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Purpose: To evaluate clinical outcomes of CT-based adaptive intracavitary and interstitial brachytherapy (IC followed by IC-ISBT) in locally advanced cervical cancer (LACC) in resource-constrained settings., Methods and Materials: LACC patients treated with adaptive brachytherapy techniques were analyzed to evaluate treatment characteristics and clinical outcomes. The Kaplan-Meier method was used for survival analysis, and the log-rank test for univariate analysis., Results: Out of 141 eligible patients with LACC, 87 (61.7%) patients received external beam radiotherapy (EBRT) in referral hospitals, while 54 (38.3%) were treated at our center. We divided our cohort into two groups: poor EBRT responder group (n = 70 [49.6%]) where IC-ISBT was adapted to achieve optimum tumor doses and OAR optimization group 71 (50.4%) where IC-ISBT was performed to reduce OAR doses. Median HRCTV-D90 dose was 88 Gy (range 70-109 Gy) with median HRCTV volume 33cc (range 15-96). Median D2cc doses to OARs were 90 Gy (range 70-107), 71 Gy (range 55-105) and 70 Gy (range 47-90) to bladder, rectum and sigmoid, respectively. At median follow-up of 32 months, 3-year local control (LC), locoregional control (LRC), disease-free survival (DFS) and overall survival (OS) were 83%, 75%, 64% and 72%, respectively. Subgroup analysis revealed significantly better outcomes for OAR optimization compared to poor EBRT responders, with 3-year LC (95% vs. 70.1%, p < 0.001), LRC (87.3% vs. 62.7%, p < 0.001), DFS (79.2% vs. 49.4%, p < 0.001), and OS (86.2% vs. 57.4%, p < 0.001) CONCLUSION: In resource-constrained settings, implementation of Adaptive IC-ISBT is a viable alternative for optimizing OAR doses in LACC. However proactive approach employing IC-ISBT for tumor dose-escalation from first fraction of BT is warranted for improving LC in poor EBRT responders., (Copyright © 2024 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Background: Due to the paucity of reliable data to determine the components of family-based comprehensive care for cancer in India, we explored the familial implications of gynaecological and breast cancer diagnosis and treatment through a mixed-method study., Methods: The mixed method study included 130 women aged above 18 with a confirmed diagnosis of gynaecological or breast cancer recruited from three selected tertiary hospitals in Kerala, India. Information on quality of life (36-Item Short Form Survey (SF-36)), psychological distress (distress thermometer), and the familial, interpersonal, social, and community impacts of cancer (semi-structured interview guide) were elicited. Linear regression was used to identify the factors associated with distress and the factors were explored further using thematic analysis., Results: Patients included in the study (n = 130; mean age 57.5 years) had moderate or mild (66.9%) to severe (25.4%) distress. Concerns about work (93%), difficulty in; home care and housing (82%), care for dependents (65%), unempathetic family (87.6%), isolation (70%), and body image (65%) were major reasons for their distress. Physiological, social, and family-related stressors among the respondents included challenges in physical functioning, intense physical symptoms like fatigue, loss of appetite and sleep, role restrictions, alterations in family responsibilities, functional dependency, inadequate family support, challenges in social and interpersonal interactions, and an unsupportive work environment., Conclusion: Cancer is a health crisis that involves psychological, social, and economic distress, compelling professionals to design multifaceted individualized care packages rather than only concentrating on medical management to alleviate their distress., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Definitive pelvic intensity modulated radiation therapy (IMRT) in cervical cancer is susceptible to geographic miss due to daily positional and volumetric variations in target and organs at risk. Hence, despite evidence of reduced acute and late treatment-related toxicities, implementation of image-guided IMRT (IG-IMRT) with a reasonable safety margin to encompass organ motion is challenging., Methods and Materials: In this prospective, nonrandomized phase 2 study, patients with cervical cancer International Federation of Gynecology and Obstetrics (2009) stage IB2-IIIB between the ages of 18 and 65 years were treated with definitive pelvic chemoradiotherapy with a prespecified organ (bladder and rectum) filling protocol. Reproducibility of organ filling was assessed along with the implementation of daily comprehensive adaptive image-guided radiotherapy (IGRT), with a library of 3 IMRT (volumetric modulated arc therapy) plans with incremental expansions of clinical target volume (CTV) to planning target volume (PTV) (primary) margins (small, 0.7 cm; adequate, 1 cm; and large, 1.5 cm) and a backup motion robust 3-dimensional conformal radiotherapy plan; the appropriate plan is chosen based on pretreatment cone beam computed tomography (CBCT) ("plan of the day" approach)., Results: Fifty patients with a median age of 49 years (IQR, 45-56 years) received definitive radiation therapy (45-46 Gy in 23-25 fractions to pelvis, with simultaneous integrated boost to gross nodes in 15 patients) with the aforementioned IGRT protocol. In the analysis of 1171 CBCT images (in 1184 treatment sessions), the mean planning computed tomography (CT) and CBCT bladder volumes were 417 and 373 cc, respectively. Significant interfractional variation in bladder volume was noted with a mean absolute dispersion of 29.5% with respect to planning CT; significant influential random factors were postchemotherapy sessions (P ≤ .001), pre-CBCT protocol duration (P = .001), and grades of chemotherapy induced nausea vomiting (P = .001). Significantly higher variation in bladder filling was noted in patients with older age (P = .014) and larger planning CT bladder volume (P ≤ .001). Time trend analysis of fraction-wise bladder volume revealed an absolute systemic reduction of 16.3% in bladder volume means from the first to the fifth week. Variation in rectal diameter was much less pronounced, with 19.2% mean dispersion and without any significant factors affecting it. Although in 19% and 2% of sessions large IMRT PTV and 3-dimensional conformal radiotherapy were necessary to cover the primary target, respectively, reduction in treated volume was possible in 43% of sessions with small PTV selection instead of standard adequate PTV (36% sessions). Plan of the day selection had a moderate to strong correlation with nonabsolute dispersion of bladder filling (Spearman ρ =0.4; P = .001) and a weak (but significant) correlation with grades of acute toxicities. The planned protocol was well tolerated with no radiation-induced local grade 3 toxicity., Conclusions: Interfractional variation in organ filling (especially bladder) is inevitable despite fixed pretreatment protocol in definitive settings (intact cervix). Despite the logistical challenges, adaptive IGRT in the form of plan of the day based on incremental CTV-to-PTV margins is a relatively simple and feasible strategy to minimize geometric uncertainties in radical IG-IMRT of cervical cancer., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Uncontrolled hypertension and diabetes are a challenge for healthcare providers worldwide. The research documenting the underlying risk factors of uncontrolled chronic illnesses in community cohorts from India is negligible. The current cross-sectional household door-knock survey conducted among 759 participants aged 30 and above from a geographically well-defined area examines the cognitive risk factors associated with hypertension and diabetes control in the Indian population. The study used an assessment tool consisting of a socio-demographic questionnaire, items to measure cognitive factors, and onsite hypertension and diabetes measurements. Results suggested that among the participants, more than 36% had hypertension, 26% had diabetes, and of those with diagnosed diabetes and hypertension, more than 22% with hypertension and 48% with diabetes had uncontrolled conditions. Univariate analysis suggests that cognitive functioning was negatively associated with uncontrolled hypertension and psychological impairments of depression and anxiety were positively associated. The associations were not significant for uncontrolled diabetes. Only if treatments integrate psychological and cognitive interventions to ensure adherence to medical and lifestyle modifications will it achieve the WHO target of 80% control of detected conditions. The findings can inform the policies and programs to optimise government spending and modify the current chronic condition management practices., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Author(s).)

Emerging technological tools like Artificial Intelligence-based Chatbots, digital educational alternatives and market-driven educational systems pose a challenge to the fundamental aim of the higher education system; comprehensive education for well-being. Therefore, this research aims to devise and evaluate strategies to impart new-age competencies to innovate socially and morally appropriate solutions in a modern competitive innovative society. The 8-month-long immersive learning framework (ILF), was designed based on the volatility, uncertainty, complexity, and ambiguity (VUCA) paradigm. The framework was evaluated with 133 newly joined postgraduate students doing their science or arts programmes from a higher education institution in Kerala, India. The outcome variables included well-being, depressive symptoms, personality patterns, and sub-domains of philosophy of human nature. The follow-up scores showed a significant improvement in well-being (Mean difference: 1.15, p = 0.005), trustworthiness (Mean difference: 14.74, p = 0.000), strength of will (Mean difference: 10.11, p = 0.000), altruism (Mean difference: 12.85, p = 0.000), and independence (Mean difference: 11.93, p = 0.000). Depression scores did not improve significantly. However, the intervention shielded them from the adjustment issues that often accompany any transition. The ILF framework can help students develop their personal and professional selves if it is implemented collaboratively in a reflective setting. It can also instil moral rectitude and a prosocial mindset., (© 2023. Springer Nature Limited.)

Background: Falls and their incapacitating effects are a significant concern for older people, especially in low- and middle-income countries. Falls are a significant concern among older people which requires immediate public health action. The current study examines multiple fall risk factors among community-dwelling older people in Kerala, India, to devise prevention strategies., Methods: A cross-sectional survey was conducted between April and May 2020 among the community-dwelling older population aged 60 and above. Data was collected through door-knock surveys using standardized scales. Fall history and associated risks were the primary outcome variables, whereas behavioral and cognitive risk factors of depression, anxiety and stress were the other factors., Results: The study included 301 older people (aged over 60) from 573 households and found the prevalence of falls in the last year was 37.5%. Older women with moderate levels of physical activity, cognitive symptoms of anxiety and stress, and who are unemployed had higher chances of falls risk. Further, older people with higher functional disability and average and below self-rated health had higher chances of fall risk in the current population. Anxiety was the only significant risk factor which was statistically significant in multiple regression model., Conclusion: The older population with a combined risk of behavioral and cognitive factors is at higher odds of fall-related risk in Kerala., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Purpose: The sigmoid is an important organ at risk for gynecological brachytherapy (BT). However, the reliability of localization of high-dose regions during multi-fractionated treatment is limited. This work reports the methodological development of sigmoid points to summate multi-fractionated doses., Methods and Material: Ten paired MRI data sets of ring-based intracavitary brachytherapy were obtained. Simulating a virtual endoscope, a reference line was created along the central axis of the anorectosigmoid for each implant. A trendline was generated, and linear dose was determined. Three-dimensional (3D) coordinates of high-dose regions were identified, and overlap was determined. In the next step, 3D coordinates of high-dose sigmoid points were localized in reference to cervical os and re-verified for location in reference to sigmoid lumen and corroboration with 2cc doses. With minor modifications, sigmoid points were proposed., Results: In 6 of 10 patients, high-dose regions co-localized in subsequent fractions of BT. Three high-dose regions were identified along the sigmoid length and proposed as sigmoid points in reference to cervical os. (S1'= 0.5 cm right, 1.5 cm posterior, and 2.4 cm cranial; S2' = 0.3 cm anterior and 4.5 cm cranial; S3' = 2.7 cm left, 3 cm anterior, and 3.6 cm cranial to the cervical os). S1' and S2' were located in the sigmoid in 70% and 60% of data sets. The mean difference between D2cc and S1'/S2' was 0.30 Gy and 1.06 Gy respectively. S3' had limited corroboration to sigmoid lumen or 2 cc doses. The points S1' and S2' were further modified (minor) for applicability and proposed as sigmoid points 1 and 2 (SP1 0.5 right,1.5 posterior and 2.5 cm cranial to cervical os and SP2 (0.5 cm anterior and 4.5 cm cranial to cervical os))., Conclusion: SP1 and SP 2 are proposed as a surrogate for 2 cc sigmoid doses and may provide a method of reliable inter-fraction dose summation. This pilot work requires further validation., (Copyright © 2023 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Purpose: Brachytherapy (BT) for cervix cancer was listed as a level I priority and reduced number of implants and multiple fractions were recommended during COVID-19 pandemic. We present early clinical outcome of this approach., Methods and Materials: Patients treated with (chemo)radiotherapy and BT with single implant and multiple fractions BT were included. Treatment protocol included 3-5 fractions of 5-8.5 Gy with an aim to achieve point A dose of 70 Gy EQD2 10Gy (or HRCTV dose of >80 Gy EQD2 10Gy ) in those undergoing intracavitary (IC) and HRCTV dose >85 Gy EQD2 10Gy in patients undergoing Intracavitary-Interstitial (IC/IS) whereas maintaining bladder (B2cc), rectum (R2cc), sigmoid (S 2cc) doses of 90, 75, and 75 Gy EQD2 3Gy . Time to event analysis was used to report oncological endpoints. Toxicity was reported using crude proportions., Results: From April 2020 to March, 2021, 64 patients with stage IB2-IV received single implant and multi-fraction BT after external radiation of 45 Gy/25 fractions/5 weeks. Only 76.7% (n = 49) received concurrent chemotherapy. Median overall treatment time (OTT) was 56 days (38-131 days). Overall, 62.5% (n = 40) patients received IC and 37.5% (n = 24) received IC+IS. The median HRCTV was 34.7 cc (IQR 25-41). Median (IQR) point A dose, HRCTV D90, B2cc, R2cc, and S2cc for those undergoing IC was 74 Gy (71-78), 80 Gy (73-84), 86 Gy (82-89), 70 Gy (65-74), 65 Gy (59-73) respectively. For the IC+IS cohort, HRCTV D90, B2cc, R2cc, and S2cc was 84 Gy (78-89 Gy), 89 Gy (86-92), 70 Gy (67-74), 68 Gy (59-76). At a median follow-up of 16 months (5-27) the 2-year local control, pelvic control, cause specific and overall survival was 88%, 85.3%, 92.2%, and 81.3% respectively. Late gastrointestinal and genitourinary grade ≥III toxicities were 14% and 1.5% each., Conclusions: Abbreviated BT outcomes are encouraging for oncological outcomes despite delays in overall treatment time and omission of chemotherapy. Further mature follow up is needed., (Copyright © 2022 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

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

Objective: Suicide is a crucial public health concern. However, the interactions between bio psychosocial vulnerabilities and stressors leading to deliberate self-harm behavior remain unexplored, especially in the Indian context. This study examined the experiences leading to self-harm behavior among people who presented to emergency departments with suicidal attempts., Methods: In this mixed-methods study, we enrolled 44 patients who presented with self-harm behavior at three tertiary health care facilities between October and December 2019. To collect quantitative data, we employed standardized tools: General Health Questionnaire (GHQ-28), General Help-Seeking Questionnaire, Mini International Neuropsychiatric Interview, and the Brief Resilience Scale. Further, we conducted semi-structured interviews to qualitatively explore participants' life experiences and other risk factors. Qualitative analyses were performed using thematic analysis and quantitative descriptive and inferential statistics were performed using STATA software., Results: The mean age of subjects were 29.8 years. The mean suicidality score for the patients was 26 (±8.7). In univariate analysis, depression and anxiety were positively associated with suicidality. While help-seeking behavior and resilience were negatively associated with suicidality. Qualitative results were centered on three major themes; life stressors, family related stressors, and social support-related vulnerabilities. The subjects' lived experiences were introduced in the backdrop of the interplay of vulnerabilities and stressors., Conclusion: The biopsychosocial vulnerabilities remain dormant until it is activated by life stressors resulting in severe self-harm behaviors. Mental health team-driven assertive engagement, positive coping, and social support interventions would help prevent reattempts in people with self-harm behaviors., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Devassy, Scaria, Varghese, Benny, Hill and Joubert.)

Purpose: To report the clinical outcomes in patients treated with Martinez universal perineal interstitial template (MUPIT)-based interstitial brachytherapy boost for primary and recurrent vault and vaginal cancers, and to perform a comparative analysis with our previously published series of similar patients., Material and Methods: One hundred and seventeen patients treated between January, 2009 and December, 2015 were evaluated. Descriptive statistics for the patterns of relapse, local recurrence-free survival (LRFS), disease-free survival (DFS), overall survival (OS), and late toxicities were carried out. Kaplan-Meier curves were used for survival analysis. All variables with the potential to affect outcomes were tested using log-rank test for statistical significance., Results: At a median follow-up of 63 months, LRFS, DFS, and OS at 3/5 years were 77.1%/74.7%, 61%/52%, and 72.3%/63.1%, respectively. Overall treatment time (OTT) of 56 days did not affect outcomes. Bulky tumors and OTT > 63 days adversely affected LRFS. Overall treatment time also significantly impacted DFS and OS. Grade 3-4 late bladder toxicities were observed in 1.7% patients, and grade 3-4 late rectal toxicities in 5% patients. Compared to our previous series, the outcome in the current series is better in terms of severe late toxicities (5% improvement in rectal toxicity, and 2.7% improvement in bladder toxicity) and OS by 10%. This could be attributed to the increasing use of concurrent chemotherapy and relative optimization strategies for organs at risk., Conclusions: Patients with primary and recurrent vault and vaginal cancers treated with high-dose-rate interstitial brachytherapy boost using MUPIT resulted in modest clinical outcomes and acceptable late toxicities. OTT was the most important factor affecting the outcomes., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Termedia.)

Background: Mental illness in parents impairs their parenting capability, which has a lifelong detrimental impact on their children's physical and psychological health. In the current Indian context, due to weak social security nets, family is the only plausible intervention to ensure adequate substitute child care. Therefore, this study explores various risk factors and barriers to providing substitute family care., Methods: We used a mixed-method approach to gather information from 94 substitute family caregivers. Quantitative screening data were collected from four hospitals using a clinical data mining tool and an interview guide to gather caregiver perspectives on economic, familial, and social risks and barriers associated with caring. We used thematic analysis to consolidate the qualitative findings., Results: Most of the substitute caregivers were females from low-income households. The study identified 11 sub-themes and 23 specific themes associated with risks and barriers to substitute care. These themes fell into four broad areas: economic, familial, school-related risks, and specific cultural and service access barriers. Focus on economic interventions is likely to result in strengthening the substitute family caregiver., Conclusion: The paradigmatic shift of treatment focus from the patient to the entire household would benefit the children just as it does the patient.

Purpose: Higher frequency of transcriptional errors in the radiotherapy electronic charts for patients on telecobalt was noted. We describe the impact of the quality improvement (QI) initiative under the department's incident learning program (ILP)., Materials and Methods: The multidisciplinary quality team under ILP was formed to identify the root cause and introduce methods to reduce (smart goal) the current transcription error rate of 40% to <5% over 12 months. A root cause analysis including a fishbone diagram, Pareto chart, and action prioritization matrix was done to identify key drivers and interventions. Plan-Do-Study-Act (PDSA) Cycle strategy was undertaken. The primary outcome was percentage charts with transcriptional errors per month. The balancing measure was "new errors" due to interventions. All errors were identified and corrected before patient treatment., Results: The average baseline error rate was 44.14%. The two key drivers identified were education of the workforce involved and mechanical synchronization of various machine parameters. PDSA cycle 1 consisted of an education program and sensitization of the staff, post which the error rates dropped to 5.4% ( t -test P = 0.03). Post-PDSA cycle 2 (synchronization of machine parameters), 1, 3, and 6 months and 1 year, the error rates were sustained to 5%, 4%, 3%, and 4% ( t -test P > 0.05) with no new additional errors., Conclusions: With various generations of machines and technologies that are not synchronized, the proneness of transcription errors can be very high which can be identified and corrected with a typical QI process under ILP., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Medical Physics.)

Purpose: Caregivers of people with disability experience difficulties in a variety of care domains. Understanding the predictive factors of caregiver strain is important in developing and implementing evidence-based intervention to reduce the difficulties experienced by the carers., Methods: The current study is a cross sectional comprehensive one-phase survey conducted in randomly selected sub-districts (taluks) of the Ernakulam district in Kerala. Primary caregivers ( n  = 851) for persons with different kinds of disability were identified with the help of ASHAs (Accredited Social Health Activities) from the selected geographical locations and were interviewed in a house-to-house survey after obtaining written informed consent. Validated tools measuring caregiver strain, financial burden, access to services and wellbeing were used to study the population., Results: Majority of the caregivers were females (77.3%) and spouses (35.2%). Of the caregivers 27% reported high levels of caregiver strain. The major factors associated with caregiver strain were female gender ( B  = 1.379, p  = 0.000), financial issues ( B  = 0.105, p  = 0.000), the general health of caregivers ( B  = 0.467, p  = 0.000) and issues relating to employment ( B  = 0.956, p  = 0.000) and the availability of government welfare services ( B  = 1.138, p  = 0.000)., Conclusion: High caregiver burden and strain is experienced by almost a third of people caring for a person with a disability. Comprehensive interventions to reduce caregiver strain should be developed.Implications for rehabilitationThe rehabilitation sector needs to be made aware of the high levels of caregiver strain (especially in carers who were female, unemployed, have health issues and lack formal support).To improve wellbeing for people with disability we firstly need to promote social inclusion and support schemes for caregiver.Co-designed systems are needed to assist carers to access formal and informal support resources, and increase social connectedness.

Objectives: Diabetes is a significant public health concern in India, with Kerala being labeled as the diabetes capital of the country. The study aims to evaluate the prevalence, treatment, and management of diabetes to examine the unmet need for care to propose cost-effective strategies., Design: A cross-sectional study was conducted on a geographically defined cohort population in Ernakulam., Sample: This paper presents diabetes data of adults ≥30 years enrolled from the community cohort. The interviews were conducted with 997 participants at their residence., Measurement: Random blood glucose was assessed for each participant using a finger prick test., Results: The overall prevalence of diabetes was 30.1%, of which 4.1% of participants had undiagnosed diabetes. Among those with diabetes, 86.3% were aware of their diagnosis; among those aware, 86.5% were on treatment. Among those on treatment for diabetes, 54% achieved controlled blood sugar., Conclusion: The challenge in diabetes management is controlling the blood glucose levels of people who adhere to treatment. Younger employed females from lower-income quartiles have the highest risk. The study also raises questions about quality and strategies for medication compliance. The findings inspire future research on care needs, policies, and program responses to reduce the diabetes disease burden., (© 2022 Wiley Periodicals LLC.)

Background: This study is a low-cost community mental health task-sharing model driven by university students to strengthen the mental health workforce in poor resource settings. This article presents the feasibility of a stepped referral model using the community health workforce and university students. The primary feasibility objective is to detect and refer people with mental illness from the community using a task-sharing approach., Methods: We tested the model using a cross-sectional, one-phase door-knock survey in three geographically defined locations in Kerala, India, between May and July 2019. Students surveyed 549 residents above 18 years of age who consented to participate in the study to detect depressive symptoms and suicidality. The feasibility of the current model was evaluated based on four criteria: (a) identification and deployment of untapped human resources, (b) coordination of community health resources, (c) the acceptability of stepped referral pathways, and (d) identification of implementation challenges., Results: The mean age of the participants was 38.8, and more than 62% of the respondents were women. The results showed that 11.29%, 8.38%, and 4.91% of people reported mild, moderate, and severe levels of depression, respectively, and suicidal thoughts were found in 6.9% and suicidal ideation in 1.8%. The odds of depression were higher among females compared to males (OR: 1.64 (0.75-2.52), poor people (OR: 2.01 (1.14-2.88), and people with chronic illnesses (OR: 2.03 (1.24-2.81). The agreement of the findings with professional-administered research validated the strategy's efficiency. Twenty-seven patients with severe/extreme degrees of depression were sent for high-intensity interventions led by the mental health team, whereas 135 individuals with mild and above depression were referred for low-intensity interventions., Conclusions: The newly recruited mental health workforce-driven screenings were acceptable and effective in detecting mental illness in the community population. We tested the care coordination systems and processes in creating referral pathways for the detected patients. Further, task-sharing stepped referral model will be tested in five panchayats (the lowest tier of local self-government) before replicating the model across India through Unnat Bharat Abhiyan (UBA) scheme., (© 2022. The Author(s).)

Background: Suicide is a substantial public health concern for countries worldwide. Effective preventive and curative interventions for self-harm behavior (SHB) are imperative for nations with an alarmingly high rate of suicide and self-harm behaviors. The intervention protocol named FASE (Family and Social Engagement) consists of comprehensive assessment, Attachment-Based Family Therapy (ABFT), and community linkages for people presenting with suicide or self-harm in emergency departments of tertiary hospitals., Methods: This article reports the design and protocol for a cluster randomized control trial for suicide prevention and management. After the developed intervention is pilot tested in a tertiary hospital in Kerala, the intervention will be scaled up to be implemented in various tertiary hospitals in Kerala. Each hospital emergency department will be considered a cluster, and these clusters will be randomized to the intervention group and control group in a 1:1 ratio. The eligible people from the intervention clusters will undergo a baseline assessment, a structured moderate intense intervention with twelve sessions spread across 6 months by the trained social workers supervised by the Mental health team, and a follow-up assessment at the end. Participants will be recruited after obtaining consent and explaining the study. The primary outcome includes suicidality measured by the Depressive Symptom Inventory-Suicidality Subscale (DSI-SS), Depression, Anxiety and Stress Scale (DASS), MOS Social Support Survey, and Brief resilience scale (BRS)., Discussion: Knowledge generated from this trial can significantly affect new programmatic policy and clinical guidelines that will improve the reduction of suicide rates in the country., Trial Registration: Prospectively registered in Clinical Trial Registry India (ICMR-NIMS) on 18/10/2021 (ref number- REF/2021/10/048264)., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Devassy, Scaria, Benny, Cheguvera, Varghese and Joubert.)

Purpose: The Radiation Therapy Oncology Group (RTOG) under NRG Oncology recently published updated contouring guidelines for intensity modulated radiation therapy in postoperative treatment for endometrial and cervical cancer. The present study was designed to evaluate the implications of newly published guidelines., Methods and Materials: We recruited 300 patients in a phase 3 randomized controlled trial of adjuvant chemoradiation therapy for cervical cancer (NCT01279135) to understand patterns of relapse. For those patients with pelvic relapse, we imported radiation therapy structure sets, treatment plans, and diagnostic images at relapse on the treatment planning system. We performed rigid registration with treatment planning images that contained the delineated planning target volume and radiation dose information. We delineated gross tumor volume at time of relapse on the diagnostic scans and superimposed it on the radiation therapy treatment scans. We categorized the site of pelvic relapse as "within field of old RTOG/[Postoperative Adjuvant Radiation in Cervical Cancer (PARCER)] target delineation guidelines" or "within field of new NRG/RTOG guidelines," or both, and compared proportions of recurrences contained within the 2 guidelines. We consider a P value of <.05 statistically significant. Additionally, we generated intensity modulated radiation therapy treatment plans based on the new guidelines for a limited set of patients to see if these new guidelines increased the organ at risk doses., Results: Most common form of relapse was distant metastasis (15%). Pelvic relapse rate in our study was 8%. Overall, 9 out of 19 relapses were encompassed in the contouring guidelines of the old RTOG/ Postoperative Adjuvant Radiation in Cervical Cancer (PARCER) trial, and 12 out of 19 were encompassed within the new RTOG 2021 contouring guidelines. This corresponded to a further 1% reduction in local relapses (P = .007). Dose to rectum was marginally increased with the new contouring, with no difference in other organs at risk. Salvage treatment was offered in 25 out of 60 patients who relapsed. Patients who received local treatment after relapse had a mean survival after relapse of 27.2 months compared with 8 months among those who received supportive care alone., Conclusions: Our study supports the use of newly published NRG/RTOG contouring guidelines in patients with cervical cancer who have undergone hysterectomy. Further data are needed to ascertain if anterior extension of the clinical target volume is needed as in the Postoperative Adjuvant Radiation in Cervical Cancer trial., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background Low birth weight (LBW) is susceptible to neonatal complications, chronic medical conditions, and neurodevelopmental disabilities. We aim to describe the determinants of very low birth weight (VLBW) in India and compare it with the determinants of LBW based on the National Family Health Survey - 4 (NHFS-4) Methods Data from the NFHS-4 on birthweight and other socio-demographic characteristics for the youngest child born in the family during the five years preceding the survey were used. Data of 147,762 infant-mother pairs were included. Multiple logistic regression models were employed to delineate the independent predictors of VLBW (birth weight<1500 g) or LBW  (birth weight: 1500-2499 g). Results Of the 147,762 children included in the study, VLBW and LBW were observed in 1.2% and 15.8% of children, respectively. The odds of VLBW were higher in female children (aOR: 1.36, 95% CI: 1.15-1.60), among mothers aged 13-19 years (aOR: 1.58, 95% CI: 1.22-2.07), mothers with severe or moderate anaemia (aOR: 1.61, 95% CI: 1.34-1.94), mothers without recommended antenatal care (aOR: 1.47, 95% CI: 1.31-1.90), maternal height less than 150 cm (aOR: 1.54, 95% CI: 1.29-1.85) and among mothers with multiple pregnancy (aOR: 21.34, 95% CI: 14.70-30.96) in comparison to their corresponding counterparts. In addition to the variables associated with VLBW, educational status of mothers (no education; aOR: 1.08, 95% CI: 1.02-1.15 and primary education; aOR: 1.16, 95% CI: 1.08-1.25), caste of the children (scheduled tribe; aOR: 1.13, 95% CI: 1.03-1.24), and wealthiness of the family (poorest wealth quintiles; aOR: 1.11, 95% CI: 1.03-1.19) were associated with LBW. Conclusions Interventions targeting improvements in antenatal care access, maternal health, and nutritional status may reduce the number of VLBW infants. Social determinants of LBW require further detailed study to understand the high propensity of low birth-weight phenotypes in the disadvantaged communities in India., Competing Interests: No competing interests were disclosed., (Copyright: © 2022 Scaria L et al.)

Purpose: Treatment of isolated post-surgical vault recurrence of cervical and endometrial cancers in previously unirradiated patients includes external beam radiotherapy (EBRT) ± concomitant chemotherapy, followed by brachytherapy (BT) boost. Supra-vaginal component of vault disease often requires interstitial BT for optimal dose coverage. We describe technical details and preliminary case series using modified Houdek vault applicator (MHVA) developed at our institution for limited intra-cavitary plus interstitial high-dose-rate (HDR) vault BT., Material and Methods: Nineteen patients with vaginal vault recurrences received BT boost with MHVA between October 2015 and May 2018. All underwent BT application and CT-based BT planning after completion of EBRT ± concomitant chemotherapy., Results: Median EQD 2 of BT dose in patients with carcinoma cervix recurrence ( n = 15, α/β = 10) was 18.8 Gy, and in those with endometrial cancer recurrence was 22.08 Gy ( n = 4, α/β = 4.5). Median total EQD 2 was 68.8 Gy and 72.08 Gy, respectively. Mean 2 cc of bladder, rectum, and sigmoid EBRT + BT doses (EQD 2 , α/β = 3) were 65.38 Gy (±7.76), 63.37 Gy (±5.52), and 57.04 Gy (±4.45), respectively. At 6-8 weeks, 17 patients showed complete response (CR). With median follow-up of 20.5 months, 2-year overall survival was 95% (95% CI: 85.2-100.0%), and 2-year progression-free survival was 79.4% (95% CI: 61.0-97.8%). Late toxicities seen were grade 2 proctitis in 1 patient, grade 1 proctitis in 5, grade 2 urethritis in 1, grade 3 cystitis in 1, and recto-vaginal fistula in 1 patient (with disease controlled). Recurrence rate was 6.7 times higher in patients with post-EBRT disease greater than 10 mm ( p = 0.01)., Conclusions: MHVA is a simple solution for intra-cavitary and interstitial HDR-BT boost in isolated vault cancers post-surgery, achieving acceptable dosimetric parameters. Preliminary clinical outcomes and late toxicities are satisfactory., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Termedia.)

Purpose: To report real-world compliance to radiation in gynecologic cancers during the complete lockdown phase of COVID-19 pandemic., Methods and Materials: From March 23, 2020, until June 30, 2020, complete lockdown was imposed in India. During this period there was restructuring of cancer care and radiation oncology department due to operational policies prevalent in the institution, and the care for gynecological cancer was based on the evolving international recommendations. Institutional review board approval was obtained to audit patterns of care during the complete lockdown phase. Descriptive variables were used to report on patient characteristics, compliance, delays, toxicity, and observed deviations in recommended care., Results: During the lockdown period spanning 100 days, treatment of 270 and telephonic follow-up of 1103 patients with gynecological cancer was undertaken. Of 270 new patients, due to travel restrictions, 90 patients were referred to the facilities in vicinity of their residence. Of the remaining 180 patients, 138 were planned for complete treatment at our institution and 42 were referred to our center for brachytherapy. Of 138 patients, only 106 (76%) completed the planned external radiation. Twenty-four (26%) patients completed full course of concurrent chemotherapy, 11 (12%) received chemotherapy dose reduction, and 57 (62%) received no concurrent chemotherapy. Treatment delay of up to 3 weeks was noted in 8.6% patients due to COVID-19 infection. No grade 4 to 5 acute sequelae were observed. No excess adverse effects were observed in high-risk population. Low rate of symptom burden was observed among 1103 patients on telephonic follow-up. With 100 (9.6%) patients reporting symptoms, among these, 54% (54 of 100) had complete resolution of symptoms within 4 weeks of teleconsultation, and 10% had disease progression., Conclusions: Low compliance with planned treatment was observed for radiation and concurrent chemotherapy due to lockdown and fear of contracting COVID-19 and will likely lead to increased risk of cancer-related mortality. Rapid restructuring of care is needed to prevent the same as COVID-19 pandemic further evolves., (© 2021 The Authors.)

Background: The lockdown associated with the COVID-19 pandemic is likely to impact people's mental health, especially those from economically disadvantaged and vulnerable sections of society. Mental health can be affected by many factors, including fear of disease transmission, from response measures against the pandemic like social distancing, movement restriction, fear of being in quarantine, loneliness, depression due to isolation, fear of losing work and livelihood and avoiding health care due to fear of being infected. Telephonic befriending intervention by non-specialists will be used to provide social and emotional support to the youth from the Deen Dayal Upadhyaya Grameen Kaushalya Yojana (DDUGKY), an initiative of the Government of India. This study aims to promote mental wellbeing and reduce depressive symptoms by assisting participants to mobilise social support from family, friends and significant others by using the telephonic befriending intervention., Methods: In this article, we report the design and protocol of a multi-centre cluster randomised controlled trial. In total, 1440 participants aged 18-35 years who have recently completed their course out of the DDU-GKY initiative will be recruited in the study from 12 project-implementing agencies (PIAs) across six geographical zones of India. Participants from 6 of these agencies will be assigned to the telephonic befriending intervention arm, and the other six agency participants will be assigned to the general enquiry phone call arm (control). The primary outcomes of this study are mental wellbeing, depressive symptoms and perceived social support. Baseline assessments and follow-up assessments will be carried out 1 month following the intervention using WHO-5, PHQ and MSPSS-12 questionnaires. The befriending intervention will be provided by DDU-GKY staff, whom a virtual training programme will train., Discussion: This trial will help assess whether participants who are offered emotional, social and practical support through befriending will experience lesser symptoms of depression and better mental health compared to participants who do not receive this intervention through mobilised social support from friends, family and others., Trial Registration: Clinical Trial Registry India (ICMR-NIMS) CTRICTRI/2020/07/026834 . Registered on 27 July 2020., (© 2021. The Author(s).)

Social networks protect individuals from mental health conditions of depression and anxiety. The association between each social network type and its mental health implications in the Indian population remains unclear. The study aims to determine the association of depression and anxiety with different social network types in the participants of a community cohort. We conducted a cross-sectional household survey among people aged ≥30 years in geographically defined catchment areas of Kerala, India. We used cross-culturally validated assessment tools to measure depression, anxiety and social networks. An educated male belonging to higher income quartiles, without any disability, within a family dependent network has lower odds of depression and anxiety. Furthermore, 28, 26.8, 25.7, 9.8 and 9.7% of participants belonged to private restricted, locally integrated, wider community-focused, family-dependent and locally self-contained networks, respectively. Close ties with family, neighbours, and community had significantly lower odds of anxiety and depression than private restricted networks. The clustering of people to each social network type and its associated mental health conditions can inform social network-based public health interventions to optimize positive health outcomes in the community cohort.

Background: Kerala is known as the diabetes mellitus (DM) and hypertension (HTN) capital of the world, thus compelling health professionals to model strategies, addressing their social, behavioural, and cognitive risk factors and eliminating various barriers to management. This paper describes the protocol of our study that aims to examine the effectiveness and sustainability of an integrated care model for the management of chronic conditions and their risk factors through a family-based intervention. The proposed care model targets to modify systems and processes that predispose to chronic conditions by enhancing social cohesion and social networks, preventing lifestyle risks, developing iterative cognitive interventions, and engaging the family into customised treatment adherence strategies navigated by community health social workers (CHSWs)., Methods: A cluster randomised controlled trial (RCT) in selected participants will be conducted involving additional assessments prior to the baseline assessment. The assessment will identify and categorise patients into four risk groups, namely behavioural, social, cognitive, and multiple, based on dominant risks identified. Eligible participants will be randomly allocated (at a ratio of 1:1) into the intervention or control arm. The intervention arm will receive social, behavioural, and cognitive or multiple interventions corresponding to the identified risk groups, whereas the control arm will receive general intervention. Both the groups will be followed up at 6 months and 12 months post baseline to measure outcomes. The primary outcome will be the control of HTN and DM, and secondary outcomes include decreased depression and anxiety and improved functioning, social cohesion, and social network linkages. The sustainability and scalability of this intervention will be assessed through cost effectiveness, acceptability, and user friendliness of the integrated approach by performing a qualitative evaluation., Discussion: This RCT will inform the potential paradigm shift from a medical model of chronic condition management to a multidimensional, multisystem, and multidisciplinary convergence model navigated by CHSWs. Such a model is not currently considered in the management of chronic conditions in Kerala., Trial Registration: Trial has been prospectively registered on Clinical Trial Registry of India- CTRI/2020/12/029474 on 1st December 2020.

Purpose: The purpose of the study was to report dosimetric differences for breast brachytherapy plans optimized for clinical target volume (CTV) generated using conventional isotropic expansion of tumor bed volume (TBV) and Groupe Européen de Curiethérapie-European Society for Radiotherapy and Oncology (GEC-ESTRO) recommendations to expand the TBV anisotropically to achieve a total safety margin of 2 cm (resection margin size + added safety margin)., Methods: Institutional records of 100 patients who underwent accelerated partial breast irradiation using multicatheter interstitial brachytherapy from May 2015 to March 2020 were reviewed retrospectively. Two sets of CT-based plans were made, one with 1-cm isotropic margins around the tumor bed (CTV&#95;ISO) and the other with anisotropic margins (CTV&#95;GEC). Plans were evaluated and compared using the American Brachytherapy Society and GEC-ESTRO guidelines., Results: The median TBV was 36.97 cc. The median margin widths were as follows: anterior 1.2, posterior 1.0, superior 1.0, inferior 0.9, medial 1.2, and lateral 1.2 cm. The mean tumor bed coverage index was 0.94; 0.93 [p.066], the CTV coverage index 0.86; 0.84 [p 0.001], the dose homogeneity index (DHI) 0.77; 0.75 [p < 0.001] and the conformity index 0.66; 0.64 [p < 0.001] in CTV&#95;ISO and CTV&#95;GEC plans, respectively. In smaller volume implants (TBV< 35 cc), the DHI was 0.76; 0.75 [p 0.008] and the conformity index was 0.66; 0.62 [p < 0.001], whereas in larger volumes >35 cc, the CTV coverage index was 0.86; 0.84 [p 0.003] and the DHI 0.78; 0.76 [p 0.001] in CTV&#95;ISO and CTV&#95;GEC plans, respectively., Conclusions: In this cohort of patients who underwent accelerated partial breast irradiation, plans with anisotropic margins had lower conformity, the impact of which was predominantly seen in smaller implants. Rest of the dosimetric constraints were achieved in both the plans as per the American Brachytherapy Society and GEC-ESTRO guidelines., (Copyright © 2021 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

In India, cardiovascular disease (CVD), with hypertension as its foremost risk factor, has the highest prevalence rate of non-communicable diseases (NCDs) and a rising mortality. Previous research has found a clustering of behavioural and social risks pertaining to NCDs, though the latter are infrequently addressed in public health interventions in India. This paper reaches toward the development of a social intervention to address social determinants of NCD relating to hypertension and diabetes. We used Theory of Change (ToC) as a theoretical approach to programme design. Mixed methods were used, including qualitative interviews with community members ( n = 20), Accredited Social Health Activists ( n = 6) and health professionals ( n = 8), and a stakeholder workshop ( n = 5 participants). The recruitment of participants from one local area in Kerala enabled us to map service provision and gain a holistic understanding of how to utilise the existing workforce to target social risk factors. The findings suggest that social interventions need to focus on ensuring health behaviour information reaches all parts of the community, and that those with more social risk factors are identified and supported to engage with treatment. Further research is required to test the resulting intervention model.

The Tomographic Quantitative Electroencephalography (qEEGt) toolbox is integrated with the Montreal Neurological Institute (MNI) Neuroinformatics Ecosystem as a docker into the Canadian Brain Imaging Research Platform (CBRAIN). qEEGt produces age-corrected normative Statistical Parametric Maps of EEG log source spectra testing compliance to a normative database. This toolbox was developed at the Cuban Neuroscience Center as part of the first wave of the Cuban Human Brain Mapping Project (CHBMP) and has been validated and used in different health systems for several decades. Incorporation into the MNI ecosystem now provides CBRAIN registered users access to its full functionality and is accompanied by a public release of the source code on GitHub and Zenodo repositories. Among other features are the calculation of EEG scalp spectra, and the estimation of their source spectra using the Variable Resolution Electrical Tomography (VARETA) source imaging. Crucially, this is completed by the evaluation of z spectra by means of the built-in age regression equations obtained from the CHBMP database (ages 5-87) to provide normative Statistical Parametric Mapping of EEG log source spectra. Different scalp and source visualization tools are also provided for evaluation of individual subjects prior to further post-processing. Openly releasing this software in the CBRAIN platform will facilitate the use of standardized qEEGt methods in different research and clinical settings. An updated precis of the methods is provided in Appendix I as a reference for the toolbox. qEEGt/CBRAIN is the first installment of instruments developed by the neuroinformatic platform of the Cuba-Canada-China (CCC) project., (Copyright © 2020 Bosch-Bayard, Aubert-Vazquez, Brown, Rogers, Kiar, Glatard, Scaria, Galan-Garcia, Bringas-Vega, Virues-Alba, Taheri, Das, Madjar, Mohaddes, MacIntyre, CHBMP, Evans and Valdes-Sosa.)

Background: Cardiovascular disease (CVD) is the leading cause of mortality in India. Social and behavioural factors are strongly interrelated in the prevention and control of CVD. The ability to make lifestyle changes to control hypertension and diabetes (major risk factors for CVD) is determined by factors such as education, gender, caste, poverty, and urbanicity. This study aimed to improve our understanding of the inter-relationship of social and behavioural factors in the management of elevated serum glucose and high blood pressure and co-morbid mental health conditions., Methods: A population-based catchment area cross sectional survey was conducted in Kerala, India. Data were collected from residents aged over 30 years (n = 997) using standardized tools and clinical measures. We performed latent class analysis incrementally to extract homogeneous latent classes of individuals based on their responses to social and behavioural risk factors in the survey. Using structural equation models, we assessed the mediating effect of depression and anxiety, and social or behavioural risk factors, on management of high blood pressure and raised serum glucose levels., Results: The prevalence of high blood pressure and blood glucose in the sample was 33 and 26% respectively. Latent class analysis found three clusters of risk factors. One had a predominance of behavioural characteristics, another of social risk factors and the third was a low risk group. Age, female sex, and marital status had an effect on high blood pressure and high glucose, though were mediated by mental health, social and behavioural risk factors., Conclusions: Interventions to improve the management of risk factors for CVD need to address social risk factors and be sensitive to the needs of population sub-groups that may require additional support to access health services. An integration of social and health services may be required to achieve this.

Objectives: The purpose of this study is to examine the existing literature of the major social risk factors which are associated with diabetes, hypertension and the comorbid conditions of depression and anxiety in India., Design: Scoping review., Data Sources: Scopus, Embase, CINAHL Plus, PsycINFO, Web of Science and MEDLINE were searched for through September 2019., Eligibility Criteria for Selecting Studies: Studies reporting data on social risk factors for diabetes or hypertension and depression or anxiety in community-based samples of adults from India, published in English in the 10 years to 2019, were included. Studies that did not disaggregate pooled data from other countries were excluded., Data Extraction and Synthesis: Two independent reviewers extracted study aims; methods; sample size and description; demographic, social and behavioural risk factors and a summary of findings from each paper. Risk factors were synthesised into six emergent themes., Results: Ten studies were considered eligible and included in this review. Nine presented cross-sectional data and one was a qualitative case study. Six themes emerged, that is, demographic factors, economic aspects, social networks, life events, health barriers and health risk behaviours., Conclusions: Literature relating to the major social risk factors associated with diabetes, hypertension and comorbid depression and anxiety in India is sparse. More research is required to better understand the interactions of social context and social risk factors with non-communicable diseases and comorbid mental health problems so as to better inform management of these in the Indian subcontinent., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Methods: In this prospective family-based cohort study, 573 families were included with a total of 997 participants aged 30 years and above. Baseline interviews were conducted in participant's homes using a combination of self-structured and standardized questionnaire. Blood pressure and plasma glucose were assessed for each participant., Results: The prevalence of hypertension was 43%. It was slightly higher in women than men (43.7% vs. 41.4%). The mean systolic blood pressure in the hypertensive population was 141.9 mmHg and mean diastolic blood pressure was 85.3 mmHg. In total, 78% (86.2% in women, 62.9% in men) of the participants were aware of their hypertension. Among those aware, 60.4% (63.5% in women, 52.6% in men) of the participants were on treatment, and hypertension was controlled in 75.1% (77.5% women, 68% in men) of the participants on treatment. The prevalence of hypertension was higher among persons with comorbidities (diabetes 64.5%, transient ischemic attack 54.7%, and heart disease 64.4%). Prevalence was lower among persons who did regular vigorous intensity exercise versus those who did moderate intensity exercise (32% vs. 45.7%) and among nonsmokers versus smokers (42.2% vs. 46.6%)., Conclusion: The prevalence of hypertension in Kerala is high. Although awareness is quite high, there is a need to improve the number of persons with hypertension taking treatment., Competing Interests: The authors declare that there are no conflicts of interest., (Copyright © 2020 M. D. Saju et al.)

Purpose: In response to the need for more advanced and longitudinal data concerning chronic diseases, behavioural risk factors and social support systems in India, the SWADES (Social Well-being and Determinants of Health Study) was established., Participants: At baseline, 997 adults aged 30 years and over, living in the semi-urban area were interviewed in their home., Findings to Date: Data collected included self-reports of demographic details, health, depression, morbid conditions and healthcare utilisation, risk factors (physical, behavioural and social) of chronic diseases, common mental disorders, out-of-pocket expenditure, social support network, social cohesion, disability, education and wealth. Objective data for hypertension, diabetes and cognitive function were also collected., Future Plans: The first annual follow-up interviews were completed in 2019; the subsequent annual follow-up will be conducted until 2030. The SWADES data are held at the International Centre for Consortium Research in Social Care (ICRS), Rajagiri College of Social Science, Kerala, India. Procedures for data access, information on collaborations, publications and other details can be found at (http://icrs.in)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Microarray gene data is widely known for its high dimensionality and volume. The utilization of microarray gene data is increasing now-a-days, owing to the advancement of medical science. Microarray gene data helps in diagnosing diseases quite accurately. However, processing microarray gene data is difficult and is usually not understandable. Taking this challenge into account, this work presents a user-friendly rule based classification model, which is easily understandable and does not demand users to have prior knowledge. The classification rules are formed with the help of cuckoo search optimization algorithm and the rules are pruned by the associative rule mining. Finally, the classification is performed with the help of the pruned rules. The performance of the proposed approach is satisfactory in terms of accuracy, sensitivity, specificity and time consumption.