Development and validation of a Refined Grahani Assessment Scale based on...

[Full title: Development and validation of a Refined Grahani Assessment Scale based on constitutional features for evaluating Grahani Roga]

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[Find the meaning and references behind the names: Sri, Vega, Anna, Naveen, Manas, Pradeep, Mala, Seema]

ORIGINAL ARTICLE July 2024 Journal of Ayurveda and Integrated Medical Sciences | July 2024 | Vol. 9 | Issue 7 64 Development and validation of a Refined Grahani Assessment Scale based on constitutional features for evaluating Grahani Roga Roopali R. Shindhe 1 , Naveen V 2 , Seema Pradeep 3 1 Post Graduate Scholar, Department of PG studies in Dravyaguna, Sri Sri College of Ayurvedic Science and Research, Kanakapura Rd, Bengaluru, Karnataka, India. 2 Associate professor, Department of PG studies in Dravyaguna, Sri Sri College of Ayurvedic Science and Research, Kanakapura Rd, Bengaluru, Karnataka, India. 3 Professor and HOD Department, Department of PG studies in Dravyaguna, Sri Sri College of Ayurvedic Science and Research, Kanakapura Rd, Bengaluru, Karnataka, India. I NTRODUCTION Grahani , is considered the seat of Agni , the reciprocal relationship between Grahani and Agni highlights the importance of maintaining the integrity of both as it Address for correspondence: Dr. Roopali R. Shindhe Post Graduate Scholar, Department of PG studies in Dravyaguna, Sri Sri College of Ayurvedic Science and Research, Kanakapura Rd, Bengaluru, Karnataka, India. E-mail: roopalishindhe 1@gmail.com Submission Date: 14/05/2024 Accepted Date: 22/06/2024 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.9.7.8 having Adhara Adheya Sambandhana [1] It is also mentioned in Sushruta Samhita that Grahanya Balam Agnirhi which means the strength of Grahani is Agni [2] The same action is altered when the Agni becomes Durbala or Dushta [3] Therefore, assessing Agni becomes crucial for predicting the future course of an illness like Grahani Roga . Grahani Roga is mainly caused by Agnidushti . It is caused due to the dietary habits like irregular eating habits ( Vishamasana ), overeating ( Atibhojana ), indigestion ( Ajeerna ), intake of overly cold substances ( Atisheeta ), dry or rough food ( Rooksha ), unsuitable diet ( Asatmya Bhojana ), and lifestyle like staying awake late at night ( Ratri Jagarana ), suppression of natural urges ( Vega Vidharana ) due to which it causes Agni Dushi . Dustagni further will not digest the food properly, causing Apachita Anna which leads to Visha Roopatha [4] The A B S T R A C T Introduction: Grahani is regarded as the seat of Agni , and their interdependent relationship underscores the need to preserve their integrity. Grahani Roga manifests with symptoms such as Muhur Badham and Muhur Dravam Mala . Earlier Grahani assessment scales are predominantly based on consistency of Mala rather than comprehensive Lakshanas of Grahani Roga and neither these scales were validated. Hence, development and validation of Refined Grahani Assessment Scale (RGAS) based on the Lakshanas of Grahani Roga is essential. Methodology: A thorough literature review and expert consultations were carried out to identify the most relevant signs and symptoms of Grahani disorders. Following this, the content was validated, questions were refined, and the questionnaire underwent pilot testing and validation. The finalized questionnaire was then prepared as a Google Form. The study results were used to assess the reliability of the questionnaire. Results: 235 participants participated in the survey, among whom 103 individuals were diagnosed with Grahani Roga according to specific criteria and the responses revealed validation and reliability of Refined Grahani Assessment Scale (RGAS). Conclusion: Currently, investigations into Grahani Roga focus on specific symptoms. To address this, the Refined Grahani Assessment Scale (RGAS) was developed. The creation and validation of RGAS represent a significant advancement in evaluating this condition. Applying this scale in research can enhance our understanding Lakshanas of Grahani Roga based on Agni, Kosta, Nidra, Manas and other systematic symptoms. Furthermore, its application in research can enhance understanding of Grahani Roga , leading to further progress in the field. Key words: Refined Grahani Assessment Scale, Grahani, Ayurveda, Validation study

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[Find the meaning and references behind the names: Ayush, April]

Roopali R. Shindhe et al. Development and validation of a refined Grahani Assessment Scale ISSN: 2456-3110 ORIGINAL ARTICLE July 2024 Journal of Ayurveda and Integrated Medical Sciences | July 2024 | Vol. 9 | Issue 7 65 partially digested ( Pakwa ) and partially undigested food ( Apakwa ) moves downwards leading to Muhurbadha , Muhurdhrava Mala , and other Lakshanas such as Ajeerna , Alasya , Aruchi , Udgara , Kasa , Pinasa , Karnaswana etc. and this condition is called Grahani Gada [5,6] Grahani assessment scales developed previously are predominantly based on symptoms related to consistency of stool and have not considered other factors. Hence, there is a need for development and validation of Grahani Assessment Scale for the diagnosis of the Grahani Roga based on cumulative signs and symptoms. A Refined Grahani Assessment Scale (RGAS), is developed and validated for its content validation and reliability in the present study. M ATERIALS AND M ETHODS Study setting This study was conducted at the PG Department of Dravyaguna , Sri Sri College of Ayurveda Science and Research, where the RGAS was developed and first validated. Face and content validity were ensured through the involvement of domain experts from the institution. Time frame of the study Development of the RGAS commenced in October 2023 and concluded in April 2024. Following the initial validation of the instrument, clinical testing of the RGAS took place from December 2023 to April 2024 on 235 participants. The collected data was then subjected to statistical analysis in May 2024. Conduction of the study The study comprised two sequential phases. Firstly, it focused on framing the Refined Grahani Assessment Scale (RGAS) for evaluating Grahani Roga based on existing classical literature. This phase encompassed several stages, starting from literature review to the refinement of tool components post-pilot testing. The subsequent phase involved validating the developed RGAS and establishing correlations between RGAS observations and Lakshanas of Grahani Roga . The methodology used in this research to develop and validate the new tool was verified through relevant studies in Ayurveda , ensuring its reliability. L ITERATURE R EVIEW To initiate the development of RGAS , classical Ayurvedic texts like Charaka Samhita , [7] Sushruta Samhita , [8] Ashtanga Sangraha , [9] Madhava Nidana , [10] Yogaratnakara , [11] Bhavaprakasha , [12] Haritha Samhitha, [13] and Gananatha Sen [14] were referred for characteristics related to Grahani Roga . Following a thorough review, signs and symptoms relevant to Grahani pathology were identified. These indicators were then collated to identify commonalities across all texts consulted upon which 35 features consistently described in similar or slightly varied language were identified. Those features which couldn't be assessed by the questionnaire were excluded. Finally, 28 features relevant to the systemic presentation of Grahani Roga were identified, incorporated into a questionnaire, and used for further study. Identifying Standard Ayurvedic Terms (SAT) and Corresponding English Equivalents for Selected Items The 28 chosen items were matched with their respective Standard Ayurvedic Terminologies (SAT) and morbidity categories using the National Ayurveda Morbidity Code and Standard Terminology Portal (NAMSTP) application, developed by the Ministry of Ayush, Government of India. Content validity of the selected items After initially selecting items that reflect the clinical presentation of Grahani Roga , these items were further evaluated by five clinical experts in Ayurveda. The experts were chosen based on their extensive experience in treating Grahani Roga . Each expert received a detailed item sheet containing all 35 selected items and was asked to assess the relevance of each item to the disease activity status of Grahani Roga using a scale ranging from 1 to 10, where 1 indicated minimum relevance and 10 indicated maximum relevance. This assessment was conducted by providing 35 selected item list to the experts. Responses from all five experts were collected within the specified timeframe. Based on the aggregated responses, items scoring on an average of four or higher were chosen to frame the final index tool.

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Roopali R. Shindhe et al. Development and validation of a refined Grahani Assessment Scale ISSN: 2456-3110 ORIGINAL ARTICLE July 2024 Journal of Ayurveda and Integrated Medical Sciences | July 2024 | Vol. 9 | Issue 7 66 Overall, 28 items were unanimously recognized by all experts as highly relevant to systemic clinical features. Refining questions for practical use of RGAS and establishing scoring criteria Once approved through consensus by a panel of experts, the selected items were transformed into questions to ensure clarity for individuals who might participate in the study. The questionnaire included demographic data of the participants, followed by a list of 28 items in the form of both open-ended and closedended questions. A scaling system of 0 to 3 was applied where ever necessary. Selected Clinical Features for Assessing Lakshanas in Grahani Roga based on NAMASTP portal ( https://namstp.org. ) SN Grahani Lakshana English Terminologies 1 चिरात पाक / Annam Pachyate Dukham Delayed digestion 2 अरोिक Tastelessness 3 उद्गारः Belches/reflux 4 सदन / Dourbalya Fatigue 5 मन सदन Mental fatigue/stressed 6 आलसय Lazy 7 जिर्न्ने जिययते ि अध्मना Bloating after digestion 8 पुनापुना स्रुिेत् वियस ् Repeated defaecation 9 पपनास Cold 10 कासा Cough 11 आस्य उपदेह मधुयाय Sweetness in mouth mouth/stickiness 12 छर्दय Vomiting 13 कर्यस्वना Tinnitus 14 ग्रुपिसवयरसः Desire for food including all kind of taste 15 रोगननपपडिता Suffering from any disease 16 नतममरा Blurring of vision 17 अिीर्य Indigestion of food 18 तृष्र्ा Thirst 19 पार्श्य , उरु , ग्रीव रुिहा Flank, thigh, neck pain 20 कार्शयय Emaciated Validity testing of the formatted prototype questionnaire Throughout the development of the RGAS, the prototype questionnaire was rigorously evaluated to validate its content and structure. The main focus was to ensure that the items could predict Agni Bala and Mala Pravruth i in Grahani Roga patients according to predefined criteria. Construct validity was confirmed by ensuring each item matched the concept, ensuring accurate assessment of the targeted information. Pilot testing of the prototype questionnaire The initial evaluation of the prototype RGAS included conducting pilot testing on 10 patients diagnosed with Grahani Roga , meeting predefined inclusion and exclusion criteria for clinical validation of the instrument. These participants were recruited from the outpatient clinic of Sri Sri Ayurveda Hospital during regular outpatient days. During the pilot testing phase, RGAS was converted to Google forms and was administered to the participants to gather their responses and identify any potential issues with interpretation under personal supervision. During the evaluation, one item and its question were found to be ambiguous. To fix these, modifications were made to clarify and expand upon this question aiming to enhance clarity, and further two additional

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Roopali R. Shindhe et al. Development and validation of a refined Grahani Assessment Scale ISSN: 2456-3110 ORIGINAL ARTICLE July 2024 Journal of Ayurveda and Integrated Medical Sciences | July 2024 | Vol. 9 | Issue 7 67 questions were added to the final version of the questionnaire for the same. After implementing these adjustments, the revised questionnaire, validated following the pilot testing phase, formed the foundation for subsequent validation studies of the instrument. This ensured that the RGAS was rigorously evaluated and improved, resulting in its complete validation and use in clinical settings. Inclusion Criteria: 1 Subjects who were willing to participate in the survey and willing to give consent will be selected for the study. 2 Subjects of age group between 21 to 60 years were included irrespective of their gender. Methodology Flowchart This is the final questionnaire prepared and used for the study. You can access it through the link below. https://jaims.in/jaims/article/view/3597/5341 R ESULTS 235 participants participated in the survey, among whom 103 individuals were diagnosed with Grahani Roga according to specific criteria, while those who did not meet these criteria were excluded from further study. The reliability of the questionnaire was evaluated using Cronbach's Alpha, which resulted in a value of 0.674 for 20 items DISCUSSION The selection process reduced the items from 35 to 28, as many Lakshanas (symptoms) were repetitive, and some could not be assessed by a single question. The identification of Grahani Roga in 103 out of 235 participants indicates a significant prevalence within the surveyed group. The results provide initial demographic data of the patients and their lifestyle, incorporating both closed-ended questions for structured responses and open-ended questions for individual insights. Through content validation, 28 items were unanimously recognized by experts as highly relevant to systemic clinical features. Then, Construct validity was confirmed by ensuring each item accurately represented the concept, enabling precise assessment of the targeted information. Pilot testing allowed for modifications that clarified and expanded the questions, enhancing their clarity. Finally, the preparation of the questionnaire emphasized the necessity of precise diagnostic criteria, ensuring that the scale is both reliable and consistent, making it a valuable resource for clinicians and researchers. CONCLUSION Currently, investigations pertaining to Grahani Roga are limited to assessing Vyadhi through specific Lakshanas such as Chirat Paka, Muhurbadham- Muhurdravam, Punaha Punaha Srujet . This disease has many other causes, signs and symptoms, including food, stress, and sleep, which are crucial to include in diagnostic assessments. Therefore, the development and validation of the Refined Grahani Assessment Scale represent its significance in evaluating Grahani Roga . The validation process of Refined Grahani Assessment Scale ensures the scale's validity and reliability making it a valuable tool. Furthermore, its application in research can enhance understanding of Grahani Roga , leading to further progress in the field. Further studies with a larger sample size can be conducted for a more comprehensive analysis.

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Roopali R. Shindhe et al. Development and validation of a refined Grahani Assessment Scale ISSN: 2456-3110 ORIGINAL ARTICLE July 2024 Journal of Ayurveda and Integrated Medical Sciences | July 2024 | Vol. 9 | Issue 7 68 REFERENCES 1 Acharya YT. Charaka Samhita with Ayurvedadipika Commentary by Chakrapanidatta. Varanasi: Chaukhamba Surabharathi Prakashan; 2011. p. 517. 2 Acharya YT, Acharya NR. Sushruta Samhita of Sushruta. 6 th ed. Varanasi: Chowkamba Orientalia; 1997. p. 709. ut 40/170. 3 Shastri K, Pandeya G. Charaka Samhita of Agnivesha. Vol-2, 5 th ed. Varanasi: Choukhambha Sanskrit Sansthan; 1997. p. 388. chi 15/56. 4 Agnivesha. Charaka Samhita, English Translation of Chakrapani Commentary by RK Sharma, Bhagavan Dash. Varanasi: Choukamba Sanskrit Series; 2011. Vol 4. p. 24. cha chi 15/44. 5 Jadavji Trikamji Acharya. Sushruta Samhita. Varanasi: Chowkamba Sanskrit Samsthan; 2010. p. 709. ut 40/171. 6 Srikantha Murthy. Ashtanga Sangraha of Vagbhata. 4 th ed. Varanasi: Chowkamba Orientalia; 2003. p. 196. ni 8/24. 7 Yadavji Trikamji Acharya. Charaka Samhita of Agnivesha. Varanasi: Choukhambha Prakashan; 2011. p. 517. chi 15/53. 8 Jadavji Trikamji Acharya. Sushruta Samhita. Varanasi: Chowkamba Sanskrit Samsthan; 2010. p. 709. ut 40/171. 9 Srikantha Murthy. Ashtanga Sangraha of Vagbhata. 4 th ed. Varanasi: Chowkamba Orientalia; 2003. p. 196. ni 8/24. 10 Sri Sudrshana Shastry. Madhavanidana with Madhukosha Sanskrit Commentary by Sri Vijayarakshita and Srikantadatta. Varanasi: Choukhambha Sanskrit Sansthan; 2006. p. 179. Ma ni 4/3. 11 Yogaratnakar with Vidyothini Commentary by Vaidya Lakshmipathy Shastry. Varanasi: Chaukhamba Prakashan; Edited by Bhishagratna Bramhashankar; 2006. p. 183. 12 Sri Bhavamishra. Bhavaprakasha, Vidyotini Hindi Commentary by Pandit Sri Brahma Shankar Mishra. Varanasi: Choukamba Sanskrit Samsthan; 2003. Vol 2. p. 31. BH pp. 4/5-6. 13 Srimad Atreya Maharshi Haritamunisavadarupa. Harita Samhita. Edited by Kshemaraja, Srikrishnadasa; 1984. p. 226. 14 Gananatha Sen. Siddanta Nidana. Vol 2. Varanasi: Chowkamba Sanskrit Series Office; 1966. p. 166 ******************************* How to cite this article: Roopali R. Shindhe, Naveen V, Seema Pradeep. Development and validation of a Refined Grahani Assessment Scale based on constitutional features for evaluating Grahani Roga. J Ayurveda Integr Med Sci 2024;7:64-68. http://dx.doi.org/10.21760/jaims.9.7.8 Source of Support: Nil, Conflict of Interest: None declared. Copyright © 2024 The Author(s); Published by Maharshi Charaka Ayurveda Organization, Vijayapur (Regd). This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/unported [CC BY 4.0]), which permits unrestricted use, distribution, and perform the work and make derivative works based on it only for non-commercial purposes, provided the original work is properly cited

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Lakshana, Ayurveda, Sushruta-samhita, Alasya, Kasa, Pinasa, Vagbhata, Agnidushti, Udgara, Vishamashana, Chakrapanidatta, Charakasamhita, Bhavaprakasha, Atibhojana, Aruchi, Vyadhin, Agnivesha, Madhavanidana, Vegavidharana, Agnibala, Ratrijagarana, Ashtangasamgraha, Yogaratnakara, Grahaniroga, Grahanigada, Tinnitu, Vomiting, Tastelessness, Thirst, Cold, Fatigue, Reliability, Desire for food, Emaciated, Cough, English equivalent, Indigestion of food, Clinical feature, Lazy, Demographic Data, Ayurvedic text, Content validity, Construct validity, Pilot testing, Blurring of vision, Ajeerna, Asatmya Bhojana, Assessment Scale, Questionnaire, Closed-ended questions, Google Form, Open ended question.