Frequency Of Premenstrual Syndrome Research Articles

Study to assess the association of PMS with sociodemographic factors and various coping behaviors adopted for premenstrual symptoms

Background: Some women get through their monthly periods easily with few or no concerns. However, other women experience a host of physical and/or emotional symptoms just before and during menstruation (heavy bleeding and missed periods to unmanageable mood swings). These premenstrual syndrome (PMS) symptoms usually start to be problematic in the adolescent years and decline in the climacteric. Symptoms have a devastating effect which starts early in life. Aims and Objectives: The study was conducted to estimate the prevalence of PMS and its association with sociodemographic factors among female students of colleges situated in Ujjain city and coping behavior adopted to alleviate these symptoms. Materials and Methods: An observational follow-up study was conducted at 4 colleges selected by convenience sampling located in Ujjain city. PMS and menstrual profile-related data from 250 girls (18–25 years) who consented to participate were collected using a modified version of the Daily Record of Severity of Problems for at least 2 consecutive menstrual cycles. The diagnosis of PMS was made using the American College of Obstetrics and Gynecology criteria. Data analysis was done using SPSS version 16.0. Results: The prevalence of PMS was 39.6% and was not associated with any of the sociodemographic factors. It was found that majority of participants turned to healthy way of dealing with symptoms, i.e., taking hot or cold beverages and talking to family members. Conclusion: The frequency of PMS is relatively common in young girls, and most of the girls adopt home remedies to alleviate symptoms.

The longitudinal predictive effect of self-reported frequency of premenstrual syndrome on depression: Findings from the Australian Longitudinal Study on Women's Health.

Previous studies have revealed a high comorbidity between premenstrual syndrome (PMS) and depression; however, whether PMS can longitudinally predict depression has not been examined in large sample studies. This study surveyed 8,133 women from the 1973-78 cohort of the Australian Longitudinal Study on Women's Health. Participants completed seven repeated measurements at 3-year intervals starting in 2000 (aged 22-27 years). Binary logistic and multivariate ordered logistic regression models were used to examine the predictive role of self-reported frequency of PMS symptoms in 2000 on self-reported diagnosis of depression and frequency of depressive symptoms, respectively, for each follow-up survey. Self-reported frequency of PMS symptoms in the year 2000 predicted self-reported diagnosis of depression in most follow-up surveys. Specifically, compared to women who reported "never" had PMS symptoms in 2000, those who reported "often" had them were more likely to report a diagnosis of depression in 2006 (OR = 1.72), 2012 (OR = 1.88), 2015 (OR = 1.49), and 2018 (OR = 1.90); and those who reported "sometimes" had PMS symptoms in 2000 were more likely to report a diagnosis of depression in 2012 (OR =1.37) and 2018 (OR = 1.59). Furthermore, self-reported frequency of PMS symptoms in 2000 predicted self-reported frequency of depressive symptoms in each follow-up survey. Compared to women who reported "never" had PMS symptoms in 2000, those who reported "sometimes", or "often", had PMS symptoms reported depressive symptoms more frequently. Self-reported frequency of PMS can predict the self-reported frequency of depressive symptoms and the subsequent diagnosis of depression.

Premenstrual syndrome predicts alcohol craving in women with substance use disorders

ABSTRACT Premenstrual Syndrome (PMS) comprises psychological, somatic, and behavioral symptoms during the luteal phase of almost every menstrual cycle. PMS and premenstrual dysphoric disorder (PMDD) may be associated with substance use. Between 2018 and 2020 we studied the relationship between PMS and substance use within a prospective case-control design comparing a consecutive series of women having a substance use disorder and being treated in an addiction treatment center (ATC group, n = 151)) and one with community dwelling women attending their general practitioner (GP group, n = 101). The psychoactive substance use disorder women in the ATC were most frequently treated for was alcohol (39.7 percent), cannabis (20.5) and cocaine 7.9 percent) respectively. The relationship between PMS, problematic alcohol use, and craving for alcohol was explored with the Alcohol Use Disorders Identification Test (AUDIT), Premenstrual Screening Symptoms Tool (PSST), and Penn Alcohol Craving Scale (PACS). Descriptive analyses were used to report demographic variables, and the prevalence and nature of SUD according to DSM-5 and PMS in the two study populations and a two-step multiple hierarchical linear regression to assess the contribution of the variance of the AUDIT and PSST to craving, as measured with PACS. The frequency of PMS and PMDD is significantly higher in the ATC group than in the GP group (48.3 versus 26.7 percent and 16.6 versus 5.9 percent). Craving in the ATC group is better predicted (50 percent) by alcohol-related problems as measured by the AUDIT than in the GP group (25 percent). PMS complaints do contribute to craving in ATC group and not in GP group. There is a high prevalence of PMS/PMDD in the population with a substance use disorder. If these patients with PMS symptoms experience higher levels of craving, it may increase the risk of substance use relapse.

Pre-menstrual syndrome among the general female population of Saudi Arabia: Are there any Opportunities for Pharmacist’s involvement in patients education?

Background: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) affects up to 20% of reproductive-aged women and contribute to marked impairment of interpersonal or workplace performance in about 3-8%. Thus, a study was conducted to find out the frequency of PMS in Saudi female population using modified Moos menstrual distress questionnaire (MDQ) and assess the severity of emotional, physical, and behavioural symptoms. Method: The pharmacists-led cross-sectional questionnaire-based study was conducted from January to April 2020 among the female population in Asir region, Saudi Arabia. The study questionnaire was first distributed to university students and was requested to pass it on to their family members and others. Results: There was a total of 383 public responded to our study, whereas 60 responses were excluded due to incomplete data. Among the respondents, majority were between the age group of 21¬ to 25 years (n=167; 51.7%), students (n=209; 64.7%), single (n=224; 69.3%). Most of the respondents in all age groups experienced any one of these PMS ranging from moderate to severe intensity. Under every domain of the PMS, most reported severe mood swing as the negative effects by 121 (37.5%); in cognitive symptoms, mild lack of concentration by 117 (36.2%); in fluid retention, breast pain by 101 (31.3%); in behaviour change, mild lack of performance by 111 (34.4%); in somatic symptoms, severe body aches by 132 (40.9%); and in autonomic reactions, mild sweats by 81 (25.1%), respondents. Among the respondents, negative effects, behaviour change, and somatic symptoms were commonly seen with varying intensity which was ranging from 15.5% to 37.5%, 9.9% to 34.4%, and 14.2% to 40.9%, respectively. Conclusion: A considerable high prevalence of PMS was found among the study population. Healthcare professionals especially pharmacists involvement is highly required to conduct health education and awareness programs, and counselling services for female population on symptoms of PMS and prevention through lifestyle modification.

Does premenstrual syndrome before pregnancy increase the risk of postpartum depression? Findings from the Australian Longitudinal Study on Women's Health

BackgroundPrevious literature suggests a positive association between history of premenstrual syndrome (PMS) and development of postpartum depression (PPD); however, limited evidence has come from prospective population-based studies and whether history of depression affects this association is unknown. MethodsThis study included 5479 women from the 1973-78 cohort of the Australian Longitudinal Study on Women's Health and estimated the association between pre-pregnancy PMS and PPD. Participants were followed from 22-27 years in 2000 to 37-42 years in 2015. PMS was collected from a 4-category Likert-scale reporting on frequency of PMS in the last 12 months (never, rarely, sometimes, or often) at the survey preceding an index birth. PPD was ascertained from reports of doctor diagnoses for each birth. Relative risks (RRs) and 95% confidence intervals (CIs) were used to estimate the association of interest. The role of history of depression was assessed by testing its interaction with pre-pregnancy PMS. ResultsDuring 15 years’ follow-up, 15.4% of participating women reported PPD; and 55.1% reported PMS (rarely: 17.2%, sometimes: 25.7%, and often: 12.2%). Compared to women who had no PMS before pregnancy, those who rarely had PMS had similar risk of PPD (1.03, 0.82-1.30); whereas those who sometimes or often had PMS had significantly higher risk of PPD (1.31, 1.09-1.57 and 1.51, 1.22-1.87, respectively). History of depression did not affect the association. LimitationsPMS was self-reported. PMS severity was not collected. ConclusionsThis large population-based study provides evidence of a dose-response relationship between PMS prior to pregnancy and PPD, independent of history of depression. Evidence to date suggests PMS has the potential to help identify women at increased risk of PPD before pregnancy.

The impact of competitive sports on menstrual cycle and menstrual disorders, including premenstrual syndrome, premenstrual dysphoric disorder and hormonal imbalances.

With the considerable increase of female participation in youth sports, it has become crucial for medical professionals, coaches and parents to improve their competitiveness by understanding the conditions for which these females are at elevated risk and mitigating possible health consequences. The aim of this study was to evaluate the effect competitive sports have on the disorders of the menstrual cycle, to investigate the frequency of PMS (premenstrual syndrome)/PMDD (premenstrual dysphoric order) in professional female athletes and to identify risk factors predisposing for PMS and PMDD. Additionally, the levels of selected hormones such as serum estradiol, FSH, LH and prolactin were investigated to identify any hormonal perturbances that might have influence or be the risk factors for menstrual dysfunctions. The study group consisted of 75 professional athletes (girls and young women at the age of 16-22) who lived on the territory of Silesia. The control group consisted of 50 girls and young women at the same age, who did not practice any sport. The research tools included daily diary of PMS symptoms created in line with The American College of Obstetricians and Gynecologists (ACOG) recommendations and ICD-10 diagnostic criteria, daily diary of PMDD symptoms created according to DSM-V diagnostic criteria of the American Psychiatric Association (APA) and premenstrual symptoms screening tool (PSST). The analysis of menstrual cycle disorders showed statistical significance for heavy menstrual bleeding (p = 0.01) and longer breaks between menstrual bleeds (p = 0.01). PMDD was diagnosed in 8% and PMS in more than 42% of respondents. The incidence of PMDD was not at significant variance between the groups (9.33% in contrast to 6.0%), while incidence of PMS was statistically different in both groups (p = 0.045) (49.33% vs 32.0%). A significant correlation between PMS, average age (p = 0.00001) and menarche age (p = 0.03) in young active athletes has been shown. The risk of PMS increased with age (by 1.71 with each year) (p = 0.0007). A number of other risk factors predisposing for PMS and PMDD has also been identified. The findings of these researches will enable the athletic care network to provide better care for young female athletes.

The relationship between body mass index, body composition and premenstrual syndrome prevalence in girls.

Premenstrual Syndrome (PMS) is a cluster of physical and emotional symptoms occurring in the luteal phase of the menstrual cycle. The study aim was to determine the relationship between PMS, and state of nutrition expressed as Body Mass Index (BMI) and body composition in 18-year-old females. The study was conducted on 476 women divided into two groups i.e. those suffering from PMS (n = 233) and those without symptoms (n = 243). The women were examined during their luteal phase using bioelectrical impedance analysis to determine their body composition. Height and weight were measured using digital medical scales with an electronic height rod. BMI was calculated thus: BMI = body mass (weight) (kg)/height (m2). The subjects were di- vided into two sub-groups: BMI < 25 kg/m2 and BMI ≥ 25 kg/m2. Statistical analysis was carried out using STATISTICA 10 PL software and the Mann-Whitney test. The women with normal BMI suffered from PMS twice as often as the women with BMI ≥ 25 kg/m2 (68.2% vs. 31.8%). There were significantly higher values for Fat Mass (FM) (%) (p < 0.01) and FM (kg) (p < 0.001) in women without PMS, and significantly higher values for Fat-Free Mass (FFM) (%) (p < 0.001) and Total Body Water (TBW) (%) (p < 0.001) in women with PMS. Higher values were reported for FFM (kg) and TBW (kg) (p < 0.05) in girls with PMS and BMI ≥ 25. These results show PMS is more frequent in patients with BMI < 25, and less frequent in patients with higher FM (kg) and FM (%). Moreover, significant frequency of PMS was observed in patients with higher FFM and TBW. Such statistical significance was not confirmed in girls with a BMI < 25.

PREMENSTRUAL SYNDROME FREQUENCY, PREMENSTRUAL SYNDROME COPING STRATEGIES AND FACTORS AFFECTING PREMENSTRUAL SYNDROME IN UNIVERSITY STUDENTS IN TURKEY

Premenstrual syndrome (PMS) symptoms influence women’s lives to a large extent. This study was conducted to understand the frequency of PMS, coping strategies and factors affecting PMS in university students in Sanliurfa, Turkey. In this cross-sectional study in which 376 university students were reached. 52.1% of the students were found to experience PMS. Engaging in various activities to expend energy eating sweets and using analgesics were found to be the most common methods used by the students to cope with PMS symptoms; however, they were not able to cope efficiently with water retention, balance/control issues and autonomic reactions. The logistic regression analysis showed that a unit of increase in age led PMS risk to increase by a factor of 1.179, whereas a unit of increase in weight led to an increase in PMS risk by a factor of 1.025. Also, low income increased PMS risk by a factor of 1.884, fast food consumption increased it by a factor of 2.069, high salt consumption by a factor of 1.884, and anemia presence by a factor of 1.739. In conclusion, the prevalence of PMS was found to be high in the students and they were observed to have difficulty in coping with certain symptoms. On the basis of the results of the study, it is recommended that university students be given information about factors affecting PMS, how to cope with symptoms, what treatments are available, and that they been couraged to receive treatment for PMS. Article DOI: https://dx.doi.org/10.20319/lijhls.2019.43.138155 This work is licensed under the Creative Commons Attribution-Non-commercial 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/ or send a letter to Creative Commons, PO Box 1866, Mountain View, CA 94042, USA.

Premenstrual Syndrome: Prevalence, Severity, and its Association with Academic and Social Performance among College Students, Jimma Southwest Ethiopia

Background: The frequency of premenstrual syndrome (PMS) is high among young women, and the severity of its symp- toms could interfere with their daily activities. Although it has been widely studied in many western countries, little is known about the impact of PMS in low income setting. This study aims to evaluate the prevalence and severity of PMS and its influence on academic and social activities. Method: A cross-sectional study was conducted among female students of Jimma Teachers Training College in January, 2011. Seven hundred and six female students were selected using a simple random sampling technique. A structured and pre-tested self-administered questionnaire was employed for data collection. The criteria proposed by American College of Obstetrics and Gynaecology (ACOG) were used to diagnose PMS. Data analysis was made using SPSS Version 15.0. Result: The prevalence of PMS was 84.4% in the present study. Family income and duration of menstrual bleeding have shown significant association with PMS (p &lt; 0.05). The prevalence of Premenstrual Dysphoric Disorder, which is the se- vere form of PMS, was 30.9%. PMS was significantly associated with academic performance and social activities of fe- male students. About 77.9% of the students who had PMS have lost concentration on academics in the class room lessons, and 64.5% of them had difficulties to study at home. Concerning the implication of PMS on social activities of females; 81.0% of the students missed recreational activities and 79.0% restricted from daily home chores. Academic and social problems were pronounced in students who had ppremenstrual dysphoric disorder (PMDD). Conclusion: The present study revealed a high prevalence rate of PMS with a negative impact on academic endeavor and daily social activities of the students. Therefore, health education and counseling services are highly recommended for female students in the higher institutions (Ethiopian Journal of Reproductive Health, 2014, Volume 7(1),31-41). Key Words: Premenstrual syndrome, prevalence, severity, academic performance

Premenstrual dysphoric disorder and suicide attempts as a correlation among women in reproductive age.

Women likely attempt suicide more than men and sex hormones or menstrual cycle may be associated with female suicide attempts. There are debates regarding the correlation of premenstrual dysphoric disorder (PMDD) and suicidal behaviors. The objective of this study was to examine if PMDD was associated with suicidal attempts as sex hormones are contributed in its pathogenesis. As a case-control study 120 fertile woman with regular menstrual cycles attempting suicide and admitted to a general hospital were compared with a matched control group of 120 women selected among those accompanying other patients in other wards. Psychiatric interview based on DSM-5 criteria was conducted for diagnosing PMDD. There was a significantly higher frequency of PMDD in suicide attempters than in the controls (P = 0.001); while no remarkable difference was seen in frequency of premenstrual syndrome (PMS) between the two groups (P = 0.294) and attempting suicide was not related to the menstrual cycle (P = 0.52). This study suggests that PMDD may be associated with suicidal attempts, however it is not related to menstrual cycle. No relationship was found between PMS and suicidal acts.

A Census of Premenstrual Syndrome in Young Adolescent Girls: Facts about Women Health in Developing Country

Introduction: Women often experienced ragged and unpredicted kind of behavior and hardly recognize their attitude as premenstrual syndrome. Adolescent girls are particularly naive and unacquainted of the symptoms and if aware, hide due to shyness. Method: In this cross sectional study, a survey was conducted in educational institutes to determine the prevalence of various categories of PMS in young teen agers girls at different stages of their luteal phase. Predominance of PMS was finding out by applying Chi square test and significant incidences of PMS was observed. Result: PMS-A is recognized as a recurring phenomenon with most number of victims. Mild anxiety experienced by 38% respondents and severe mood swings affected more than 22% college going girls. PMS-H vie PMS-A having maximum numbers of females with complain of spartan type of fluid retention. Abdominal bloating and breast tenderness found as customary signs and 70% pubescent girls face these troubles before and during menstruation. Depression crying and fatigue are other major warning cryptograms of PMS. Conclusion: Frequency of premenstrual syndrome must be figure out in adolescent girls and they must educate about its indications, complications and outcomes to ensure the good quality of women health at their reproductive age.

Upaya Peningkatan Tingkat Pengetahuan Siswi MAN 2 Palembang Mengenai Sindrom Pra Menstruasi

Premenstrual syndrome characterized by affective, physical, and behavior symptoms with moderate to severe grade, that usually recurrent every luteal phase of menstrual cycle and disappear within menstruation. The frequency of premenstrual syndrome is still high, in Indonesia and all over the world. To overcome this situation, there should be a health promotion. The aim of this community service was to increase the girl’s knowledge of premenstrual syndrome. This community service was held in one day on November 2016 in public islamic high school MAN 2 Palembang. The schedule was start with pre test consist of 15 questions, counseling sesssion using power point media, discussion session, and post test consist of the same questions to measure the knowledge after counseling. Pre test score showed that 13.9% students had good knowledge and post test score showed an increase of good knowledge (66.7%). Conclusion, heatlh education through counseling method bring a change of knowledge.

Assessment of the Symptoms of Premenstrual Syndrome in Physically Active and Sedentary Adult Women

To assess the symptoms of premenstrual syndrome (PMS) and the nutritional status of physically active and sedentary adult women. This case-control study included 60 women, aged 18 to 35 years, recruited from two fitness centers or from an outpatient nutrition clinic. Four evaluations were conducted, on the follicular and luteal phase in two months. Questionnaires were applied to collect information about the socioeconomic condition and PMS symptoms. Weight and height were measured to calculate body mass index. Electrical bioimpedance was used to determine body composition, and food consumption was assessed using a food frequency questionnaire. The Student's t test and Chi-square test were applied to compare means and proportions between the groups. The occurrence of PMS was observed in 63.3% of women in the physically active group and 86.7% of participants in the sedentary group (p=0.074). Analysis of results relative to food consumption showed in the physically active group a low calorie consumption in 53.3% and 33.3% of the participants in the pre- and post-menstrual phases, respectively (p=0.039). In the sedentary group, a high calorie consumption was observed in 43.3% and 23.3% of the participants in the pre- and post-menstrual phases, respectively (p=0.007). The sedentary group presented carbohydrate consumption of 281.9 ± 61.1 grams and 252.1 ± 55.9 grams in the pre- and post-menstrual phases, respectively (p=0.001); increased consumption of lipids was also observed in these phases, 74.4 ± 23.4 grams 63.2 ± 19.4 grams, respectively (p=0.001). The results show that the sedentary group presents an increased frequency of PMS and increased consumption of calories, carbohydrates, lipids and sodium. In the physically active group there was association between reactance and fat percentage.

Premenstrual syndrome in Turkish medical students and their quality of life

This study aimed to analyse the frequency and symptoms of premenstrual syndrome (PMS) and its effect on quality of life in medical students. Sociodemographic data, a symptom calendar for the following consecutive two menstrual periods and SF-36 quality of life questionnaire were collected. A total of 228 students joined the survey. The average age of the students was 20.77 ± 1.90. The frequency of PMS was 91.8%. The most frequent symptoms were abdominal bloating (89.5%), irritability (88.3%) and breast tenderness (82.6%). Quality of life scores ranged from 17.00 to 97.00 and were lowest in the severe PMS group. Alcohol consumption, stress events and fat rich diets increased the severity of PMS. Family history significantly affected the severity of PMS and quality of life scores. Premenstrual syndrome was found to be a frequent entity among medical students and seemed to affect quality of life in a moderate way.

Life Style Factors Associated with Premenstrual Syndrome among El-Minia University Students, Egypt

Aim. To determine the score and frequency of premenstrual syndrome (PMS) among female college students and to detect the possible risk factors of PMS. A trial of life style modification regarding prevention and control of PMS symptoms was carried out using counseling. Materials and Methods. A cross-sectional study was conducted on 253 El-Minia University unmarried female students. A self-administered questionnaire inquiring about symptoms of PMS in the previous three months and risk factors possibly related to it was used. PMS score was calculated. Multiple regression analysis was performed to determine which of several biopsychosocial and dietary factors influenced PMS. Life style modification counseling was done to prevent and control PMS. Results. The study revealed that 80.2% of the participants experienced various degrees of PMS symptoms which were significantly associated with a family history of PMS, physical inactivity, habitual excess consumption of coffee, BMI, frequent consumption of fast food, and smoking, but these factors explained only 52% of the variability in the logistic regression model. Conclusion. We recommend the introduction of a reproductive health component into school and college health education programs and encourage female adolescents and young adults to adopt a healthy behavior.

P03-518 - Evaluation of the frequency of premenstrual dysphoric disorder and premenstrual syndrome in students of girls’ high schools of Kermanshah-Iran

IntroductionMany women in fertile period of their lives experience some mental and physical symptoms that begin on 7–10 days before menses and cease after bleeding. Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) are the terms to indicate these symptoms. The prevalence of PMS has been estimated to be about40% to70%, PMDD has lower prevalence.ObjectiveThis study has evaluated the frequencies of PMS and PMDD along with related factors in students of girls’ high schools in Kermanshah.MethodsIn this descriptive-analytic study, 800 students of girls’ high schools were chosen by incidentally and clustery sampling. Everyone who was volunteer included in the study. Excluding criteria were: history of depression; medical illnesses like epilepsy, meningitis, encephalitis, heart diseases…; history of consumption of β-blockers or other drugs of heart diseases, Phenobarbitals, and anticonvulsants. The diagnosis was made according to DSM.IV.TR. The data was processed using SPSS software, version 11.5, and by descriptive and analytic statistical methods.Results1.The frequencies of PMS and PMDD were 41.5% and 9.4% respectively.2.The disorder was more frequent in students older than 16 years-old.3.Mood symptoms were the most frequent, followed by physical and behavioral symptoms respectively.4.There was lower frequency of the disorder in students whose mothers were high educated.5.The frequency of PMS was higher in those with positive family history.ConclusionThe high frequencies of PMS and PMDD which result to problems in education of students need serious considerations to elevate mental health of students and to refer the severe cases to specialized centers.

P01-304-Frequency of pre-menstrual dysphoric disorder (PMDD), premenstrual syndrome (PMS) and some related factors in students of girls’ high schools of esfahan

IntroductionMany women in fertile period of their lives experience some bothering mental and physical symptoms. After presentation of DSM-IV, these symptoms already known as Pre-menstrual syndrome (PMS) were called Pre-menstrual dysphoric disorder (PM DD).The prevalence of PMS has been estimated to be about 40% to 70% but severe signs (PMDD) have lower prevalence. This study has evaluated the frequency of PMS and PMDD and some related factors in girls’ high schools.Methods and materialsIn this descriptive-analytic study, 800 students of girls’ high schools were chosen by randomized cluster sampling. A researcher made questionnaire assessing PMS and PMDD according to DSM.lV.TR criteria as well as a demographic questionnaire were administered to participants. Data were analyzed running SPSS software -version 11.5.FindingsFrequencies of PMS and PMDD were 41.5% and 9.4% respectively. The disorder was more frequent in students older than 16 years old. Mood symptoms were the most frequent presentation, followed by physical and behavioral symptoms. There was a lower frequency of the disorder despite a higher frequency of the syndrome in students with highly educated mothers. The frequency of PMS was higher in students with positive family history.DiscussionBecause of the potential adverse effects of PMS and PMDD on academic achievement and mental health of students, the high frequency of these problems need urgent attention. Planning mental health evaluations and interventions is necessary for these age group students. Diagnosis of severe cases and referring them should be considered in such programs.