ABSTRACT
Context:
Noncommunicable diseases (NCDs) kill 41 million people each year globally. The financial burden of NCDs, including lifelong and expensive treatment with loss of income, forces many people into poverty. Healthcare workers (HCWs) are an essential group of the workforce in building a healthier society. They must choose a healthy lifestyle to have better health for themselves.
Aim:
To estimate the prevalence of self-reported NCDs in grassroot-level HCWs of Petlad taluka along with the study of various healthcare and lifestyle practices among them
Methods and Material:
In this cross-sectional study, grassroot-level HCWs of Petlad taluka of Anand district were given a self-administered questionnaire, which included their demographic details, their current health status, and health practices followed by them
Statistical Analysis:
The data collected were entered in Microsoft Excel-2019 and analysed by SPSS version 15. Descriptive analysis and univariate analysis were performed.
Results:
NCDs’ prevalence was 10.2%. Hypertension and diabetes were the commonest. Nearly 50% HCWs have their body mass index in a normal range. The majority of them were aware of healthy diet practices and exercise.
Conclusions:
Our study reported a lower prevalence of NCDs than other studies (50%). Dietary practices appear to be healthy, but a significant proportion of them are overweight. The majority of them prefer to consult at a government hospital. Healthy behaviour and practices should be encouraged and maintained in HCWs.
Keywords: Gujarat, health practices of health workers, lifestyle of health workers, NCD in health workers, STEPwise approach for NCDs
Introduction
Noncommunicable diseases (NCDs) are important causes of morbidity and mortality worldwide. According to the WHO factsheet, NCDs kill 41 million people worldwide annually, equivalent to 71% of all deaths globally.[1] Every year, more than 15 million people die from NCDs between the ages of 30 and 69 years, which is an economically and socially productive age group.[1] Eighty-five percent of these “premature” deaths are seen in low- and middle-income countries. The gradual increase in NCDs in these countries is due to urbanization, sedentary lifestyles, and the increased availability of nutrient-poor processed foods along with various addictions.
Among deaths caused by NCDs, cardiovascular diseases account for most deaths (17.9 million), followed by cancers (9.3 million), respiratory diseases (4.1 million), and diabetes (1.5 million).[1] These four groups of diseases are responsible for over 80% of all premature NCD deaths.[1]
Sustainable development goals for NCDs include a target of reducing premature deaths from NCDs by one-third by 2030.[2] In low-income countries, healthcare costs for NCDs drain household resources. The costs of NCDs, including treatment which is often lengthy and expensive, combined with a loss of income, force millions of people into poverty annually and impair economic development.
Healthcare providers are an essential and diverse group of the workforce that devote most of their time to build a healthier society. Based on their knowledge and training, we can assume that they make healthy lifestyle choices and have better health compared with others. It is also expected that the prevalence of NCDs and their risk factors would be relatively low among them.
A study conducted by Binod K. Behera et al.[3] stated that more than half of the healthcare workers (HCWs) at the grassroot level have some form of chronic disease. Moreover, their nutritional status and knowledge about healthy diets are poor among them.
Mithila Faruque et al.[4] in a study conducted Bangladesh stated that about 87% of the health professionals were physically inactive, which was about twice the national rate (45.7%) of work-related physical inactivity.
In a cross-sectional study by Sobrino et al.,[5] conducted in Spain, it was observed that the prevalence of masked hypertension was observed 23.9%. The most prevalent cardiovascular risk factor in the total population was smoking (24.9%).
In recent years, much has been studied about patients’ well-being and quality of treatment, but less has been studied on the well-being of HCWs who offer comprehensive health care to patients. Also, it is necessary to know that what we are expecting that community will do, are we setting example for the same or not. Working as a clinician or public health experts, we should be aware that those who work in the field at the grassroot level are true inspiration for community. If they are practicing high risk behaviour or having ignorance, community awareness and participation becomes difficult to achieve.
Objective
This study was conducted to estimate the prevalence of NCDs in grassroot-level health workers including Accredited Social Health Activists (ASHAs), Female Health Workers (FHWs), and Multi-Purpose Health Workers (MPHWs) along with the study of various healthcare and lifestyle practices followed by them.
Methodology
Study type
The present study is a descriptive cross-sectional study.
Study area
The study was conducted in Petlad taluka of Anand district in Gujarat state. Petlad is one of the eight talukas of the Anand district. The population of Petlad taluka is 2.97 lakhs, among which 1.21 lacs are male and 1.11 lacs are female.[6]
Study period
The study was conducted in March 2022.
Ethical approval
Ethical approval was taken from Institutional Ethics Committee, following which permission was obtained from the Taluka Health Officer of Petlad district.
Inclusion criteria
The study included all ASHAs, FHWs, and MPHWs working in Petlad Taluka.
Sample size
A sample size of 319 was obtained by the complete enumeration method [237 ASHAs (227 rural and 10 urban) + 39 MPHWs (36 rural and 3 urban) + 43 FHWs (37 rural and 6 urban)].
Subsequently, informed written consent was taken and data was collected from ASHAs, MPHWs, and FHWs by self-administered questionnaires.
A questionnaire was designed using STEPwise Approach to NCD Risk Factor Surveillance,[7] an instrument developed by WHO as a reference document and was modified appropriately and translated into the Gujarati language. It was validated in Gujarati by three public health professionals and two medical social workers. The first part of the questionnaire had demographic details, while the second part contained information regarding addiction, comorbidity, treatment status, and regular check-ups for comorbidities. Comorbidities included in the studies were diabetes, hypertension, ischemic heart disease, hypo/hyperthyroidism, cancer, and mental disorders. In the third part, details were asked regarding dietary and lifestyle practices. Data entry was done in M.S. Excel 2019, and analysis was done using SPSS software.
Results
Out of total 270 female health workers (ASHAs & FHWs) 261 (96.66%) and from 36 MPHWs 24 (66.66%) MPHWs gave informed written consent. Demographic details of study participants are depicted in Table 1. NCD prevalence was found to be 10.2%. Diabetes and hypertension are the commonest. The majority of them take regular medications.
Table 1.
Socio-demographic and health profile of participants
| Characteristic | Male (n=24) | Female (n=261) | Total (n=285) |
|---|---|---|---|
| Age | 34.79±6.75 | 39.30±8.75 | 38.92±8.68 |
| Marital status | 23 (95.8%) | 232 (88.9%) | 255 (89.5%) |
| Married | 0 | 17 (6.5%) | 17 (6%) |
| Unmarried | 0 | 7 (2.7%) | 7 (2.5%) |
| Widow | 1 (4.2%) | 5 (1.9%) | 6 (2%) |
| Divorced | 7 (29.2%) | 224 (85.8%) | 231 (81.1%) |
| Education | |||
| ≤12th std. | 17 (70.8%) | 37 (14.2%) | 54 (18.9%) |
| >12th std. | 1 (4.2%) | 116 (44.4%) | 117 (41.1%) |
| Monthly income | |||
| <10,000 INR | 17 (70.8%) | 129 (49.5%) | 146 (51.2%) |
| 10,000-50,000 INR | 6 (25%) | 16 (6.1%) | 22 (7.7%) |
| >50,000 INR | 0 | 43 (16.5%) | 43 (15.1%) |
| BMI group (BMI value) | |||
| Undernourished (<18.5) | 12 (50%) | 138 (52.9%) | 150 (52.6%) |
| Normal (18.5-24.9) | 10 (41.7%) | 62 (23.8%) | 72 (25.3%) |
| Over weight (25-29.9) | 2 (8.3%) | 18 (6.8%) | 20 (7%) |
| Obese (>30) | 2 (8.3%) | 27 (10.3%) | 29 (10.2%) |
| Presence of any co-morbidity | |||
| Present | 22 (91.7%) | 234 (89.7%) | 256 (89.8%) |
| Absent | 0 | 8 (29.62%) | 8 (27.58%) |
| Co-morbidity (n=2 for male; n=27 for female) | |||
| Hypertension | |||
| Diabetes | |||
| Hypertension & Diabetes | 0 | 4 (14.81%) | 4 (13.79%) |
| Ischemic heart disease | 0 | 5 (18.52%) | 5 (17.25%) |
| Cancer | 1 (50%) | 0 | 1 (3.44%) |
| Thyroid disorders | 0 | 0 | 0 |
| Other | 0 | 4 (14.82%) | 4 (13.80%) |
| Duration since diagnosis of comorbidity (n=2 for male; n=27 for female) | |||
| <5 years | 1 (50%) | 6 (22.23%) | 7 (24.14%) |
| >5 years | 2 (100%) | 26 (96.30%) | 28 (96.55%) |
| Treatment status (n=2 for male; n=27 for female) | 0 | 1 (3.70%) | 1 (3.45%) |
| Not on treatment | 0 | 1 (3.70%) | 1 (3.44%) |
| Takes treatment irregularly | |||
| Takes regular treatment | 0 | 5 (18.52%) | 5 (17.25%) |
| Alternate medicine (Homeopathic/Ayurvedic medicine) | 2 (100%) | 21 (77.78%) | 23 (79.31%) |
| Uses alternate medicines | 1 (4.2%) | 27 (10.3%) | 28 (9.82%) |
| Do not use alternate medicine | 23 (95.8%) | 234 (89.7%) | 257 (90.18%) |
Table 2 shows a variety of health practices followed by HCWs and compares these practices in diseased and nondiseased workers. It is observed that HCWs are more aware of regular checkups of blood pressure and blood sugar but not of thyroid profile. On evaluating their dietary history, good dietary practices like consumption of green leafy vegetables and fruits for more than 3 days per week are observed in 78.6 and 53%, respectively, while poor dietary practices like consumption of fried or packaged food for less than 3 days per week and outside food consumption is seen for less than 3 days in 73% and 94% HCWs, respectively. More than 50% of HCWs were doing physical exercise regularly. The majority of diseased and nondiseased HCWs are aware of restricted salt intake in the routine diet, but on the other side, intake of papad/pickle is observed more in nondiseased individuals on a daily basis. Even in diseased individuals, who were aware of salt restriction, intake of papad and pickle is nearly 50%. Diseased individuals have more habit of taking family members to government hospitals than nondiseased, which may be due to more knowledge of services provided by a government hospital in diseased individuals than nondiseased. Nondiseased individuals are more habituated to trying out home remedies first before taking family members to the hospital. None of the HCWs choose the option of going to the temple for taking badha or going to quacks as an exclusive option for the treatment of their family members. Forty-four percent of HCWs still do not possess any type of health insurance.
Table 2.
Comparison of health practices in diseased vs. non-diseased participants
| Habits | Diseased (n=29) | Non-diseased (n=256) | Total (n=285) | P |
|---|---|---|---|---|
| Regular check-up of blood pressure in last 1 year | ||||
| Yes | 28 (96.6%) | 207 (80.9%) | 235 (82.5%) | 0.035* |
| No | 1 (3.4%) | 49 (19.1%) | 50 (17.5%) | |
| Regular check-up of blood sugar in last 1 year | ||||
| Yes | 24 (82.8%) | 207 (80.9%) | 231 (81.1%) | 0.805 |
| No | 5 (17.2%) | 49 (19.1%) | 54 (18.9%) | |
| Regular check-up of thyroid profile in last 1 year | 11 (37.9%) | 152 (59.4%) | 114 (40.4%) | 0.283 |
| Yes | 18 (62.1%) | 104 (40.6%) | 170 (59.6%) | |
| No | ||||
| Green leafy vegetables intake in last 1 week | ||||
| <3 days | 7 (24.2%) | 54 (21.1%) | 61 (21.4%) | 0.863 |
| 3-5 days | 13 (44.8%) | 128 (50%) | 141 (49.5%) | |
| >5 days | 9 (31%) | 74 (28.9%) | 83 (29.1%) | |
| Fruit intake in last 1 week | ||||
| <3 days | 13 (44.8%) | 121 (47.3%) | 134 (47%) | 0.696 |
| 3-5 days | 13 (44.8%) | 97 (37.9%) | 110 (38.6%) | |
| >5 days | 3 (10.4%) | 38 (14.8%) | 41 (14.4%) | |
| Fried/packaged food intake in last 1 week | ||||
| <3 days | 21 (72.4%) | 188 (73.4%) | 209 (73.3%) | 0.982 |
| 3-5 days | 5 (17.3%) | 44 (17.2%) | 49 (17.2%) | |
| >5 days | 3 (10.3%) | 24 (9.4%) | 27 (9.5%) | |
| Outside food intake in last 1 month | ||||
| <3 times | 21 (72.4%) | 247 (96.5%) | 268 (94.03%) | 0.893 |
| 3-5 times | 5 (17.3%) | 8 (3.1%) | 13 (4.56%) | |
| >5 times | 3 (10.3%) | 1 (0.4%) | 4 (1.4%) | |
| Days of exercise per week | ||||
| <3 days | 7 (24.1%) | 76 (29.7%) | 83 (29.1%) | 0.823 |
| 3-5 days | 8 (27.6%) | 65 (25.4%) | 73 (25.6%) | |
| >5 days | 14 (48.3%) | 115 (44.9%) | 129 (45.3%) | |
| History of additional salt to the diet | ||||
| No | 22 (75.9%) | 197 (77%) | 219 (76.8%) | 0.912 |
| Yes, daily | 4 (13.8%) | 29 (11.3%) | 33 (11.6%) | |
| Yes, sometimes | 3 (10.3%) | 30 (11.7%) | 33 (11.6%) | |
| History of intake of pickle/Papad in diet | 15 (51.7%) | 86 (33.5%) | 101 (35.4%) | 0.248 |
| No | 8 (27.6%) | 111 (43.4%) | 119 (41.8%) | |
| Yes, daily | 6 (20.7%) | 59 (23.1%) | 65 (22.9%) | |
| Yes, sometimes | ||||
| Possession of any type of health Mediclaim or cards | ||||
| Yes | 17 (58.6%) | 143 (55.9%) | 160 (56.1%) | 0.776 |
| No | 12 (41.4%) | 113 (44.1%) | 125 (43.9%) | |
| Attitude towards illness in family | 18 (62.1%) | 133 (52%) | 151 (53%) | 0.318 |
| Taken to nearby Gov hospital | 6 (20.7%) | 48 (18.7%) | 54 (18.9%) | |
| Private hospital | 1 (3.4%) | 3 (1.2%) | 4 (1.4%) | |
| Home remedies | 4 (13.8%) | 72 (28.1%) | 76 (26.7%) | |
| First home remedies and then Hospital | ||||
| Temple or Bhuva visit | 0 | 0 | 0 | |
| Takes Badha | 0 | 0 | 0 |
*Statistically significant P
Table 3 shows a bivariate analysis between education and health practices to know whether the education of HCWs affects their lifestyle and health practices or not.
Table 3.
Bivariate analysis between education and various healthcare practices
| Characteristic | Education | P | ||
|---|---|---|---|---|
|
| ||||
| ≤10th standard (n=126) | >10th standard (n=159) | Total (n=285) | ||
| BMI | ||||
| Underweight | 21 (16.7%) | 22 (13.8%) | 43 (15.1%) | 0.648 |
| Normal | 64 (50.8%) | 86 (54.1%) | 150 (52.6%) | |
| Overweight | 30 (23.8%) | 42 (26.4%) | 702 (25.3%) | |
| Obese | 11 (8.7%) | 9 (5.7%) | 20 (7%) | |
| Regular check-up of blood pressure in last 1 year | ||||
| Yes | 107 (84.92%) | 128 (80.5%) | 235 (82.46%) | 0.330 |
| No | 19 (15.08%) | 31 (19.50%) | 50 (17.54%) | |
| Regular check-up of blood sugar in last 1 year | ||||
| Yes | 106 (84.13%) | 125 (78.62%) | 231 (81.05%) | 0.238 |
| No | 20 (15.87%) | 34 (21.38%) | 54 (19.13%) | |
| Regular check-up of thyroid profile in last 1 year | ||||
| Yes | 53 (42.06%) | 61 (38.36%) | 114 (40%) | 0.403 |
| No | 73 (57.94%) | 98 (61.64%) | 171 (60%) | |
| Green leafy vegetables intake in last 1 week | ||||
| <3 days | ||||
| 3-5 days | 29 (23.02%) | 32 (20.13%) | 61 (21.4%) | 0.6 |
| >5 days | 64 (50.79%) | 77 (48.43%) | 141 (49.47%) | |
| Fruit intake in last 1 week | 33 (26.19%) | 50 (31.44%) | 83 (29.13%) | |
| <3 days | ||||
| 3-5 days | 71 (56.35%) | 63 (39.62%) | 134 (47.02%) | 0.018* |
| >5 days | 41 (32.54%) | 69 (43.40%) | 110 (38.60%) | |
| Fried/packaged food intake in last 1 week | 14 (11.11%) | 27 (16.98%) | 41 (14.38%) | |
| <3 days | ||||
| 3-5 days | 93 (73.81%) | 117 (73.58%) | 210 (73.40%) | 0.838 |
| >5 days | 22 (17.46%) | 27 (16.98%) | 49 (16.72%) | |
| Days of exercise per week | 11 (8.73%) | 15 (9.44%) | 26 (8.9%) | |
| <3 days | ||||
| 3-5 days | ||||
| >5 days | 40 (31.75%) | 43 (27.04%) | 83 (29.12%) | 0.474 |
| History of additional salt to diet | 34 (26.98%) | 39 (24.53%) | 73 (25.61%) | |
| No | 52 (41.27%) | 77 (48.43%) | 129 (45.27%) | |
| Yes, daily | ||||
| Yes, sometime | 99 (78.57%) | 120 (75.47%) | 219 (76.84%) | 0.384 |
| History of intake of pickle/Papad in diet | 11 (8.73%) | 22 (13.84%) | 33 (11.58%) | |
| No | 16 (12.70%) | 17 (10.69%) | 33 (11.58%) | |
| Yes, daily | ||||
| Yes, sometimes | ||||
| Possession of any type of health Mediclaim or cards | 46 (36.51%) | 55 (34.59%) | 101 (35.44%) | 0.626 |
| Yes | 55 (43.65%) | 64 (40.25%) | 119 (41.75%) | |
| No | 25 (19.84%) | 40 (25.16%) | 65 (22.81%) | |
| Attitude towards illness in family | ||||
| Taken to nearby Gov hospital | 73 (57.94%) | 87 (54.72%) | 160 (56.14%) | 0.586 |
| Private hospital | 53 (42.06%) | 72 (45.28%) | 125 (43.86%) | |
| Home remedies | 74 (58.70%) | 77 (48.43%) | 151 (52.98%) | 0.360 |
| First home remedies and then Hospital | 21 (16.67%) | 33 (20.75%) | 54 (18.95%) | |
| Temple or Bhuva visit | 2 (1.59%) | 2 (1.26%) | 4 (1.4%) | |
| Takes Badha | 29 (23.01%) | 47 (29.56%) | 76 (26.67%) | |
| 0 (0%) | 0 (0%) | 0 (0%) | ||
| 0 (0%) | 0 (0%) | 0 (0%) | ||
*Statistically significant P
Discussion
This cross-sectional study was conducted in Petlad Taluka of Anand district to know health status and lifestyle practices of grassroot-level HCWs.
The health status of an individual depends not only on physical, mental, or social aspects but also on the vocational aspect. HCWs are responsible for providing basic healthcare and health education to the community. Among these, grassroot-level HCWs are a link between the community and doctors. For providing health education, HCWs themselves need to understand and implement healthy lifestyle practices. If they are disease-free, only then they can advise to adopt healthy practices in the community to prevent diseases. Studies are done to know the health status of various factory workers, other occupational workers, and even among HCWs on doctors, nurses, etc.[8–15] However, a smaller number of studies have focused on the health status of grassroot-level HCWs.
This study reported a lower prevalence of NCDs which was 10.2% than other studies in which prevalence was as high as 50%.[3] Most prevalent NCDs were hypertension and diabetes. The prevalence of hypertension among all study participants was 2% and that of diabetes was 1.4%. These values are lower than the national average of 15 and 24%, respectively.[16] Also, nearly 90% of study participants were on regular treatment. Dietary health practices appear to be healthy, but still significant proportion of them were overweight (25.3%) and obese (7%). It is one of the most important modifiable risk factors for NCDs. According to National Family Health Survey V prevalence of obesity are 20% in males and 18% in females.[16] HCWs are aware of the restriction of additional salt in their diet, but at the same time, they are consuming fermented or high salt-containing foods like papad and pickle. Exercise is one of the major protective factors against NCDs. In this study, nearly 70% of HCWs are engaged in regular physical activity.
All HCWs should promote consultation at various government hospitals, and they should be aware of a variety of benefits and schemes provided by the government. This study observed that 53% of HCWs opted for government hospital consultation when any of their family members were ill; still 47% of HCWs chose other options like private hospitals or trying home remedies first. In India, the government provides a variety of social security schemes like the Employees’ State Insurance Scheme,[17] Ayushman Bharat card,[18] Mukhyamantri Amrutam card,[19] etc. The benefits of these schemes should reach that subset of the population who actually needs that. Among HCWs only 56% of HCWs had either government or private social security schemes; they should be encouraged to use them.
We did not find any significant statistical association between participants’ education and their behavioural practices, which denotes that without having a graduate degree also you can be healthy and can have better health practices only if you know the same. This can be applied at a community level in those areas where we do not expect people of having higher education, but if we make them understand why any health practice is beneficial or harmful for them, we can make the change.
A major limitation of this study is that the study questionnaire was self-administered, which increases the chances of false reporting and induces social desirability bias. Also, we could not do any physical examination or investigations on study participants, thus those who have the NCDs but are not yet diagnosed may be missed. We included all grassroot HCWs in our study to eliminate selection bias. The overall response rate of participants was also more than 80%.
At the primary care level, physicians and grassroot-level workers work as a team to provide optimal health services to the community. For providing that they all must be healthy and give their best performance in physical, mental, social, and vocational aspects.
Conclusion
An important way to control NCDs is to focus on reducing the risk factors associated with these diseases. Essential NCD interventions can be delivered through a primary health care approach to strengthening early detection and timely treatment. However, to deliver quality care services, HCWs should be healthy. Studies like this will help to know the prevalence of NCDs in HCWs, thus helping to reduce the burden of NCDs on caregivers first who can further work for the betterment of the community.
Take home message
The ultimate aim of preventive medicine is to instil healthy practices in the community which can prevent them from acquiring a disease. To do so, we need healthy workforce to encourage community to remain healthy. We, as a primary care physician, have the responsibility to generate healthy workforce. By doing so, ultimately, we can contribute for the betterment of community.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Annexure
List of abbreviations
| Abbreviation | Definition |
|---|---|
| NCD | Noncommunicable diseases |
| HCW | Health-care workers |
| BMI | Body mass index |
| ASHA | Accredited social health activists |
| FHW | Female health worker |
| MPHW | Multipurpose health worker |
| NFHS | National Family Health Survey |
| ESI | Employees’ State Insurance Scheme |
| MA | Mukhyamantri Amrutam |
Contribution details
| Contributor 1 | Contributor 2 |
|---|---|
| Concepts, design, definition of intellectual content, investigation, and manuscript writing | Concepts, design, definition of intellectual content, manuscript review, and finalization |
Reporting guidelines for original research articles (case control, cohort, and cross-sectional studies): STROBE (2007)
| Item no | Recommendation | Yes/No | |
|---|---|---|---|
| Title and abstract | 1 | (a) Indicate the study’s design with a commonly used term in the title or the abstract | Yes |
| (b) Provide in the abstract an informative and balanced summary of what was done and what was found. Structured abstract: Aims & Objectives, Materials & Methods, Results, Conclusion Format to be consistent | Yes | ||
| Introduction | |||
| Background/rationale | 2 | Explain the scientific background and rationale for the investigation being reported | Yes |
| Objectives | 3a | State specific objectives, including any prespecified hypotheses. The research objective should not be biased. | Yes |
| 3b | Statements to be appropriately cited | Yes | |
| Methods – Structured methods section (with subheadings) is preferred | |||
| Study design | 4a | Present key elements of study design early in the paper (cross-sectional/cohort/case-control) | Yes |
| 4b | Is the study design robust and well-justified? | Yes | |
| Setting | 5a | Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection | Yes |
| 5b # | Mention the details of the Supplier/manufacturer of the equipment/materials (e.g., chemicals) used in the study | NA | |
| 5c # | Mention the details of the drugs (manufacturer, dosage, dilution, frequency, and route of administration, monitoring equipment) used in the study | NA | |
| 5d # | Mention the details about the cell lines (names and where it was obtained from) | NA | |
| 5e # | Mention the details of plant sample collection (location, time period, validation of the specimen, institution where the specimen is submitted, and the voucher specimen number) | NA | |
| Participants | 6 | (a) Cohort study—Give the eligibility criteria (Inclusion/exclusion), and the sources and methods of selection of participants. Describe methods of follow-up | NA |
| Case-control study—Give the eligibility criteria (Inclusion/exclusion), and the sources and methods of case ascertainment and control selection. Give the rationale for the choice of cases and controls | NA | ||
| Cross-sectional study—Give the eligibility criteria (Inclusion/exclusion), and the sources and methods of selection of participants | Yes | ||
| (b) Cohort study—For matched studies, give matching criteria and number of exposed and unexposed | NA | ||
| Case-control study—For matched studies, give matching criteria and the number of controls per case | NA | ||
| Variables | 7a | Clearly define all outcomes (primary and secondary), exposures, predictors, potential confounders, and effect modifiers. | Yes |
| 7b | Give diagnostic criteria, if applicable | NA | |
| Data sources/measurement | 8* | For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group | NA |
| Bias | 9 | Describe any efforts to address potential sources of bias | Yes |
| Study size | 10 | Explain how the study size (sample size) was arrived at | Yes |
| Quantitative variables | 11 | Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why | Yes |
| Statistical methods (a separate heading needed) | 12 | (a) Describe all statistical methods, including those used to control for confounding | Yes |
| (b) Describe any methods used to examine subgroups and interactions | NA | ||
| (c) Explain how missing data were addressed | NA | ||
| (d) Cohort study—If applicable, explain how loss to follow-up was addressed Case-control study—If applicable, explain how the matching of cases and controls was addressed Cross-sectional study—If applicable, describe analytical methods taking account of the sampling strategy | NA | ||
| (e) Describe any sensitivity analyses | NA | ||
| Results | |||
| Participants | 13* | (a) Report numbers of individuals at each stage of study—e.g., numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing follow-up, and analysed | NA |
| (b) Give reasons for nonparticipation at each stage | Yes | ||
| (c) Consider the use of a flow diagram | NA | ||
| Descriptive data | 14* | (a) Give characteristics of study participants (e.g., demographic, clinical, social) and information on exposures and potential confounders | Yes |
| (b) Indicate number of participants with missing data for each variable of interest | NA | ||
| (c) Cohort study—Summarize follow-up time (e.g., average and total amount) | NA | ||
| Outcome data | 15* | Cohort study—Report numbers of outcome events or summary measures over time | NA |
| Case-control study—Report numbers in each exposure category, or summary measures of exposure | NA | ||
| Cross-sectional study—Report numbers of outcome events or summary measures | Yes | ||
| Main results | 16 | (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (e.g., 95% confidence interval). Make clear which confounders were adjusted for and why they were included | NA |
| (b) Report category boundaries when continuous variables were categorized | NA | ||
| (c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period | NA | ||
| Other analyses | 17 | Report other analyses done—e.g., analyses of subgroups and interactions, and sensitivity analyses | NA |
| Presentation | 18a | Tables and graphs are properly depicted with no repetition of the data in the text | Yes |
| 18b | Annotation/footnotes to be mentioned appropriately | Yes | |
| 18c | Abbreviations to be defined in the footnotes | Yes | |
| Discussion | |||
| Key results | 19 | Summarize key results with reference to study objectives | Yes |
| Limitations | 20 | Discuss the limitations of the study, taking into account sources of potential bias or imprecision. Discuss both the direction and magnitude of any potential bias | Yes |
| Interpretation | 21 | Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from similar studies, and other relevant evidence | NA |
| Generalizability | 22 | Discuss the generalizability (external validity) of the study results | Yes |
| Citations | 23a | The statements should be adequately cited | Yes |
| 23b | Recent citations (last 5 years) to be cited in a greater proportion | Yes | |
| Other information | |||
| Funding | 24a | Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based | NA |
| 24b | Mention the grant number | NA | |
| Ethical approval and patient consent | 25a | Mention the IRB approval and the approval number (for animal and human subjects) | NA |
| 25b | Mention if the study has been conducted in accordance with the ethical principles mentioned in the Declaration of Helsinki (2013) | NA | |
| 25c | Mention if the patients have consented to participate in the study To mention if consent has been waived/exempted by IRB | NA | |
| Conflict of Interest | 26 | Mention the financial, commercial, legal, or professional relationship of the author (or the author’s employer) with sponsors/organizations that could potentially influence the research. | NA |
| Language | 27 | The language should be understandable without grammatical errors that hinders the readability | Yes |
*Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies, # Give information depending on the study sample
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