International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - Vol 07 Issue 10, May, 2015

Pages: 14-19

Date of Publication: 30-Nov--0001

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Author: Adwitiya Das, Aparajita Dasgupta

Category: General Sciences

Abstract:Background: Accredited Social Health Activist (ASHA), a voluntary worker operating under National Rural Health Mission (NRHM), was launched with the intention of improving the reproductive and child health (RCH) services in rural India. Objectives: This study aimed to assess the knowledge and practice of ASHAs in rural Bengal, find out the predictors of poor performance, and search for causes of dissatisfaction and difficulties faced during work. Methods: This cross-sectional study was conducted for a period of three months on 56 ASHAs, working in a particular service area. Mixed methods were employed. Results: Out of 56 ASHAs participating in the study, working as ASHA was the only source of income in 76.79%. Majority received inadequate modular trainings (73.21%), and 39.29% lacked job satisfaction. 44.64% ASHAs had poor performance. Predictors of poor performance were age > 35 years, education less than graduate, and lack of job satisfaction. Focused Group Discussion (FGD) revealed that they were dissatisfied with inadequate remuneration and troubled by lack of essential medicine supply. Conclusion: Urgent and effective measures should be taken for betterment of the performance of ASHAs, and to redress their grievances.

Keywords: ASHA, NRHM, RCH, knowledge, Practice, Job satisfaction

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The Millennium Development Goals (MDGs) aim towards improvement of the physical health as well as quality of life of the people, but their achievement is limited by resource constraints, mainly dearth of health manpower.1 There is a growing concern about shortage of medical personnel and health workers worldwide as the population continues to rise.2 This shortage is far more prominent in the developing countries. Moreover, there is clustering of health workers in urban regions, along with resultant paucity of manpower in rural and remote areas.3,4,5 At this point of time, the gradually increasing role of community health workers (CHWs) is being recognized, as they are indispensable for achievement of the MDGs.6 In general, CHWs workers are healthcare providers who belong to a particular community, are selected from and trained in the same community, work for the same community and are acceptable to that community.7 CHWs is a generalized term which includes nurse-midwives, home-based care givers, salaried personnel and volunteers.6 The Accredited Social Health Activist (ASHA) is a voluntary worker, operating in the rural health system of India, introduced as the main task-force of National Rural Health Mission (NRHM). The NRHM, launched by the Government of India on April 2005 was an initiative towards achievement of the MDGs in India.8 The aim of NRHM is comprehensive healthcare, focused mainly on the rural women and children, thereby improving the reproductive and Child Health (RCH) services. ASHAs represent the cornerstone of the NRHM. The actualization of the goals of NRHM depends on the proper functioning of ASHAs. ASHAs are trained according to modules, and expected to act as a link worker between the rural popu lation and the health infrastructure.8 The present study aimed to assess the knowledge and practice of ASHAs in rural West Bengal, and find out the predictors of poor performance, along with exploratory analysis of various difficulties and causes of dissatisfaction among the ASHAs.


This cross-sectional study was conducted in the service area of Rural Health Unit and Training Centre, Singur, Hooghly district, West Bengal, under the purview of All India Institute of Hygiene and Public Health (AIIH and PH), for a period of 3 months, starting from July 2012 to September 2012. Mixed methods, i.e. combination of a quantitative survey and qualitative technique consisting of focused group discussions (FGDs) were employed in this study. The study population comprised all ASHAs working in the said service area, and giving informed consent for inclusion in the study. For the quantitative survey, a pre-designed, pretested semi-structured questionnaire was used. The questionnaire included information regarding socio-demographic variables, a schedule for interview regarding the knowledge about the service area as well as responsibilities and practice of different services provided, job related difficulties, time allocation, and a checklist regarding training and recruitment norms. Content and face validity was ensured and translation from English to Bengali was done with care for semantic equivalence. The Crohnbach-Alpha for reliability was 0.85. The knowledge and performance were scored, with each correct response fetching ‘1’ mark, and every wrong/ unanswered response fetching ‘0’ marks respectively. The cumulative score was calculated. Median score was calculated, and ASHAs scoring less than median score were considered to have scored poorly. Finally, 56 ASHAs operating in the service area were included. For the qualitative part, 5 FGDs were conducted for 43 ASHAs, with 7-9 different participants in each, with assurance of confidentiality, anonymity and choice of dropping out at any point of time. Each FGD was about 45 minutes long, and interviews were carried on until saturation of data was achieved. The interviews were conducted in the local language, Bengali. Topics like causes of dissatisfaction about work, difficulties faced during performing their duties and attitudes of the rural people towards the ASHAs were covered. They were also asked to discuss about possible solutions to the problems they face. Written informed consent was obtained from each participant, and participation was completely voluntary. The study received clearance from the Institutional Ethics Committee of AIIH and PH. The quantitative data was entered and analyzed in IBM SPSS version 20.0. A p value less than 0.05 was considered as statistically significant. The qualitative data analysis was done after verbatim transcription and methodical and meticulous collection, collation and coding of the items into the following themes: Relevant themes were classified as individual, community, and health system. The qualitative findings were corroborated with the quantitative data appropriate to the conceptual framework of the study.


The background parameters of the study population is shown in Table 1. Most of the ASHAs belonged to the age group of 31-35 years (41.07%), completed graduation (33.9%), were married (94.6%), and had a low family income (55.36%). Most of them were working as ASHA for 2 years or more (82.14%). Working as ASHA was the only source of income in 76.79%. Majority received less than/equal to five modular trainings (73.21%). Nearly 39.29% reported to be not satisfied with their job as ASHA. All of them were not satisfied with their remuneration and role clarity (not shown in the table). On assessment of the knowledge regarding responsibilities and performance of ASHAs, it was observed that only 51.79% had correct knowledge about their service area and the population served. Knowledge regarding various do-s and don’t-s for maintaining optimum maternal and child health was present in 69.64% and 78.57% respectively. Regarding choice, availability and timing of contraception and family planning, only 35.71% had correct knowledge, whereas, regarding the other miscellaneous activities like community mobilization, counselling and organizing activities on nutrition and sanitation, and role as drug-depot holder was present in only 32.14% ASHA. (Table 2) Satisfactory performance in the area of maternal health, family planning, child health were present among 57.14%, 21.43% and 62.5% respectively. (Table 2) Regarding escorting the mothers and child for perinatal visits, immunizations and during minor ailments, along with staying with them when required was rather neglected (42.86%). The ASHAs facilitated institutional deliveries in only 36 (64.29%) cases (not shown in table). Other miscellaneous activities were satisfactorily performed by only 30.36% ASHAs. The median knowledge score was 6[Inter-quartile range (IQR) 5-10; Range 1-14], and median performance score was 14[IQR 12-17; Range 7-27]. When cumulative scores were calculated by summing up both the scores, median was 20 [IQR 18-26; Range 9-41]. Scores less than median were taken as poor cumulative scores. Twenty five (44.64%) ASHAs had a poor cumulative score. On multivariate analysis, covariates of poor cumulative scores were age more than 35 years, education less than graduation, and absence of job satisfaction. (Table 3)

FGDs revealed several sensitive, confidential and hidden societal aspects regarding the grievances, and commonly faced difficulties. One middle-aged ASHA said: “We are not able to carry out our duty properly most of the time, as we have to deal with inadequate and irregular medicine supply.”Another ASHA opined: “People treat us harshly, and some consider us as unwanted. I remember, one day I was not allowed to enter the premises of a house to weigh a newborn, as I belong to a backward class. In this scenario, it is impossible for us to carry out our work.” Lack of co-operation and avoidant attitude on the part of villagers was also pointed out by some ASHAs. All the ASHAs were dissatisfied with remuneration. A young ASHA commented: “I will rather pursue some clerical job in an office than continue this job. There is no fixed salary, and the remuneration is also insignificant.” Most of the ASHAs were of the opinion that the remuneration was too little for too much work: “We want to serve the villagers. But if we are paid this less, how can we continue this job? We have dependent family members.” Last year, some of the ASHAs had to leave their job because of the inadequate and inconsistent remuneration, they said. Nobody could definitely point out any possible solution, except one ASHA who asked: “Why doesn’t the government do something for us, like a fixed payment along with job-based incentives?” All the others agreed. The findings of the FGD are summarized in figure 1.


Our study revealed poor knowledge and performance in 44.64% of the ASHAs in this service area. We also found out a few predictors of poor knowledge and performance, in the form of increased age, low education and lack of job satisfaction. FGD revealed that inadequate medicine supply and harsh behaviour towards ASHAs were the main barriers to their proper functioning, and all of them were displeased regarding remuneration. The utilization of ASHA services in different scenarios and for various purposes was assessed by some authors. ASHAs have been called as a link worker, who bridges the gap between the facilities and the beneficiaries.9 However, the proper functioning of ASHAs as well as proper utilization of their services is always not possible.6 ASHA’s capacity in influencing the pregnant women to deliver in public institutions as a part of Janani Suraksha Yojana (JSY) appeared limited in a study in Ujjain district.10 On the other hand, Stalin et al have commented that ASHAs can be effectively involved in the newborn care, provided they are trained adequately.11 Studies from other parts of the country have aimed at exploring the performance of ASHAs and finding factors on which poor performance depends. Kansal et al have found that low education was a predisposing factor for poor performance, when it comes to keeping records in village health registers. He also found that performance was satisfactory in the areas of antenatal care and child care.12 Swain et al, Haider et al and Malini et al have expressed similar views.13,14,15 In our study, we observed that increasing age of ASHAs was an important predictor of poor scores in knowledge regarding responsibilities, and performance. In the present study, mean age was 33.06 years, similar to Kansal et al and Jain et al.12, 16 However, no other study has thrown any light on the effect of age on knowledge or performance. Surprisingly, in a study by Shrivastava et al, it was discovered that many of the ASHAs were below 25 years of age, which is against the rule. This, the authors explain, was due to paucity of candidates who could serve as ASHAs.17 While we found lacunae in the fields of contraception, nutrition, sanitation and imparting health education, Shrivastava et al have found deficits in the field of childhood illness recognition and referral. Jain et al have found that 70% of the institutional deliveries were facilitated by ASHA, a finding similar to our study.16 A sharp contrast is the study by Shrivastava et al. who found that ASHA facilitated institutional delivery in about 100% cases. Qualitative research in the form of focused group discussion revealed that ASHAs preferred greater hours of training and less hours of meeting.6 No other study mentions adequately about job satisfaction of ASHAs, and their grievances.


The present study, in spite of having a small sample size and cross-sectional nature, hints at probable factors which might influence proper functioning of ASHAs. However, to formulate effective measures to improve the performance of ASHAs as well as facilitate the adequate utilization of ASHA services by the beneficiaries, large-scale longitudinal and interventional studies are required. To our belief, this study might carve the path for future research regarding improper functioning of ASHAs.


Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.


1. Mannan H, Boostrom C, Maclachlan M, McAuliffe E, Khasnabis C, Gupta N. A systematic review of the effec-tiveness of alternative cadres in community based rehabilitation. Hum Resour Health. 2012; 10: 20.

2. Ossai E N, Ibiok N C, Chukwuogo O, Umeobieri A K, Aniwada E C, Ugwunna N C. Rural retention of human resources for heath. Niger J Med. 2012;21:138-45.

3. Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention. BMC Health Services Research. 2008; 8: 19.

4. Dussault G, Franceschini M C. Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Human Resources and Health. 2006; 4: 1.

5. Schriver M, Ertner G, Aabenhus M M, Kallestrup P. [Solutions to the global shortage of health workers]. Ugeskr Laeger. 2012; 174: 1521-4.

6. Gopalan S S, Mohanty S, Das A. Assessing community health workers’ performance motivation: a mixed-methods approach on India’s Accredited Social Health Activists (ASHA) program. BMJ Open. 2012; 2.

7. Scott K, Shanker S. Tying their hands? Institutional obstacles to the success of the ASHA community health worker program in rural north India. AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV 2010; 22 Suppl 2:1606-12.

8. Government of India. National Rural Health Mission (2005- 2012) Mission Document. New Delhi: Ministry of Health and Family Welfare, 2005.

9. Singh M K, Singh JV, Ahmad N, Kumari R, Khanna A. Factors Influencing Utilization of ASHA Services under NRHM in Relation to Maternal Health in Rural Lucknow. Indian J Community Med. 2010; 35: 414–419.

10. Sidney K, Diwan V, El-Khatib Z, De Costa A. India’s JSY cash transfer program for maternal health: Who participates and who doesn’t - a report from Ujjain district. Reprod Health. 2012; 9: 2.

11. Stalin P, Krishnan A, Rai S K, Agarwal R K. ASHA’s Involvement in Newborn Care: A Feasibility Study. Indian Pediatrics. 2011; 48: 897-899.

12. Kansal S, Kumar S, Kumar A. Is educational level of ASHA matters for their effective functioning? A cross- sectional study in eastern Uttar Pradesh. Indian Journal of Community Health. 2012; 24: 41-44.

13. Swain S, Swain P, Nair K S, Dhar N, Gupta S, Nandan D. A rapid appraisal of functioning of ASHA under NRHM in Orrisa. Health and Population: Perspectives and Issues. 2008; 31: 73-79.

14. Haider S, Adhisih V, Gupta S, Dhar N, Datta U, Manon S, Nandan D. A rapid appraisal of Sahiya in Jharkhand. Health and Population: Perspectives and Issues. 2008; 31: 80-84.

15. Malini S, Tripathi R M, Khatter P, Nair K S, Tekhere Y L, Dhar N, Nandan D. A rapid appraisal of functioning of JSY in south Orrisa. Health and Population: Perspectives and Issues. 2008; 31: 126-131.

16. Jain N, Srivastava NK, Khan AM, Dhar N, Manon S, Adhish V, Nandan D. Assessment of functioning of ASHA under NRHM in Uttar Pradesh. Health and Population: Perspectives and Issues. 2008; 31: 132-140.

17. Shrivastava SR, Shrivastava PS. Evaluation of trained Accredited Social Health Activist (ASHA) workers regarding their knowledge, attitude and practices about child health. Rural and Remote Health. 2012; 12: 2099.


Dr. Pramod Kumar Manjhi joined Editor-in-Chief since July 2021 onwards

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This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to for more details.

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A Study by Amr Y. Zakaria et al. entitled "Single Nucleotide Polymorphisms of ATP-Binding Cassette Gene(ABCC3 rs4793665) affect High Dose Methotrexate-Induced Nephrotoxicity in Children with Osteosarcoma" is awarded Best Article for Vol 13 issue 19
A Study by Kholis Ernawati et al. entitled "The Utilization of Mobile-Based Information Technology in the Management of Dengue Fever in the Community Year 2019-2020: Systematic Review" is awarded Best Article for Vol 13 issue 18
A Study by Bhat Asifa et al. entitled "Efficacy of Modified Carbapenem Inactivation Method for Carbapenemase Detection and Comparative Evaluation with Polymerase Chain Reaction for the Identification of Carbapenemase Producing Klebsiella pneumonia Isolates" is awarded Best Article for Vol 13 issue 17
A Study by Gupta R. et al. entitled "A Clinical Study of Paediatric Tracheostomy: Our Experience in a Tertiary Care Hospital in North India" is awarded Best Article for Vol 13 issue 16
A Study by Chandran Anand et al. entitled "A Prospective Study on Assessment of Quality of Life of Patients Receiving Sorafenib for Hepatocellular Carcinoma" is awarded Best article for Vol 13 issue 15
A Study by Rosa PS et al. entitled "Emotional State Due to the Covid – 19 Pandemic in People Residing in a Vulnerable Area in North Lima" is awarded Best Article for Vol 13 issue 14
A Study by Suvarna Sunder J et al. entitled "Endodontic Revascularization of Necrotic Permanent Anterior Tooth with Platelet Rich Fibrin, Platelet Rich Plasma, and Blood Clot - A Comparative Study" is awarded Best Article for Vol 13 issue 13
A Study by Mona Isam Eldin Osman et al. entitled "Psychological Impact and Risk Factors of Sexual Abuse on Sudanese Children in Khartoum State" is awarded Best Article for Vol 13 issue 12
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A Study by Kumar S. et al. entitled "A Study on Clinical Spectrum, Laboratory Profile, Complications and Outcome of Pediatric Scrub Typhus Patients Admitted to an Intensive Care Unit from a Tertiary Care Hospital from Eastern India" is awarded Best Article for Vol 13 issue 09
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A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness
A Study by Gainneos PD et al. entitled "A Comparative Evaluation of the Levels of Salivary IgA in HIV Affected Children and the Children of the General Population within the Age Group of 9 – 12 Years – A Cross-Sectional Study" is awarded Best Article of Vol 13 issue 05 Special issue on Recent Advances in Dentistry for better Oral Health
A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" is awarded Best Article of Vol 13 issue 06
A Study by Chen YY and Ghazali SRB entitled "Lifetime Trauma, posttraumatic stress disorder Symptoms and Early Adolescence Risk Factors for Poor Physical Health Outcome Among Malaysian Adolescents" is awarded Best Article of Vol 13 issue 04 Special issue on Current Updates in Plant Biology to Medicine to Healthcare Awareness in Malaysia
A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05
A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
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A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
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A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by situs slot and Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
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A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
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A Study by Muhammet Lutfi SELCUK and Fatma situs slot entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
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A Study by situs slot et al entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09
Late to bed everyday? You may die early, get depression situs slot
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A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award

A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award

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