Browsing by Author "Kutty, VR"

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    Advancing the application of systems thinking in health: understanding the growing complexity governing immunization services in Kerala, India
    (Health Res Policy Syst, 2014-12) Varghese, J; Kutty, VR; Paina, L; Adam, T
    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.
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    Assessment of Internalized Stigma Among Patients With Mental Disorders in Thiruvananthapuram District, Kerala, India
    (Asia Pac J Public Health, 2014-12) James, TT; Kutty, VR
    This study aims to compare the prevalence of high internalized stigma of mental illness among patients attending community-based and psychiatric hospital-based care in Thiruvananthapuram district, Kerala, India and to examine the factors associated with high internalized stigma. A cross-sectional survey was conducted among 290 patients, mean age 45 years, 38.2% and 61.8% female. A Malayalam version of the Internalized Stigma of Mental Illness inventory was used for assessing internalized stigma. A multistage random sampling method was adopted. The prevalence of high internalized stigma was higher among patients from community-based care (44.7%) as compared with those from psychiatric hospital-based care (34.1%). Apart from treatment in community-based care, age ≤45 years, unemployment, absence of long-term friendships, no hope of cure with medication, presence of other illnesses, and substance use were significantly associated with high internalized stigma. More than one third of the subjects had high internalized stigma.
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    Barriers to Immunization Among Children of HIV-Infected Mothers in Kolkata, India: A Qualitative Study
    (ASIA-PACIFIC JOURNAL OF PUBLIC HEALTH, 2015) Sensarma, P; Bhandari, S; Kutty, VR
    More than one fourth of children of HIV-infected mothers living in Kolkata city are not completely immunized by 12 months of age. This qualitative study aims to explore the barriers to immunization of these children as perceived by their caregivers and the local health care service providers. In-depth interviews were conducted after obtaining written informed consent. Audio recording and hand-recorded notes were used with permission. The transcripts were coded and analyzed using grounded theory. Deteriorating socioeconomic status, tightening of time schedule of caregivers due to illness in the family, stigma, discrimination, and lack of awareness about immunization prove to be major barriers for immunization of the HIV-exposed children. Interplay of these factors coupled with harassment and negative attitudes of service providers toward HIV-affected/HIV-infected people also impede immunization. The intervention efforts need to address these social barriers and adverse life events to improve immunization coverage.
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    Chnaging epidemiology of maternal mortality in rural India: time to reset strategies for MDG-5.
    (Tropical Medicine and International Health. 2014; 19:568-575, 2014-03) Shah, P; Shah, S; Kutty, VR; Modi, D
    Objective To understand changes in epidemiology of maternal mortality in rural India in the context of increasing institutional deliveries and implementation of community-based interventions that can inform policies to reach MDG-5. Methods This study is a secondary analysis of prospectively collected community-based data of every pregnancy and its outcomes from 2002 to 2011 in a rural, tribal area of Gujarat, India as part of safe-motherhood programme implemented by voluntary organisation, SEWA Rural. The programme consisted of community-based interventions supported by a first referral unit, and promotion of institutional deliveries. For every maternal death, a verbal autopsy was conducted. The incidence rates for maternal mortality according to place, cause and timing of maternal deaths in relation to pregnancy were computed. Annual incidence rate ratios (IRR) and 95% confidence intervals, adjusted for caste and maternal education, were estimated using Poisson regression to test for linear trend in reduction in mortality during the study period. Results Thirty-two thousand eight hundred and ninety-three pregnancies, 29 817 live births and 80 maternal deaths were recorded. Maternal mortality ratio improved from 607 (19 deaths) in 2002–2003 to 161 (five deaths) in 2010–2011. The institutional delivery rate increased from 23% to 65%. The trend of falling maternal deaths was significant over time, with an annual reduction of 17% (adjusted IRR 0.83 CI 0.75–0.91, P-value <0.001). There were significant reductions in adjusted incidence rate of maternal deaths due to direct causes, during intrapartum and post-partum periods, and those which occurred at home. However, reductions in incidence of maternal deaths due to indirect causes, at hospital and during antepartum period were not statistically significant. Most maternal deaths are now occurring at hospitals and due to indirect causes. Conclusion Gains in institutional deliveries and community-based interventions resulting in fewer maternal deaths due to direct causes should be maintained. However, it would be essential to now prioritise management of indirect causes of maternal mortality during pregnancy at community and hospitals for further reduction in maternal deaths to achieve MDG-5.
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    Construction and Validation of a Women's Autonomy Measurement Scale with Reference to Utilization of Maternal Health Care Services in Nepal
    (JOURNAL OF NEPAL MEDICAL ASSOCIATION, 2014) Bhandari, TR; Dangal, G; Sarma, PS; Kutty, VR
    Introduction: Women's autonomy is one of the predictors of maternal health care service utilization. This study aimed to construct and validate a scale for measuring women's autonomy with relevance to developing countries. Methods: We conducted a study for construction and validation of a scale in Rupandehi and further validated in Kapilvastu districts of Nepal. Initially, we administered a 24-item preliminary scale and finalized a 23-item scale using psychometric tests. After defining the construct of women's autonomy, we pooled 194 items and selected 24 items to develop a preliminary scale. The scale development process followed different steps i.e. definition of construct, generation of items pool, pretesting, analysis of psychometric test and further validation. Results: The new scale was strongly supported by Cronbach's Alpha value (0.84), test-retest Pearson correlation (0.87), average content validity ratio (0.8) and overall agreement-Kappa value of the items (0.83) whereas all values were found satisfactory. From factor analysis, we selected 23 items for the final scale which show good convergent and discriminant validity. From preliminary draft, we removed one item; the remaining 23 items were loaded in five factors. All five factors had single loading items by suppressing absolute coefficient value less than 0.45 and average coefficient was more than 0.60 of each factor. Similarly, the factors and loaded items had good convergent and discriminant validity which further showed strong measurement capacity of the scale. Conclusions: The new scale is a reliable tool for assessing women's autonomy in developing countries. We recommend for further use and validation of the scale for ensuring the measurement capacity.
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    Determinants of positive mental health: a path model
    (Mental Health Review Journal., 2014-12) Ganga, NS; Kutty, VR; Thomas, I
    Purpose – A public health approach for promoting mental health has become a major health policy agenda of many governments. Despite this worldwide attention on research addressing population mental health and general wellbeing, very little is heard on positive mental health from the low-and middle-income countries. This paper aims to present an attempt to develop a model of positive mental health among young people. This could be used for integrating the concept of positive mental health (PMH) into public health interventions. Design/methodology/approach – The study was conducted in the state of Kerala, India. The paper administered the “Achutha Menon Centre Positive Mental health Scale” to a sample of 453 (230 men and 223 women) in the age group 18-24, along with an interview schedule exploring the relationship of PMH with many explanatory variables such as sex, beliefs, religion, education, employment and social capital. The paper developed an input path model through a series of multiple regressions explaining the levels of PMH in the community, which was then tested statistically (using AMOS version 7.0). The input model was created by identifying the determinants and correlates of PMH based on their predictive power on the outcome variable, the PMH score. The input diagram was used to test the model fit of the data. Findings – The path model (Figure 1) clearly specified the determinants of PMH. Among them, the variables that have a direct determinant effect on PMH are: quality of home learning environment, employment status, education status, marital status, self-perception on possession of skills, happiness with life, membership in social organizations and socializing capability. Research limitations/implications – In this study, path model is used to confirm relationships among observed and latent variables. The path diagram assesses the comparative strength of the correlations between the variables and does not test the directionality. Or, the model itself cannot prove causation. Practical implications – Determinants of PMH those are amenable to interventions as well as those which help in recognizing characteristic groups for intervention could help to plan future intervention programs. Originality/value – Original paper based on primary data collected through a cross-sectional survey.
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    Elevated serum levels of 25-hydroxyvitamin D-3 in outdoor workers of South India
    (CURRENT SCIENCE, 1999) Rajasree, S; Kutty, VR; Sreenivasan, K; Kartha, CC
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    Excess Mortality Associated With Hypopituitarism in Adults: A Meta-Analysis of Observational Studies
    (JOURNAL OF CLINICAL ENDOCRINOLOGY & METABOLISM, 2015) Pappachan, JM; Raskauskiene, D; Kutty, VR; Clayton, RN
    Context: Several previous observational studies showed an association between hypopituitarism and excess mortality. Reports on reduction of standard mortality ratio (SMR) with GH replacement have been published recently. Objective: This meta-analysis assessed studies reporting SMR to clarify mortality risk in hypopituitary adults and also the potential benefit conferred by GH replacement. Data Sources: A literature search was performed in Medline, Embase, and Cochrane library up to March 31, 2014. Eligibility Criteria: Studies with or without GH replacement reporting SMR with 95% confidence intervals (95% CI) were included. Data Extraction and Analysis: Patient characteristics, SMR data, and treatment outcomes were independently assessed by two authors, and with consensus from third author, studies were selected for analysis. Meta-analysis was performed in all studies together, and those without and with GH replacement separately, using the statistical package metafor in R. Results: Six studies reporting a total of 19 153 hypopituiatary adults with a follow-up duration of more than 99 000 person years were analyzed. Hypopituitarism was associated with an overall excess mortality (weighted SMR, 1.99; 95% CI, 1.21-2.76) in adults. Female hypopituitary adults showed higher SMR compared with males (2.53 vs 1.71). Onset of hypopituitarism at a younger age was associated with higher SMR. GH replacement improved the mortality risk in hypopituitary adults that is comparable to the background population (SMR with GH replacement, 1.15; 95% CI, 1.05-1.24 vs SMR without GH, 2.40; 95% CI, 1.46-3.34). GH replacement conferred lower mortality benefit in hypopituitary women compared with men (SMR, 1.57; 95% CI, 1.38-1.77 vs 0.95; 95% CI, 0.85-1.06). Limitations: There was a potential selection bias of benefit of GH replacement from a post-marketing data necessitating further evidence from long-term randomized controlled trials. Conclusions: Hypopituitarism may increase premature mortality in adults. Mortality benefit from GH replacement in hypopituitarism is less pronounced in women than men.
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    Falls among Older Adults: A Community-Based Study in Rural Kerala, India
    (Global Journal of Health Science., 2017-11) Rekha, MR; Mini, GK; Kutty, VR
    The study examined the frequency and correlates of falls among community dwelling older adults (≥60 years) in rural Kerala. We did a cross-sectional survey among 202 older adults using a pre-tested structured interview schedule. Falls in the previous year was reported by 27%, among them, 20% fell more than once making a total of 74 falls. Injuries were reported among 58% of the fallers. Slips were the frequent cause of fall (25.6%). Most falls happened outdoors (77%). Age-sex adjusted results of multivariate logistic regression analysis showed that those having any morbidity, those with a history of previous falls and those with no formal education were more likely to fall compared to their counterparts. Awareness programs on the risk of falls for older adults and their close relatives are required in this population. Prevention strategies should focus on those having any morbidity, those with a history of previous falls and those without formal education.
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    Geographical distribution of endomyocardial fibrosis in south Kerala
    (INTERNATIONAL JOURNAL OF EPIDEMIOLOGY, 1996)
    Background. Endomyocardial fibrosis (EMF) is a chronic heart disease confined to a few geographically specific locations within 15 degrees of the equator. Several aetiological hypotheses exist, among them filarial infection, eosinophilia, and toxic effect of the monazite element cerium from the soil. This study attempts to find out whether the pattern of distribution of EMF in south Kerala in India is consistent with the geochemical hypothesis.Methods. From hospital records we identified all patients from south Kerala who had a confirmed diagnosis of EMF during the period 1978-1994, Our controls were patients from the southern districts diagnosed to have rheumatic heart disease (RHD) during the same period. We traced their residence address to the administrative subunit of taluk, and plotted the distribution of patients with EMF and RHD for each taluk in south Kerala. The taluks were then grouped into areas of high (>4/100 000), medium (2.01-4/100 000), and low (less than or equal to 2/100 000) density in each case.Results. We identified an area of high density of EMF comprising four taluks near the coastline situated within the dis districts of Alapuzha, Kollam, and Pathanamthitta. Two coastal taluks in Kollam and Alapuzha districts are known areas of deposits of monazite elements in the state. Geographical distribution is not related to prevalence of filariasis and eosinophilia.Conclusion. Coexistence of high density of occurrence of EMF and deposits of monazite elements support the geo chemical hypothesis.
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    Health care utilization surveys: What do they tell us?
    (NATIONAL MEDICAL JOURNAL OF INDIA, 1996) Kutty, VR
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    INFLUENCE OF GENDER ON POSITIVE MENTAL HEALTH OF YOUNG PEOPLE IN KERALA
    (JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH, 2011) Mathew, S; Kutty, VR
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    Measuring Positive Mental Health: Development of the Achutha Menon Centre Positive Mental Health Scale
    (ASIA-PACIFIC JOURNAL OF PUBLIC HEALTH, 2015) Ganga, NS; Kutty, VR
    The authors developed a scale for positive mental health (PMH), which encompasses positive state of mind and positive functioning. The existing tools are inadequate to measure the construct, especially in a community where the self-statement format of a scale is difficult to internalize. The authors constructed a tool from an initial item pool with the help of experts and validated it in a sample of 326 young people in the state of Kerala, India. Factor analysis gave 4 underlying factors for the construct of PMH. The scale (mean = 67.41 +/- 9.49) has Cronbach's a value of .76 and test-retest correlation of .84. Convergent validity with the PMH Inventory is .864; discriminant validity with the Mental Health Inventory is .422. The findings prove that the scale, named the Achutha Menon Centre Positive Mental Health Scale, is reliable and valid and can be used in both individual-and population-based studies for measuring PMH.
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    On transfusion medicine
    (CURRENT SCIENCE, 1996) Mathai, J; Kutty, VR
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    Pattern of cardiac fibrosis in rabbits periodically fed a magnesium-restricted diet and administered rare earth chloride through drinking water
    (BIOLOGICAL TRACE ELEMENT RESEARCH, 1998)
    It has been postulated that causation of the tropical cardiomyopathy endomyocardial fibrosis (EMF) is linked to magnesium (Mg) deficiency and cardiac toxicity of the rare earth element cerium (Ce). The aim of the present study was to define the myocardial lesions in rabbits that were fed on Mg-restricted diet (70-80 ppm) periodically and were provided drinking water contaminated with rare earth chloride (1 g/L). Forty New Zealand white rabbits were divided into four groups following a 2 x 2 factorial design. Two groups were periodically fed on Mg-restricted diet with one of them receiving water contaminated with rare earth chloride. The other two groups were continuously fed on Mg-sufficient diet (350-400 ppm) with one of them receiving water contaminated with rare earth chloride. AU animals were sacrificed at the end of 6 mo. Cardiac tissues were subjected to histology, elemental analysis (calcium [Ca], Mg, and Ce) and estimation of collagen content and collagen phenotypes. Histological lesions were compared with those of EMF in humans and those of acute Mg deficiency in animals. The results suggest that in rabbits, recurrent episodes of Mg deficiency lead to myocardial fibrosis similar to the pattern observed in human EMF.
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    Plasma level of cyclophilin A is increased in patients with type 2 diabetes mellitus and suggests presence of vascualr disease.
    (Cardiovascular Diabetology. 2014;13:, 2014-03) Ramachandran, S; Venugopal, A; Kutty, VR; Vinitha, A; Divya, G; Chitrasree, C; Mullassari, A; Pratapchandran, NS; Santosh, KR; Pillai, MR; Kartha, CC
    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.
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    Plasma level of cyclophilin A is increased in patients with type 2 diabetes mellitus and suggests presence of vascualr disease.
    (Cardiovascular Diabetology., 2014-03) Ramachandran, S; Venugopal, A; Kutty, VR; Vinitha, A; Divya, G; Chitrasree, C; Mullassari, A; Pratapchandran, NS; Santosh, KR; Pillai, MR; Kartha, CC
    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.
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    Plasma level of cyclophilin A is increased in patients with type 2 diabetes mellitus and suggests presence of vascular disease
    (CARDIOVASCULAR DIABETOLOGY, 2014) Ramachandran, S; Venugopal, A; Kutty, VR; Vinitha, A; Divya, G; Chitrasree, V; Mullassari, A; Pratapchandran, NS; Santosh, KR; Pillai, MR; Kartha, CC
    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.