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\begin{document}


\def\RunningAuthor{Byadgi P S et al.}
\firstPage{1916}
\articleType{Original Article}
\receivedDate{03 Jan 2020}
\acceptedDate{26 Feb 2020}
\revisedDate{06 Feb 2020}
\journalVolume{2020, 11}
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\journalDoi{ijrps.v11i2.2108}
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\title{Clinical Assessment Scales For The Kostha}
\author{Neera~Saini\textsuperscript{1},  
            Pradeep~Kumar~Pal\textsuperscript{2},  
            Shukla~S~K\textsuperscript{3},  
            Rakesh~Kumar~Singh\textsuperscript{4}, 
            Byadgi~P~S\textsuperscript{*}\textsuperscript{5}~\\[5pt]{\textsuperscript{1}Department of Roga-Nidana avum Vikriti Vigyan, Vijay Ayurvedic Medical College, Kaithi, Varanasi, Uttar Pradesh, India}~\\{\textsuperscript{2}Department of Rachana Sharir, Faculty of Ayurveda, IMS, BHU, Varanasi, Uttar Pradesh, India}~\\{\textsuperscript{3}Department of Gastroenterology, IMS, BHU, Varanasi, Uttar Pradesh, India}~\\{\textsuperscript{4}Department  of Shalakya Tantra, Vijay Ayurvedic Medical College Hospital and Research Centre, Bhandaha Kala ,Kaithi Varanasi, Uttar Pradesh {\textendash} 221116, India}~\\{\textsuperscript{5}Department of Vikriti Vigyan, Faculty of Ayurveda, IMS, BHU, Varanasi, Uttar Pradesh, India}}

\begin{abstract}
The present clinical study is planned to develop a scale to assess the \textit{Kostha}. \textit{Kostha\textbf{\space }} is accredited in the scriptures as \textit{Mahasrotas} (the great channel), \textit{Sharira} \textit{Madhya} (central section of the body), \textit{Mahanimna} (the inmost part of the body) and \textit{Amapakvashaya} (stomach and intestines). The term \textit{Kostha} is expressed in the context of bowel habit and clinically it is classified into three types\textit{ Mridu}, \textit{Madhyama } and\textit{ Krura}. Regarding the assessment of \textit{Kostha.i.e. } bowel habit should be examined considering the frequency, consistency, straining during defecation etc. Randomly 60 healthy cases were registered for the assessment of \textit{Kostha}. A self developed 10-items was introduced earlier and 9-items in the final scale. Mean, Median, Standard deviation, higher and lower values etc. of total score were calculated. The reliability of the scale was calculated by administering Cronbach-alpha, was found 0.835, indicating higher reliability of the test. Construct validity of the test was determined by finding coefficient of correlation between scores and reliability of the scores. It was found 0.913 \& it indicates higher validity.
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Kostha,\newline Bowel habit,\newline Mahasrotas Mridu,\newline Madhyama,\newline Krura
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Byadgi~P~S~\\ Phone:\ 9450711759~\\  Email:\ psbyadgi@gmail.com
        \par}\vspace*{-11pt}\hrulefill\par{\fontsize{12}{14}\selectfont ISSN: 0975-7538}\par% 
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\section{Introduction}
\textit{Kostha }is derived from the word\textit{ ``Kush Dahe'' Dhatu, } means in which digestion occurs is identified as Kostha \unskip~\citep{708781:16804035}. \textit{Kostha }is also one of the pathway of diseases and is known as internal pathway of diseases \unskip~\citep{708781:16804036}. Although the concept of \textit{Kostha} is described in many places, clinically it is classified into three type's .i.e. \textit{Mridu } (soft bowel), \textit{Madhyama } (normal bowel)\textit{\space } and\textit{ Krura } (hard bowel) in the context of \textit{Samshodhana } (purification therapy) as \textit{Snehana } (oleation), \textit{Virechana} etc. 

According to some \textit{Acharya}, \textit{Kostha} is of four types \textit{e.g}. \textit{Mridu, Madhyama, Sama } and Krura \unskip~\citep{708781:16804037}. Clinically\textit{\space } the term \textit{Kostha} is expressed in the context of bowel habit and it mostly depends on individual's \textit{Prakriti } (constitution of body). That's why for the assessment of \textit{Kostha} bowel habit should be examined considering frequency, consistency, straining during defecation, required more time for proper defecation, feeling of lightness, satisfaction etc. prior encounters of diarrhoea and constipation and earlier experiences of purgatives and laxatives \unskip~\citep{708781:16804038}.


\begin{table*}[!htbp]
\caption{\boldmath {Scales for Kostha assessment } }
\label{tw-3b16caf05348}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.0677\linewidth-2\tabcolsep}p{\dimexpr.2523\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.16\linewidth-2\tabcolsep}p{\dimexpr.20\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S.N. & Items  & Mridu Kostha  & Madhyama Kostha  & Krura Kostha  & Cronbach's alpha \\
\tblmidrule 
1.  &
  Do you pass stool regularly  &
  2-3 times/ day &
  Once a day &
  No &
  0.831\\
2. &
  What is usual nature of stool   &
  Semi formed (slightly loose) &
  Formed stool  &
  Hard and dry &
  0.805\\
3. &
  Do you feel lightness after passing of stool  &
  Yes &
  Yes &
  No &
  0.804\\
4. &
  Do you need straining during defecation  &
  Easy defecation &
  Required minimal strain &
  Required more strain &
  0.804\\
5. &
  What is usual time for proper defecation  &
  Up to five minutes  &
  5 to 15 minutes   &
  More than 15 minutes  &
  0.825 \\
6. &
  Do you feel satisfaction after defecation  &
  Yes &
  Yes &
  No &
  0.817\\
7. &
  Whether do you take purgatives   &
  Not at all &
  Occasionally  &
  Regularly  &
  0.824\\
8. &
  Do you have history of watery stool due to hot drinks, tea etc.  &
  Usually &
  Sometimes &
  No &
  0.817\\
9. &
  Effect of milk intake on bowel habit  &
  Loose motion &
  Slightly loose stool. &
  No effect &
  0.834\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Cronbach's alpha reliability of the selected questions after item analysis } (Reliability, Validity and other StatisticalAnalysis of Kostha)}
\label{tw-ed9536171d9f}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.26050000000000004\linewidth-2\tabcolsep}p{\dimexpr.39949999999999996\linewidth-2\tabcolsep}p{\dimexpr.34\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}S No & Cronbach's alpha & Statistical Analysis data\\
\tblmidrule 
1 &
  Reliability &
  0.835\\
2 &
  Validity &
  0.913\\
3 &
  Mean &
  7.49\\
4 &
  Standard deviation &
  3.23\\
5 &
  Median &
  8.00\\
6 &
  Minimum &
  .00\\
7 &
  Maximum &
  14\\
8 &
  Range &
  14\\
9 &
  Variance &
  10.44\\
10 &
  Interquartile range &
  4.00\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
\textbf{Need of questionnaire }

During the study, the problem in assessment of \textit{Kostha, } is usually encountered. Due to lack of appropriate questionnaires for the assessment of \textit{Kostha, }it is very difficult to identify various types.\textit{\space } Hence the questionnaires were designed to assess the \textit{Kostha.} There aren't validated and standard questionnaire of \textit{Kostha} available. \textit{Kostha} is assessed based on gastrointestinal system motility and bowel habit. It is important to understand because it helps to plan the appropriate therapeutics based on \textit{Kostha} variety and it also helps the individuals to adopt lifestyle according to nature of Kostha \unskip~\citep{708781:16804039,708781:16804041}.

\textbf{Design of} \textbf{questionnaire}

The questionnaire was developed after studying the characters of Kostha present in Ayurvedic Samhita \unskip~\citep{708781:16804040,708781:16804042}, published articles \unskip~\citep{708781:16804043} and other text books. Further to this study, each character of \textit{Kostha } questionnaire was validated. The questionnaire was designed in such a way that each trait was converted into simple form keeping the original idea intact. Each question/trait was allocated equal marks for \textit{Kostha} assessment. Total 9 questions were designed in \textit{Kostha} assessment questionnaire. One has to simply read the question and has to assess the trait in him/her and has to allocate the marks likewise at the end, one can calculate the scores for different types of Kostha \unskip~\citep{708781:16804044,708781:16804045}.

\textbf{Process of Validation of the questionnaire}

New questionnaires were designed by Byadgi, Saini et al , therefore its validation is necessary. 

\textbf{Determining Validity Experimentally}

The validity of a test is determined experimentally by finding the correlation between the test and some independent criteria. A criterion may be an objective measure of performance, or a qualitative measure such as a judgement of the character or excellence of work done \unskip~\citep{708781:16804046}. A trade test may be validated against time taken to carry out standard operations, amount done in a given time or excellence of work. A high correlation between a test and a criterion is, evidence of validity provided (1) the criterion was set up independently and (2) both the test and criterion are reliable. The index of reliability is sometimes taken as measure of validity \unskip~\citep{708781:16804047}. The correlation coefficient, it will be recalled, gives the relationship between obtained scores and their theoretical true counterparts. If the reliability coefficient of a test is 0.81, for example $r_{1\infty}\;is\;\sqrt{0.81} $ or 0.90. This means that the test measures true ability to the extent expressed by an r of 0.90 \unskip~\citep{708781:16804090,708781:16804124}.

\textbf{Test for Reliability/Consistency}

The data was fed on to the computer using the software `Statistical Package for Social Sciences (SPSS)' (Version 16.0). For the conversion of responses into numerical format, positive response for \textit{Krura Kostha} feature was incorporated as ``0'' for all 9 questions, for \textit{Madhyama}\textit{Kostha} feature was incorporated as ``1'' and for \textit{Mridu Kostha} feature was incorporated as ``2'' for 7 questions. In question no. 3 and 6 positive responses for either \textit{Madhyama} \textit{Kostha } or \textit{Mridu Kostha} feature was incorporated as ``1''. \textit{Kostha} was assessed as \textit{Krura, Mridu} and \textit{Madhyama}. \textit{Kostha} was assessed as having at least 5 or more than 5 traits of a particular type of \textit{Kostha}.

 Reliability test in form of Cronbach's coefficient Alpha was carried out after Item Analysis and Correlation. This was done to find out the correlation between the respective item and total sum score and the internal consistency of the scale if the respective item would be deleted.

Cronbach's Alpha=\textbf{$\frac{N._\overline c}{\overline v+(N-1).\overline c} $}

N= Number of items

$\overline c $ = Average inter item covariance among items

$\overline v $ = Average variance

For the validation of scale, value of alpha greater than 0.7 was considered acceptable. \textbf{\space }

\textbf{The Pilot Study }

 An initial administration of the scale (Table~\ref{tw-3b16caf05348}) utilized 60 volunteer subjects ranging from age 16 and above. Ninety percent of the scores were indicative of satisfaction. Majority of scores being high and indicative satisfaction. Item analysis of data obtained in this pilot study administration indicated that one item was to be discarded. 

\textbf{The Final Study }

After a scale is developed and its reliability and validity are established, its research practicality must also be demonstrated. One indication of its proper development should be that it will function appropriately when used as intended. So finally 9 items were administered to a group of 60 volunteer living in of Varanasi. Result of this study indicated that, in general, items correlated well with the total scale, that there was a very high level of internal consistency.

As the above Table~\ref{tw-ed9536171d9f} of \textit{Kostha } shows the value of ``Alpha if item deleted'' is not much altering resultant Cronbach's Alpha of \textit{Kostha} (.835). Cronbach's Alpha of near to 0.8, that shows its good consistency/reliability. 
    
\section{Conclusions}
Relaible and valid scales were needed to assess the \textit{kostha}. Hence questionnaire was developed in the form of scale for the purpose of assessing \textit{Kostha}. It was administered to a total of 60 subjects. The scale was proved to be of sufficient reliability and of high internal consistency.
    

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