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Pre-operative anxiety in patients undergoing coronary artery bypass graft

surgery - A cross-sectional study

Article  in  International Journal of Africa Nursing Sciences · June 2017

DOI: 10.1016/j.ijans.2017.06.003

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 International Journal of Africa Nursing Sciences 7 (2017) 31–36

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International Journal of Africa Nursing Sciences

journal homepage: www.elsevier.com/locate/ijans

Pre-operative anxiety in patients undergoing coronary artery bypass

graft surgery – A cross-sectional study
C. Ramesh a,⇑, Baby S. Nayak a,1, Vasudev Baburaya Pai b,2, Anice George a,1, Linu Sara George a,3,
Elsa Sanatombi Devi a,4
a
Manipal College of Nursing, Manipal University, Manipal, India
b
Department of Cardiovascular & Thoracic Surgery, Kasturba Medical College, Manipal University, Manipal, India

a r t i c l e i n f o a b s t r a c t

Article history: Background: Coronary artery bypass graft surgery is an important treatment for the patients with
Received 17 November 2016 coronary artery disease to reduce angina and enhance the quality of life. Anxiety is a usual reaction to
Received in revised form 13 June 2017 a stressful situation and is existing in patients awaiting surgery.
Accepted 23 June 2017
Objective: The objective of the study was to assess pre-operative anxiety in patients who were
Available online 27 June 2017
undergoing coronary artery bypass graft surgery.
Methods: A cross-sectional study consisting of 140 patients undergoing coronary artery bypass graft
Keywords:
surgery were included in the study using a convenience sampling technique in a tertiary care referral hos-
Preoperative period
Anxiety
pital. The data was collected using state-trait anxiety inventory. The data were entered into SPSS (version
Coronary artery bypass – 20.0) for windows and descriptive and inferential statistics were performed.
Perioperative care Results: The study enrolled 140 (117 males and 23 females) patients. Their mean age was 57.29 ± 8.14
(range 35–70 years). Most of the patients 118 (84%) had preoperative anxiety before coronary artery
bypass graft surgery. There was an association found between gender and anxiety with Pearson
chi-square value of 11.57 (p < 0.001).
Discussion: Patients undergoing coronary artery bypass graft surgery is experiencing the high level of
pre-operative anxiety and females had higher anxiety than the males. Identification of the pre-
operative anxiety in patients undergoing CABG surgery is essential because it helps the health profession-
als and nurses to develop effective and appropriate interventions.
Ó 2017 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Coronary artery disease (CAD) is one of the leading causes of
morbidity and mortality in both the developing and the developed
countries (Sekhri et al., 2014). Coronary artery bypass graft (CABG)
surgery is one of the important treatment for the patients with
⇑ Corresponding author at: Department of Medical Surgical Nursing, Manipal
College of Nursing, Manipal University, Manipal, Udupi, Karnataka 576104, India.
E-mail addresses: rameshmsn08@yahoo.com (C. Ramesh), baby.s@manipal.edu
(B.S. Nayak), vasudev.pai@manipal.edu (V.B. Pai), anice.george@manipal.edu
(A. George), linu.j@manipal.edu (L.S. George), elsa.sana@manipal.edu (E.S. Devi).
1
Manipal College of Nursing, Manipal University, Manipal, Udupi, Karnataka
576104, India.
2
Department of Cardiovascular and Thoracic Surgery, Kasturba Medical College &
Hospital, Manipal University, Manipal, Udupi, Karnataka 576104, India.
3
Department of Fundamentals of Nursing, Manipal College of Nursing, Manipal
University, Manipal, Udupi, Karnataka 576104, India.
4
Department of Medical Surgical Nursing, Manipal College of Nursing, Manipal
University, Manipal, Udupi, Karnataka 576104, India.
CAD, bearing in mind that the technique reduces angina and
enhances the quality of life of the patients (McKenzie, Simpson,
& Stewart, 2010). The CABG is the most commonly performed sur-
gery throughout the world, with an annual estimate of 686000
CABG surgeries have been conducted in the United States.
In 2010, the annual number of CABG surgery in India was about
60,000 (Kaul & Bhatia, 2010) and in 2012 the number was about
1.5 lakhs (Panda, 2012). In 2012, an annual number of CABG sur-
gery in England was about 20000 in the United Kingdom
(Bhatnagar, Wickramasinghe, Williams, Rayner, & Townsend,
2015). CABG have been considered a routine operation for more
than 30 years. In South Africa, approximately 8400 coronary
bypass operations are performed per year (The Heart & Stroke
Foundation, 2016).
Undergoing cardiac surgery may be a stressful experience for
the patients physically and psychologically. The reason for stress
while undergoing major cardiac surgery may be due to fear and
anxiety on the outcomes of the surgery as a vital organ, the heart,

http://dx.doi.org/10.1016/j.ijans.2017.06.003
2214-1391/Ó 2017 Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
32 C. Ramesh et al. / International Journal of Africa Nursing Sciences 7 (2017) 31–36
is involved. While waiting for major heart surgery significant phys-
ical and psychological stressors, including higher anxiety, uncer-
tainties, depression, and worries regarding outcomes of the
surgery are typically experienced by the patients. These factors
may aggravate the symptoms of existing disease and can have an
adverse effect on physiological parameters during anesthesia,
before and after surgery, and also can lead to disturbed recovery
after the surgery (Guo, East, & Arthur, 2012).
The major changes in a general routine lifestyle provoke anxiety
in the individuals, and one of the incidents is undergoing coronary
artery bypass grafting. Hospitalization, regardless of any medical
condition, is familiar to cause anxiety in the patients admitted
for surgical treatment. If not recognized sustained anxiety builds
stress which may consequently disturb the patients and their prog-
nosis (Goebel, Kaup, & Mehdorn, 2011; Yilmaz, Sezer, Gürler, &
Bekar, 2012). In the concept of the pre-operative nursing care, car-
ing for the pre-operative anxiety is more challenging. The majority
of the patients who are shortlisted for major heart surgery experi-
ence anxiety and it is an anticipated reaction and widely accepted
(Nigussie, Belachew, & Wolancho, 2014).
There are many factors leading to anxiety due to cardiac sur-
gery, which includes extreme chest pain and subsequent fatigue,
disability, fear of death, and persistent symptoms despite heart
surgery (Bagheri-Nesami et al., 2014). Anxiety is an unpleasant
experience that disturbs the patients emotionally, physically, and
psychologically. In the pre-operative period, the patients awaiting
heart surgery may experience a high level of anxiety and symp-
toms of depression impaired functional status, chest pain, and
shortness of breath due to worries, fears, and outcomes of surgery
(Guo, 2014).
Symptoms of anxiety, stress, depression, and pain are usual dis-
turbances in patients with CAD, including those undergoing the
CABG surgery (Cserép et al., 2012). All these factors aggravate the
symptoms of the prevailing disease, affect physiological parame-
ters adversely before and during anesthesia, and may cause pro-
longed recovery and compromise quality of life following the
surgery (Guo et al., 2012; Nerbass, Feltrim, de Souza, Ykeda, &
Lorenzi-Filho, 2010). A recent study conducted by Flinders Medical
Centre, South Australia reported that anxiety symptoms in the
postoperative period were associated with atrial fibrillation
(Tully et al., 2011).
Currently, as India is having a higher incidence of CAD and
CABG surgeries as compared to the other countries in the world.
Although there are some previously published studies on assess-
ment of preoperative anxiety among CABG surgery from various
countries, there is a research gap as it is not found among the
Indian population. As the Indian population is well represented
everywhere hence the findings of this study will give new insight
on preoperative anxiety among patients undergoing CABG surgery
to the scientific community.
Nurses caring the patients undergoing CABG surgery in the pre-
operative period often notice the overwhelming anxiety, fear, and
stress that many of their patients experience. Information on
how these patients experience anxiety before CABG surgery is
important in order to plan some effective interventions that can
be applied and may aid patients to decrease their anxiety levels,
resulting in a faster recovery potentially. The findings of this study
will also provide additional evidence about pre-operative anxiety
to the nurses and health professionals in creating health care poli-
cies and to implement appropriate interventions.
1.1. Objective
The objective of the study was to evaluate preoperative anxiety
in patients who were undergoing CABG surgery. The second objec-
tive was to identify the association between preoperative anxiety
and demographic variables among the CABG surgery patients in a
tertiary care hospital.
1.2. Methods
The study approach was a quantitative research approach and
the design was a cross-sectional survey. The study population com-
prised patients who were admitted to the cardiovascular surgery
department for CABG in the tertiary care hospital. The sample size
was calculated according to a similar study (Tsushima, Johnson,
Lee, Matsukawa, & Fast, 2005) with 80 % power and 5% error and
the estimated sample size was 140. The following inclusion criteria
applied the patients undergoing elective CABG for the first time,
aged between 35 and 70 years in both the genders and able to com-
municate in English or local language.
The emergency CABG surgery, the patients with known psychi-
atric comorbidities, those who were not willing to participate, who
underwent CABG with valvular replacement or repair were
excluded from the study. The patients with known psychiatric
comorbidities were excluded as the outcome variable may be influ-
enced due to the preexisting disease condition. CABG with valvular
heart surgery was excluded as the study was intended to measure
the anxiety among isolated CABG surgery patients. Non-probability
convenience sampling technique was used to recruit the sample
for the study. As the patients get admitted in the wards of cardio-
vascular and thoracic surgery, the patients were assessed for inclu-
sion criteria and they were included they were found to be eligible.
The study was conducted in a single tertiary care center and the
data was collected one day prior to the surgery.
1.3. Ethical considerations
The investigation fits into the principles defined in the Declara-
tion of Helsinki (World Medical Association, 2013). The study was
reviewed and approved by the Institutional Review Board and
Institutional Ethics Committee (KH/IEC 52/2014). A subject infor-
mation sheet was provided with clear explanation to each study
participants and written informed consent was obtained before
including them in the study.
1.4. Instruments
The instrument had two parts. Part A comprised the items that
were used to collect the socio-demographic factors such as age,
gender, religion, education, marital status, occupation, lifestyle,
place of residence, dietary pattern, habit of smoking and alcohol,
use of tobacco, regular exercise, family history of CAD, history of
hypertension, diabetes mellitus and heart attack. Part B was the
state-trait anxiety inventory (STAI). STAI consisted of two parts
the state anxiety (STAI-S) and the trait anxiety (STAI-T) commonly
utilized anxiety to evaluate the anxiety (Spielberger, 1983). The
investigator obtained permission from the Mind Garden, the Uni-
ted States of America to use this instrument in this study. STAI is
the most popular instrument in assessing anxiety and it has 20
items for assessing trait anxiety and 20 for state anxiety. State anx-
iety items include: ‘‘I am tense; I am worried” and ‘‘I feel calm; I
feel secure.” Trait anxiety items include: ‘‘I worry too much over
something that really doesn’t matter” and ‘‘I am content; I am a
steady person.”
In responding to the state-anxiety, the study participants
reported how they felt ‘right now’ by rating the intensity of their
anxiety feelings on a four-point Likert scale: where 1 = not at all;
2 = somewhat; 3 = moderately so, and 4 = very much so. For the trait
anxiety, the patients reported how they ‘generally’ feel by rating
themselves on a Likert four-point scale where 1 = almost never;
2 = sometimes; 3 = often; 4 = almost always. The patients’ responses
 C. Ramesh et al. / International Journal of Africa Nursing Sciences 7 (2017) 31–36
were summed for a total score between 20 and 80, with the higher
score indicating the greater anxiety levels. Total anxiety scores also
can be classified into the following categories: 20–39 (low anxi-
ety), 40–59 (medium anxiety), and 60–80 (high anxiety) (Koivula,
Tarkka, Tarkka, Laippala, & Paunonen-Ilmonen, 2002).
1.5. Validity and reliabilty
Instrument Part A, which had socio-demographic factors was
given to a panel of nine subject experts to establish the content
validity. The experts were selected based on their experience and
interest in the problem being assessed in this study. I-CVI (Item
level content validity index) and S-CVI (scale level content validity
index) were calculated. The mean of both I-CVI and S-CVI was 0.97.
Therefore, the tool was found to be valid to use in the study. The
pilot study was conducted with twenty participants to assess the
reliability in the local population being studied. They were not a
part of the main study and the calculated internal consistency
Cronbach’s alpha value for the state anxiety was 0.82 and 0.86
for the trait anxiety. Hence, the tool is found to be adequate and
reliable in assessing the intended outcome of the study.
1.6. Data collection procedure
After the admission of patients to the hospital in cardiovascular
and thoracic surgery ward, from the admission book the patients
were accessed and also the investigator collected information
Fig. 1. Sample recruitment and data collection flow chart.
33
regarding patients admission from the ward in charge. One day
before the surgery a calm environment was provided. The purpose
of this research was explained to all the participants and provided
with a subject information sheet. After obtaining the written
informed consent, the patients completed the self-reported ques-
tionnaire of socio-demographic variables and state-trait anxiety
inventory. The patients completed the data collection instrument
in the cardiovascular thoracic surgery ward.
The clinical variables of the selected study participants were
collected by the principal investigator. The clinical variables were
collected from patients’case record. The average time taken by
the participants to fill the data collection form varied between 10
to 15 minutes. The data was collected between August 2015 and
July 2016. Recruitment of study the participants is shown in
Fig. 1. To summarize, 180 participants were approached to join this
study and out of 155 eligible participants, 140 were enrolled in the
study. All 140 patients completed the data collection forms pre-
operatively. No missing values occurred, as all data were collected
in person.
1.7. Statistical analysis
Statistical Package for the Social Sciences (SPSS for Windows,
version 20.0) was utilized for the analysis of data. The descriptive
and the inferential statistics were used to analyze the study data.
The frequency and the percentage were computed to report the
patient’s socio-demographics factors and mean, standard
34 C. Ramesh et al. / International Journal of Africa Nursing Sciences 7 (2017) 31–36

deviation, minimum and maximum scores were calculated to (92.9%) were married, 53 (37.9%) had higher secondary education,
report the anxiety scores. The association between anxiety scores and 80 (57.1%) skilled workers.
and demographic factors was analyzed by using the Chi-square Among the study participants 69 (49.3%) were from rural areas,
test. The results were summarized using the tables and presented 94 (67.1%) had a sedentary lifestyle, 65 (46.4%) had the habit of
with narrative descriptions. There were no missing data in the sta- smoking, and 53 (40.7%) had the habit of consuming alcohol, 39
tistical analysis. (27.9%) tobacco consumers, and 98 (70%) non-vegetarians. Only
32 (22.9%) of them had the habit of regular exercise and 53
(37.9%) participants had the family history of heart disease.
2. Results
Concerning the clinical variables, the mean body mass index
was 26.19 ± 2.02. Most of them had a history of hypertension
2.1. Sample characteristics
(65%), diabetes mellitus (62.1%), and 33 (23.6%) of them had a his-
tory of heart attack. Socio-demographic and clinical variables of
The study enrolled (117 males and 23 females) participants.
the patients are summarized in Table 1.
Their mean age was 57.29 ± 8.14 (range 35–70 years). Among the
study participants, the most of them 117 (83.6%), were males
between the age of 36 and 70 years, 118 (84.3%) Hindus, 12 2.2. Preoperative anxiety
(8.6%) Christians, and 10 (7.1%) Muslims. Most of them i.e., 130
Regarding the state anxiety, it was revealed that 22 (15.7%) of
Table 1 them had low anxiety, most of them 103 (73.6%) had medium anx-
Socio – demographic and clinical variables of the patients.
iety, and 15 (10.7%) of them high anxiety. The trait anxiety
n = 140 revealed that most of the study participants 73 (52.1%) had low
Socio-demographic and clinical variables Frequency Percentage anxiety, 62 (44.3%) had medium anxiety, and only 5 (3.6%) high
Gender Male 117 83.6
anxiety (Table 2).
Female 23 16.4 Most of the study participants 118 (84%) had considerable pre-
Religion Hindu 118 84.3 operative anxiety with mean state anxiety score 51.03 ± 10.50
Christian 12 8.6 (range 25–67). Almost half of the study participants 67 (47.9%)
Muslim 10 7.1
had increased trait anxiety with the mean score 40.22 ± 9.59
Education Non formal 28 20.0
Primary 44 31.4 (range 23–64) (Table 3).
Higher secondary 53 37.9 The mean pre-operative anxiety scores based on gender
Degree and above 15 10.7 revealed that females had the higher anxiety than males in both
Marital Status Married 130 92.9 trait and state anxiety. The mean scores of trait anxiety and state
Unmarried 1 0.7
Widowed 10 6.4
anxiety in males were 39.41 ± 9.82 and 50.83 ± 10.10 respectively.
Occupation Skilled 80 57.1 In females, the mean scores of trait anxiety and state anxiety were
Home maker 19 13.6 44.34 ± 12.23 and 52.04 ± 12.55 respectively (Table 4).
Professionals 5 3.6
Business 15 10.7
Retired 21 15.0 Table 3
Life style Sedentary 94 67.1 Mean and standard deviation of preoperative anxiety scores.
Moderately active 46 32.1
n = 140
Place of residence Rural 69 49.3
Urban 37 26.4 Anxiety Scores Mean SD Minimum Maximum
Semi urban 34 24.3
STAI - S 51.03 10.50 25 67
Habit of smoking Yes 65 46.4
STAI - T 40.22 9.59 23 64
No 75 53.6
Habit of alcohol Yes 57 40.7 Note: N= Sample size; STAI – S = State Trait Anxiety Inventory – State; STAI-T = State
No 83 59.3 Trat Anxiety Inventory – Triat; SD – Standard deviation.
Use of tobacco Yes 39 27.9
No 101 72.1
Dietary Pattern Vegetarian 42 30.0
Table 4
Non-vegetarian 98 70.0
Mean and standard deviation of preoperative anxiety scores based on gender.
Regular Exercise Yes 32 22.9
No 108 77.1 n = 140
Family history of CAD Yes 53 37.9
No 87 62.1 Anxiety Male Female
Hypertension Yes 91 65.0 Scores
Mean SD Mean SD
No 49 35.0
STAI - S 50.83 10.10 52.04 12.55
Diabetes Mellitus Yes 87 62.1
STAI - T 39.41 9.82 44.34 12.23
No 53 37.9
Heart Attack Yes 33 23.6 Note: N= Sample size; STAI – S = State Trait Anxiety Inventory – State; STAI-T = State
No 107 76.4 Trat Anxiety Inventory – Triat; SD – Standard deviation.

Table 2
Level of preoperative anxiety scores in the patients before CABG surgery.

n = 140
Instrument Low Anxiety Medium Anxiety High Anxiety
Frequency Percentage Frequency Percentage Frequency Percentage
STAI - S 22 15.7 103 73.6 15 10.7
STAI - T 73 52.1 62 44.3 5 3.6

Note: N= Sample Size; STAI – S = State Trait Anxiety Inventory – State; STAI-T = State Trat Anxiety Inventory – Triat.
 C. Ramesh et al. / International Journal of Africa Nursing Sciences 7 (2017) 31–36
Table 5
Association of level of anxiety with the gender.
n = 140
Gender Male
Frequency Percentage
Low anxiety 18 15.4
Medium anxiety 91 77.8
High anxiety 8 6.8
Note: N= Sample size; x2 – Pearson Chi-square value, df – degree of freedom.
2.3. Association of anxiety with socio-demographic and clinical
variables
There was a significant association found between gender and
level of state anxiety with Pearson chi-square value of 11.57
(p < 0.001) (Table 5). There was no association found between
the level of anxiety and the other socio-demographic variables
such as religion, education, place of residence, occupation, activity,
exercise, dietary pattern, the habit of smoking, alcohol, history of
hypertension, diabetes mellitus, family history of heart disease
and heart attack.
3. Discussion
Anxiety is a usual reaction to a stressful situation and found in
patients awaiting for major surgery. Most of the patients enter the
operation room with fear and anxiety. The results of this study
revealed that the patients following CABG surgery had increased
pre-operative anxiety and provide evidence to the mounting body
of knowledge on psychological issues among the patients having
CABG surgery. Our study results are matching with the previous
study findings of pre-operative anxiety among the patients before
CABG conducted in United States of America and Germany
(Chunta, 2009; Gallagher & McKinley, 2007; Krannich et al., 2007).
The evaluation of pre-operative anxiety revealed that most of
the patients had higher state anxiety 108 (84.3%) and 67 (47.9%)
trait anxiety before CABG. These findings are in line with the
results of the previous studies conducted in Ethiopia and Iran
(Nigussie et al., 2014; Nooghabi, 2014). There was an another study
conducted at Medical University Hospital, Poland which concluded
that there was a significant association found between depression
and anxiety (p = 0.001), suicidal thoughts (p = 0.023), and lower
subjective health status (p = 0.002). The study concluded that eval-
uation of anxiety among patients undergoing cardiac surgery is
very important (Nowicka-Sauer et al., 2016).
In comparison with gender, our study observed that the females
had the higher pre-operative anxiety scores than the males on both
state and trait anxiety. In the previous research studies conducted
in the United States of America and Taiwan the similar findings
have been reported (Gallagher & McKinley, 2009; Tung, Hunter,
Wei, & Chang, 2009). While the previous study conducted in Ethio-
pia reported that there was no difference between anxiety and
gender (Nigussie et al., 2014). Our study also identified that there
was a significant association found between the level of anxiety
(p < 0.001) and the gender. This finding is supported by the previ-
ous study conducted in Iran (Nooghabi, 2014) while one study con-
ducted in Ethiopia (Nigussie et al., 2014) opposed this and reported
that there was no significant association.
Most of the patients in the study population experienced
increased anxiety before the surgery, and hence the intervention
is necessary for the patients following CABG surgery. Intervening
prior to surgery is specifically more important because the patients
who had the higher anxiety scores in the pre-operative period often
expected to remain to be apprehensive throughout their hospital
35
2
Female x df p
value
Frequency Percentage
4 17.4
12 52.2 11.751 2 .003
7 30.4
stay and recovery. The previous study conducted at Flinders Medi-
cal Centre in South Australia reported that anxiety before the sur-
gery is a predictor and reason for increased duration of anxiety
postoperatively in addition to adverse outcomes (Tully et al., 2011).
3.1. Implications to clinical practice
Identification of the pre-operative anxiety in patients undergo-
ing CABG surgery is important because it helps the health profes-
sionals and nurses to develop effective and appropriate
interventions. The evaluation of pre-operative anxiety also is
essential to reduce the emotional tension and apprehension expe-
rienced by the patients prior to a major heart surgery. It can also
avoid adverse effects after the surgery, therefore enables faster
recovery and helps in decreasing the patient’s medical cost. Given
that the recent literature review concluded that there is a correla-
tion between the pre-operative anxiety and the adverse postoper-
ative outcomes in patients following CABG surgery (Joseph,
Whitcomb, & Taylor, 2015).
Our study results suggest that the routine evaluation of preop-
erative anxiety levels prior to surgery is recommended together
with an additional exploration of the consequence of pre-
operative anxiety on recovery during the postoperative phase in
patients undergoing CABG surgery. There is a requirement for addi-
tional research in this area, along with the development of newer
interventions for the patients in improving postoperative out-
comes and promoting faster recovery. Intervention before the sur-
gery that proves its efficacy on pre-operative anxiety should be
evaluated in well-designed randomized controlled trials.
3.2. Limitations
Some of the limitations existed in this study are noteworthy.
Particularly, the representation of a small number of patients
who underwent CABG surgery. Therefore, the results of this current
study may not represent the larger population of patients undergo-
ing CABG comparing to the previous studies. It should be noted
that the anxiety scores were evaluated by a self-reported instru-
ment. Additionally, postoperative anxiety assessment was not
done, that would have given further opportunity for analyzing
the association between the pre and the postoperative anxiety.
4. Conclusion
Our study demonstrates that the patients undergoing CABG
surgery are experiencing considerable preoperative anxiety.
Evaluating pre-operative anxiety in patients undergoing CABG sur-
gery is an important responsibility of the nurses in order to provide
quality nursing care. It is also important to address the anxiety
before the surgery in order to deliver appropriate intervention
and to prevent undesirable postoperative outcomes. Establishing
methods to evaluate pre-operative anxiety and designing appropri-
ate interventions to decrease the anxiety is recommended, in order
to improve patients’ postoperative outcomes. Finally, the routine
36 C. Ramesh et al. / International Journal of Africa Nursing Sciences 7 (2017) 31–36
pre-operative assessment, screening of anxiety and providing
treatment for individuals who are at risk should be implemented
to increase the quality of life and long-standing prognosis in
patients undergoing CABG surgery.
Conflicts of interest
The author(s) declare that they have no conflict of interests.
Acknowledgements
The authors acknowledge Mr. Shankar Rao for English language
editing and Dr. Asha Kamath, Associate Professor, Department of
Community Medicine, Kasturba medical college for her expert
opinion in the statistical analysis.
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