. Cox frailty models with random effects were used to assess associations between fruit, vegetable, and legume consumption with risk of cardiovascular disease events and mortality. FINDINGS: Participants were enrolled into the study between Jan 1, 2003, and March 31, 2013. For the current analysis, we included all unrefuted outcome events in the PURE study database through March 31, 2017. Overall, combined mean fruit, vegetable and legume intake was 3·91 (SD 2·77) servings per day. During a median 7·4 years (5·5-9·3) of follow-up, 4784 major cardiovascular disease events, 1649 cardiovascular deaths, and 5796 total deaths were documented. Higher total fruit, vegetable, and legume intake was inversely associated with major cardiovascular disease, myocardial infarction, cardiovascular mortality, non-cardiovascular mortality, and total mortality in the models adjusted for age, sex, and centre (random effect). The estimates were substantially attenuated in the multivariable adjusted models for major cardiovascular disease (hazard ratio [HR] 0·90, 95% CI 0·74-1·10, ptrend=0·1301), myocardial infarction (0·99, 0·74-1·31; ptrend=0·2033), stroke (0·92, 0·67-1·25; ptrend=0·7092), cardiovascular mortality (0·73, 0·53-1·02; ptrend=0·0568), non-cardiovascular mortality (0·84, 0·68-1·04; ptrend =0·0038), and total mortality (0·81, 0·68-0·96; ptrend<0·0001). The HR for total mortality was lowest for three to four servings per day (0·78, 95% CI 0·69-0·88) compared with the reference group, with no further apparent decrease in HR with higher consumption. When examined separately, fruit intake was associated with lower risk of cardiovascular, non-cardiovascular, and total mortality, while legume intake was inversely associated with non-cardiovascular death and total mortality (in fully adjusted models). For vegetables, raw vegetable intake was strongly associated with a lower risk of total mortality, whereas cooked vegetable intake showed a modest benefit against mortality. INTERPRETATION: Higher fruit, vegetable, and legume consumption was associated with a lower risk of non-cardiovascular, and total mortality. Benefits appear to be maximum for both non-cardiovascular mortality and total mortality at three to four servings per day (equivalent to 375-500 g/day). FUNDING: Full funding sources listed at the end of the paper (see Acknowledgments).

PPIA rs6850: A > G single-nucleotide polymorphism is associated with raised plasma cyclophilin A levels in patients with coronary artery disease.

Plasma level of cyclophilin A is a promising marker of vascular disease in patients with type 2 diabetes. Genetic variants in the peptidylprolyl isomerase A gene, encoding human cyclophilin may alter protein synthesis thus affecting its activity, function, and circulating plasma levels. We examined the effect of single-nucleotide polymorphisms (SNPs) within the PPIA gene on plasma levels of cyclophilin A and coupled this with status of vascular disease in patients with and without type 2 diabetes in 212 South Indian subjects. The regulatory region of PPIA gene was sequenced for SNPs. The association of SNPs with known blood markers of type 2 diabetes and coronary artery disease such as HbA1c, low- and high-density lipoproteins, triglycerides, fasting and postprandial blood sugar levels, and cyclophilin A were probed. We identified three SNPs namely, rs6850: A > G; (AG/-) c.*227_*228delAG and (-/T) c.*318_*319insT. Welchs two-sample t test indicated an association of SNP rs6850: A > G, located at the 5' UTR region with increased plasma levels of cyclophilin A in patients with coronary artery disease and with coronary artery disease associated with diabetes. The presence of rs6850: A > G variant was significantly associated with coronary artery disease irrespective of whether the patients had diabetes or not. In silico analysis of the sequence using different tools and matrix libraries did not predict any significant differential binding sites for rs6850: A > G, c.*227_*228delAG and c.*318_*319insT. Our results indicate that the SNP rs6850: A > G is associated with increased risk for elevated plasma levels of cyclophilin A and coronary artery disease in patients with and without type 2 diabetes.

Plasma level of cyclophilin A is increased in patients with type 2 diabetes mellitus and suggests presence of vascular disease.

AIMS/HYPOTHESIS: Cyclophilin A, an immunophilin is secreted from human monocytes activated by high glucose. Given its role as an inflammatory mediator of vascular tissue damage associated with inflammation and oxidative stress, we examined plasma levels of cyclophilin A in normal healthy volunteers and patients with type 2 diabetes (DM), with or without coronary artery disease (CAD). METHODS: Study subjects comprised of 212 patients with DM and CAD,101 patients with diabetes, 122 patients with CAD and 121 normal healthy volunteers. Diabetes was assessed by HbA1c levels while coronary artery disease was established by a positive treadmill test and/or coronary angiography. Plasma cyclophilin A was measured using a cyclophilin A ELISA Kit. Relationship of plasma cyclophilin A levels with blood markers of type 2 diabetes, blood lipid levels and medication for diabetes and coronary artery disease were also explored. RESULTS: Plasma Cyclophilin levels were higher in diabetes patients with or without CAD compared to normal subjects (P < 0.001). Age, fasting blood sugar levels and HbA1C levels were positively associated with increased plasma cyclophilin. Patients using metformin had reduced levels of plasma cyclophilin (p < 0.001).Serum levels of total cholesterol, LDL cholesterol and triglycerides had no significant association with plasma cyclophilin levels. In patients with increased serum CRP levels, plasma cyclophilin A was also elevated (p = 0.016). Prevalence odds for DM, DM + CAD and CAD are higher in those with high cyclophilin values, compared to those with lower values, after adjusting for age and sex, indicating strong association of high cyclophilin values with diabetes and vascular disease. CONCLUSIONS/INTERPRETATIONS: Our study demonstrates that patients with type 2 diabetes have higher circulating levels of cyclophilin A than the normal population. Plasma cyclophilin levels were increased in patients with diabetes and coronary artery disease suggesting a role of this protein in accelerating vascular disease in type 2 diabetes. Considering the evidence that Cyclophilin A is an inflammatory mediator in atherogenesis, the mechanistic role of cyclophilin A in diabetic vascular disease progression deserves detailed investigation.

The association between ownership of common household devices and obesity and diabetes in high, middle and low income countries.

BACKGROUND: Household devices (e.g., television, car, computer) are common in high income countries, and their use has been linked to obesity and type 2 diabetes mellitus. We hypothesized that device ownership is associated with obesity and diabetes and that these effects are explained through reduced physical activity, increased sitting time and increased energy intake. METHODS: We performed a cross-sectional analysis using data from the Prospective Urban Rural Epidemiology study involving 153,996 adults from high, upper-middle, lower-middle and low income countries. We used multilevel regression models to account for clustering at the community and country levels. RESULTS: Ownership of a household device increased from low to high income countries (4% to 83% for all 3 devices) and was associated with decreased physical activity and increased sitting, dietary energy intake, body mass index and waist circumference. There was an increased odds of obesity and diabetes with the ownership of any 1 household device compared to no device ownership (obesity: odds ratio [OR] 1.43, 95% confidence interval [CI] 1.32-1.55; diabetes: OR 1.38, 95% CI 1.28-1.50). Ownership of a second device increased the odds further but ownership of a third device did not. Subsequent adjustment for lifestyle factors modestly attenuated these associations. Of the 3 devices, ownership of a television had the strongest association with obesity (OR 1.39, 95% CI 1.29-1.49) and diabetes (OR 1.33, 95% CI 1.23-1.44). When stratified by country income level, the odds of obesity and diabetes when owning all 3 devices was greatest in low income countries (obesity: OR 3.15, 95% CI 2.33-4.25; diabetes: OR 1.97, 95% CI 1.53-2.53) and decreased through country income levels such that we did not detect an association in high income countries. INTERPRETATION: The ownership of household devices increased the likelihood of obesity and diabetes, and this was mediated in part by effects on physical activity, sitting time and dietary energy intake. With increasing ownership of household devices in developing countries, societal interventions are needed to mitigate their effects on poor health.

Advancing the application of systems thinking in health: understanding the growing complexity governing immunization services in Kerala, India.

BACKGROUND: Governing immunization services in a way that achieves and maintains desired population coverage levels is complex as it involves interactions of multiple actors and contexts. In one of the Indian states, Kerala, after routine immunization had reached high coverage in the late 1990s, it started to decline in some of the districts. This paper describes an application of complex adaptive systems theory and methods to understand and explain the phenomena underlying unexpected changes in vaccination coverage. METHODS: We used qualitative methods to explore the factors underlying changes in vaccination coverage in two districts in Kerala, one with high and one with low coverage. Content analysis was guided by features inherent to complex adaptive systems such as phase transitions, feedback, path dependence, and self-organization. Causal loop diagrams were developed to depict the interactions among actors and critical events that influenced the changes in vaccination coverage. RESULTS: We identified various complex adaptive system phenomena that influenced the change in vaccination coverage levels in the two districts. Phase transition describes how initial acceptability to vaccination is replaced by a resistance in northern Kerala, which involved new actors; actors attempting to regain acceptability and others who countered it created several feedback loops. We also describe how the authorities have responded to declining immunization coverage and its impact on vaccine acceptability in the context of certain highly connected actors playing disproportionate influence over household vaccination decisions.Theoretical exposition of our findings reveals the important role of trust in health workers and institutions that shape the interactions of actors leading to complex adaptive system phenomena. CONCLUSIONS: As illustrated in this study, a complex adaptive system lens helps to uncover the 'real' drivers for change. This approach assists researchers and decision makers to systematically explore the driving forces and factors in each setting and develop appropriate and timely strategies to address them. The study calls for greater consideration of dynamics of vaccine acceptability while formulating immunization policies and program strategies. The analytical approaches adopted in this study are not only applicable to immunization or Kerala but to all complex interventions, health systems problems, and contexts.

Reducing neonatal mortality in Jhagadia Block, Gujarat: we need to go beyond promoting hospital deliveries.

BACKGROUND AND METHODS: We examined data from a cohort of births that occurred in the period 2004-08 in the SEWA-Rural project area, covering a population of ∼175000, in Gujarat, India, to assess the trends and risk factors for neonatal mortality. RESULTS: In this population living in 168 villages, there has been a significant declining trend in infant and neonatal mortality, more marked in the tribal population, in whom this paralleled a rise in the proportion of women delivering in hospitals. The more important risk factors for neonatal mortality risk to emerge from multivariate analysis are low birth weight, prematurity, young age of mother, older mother and high birth order. CONCLUSION: Although community based interventions along with promotion of hospital birth has an impact in reducing neonatal deaths in this community, sustaining this momentum may demand more long-term policy interventions to promote better living standards and better reproductive health.

Local government stewardship for TB elimination in Kerala, India.

SETTING: The southern Indian state of Kerala has implemented 'Kerala Tuberculosis Elimination Mission' as 'People's Movement against TB' under the stewardship of local governments (LGs). The state has been certified by the Government of India for being on track to attain the UN Sustainable Development Goals related to TB elimination. OBJECTIVE: To document the role of LG stewardship in the successful implementation of the TB elimination activities in Kerala. DESIGN: 1) Key informant interviews with four state officials, 2) desk review of available documents, 3) in-depth interviews with seven LG leaders, three mid-level programme managers and three health department field staff. RESULTS: LG involvement led to the establishment of solutions based on local problems, enhanced outreach of services to the socially vulnerable individuals, improved treatment support to patients with TB, increased community ownership of TB elimination activities, reduced TB-related stigma and social determinants being addressed. Institutional mechanisms such as LG TB elimination task forces, formal guidance in planning interventions and appreciation of their performance in the form of awards were facilitators for LG involvement. CONCLUSION: LG stewardship can accelerate TB elimination. A good plan for engagement and institutional mechanisms are crucial for LG involvement.

CONTEXTE: L'État du Kérala, situé dans le sud de l'Inde, a mis en place la « Kerala Tuberculosis Elimination Mission ¼ dans le cadre du « People's Movement Against TB ¼, sous l'égide des gouvernements locaux (LG). Le gouvernement indien a certifié que le Kérala était sur la bonne voie pour atteindre les objectifs de développement durable des Nations unies en matière d'élimination de la TB. OBJECTIF: Documenter le rôle de l'intendance des LG dans la bonne mise en œuvre des activités d'élimination de la TB au Kérala. MÉTHODES: 1) Entretiens avec des informateurs clés (quatre responsables gouvernementaux), 2) analyse des documents disponibles, 3) entretiens approfondis avec sept responsables de LG, trois responsables de programme de niveau intermédiaire et trois membres du personnel de terrain du département de la santé. RÉSULTATS: L'implication des LG a permis d'établir des solutions au vu des problèmes locaux, d'améliorer l'accès aux services pour les personnes socialement vulnérables, d'améliorer le soutien au traitement des patients atteints de TB, de renforcer l'appropriation par la communauté des activités d'élimination de la TB, de réduire la stigmatisation liée à la TB et d'agir sur les déterminants sociaux. Les mécanismes institutionnels, tels que les groupes de travail pour l'élimination de la TB mis en place par les LG, les conseils officiels reçus pour planifier les interventions et l'appréciation des performances sous forme de récompenses ont facilité l'implication des LG. CONCLUSION: L'intendance des LG peut permettre d'accélérer l'élimination de la TB. Une bonne planification de l'engagement et des mécanismes institutionnels sont essentiels à l'implication des LG.

Treatment in a Stroke Unit and Risk Factor Control Reduce Recurrent Stroke Risk.

INTRODUCTION: Risk factor control is an important predictor of risk of stroke recurrence. The attributable fraction which estimates the excess risk among the exposed stroke survivors has not been studied previously. We studied the attributable fraction for stroke recurrence in consecutive incident cases of recurrent stroke. METHODS: A case-control study with incident cases of recurrent stroke and controls matched for age and poststroke period was done. A structured interview was done to collect data on sociodemographic variables, lifestyle, and medication adherence. The risk factors, treatment of index stroke, and outcome were collected. Logistic regression analysis was done to find out the factors associated with stroke recurrence. Attributable fraction and average attributable fraction were calculated. RESULTS: Among the 103 matched pairs, more than 70% were rural residents. Male gender (OR 2.59; 95% CI 1.05-6.42), the presence of depression (OR 8.67; 95% CI 2.80-26.84), memory problem (OR 10.12; 95% CI 2.48-41.34), uncontrolled diabetes (OR 3.19; 95% CI 1.42-7.19), cardioembolic stroke (OR 4.45; 95% CI 1.12-17.62), and index stroke not being treated in a stroke unit (OR 6.60; 95% CI 2.86-15.23) were associated with increased risk of stroke recurrence. The maximum average attributable fraction for stroke recurrence risk was attributed to index stroke not being treated in the stroke unit and uncontrolled diabetes. CONCLUSION: The index stroke treated in a comprehensive stroke care unit and control of risk factors can reduce recurrent stroke risk among stroke survivors. This population-attributable risk is important in planning secondary stroke prevention strategies.

Consumption of fruits, vegetables and salt in the context of control of type 2 diabetes and hypertension in Kerala, India.

BACKGROUND: Proper diet is necessary to control hypertension and diabetes. This paper describes the combined fruit and vegetable, and salt intake of adults (>=18 years) who were detected to have hypertension or diabetes. METHODS: We analysed the data from a state-wide survey of 12012 adults using the World Health Organization STEPs for NCD risk factor surveillance. We evaluated the recommended intake of fruit and vegetable (>=5 servings/day) and salt (<5 gm/day) across participants divided into four strata, and the probabilities were also estimated using the fitted multiple binary logistic regression models. RESULTS: Overall, 13.9% (95%CI: 12.2%-15.9%) and 29.4% (95%CI: 28%-30.8%) of participants consumed the recommended level of fruit and vegetable, and salt, respectively. Adjusted odds ratios were not significantly different across the four strata based on the status of treatment and control of diabetes or hypertension. The likelihood of following the recommended fruit and vegetable intake was highest for 50-69-year-old females with above high school education, obese, under treatment for diabetes or hypertension, and had normal values of FBS and BP (0.28). The likelihood for recommended salt intake was highest for 50-69-year-old males with above high school education and had normal BMI, under treatment for diabetes or hypertension, and had normal values of FBS and BP (0.69). CONCLUSION: The status of diabetes or hypertension did not show considerable influence in the fruit, vegetable, and salt intake of adults in general. A detailed exploration of the accessibility and acceptability of such recommended intakes in the Kerala context is warranted.

The ethical responsibility of healthcare providers to advise patients with diabetes on lifestyle modifications.

There is clear evidence of a link between health and physical activity (PA). PA is universally prescribed as a primary treatment for most chronic diseases. However, studies show that not many health professionals advise patients about PA. The current study examines how a cost-effective tool to improve population health has been completely neglected in professional practice in a state with maximum healthcare availability. Is this malfeasance in practice or a violation of human rights? Are healthcare providers exempted from their responsibilities because they choose to neglect them? Who should be held responsible for the increasing disease-related deaths that are easily preventable? Keywords: physical activity, inactivity, advice, low- and middle-income country, health professionals, providers, chronic disease, diabetes, lifestyle modification, counselling.

Measuring childhood socioeconomic position in health research: Development and validation of childhood socioeconomic position questionnaire using mixed method approach.

Background: There is no single best indicator to assess the childhood socioeconomic position (CSEP) in public health research. The aim of the study is to develop and validate a new questionnaire, with adequate psychometric properties, to measure the childhood SEP of the young adults. Methods: The first phase consisted of a qualitative phase to identify the variables to measure childhood SEP through the in-depth interviews among 15 young adults (18-45 years) of rural Kerala. The second phase was a quantitative phase to validate the questionnaire through a cross sectional survey among 200 young adults of Kerala. We did content validity, reliability tests and construct validity by using exploratory factor analysis of the questionnaire to demonstrate its psychometric properties. Results: The qualitative analysis reported 26 variables spread across 5 domains to measure the CSEP. Finally, the questionnaire has 11 questions with 3 domains named as value added through paternity, maternal occupation-related factors and parental education. The questionnaire has good reliability (Cronbach's α=0.88) also. Conclusion: We have developed a reliable and valid questionnaire to measure the childhood SEP of younger adults and can be used in various public health research.

Spatial Clusters of Diabetes and Physical Inactivity: Do Neighborhood Characteristics in High and Low Clusters Differ?

This study aims to find spatial clusters of diabetes and physical inactivity among a sample population in Kerala, India, and evaluate built environment characteristics within the high and low spatial clusters. Spatial clusters with a higher and lower likelihood of diabetes and physical inactivity were identified using spatial scan statistic at various radii. Built environment characteristics were captured at panchayat level and 1600 m buffer around participant location using Geographical Information Systems. Comparison of sociodemographic and built environment factors was carried out for participants within high and low spatial clusters using t tests. Ten high and 8 low spatial clusters of diabetes and 17 high and 23 low spatial clusters of physical inactivity were identified in urban and rural areas of Kerala. Significant differences in built environment characteristics were consistent for low spatial clusters of diabetes and physical inactivity in the urban scenario. Built environment characteristics were found to be relevant in both urban and rural areas of Kerala. There is an urgent call to explore spatial clustering of non-communicable diseases in Kerala and undo the one-size-fits-all approach for prevention and control of non-communicable diseases.

Gender differences in the relationship between built environment and non-communicable diseases: A systematic review.

Non-communicable diseases are on the rise globally. Risk factors of non-communicable diseases continue to be a growing concern in both developed and developing countries. With significant rise in population and establishment of buildings, rapid changes have taken place in the built environment. Relationship between health and place, particularly with non-communicable diseases has been established in previous literature. This systematic review assesses the current evidence on influence of gender in the relationship between built environment and non-communicable diseases. A systematic literature search using PubMed was done to identify all studies that reported relationship between gender and built environment. All titles and abstracts were scrutinised to include only articles based on risk factors, prevention, treatment and outcome of non-communicable diseases. The Gender Analysis Matrix developed by the World Health Organization was used to describe the findings of gender differences. Sex differences, biological susceptibility, gender norms/ values, roles and activities related to gender and access to/control over resources were themes for the differences in the relationship. A total of 15 out of 214 articles met the inclusion criteria. Majority of the studies were on risk factors of non-communicable diseases, particularly cardiovascular diseases. Gender differences in physical access to recreational facilities, neighbourhood perceptions of safety and walkability have been documented. Men and women showed differential preferences to walking, engaging in physical activity and in perceiving safety of the neighbourhood. Girls and boys showed differences in play activities at school and in their own neighbourhood environment. Safety from crime and safety from traffic were also perceived important to engage in physical activity. Gender norms and gender roles and activities have shown basis for the differences in the prevalence of non-communicable diseases. Sparse evidence was found on how built environment affects health seeking behaviour, preventive options or experience with health providers. Though yet unexplored in the developing or low/middle income countries, there seems to be a major role in the gendered perception of how men and women are affected by noncommunicable diseases. Large gaps still exist in the research evidence on gender-based differences in non-communicable diseases and built environment relationship. Future research directions could bring out underpinnings of how perceived and objective built environment could largely affect the health behaviour of men and women across the globe.

Safe delivery care practices in western Nepal: Does women's autonomy influence the utilization of skilled care at birth?

Despite various efforts to increase the utilization of skilled birth attendants (SBA), nearly two-thirds of deliveries take place at home without the assistance of SBAs in Nepal. We hypothesized that the ability of women to take decisions about their own lives-women's autonomy-plays an important part in birth choices. To know this, we conducted a community-based cross-sectional study for assessing women's autonomy and utilization of safe delivery care service in Kapilvastu district of Nepal from June to October 2014. We used multivariate modeling to associate socioeconomic factors and women's autonomy with the utilization of safe delivery care services. Just over one-third of women sought institutional delivery care during the birth of their last child. Out of the total deliveries at health facilities, nearly 58% women visited health facility for self-reported emergency obstructive care. Only 6.2% home deliveries were handled by health workers and 14.7% women used the safe delivery kit for home delivery care. Higher levels of women's education had a strong positive association (odds ratio = 24.11, CI = 9.43-61.64) with institutional delivery care. Stratified analysis showed that when the husband is educated, women's education seems to work partly through their autonomy in decision making. Educational status of women emerged as one of the key predictors of the utilization of delivery care services in Kapilvastu district. Economic status of household and husband's education are other dominant predictors of the utilization of safe delivery care services. Improving the economic and educational status may be the way out for improving the proportion of institutional deliveries. Women's autonomy may be an important mediating factor in this pathway.

Risk Factors for Fall-Related Injuries Leading to Hospitalization Among Community-Dwelling Older Persons: A Hospital-Based Case-Control Study in Thiruvananthapuram, Kerala, India.

This study intended to identify the risk factors for injurious falls that led to hospitalization of older persons living in the community. A hospital-based unmatched incident case-control study was done among 251 cases and 250 controls admitted at a tertiary care centre in Kerala. Mean age of cases was 71.6 ± 9.13 years and that of controls was 67.02 ± 6.17 years. Hip fractures were the predominant injury following falls. Falls were mostly a result of intrinsic causes. After adjusting for other variabes, the risk factors for all injuries were age above 70 years (odds ratio [OR] = 2.25; 95% confidence interval [CI] = 1.46-3.46), previous fall history (OR = 2.76; 95% CI = 1.08-7.08), impaired vision (OR = 4.49; 95% CI = 2.77-7.30), not living with spouse (OR = 1.97; 95% CI = 1.31-2.97), door thresholds (OR = 1.52; 95% CI = 1.01-2.29), and slippery floor (OR = 2.37; 95% CI = 1.31-4.32). The risk factors for hip fractures and other injuries were identified separately. Fall prevention strategies among older persons are warranted in Kerala.

Validation of the Malayalam version of the Internalized Stigma of Mental Illness (ISMI) scale.

Little is known about internalized stigma of mental illness in India. A reason for this could be the lack of valid assessment instruments adapted for the diverse cultures and languages of the country. One of the most widely used and accepted questionnaires to assess internalized stigma is the 29-item Internalized Stigma of Mental Illness (ISMI) scale. The aim of the present study was to translate and adapt the ISMI to the Malayalam-speaking population of Kerala, India and to assess its content and factorial validity. The content validity of the Malayalam-language ISMI was studied through interviews with 7 experts on stigma in India. Factorial validity was examined by means of a confirmatory factor analysis (CFA) based on a cross-sectional survey among 290 patients with mental illness attending follow-up outpatient and primary care clinics in Kerala, India. The expert panel concluded that the items of the translated questionnaire adequately represent internalized stigma in the Malayalam-speaking population of Kerala. The theorized factor structure of the ISMI consisting of five factors showed a suboptimal model fit (WRMR=0.940; TLI=0.971, CFI=0.948; RMSEA=0.059) which improved considerably after removal of the stigma resistance factor and three items with poor factor loadings (WRMR=0.819; TLI=0.982, CFI=0.966; RMSEA=0.051). Although our study identifies some sources of model ill-fit, it shows that a reduced version of the Malayalam-language ISMI can be a valuable tool for the study of internalized stigma in this cultural setting.