Formation and validation of questionnaire to assess Jāṭharāgni

Original Article Formation and validation of questionnaire to assess Jāṭharāgni H. T. Eswaran, M. B. Kavita, T. B. Tripaty, Shivakumar Department of Swasthavritta, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Hassan, Karnataka, India ABSTRACT Background: Jāṭharāgni (metabolic fire) is of the prime importance in the maintenance of health as well as causation of diseases. Food which is consumed by the person shares the major responsibility for being healthy or manifestation of diseases. The relation between food and health is mediated by Jāṭharāgni (the metabolic agent in Ayurveda). There are four different states of Jāṭharāgni viz, Mandāgni (mild or weak state of metabolic fire), Viṣamāgni (irregular state of metabolic fire), Tīkṣnāgni (sharp or intense state of metabolic fire), and Samāgni (Normal state of metabolic fire). Samāgni (Normal state of metabolic fire) is said to be the normal State and maintains the health of an individual. All the other states are considered as abnormal. Objectives: To frame and validate a Questionnaire to assess the state of Jāṭharāgni. Materials and Methods: A qualitative research that involved interview method and cluster sampling method. A total of 500 volunteers of either gender in two groups viz., apparently healthy and unhealthy were assessed for their Jāṭharāgni. Questionnaire was framed with 64 items. A total of 14 questions under Viṣamāgni (irregular state of metabolic fire), 13 under Tīkshṇāgni, 13 under Mandāgni and 24 questions under Samāgni were framed. The questionnaire was in optional format with 5 item likert s scale pattern and the validation was done by Cronbach s Alpha for internal consistency. Result: The internal consistency of the questionnaire using Cronbach s Alpha was 0.916. The internal consistency of Viṣamāgni domain was 0.909; Teekshnagni domain was 0.873; Mandāgni domain was 0.894; and Samāgni domain was 0.876. Conclusion: The internal consistency of the questionnaire was 0.909 which is indicative of the excellent internal consistency of questionnaire. The lacuna of tool to assess state of Jāṭharāgni in Ayurveda is filled by this questionnaire. KEY WORDS: Agni, Cronbach s alpha, internal consistency, Mandagni, Samagni, Teekshnagni, Vishamagni INTRODUCTION Health is a state of complete physical, mental, and social wellbeing and not merely an absence of disease or infirmity. [1] Each and every living being desires a disease free life but is bound to suffer from some sort of disease or discomfort at various stages of its life. The qualities of healthy individual as described in Ayurveda include: Equilibrium of all three doṣas viz., vāta, pitta and kapha; normal state of jāṭharāgni, normal state and function of dhāthus (tissues) viz., rasa, rakta, māṃsa, medas, asthi, majjā, śukra; normal state and function of malās viz., puriṣa (faeces), mūtra (urine), sveda (sweat); pleasant soul, pleasant mind and sound sense perception. [2] Jāṭharāgni Agni is given prime importance in the maintenance of health as well as causation of diseases. Food which is consumed by the person is the major responsible factor for the state of health and manifestation of diseases. [3] Food is ranked first, both for the maintenance of health and in the manifestation of disease. Consumed foods and drinks undergo a metabolic transformation in the digestive system. After the process of digestion, it produces effects on the body which may be agreeable or disagreeable. The process of digestion is mainly carried out by jāṭharāgni (digestive fire). Food provides nourishment to bodily tissues which is reached to the end organ by the action of agni. Hence, agni plays a vital role in this connection because tissue elements like rasa, etc., cannot originate from undigested food. Jāṭharāgni is the sole cause for the existence of life, and its extinction Access this article online Quick Response Code: Website: www.ancientscienceoflife.org DOI: DOI:10.4103/0257-7941.159829 Ancient Science of Life / Apr-Jun 2015 / Vol 34 / Issue 4 203

leads to death; its proper maintenance helps one live a long life, and its impairment gives rise to diseases. It is also caused for color, strength, health, enthusiasm, plumpness, complexion, ōjas, tējas, other varieties of agni and prāṇa. [4] The states of Jāṭharāgni There are four different states of jāṭharāgni, viz., viṣama (irregular), tīkṣṇa (intense), manda (weak), and sama (well maintained and regular) states. [5] Viṣamāgni The word viṣama means irregular. Viṣamāgni digests the food properly at times, and not so at other times. [6] Viṣamāgni is influenced by vāta doṣa [7] and hence is unpredictable in nature. When the food is not properly digested, it produces flatulence, colic pain, heaviness, upward movement of vāyu, diarrhea, heaviness, and gurgling sound in the abdomen and tenesmus. [8] If a person suffers from these discomforts even after consuming regular and measured food, then the agni is thought to be viṣamāgni. Tīkshnāgni The word tīkṣṇa means intense. Tīkṣṇāgni will digest even large amount of food quickly. [9] It is capable of tolerating all types of irregularities in the diet. [10] It is influenced by pittadoṣa [11] which is the cause of its intense nature. If the intensity of tīkshnāgni is high and sufficient food is not supplied, it causes tissue destruction. Further, it has three varieties based on its degree of intensity viz., tīkṣṇa which digests the food quickly; atyagni or bhasmaka caused by not leveling tīkshnāgni; tīkṣṇatama is the effect of not levelling aţyagni where the person is never satisfied with any quantity of food consumed. This produces burning sensation besides dryness in throat palate lips and pyrexia. [12] Mandāgni The word manda means mild. The strength of agni is less in this state. Even the slightest variation in regular amount is felt heavy for its capacity of digestion impairing the functions of agni. [13] Mandāgni is influenced by kapha doṣa. [14] It is unable to digest even small amounts of food; creates heaviness in abdomen and head, cough, dyspnea, excessive salivation, vomiting, pain all over the body. It takes long time to digest even small quantities of food. This is said to be the basic cause for all pathogenesis. [15] Samāgni The word sama means regular or balanced. Samāgni is the result of tridoṣas being in a balanced state. [16] It maintains the health so long as there are no irregularities in food consumption. It properly digests the food that is well measured and consumed in time. Minor irregularities too hamper the balanced status of agni leading to impairment in health. [17] Aims and objectives To Frame and validate questionnaire to assess the state of jāṭharāgni of an individual. MATERIALS AND METHODS Framing questionnaire to assess the state of Jāṭharāgni Considering the lack of tools for the analysis of the state of jāṭharāgni, and its importance in the maintenance of health and in the treating the diseases, a questionnaire to assess the state of jāṭharāgni was framed. The whole questionnaire is divided into four domains or subsets viz., viṣama, tīkṣṇa, manda and sama. The signs and symptoms of different states of jāṭharāgni were collected from various Ayurveda classics and compiled to structure the questionnaire. The specific portions from which the descriptions and symptoms of the different types of agni were extracted to develop the questionnaire are mentioned above. Scales and response format The questionnaire was framed in a close ended Likert format with five options for each question viz., strongly agree, agree, uncertain, disagree, and strongly disagree. It was graded 5, 4, 3, 2, and 1, respectively, except for one (item 16) which was graded in reverse order. Based on this score, the maximum score for vīshamāgni is 80; for both tīkshnāgni and mandāgni are 85 each; for samāgni, the score is 120. Generation of items The questionnaire consisted of the statements on the signs and symptoms of different states of agni. The questionnaire was framed with 64 items, that is, 16 items to confirm vīshamāgni, 17 items each to confirm tīkṣṇāgni and mandāgni, and 24 items to confirm samāgni. The statements were in English for easy understanding. Test of items The prepared questionnaire was administered to 500 subjects, 250 in each group viz., apparently healthy and unhealthy. Methodology Annexure 1 Content validation of a questionnaire helps one determine as to how well the individual items in the questionnaire 204 Ancient Science of Life / Apr-Jun 2015 / Vol 34 / Issue 4

correspond to the concept being examined. It is usually tested using qualitative techniques. Content validation of the questionnaire assessing state of agni was done using references available in the classics of Ayurveda. Feasibility of measurement of the selected variable was cross validated by Ayurvedic experts for its suitability as a dependable parameter to identify the dominance of the particular state of agni. The questionnaire so framed and validated was administered to four different groups viz., Ayurvedic academicians, Ayurvedic practitioners, people approaching Ayurvedic doctors for medicine and therapies; and also the general public those who had not come across Ayurveda. Based on their suggestions, the questionnaire was refined at different levels. Internal consistency Internal consistency is typically a measure based on the correlations between different items in the same test (or the same subscale for a larger test). It measures whether several items that are proposed to measure the same general construct produce similar scores. [18] Internal consistency was measured with Cronbach s alpha, a statistic calculated from the pairwise correlation between items. Internal consistency of each item in questionnaire varied from 0.913 0.918 which rendered it an excellent internal consistency. Factor analysis It is a general name denoting a class of procedures primarily used for data reduction and summarization. Factor analysis is an interdependence technique in which an entire set of interdependent relationships is examined without making the distinction between dependent and independent variables. Factor analysis is used in the following circumstances: To identify underlying dimensions, or factors, those explain the correlations among a set of variables To identify a new, smaller, set of uncorrelated variables in the subsequent multivariate analysis To identify a smaller set of salient variables from a large set for use in the subsequent multivariate analysis. [19] The Kaiser Meyer Olkin (KMO) measure of sampling adequacy is used to examine the appropriateness of factor analysis. This measure for the questionnaire was 0.804 which indicates an acceptable sampling adequacy. from in and around Hassan city. Subjects who were unable to respond, noncooperative and those with psychiatric illness were excluded. Execution of test Selected and consenting subjects were briefed about the study and their role in the study was clearly informed. Each subject was provided the agni assessment questionnaire along with a questionnaire requesting the subject s demographic details. Later, the score was calculated and converted into age. The domain with highest age was used to conclude the status of agni of the individual. Observations The questionnaire was administered to 500 subjects with 250 in each group of healthy and unhealthy. Of 500 subjects, 63% (315) were females, and the rest were males. Among of 250 apparently healthy participants 62.4% (156) were females, and the rest were males. Among 250 unhealthy participants, 63.6% (159) were females the rest were males. Maximum (256, 51.2%) had samāgni; 99 (19.8%) had vīṣamāgni; 87 (17.4%) had tīkṣṇāgni and 58 (11.6%) had mandāgni. Among of 250 apparently healthy participants, 64.8% (162) were diagnosed with samāgni, 12.8% (32) with viṣamāgni, 12.8% (32) with tīkṣṇāgni, and 9.6% (24) were diagnosed with mandāgni. Among 250 unhealthy participants, 37.6% (94) were diagnosed with samāgni, 26.8% (67) were diagnosed vīṣ amāgni, 22% (55) were diagnosed with tīkṣṇāgni, and 13.6% (34) were diagnosed with mandāgni. RESULTS Design The questionnaire was designed based on the available direct and a few indirect references about the different state of agni in different Ayurveda classics. All the signs and symptoms were segregated individually, and they were translated to English in the form of statements with five options. The statements were deleted if there was an improvement in the values of Cronbach s alpha value on deletion. Study and administration of the questionnaire The study consisted of 500 literate subjects of either gender including both apparently healthy and unhealthy Content validity The questions were reviewed by Ayurvedic academicians and practitioners for content validation. Ancient Science of Life / Apr-Jun 2015 / Vol 34 / Issue 4 205

Face validity Clarity of wording, layout and style of questions was assessed by giving the prepared format to the general public. Construct validity Factor analysis was done to analyze the correlation existing between the different set of variables in the questionnaire. A correlation matrix was applied and a Table 1: Different states of agni distribution of 500 participants Frequency Percent Valid Cumulative Mandāgni 58 11.6 11.6 11.6 Samāgni 256 51.2 51.2 62.8 Tīṣṇāgni 87 17.4 17.4 80.2 Vīṣamāgni 99 19.8 19.8 100.0 Total 500 100.0 100.0 Table 2: Different states of agni distribution of 250 apparently healthy participants Frequency Percent Valid Cumulative Mandāgni 24 9.6 9.6 9.6 Samāgni 162 64.8 64.8 74.4 Tīkshṇāgni 32 12.8 12.8 87.2 Viṣamāgni 32 12.8 12.8 100.0 Total 250 100.0 100.0 Table 3: Different states of agni distribution of 250 unhealthy participants Frequency Percent Valid Cumulative Mandāgni 34 13.6 13.6 13.6 Samāgni 94 37.6 37.6 51.2 Tīkshṇāgni 55 22.0 22.0 73.2 Viṣamāgni 67 26.8 26.8 100.0 Total 250 100.0 100.0 Table 4: KMO and Barlett s test value of tīkṣṇāgni Tīkshnāgni Mandāgni Vīshamāgni Samāgni KMO measure 0.864 0.818 0.866 0.793 of sampling adequacy Bartlett s test of sphericity Approximate 3.248 3.626E3 4.002 6.368 Chi square df 78 78 91 276 Significant 0.000 0.000 0.000 0.000 KMO: Kaiser Meyer Olkin KMO coefficient more than 0.7 was considered in this study [Tables 1 4]. Reliability Results of Cronbach s alpha of four domains for internal reliability: vīshamāgni, tīkshnāgni, mandāgni, and samāgni had Cronbach s alpha values of 0.909, 0.872, 0.892, and 0.876, respectively. Few items which would improve the value of reliability test if deleted were retained because of their importance in the concerned domain, e.g., the choice: I suffer from indigestion when take food at irregular intervals, a classical and direct symptom of samāgni was retained in spite of an improvement in the alpha value on deletion. Implication of results The results obtained are indicators of the variance of viṣama, tīkṣṇa, manda, and sama state of agni. This questionnaire can be utilized for the assessment of the state of agni in clinical practice and for research purpose. DISCUSSION Though the jāṭharāgni is of prime importance in the maintenance of health, the descriptions of it are strewn and scarce. Designing separate items (questions) for each state of agni was a challenging task. Thus, the indirect descriptions were also included in the questionnaire. As the different states of jāṭharāgni are influenced by individual dos.a, questions relating to the effects of dos.a related to the digestive system were included in the concerned domain. Especially, the description about samāgni was elusive which compelled us to add the questions relating to normal functions of agni in the questionnaire. The rule of thumb in the interpretation of Cronbach s alpha is >0.9: Excellent, >0.8: Good, 0.7: Acceptable, >0.6: Questionable, >0.5: Poor and <0.5: Unacceptable. [20] The value obtained for Cronbach s alpha internal consistency of the questionnaire was 0.916. The internal consistency of each domain related to the state of agni fell between 0.8 and 0.9 which is considered as good to excellent. Viṣamāgni had an alpha value of 0.909; tīkshnāgni, 0.873; mandāgni, 0.894; and samāgni, 0.876. These values indicate that the internal consistency of the questionnaire is excellent. The KMO measures the sampling adequacy. It should be >0.5 for a satisfactory factor analysis. In general, over 300 cases for sampling analysis are probably adequate. [21] There is universal agreement that factor 206 Ancient Science of Life / Apr-Jun 2015 / Vol 34 / Issue 4

analysis is inappropriate when the sample size is below 50. The recommended minimum value is 0.5 which means a barely acceptable sampling adequacy. Values between 0.7 and 0.8 are acceptable, and values above 0.9 are superb. [22] The observed KMO value of questionnaire is 0.804. The KMO test values of different domains of the questionnaire are viṣamāgni: 0.866, tīkṣṇagni: 0.864, mandāgni: 0.818, and samāgni: 0.793. Hence, the sampling adequacy is interpreted as acceptable. Bartlett s test is another indication of the strength of the relationship among variables. This tests the null hypothesis that the correlation matrix is an identity matrix. An identity matrix is a matrix in which all of the diagonal elements are 1 and all off diagonal elements are 0. [22] The Bartlett s test of sphere city of the questionnaire is 0.000. That is, its associated probability is <0.05. The values obtained for all states of agni are 0.000 and hence are significant. The majority of the subjects diagnosed with samāgni in the apparently healthy group as samāgni is a factor to maintain health. Other states of agni also found in the same group can be interpreted as the influence of related doṣa in prakṛti, the setting in of pathogenesis which may show symptoms in future days or be asymptomatic. Among the unhealthy cluster also samāgni was found. This may be credited to the reversal of ill health toward health. Striving toward maintenance of health is a continuous process and so is the maintenance of samāgni. The influence of factors like prakṛti of the individual, quality and quantity of food, time of consumption, season, mental status etc., cannot be neglected. It is a combined effect shown on the agni. CONCLUSION The assessment of the state of agni is very crucial in the practice of Ayurveda. It acts as a window first to understand the individual s digestive system. Second, the metabolism (digestion and absorption) of the food and medicine in an individual is based on the state of agni. There are very few or no tools based on Ayurveda to assess agni. Interviewing an individual based on this questionnaire will serve as effective tool in analyzing the state of agni. 3. Acharya YT, editor. Susruta Samhitha. Varanasi: Chaukhambha Sanskrit Sansthan; 2010. p. 75. 4. Acharya YT, editor. Susruta Samhita. Varanasi: Chaukhambha Sanskrit Sansthan; 2010. p. 181. 5. Acharya YT, editor. Susruta Samhita. Varanasi: Chaukhambha Sanskrit Sansthan; 2010. p. 512. 6. Acharya YT, editor. Susrutha Samhita. Varanasi: Chaukhambha 7. Acharya YT, editor. Susrutha Samhita. Varanasi: Chaukhambha 8. Acharya YT, editor. Susrutha Samhita. Varanasi: Chaukhambha 9. Acharya YT, editor. Susrutha Samhita. Varanasi: Chaukhambha 10. Acharya YT, editor. Susrutha Samhita. Varanasi: Chaukhambha 11. Acharya YT, editor. Susrutha Samhita. Varanasi: Chaukhambha 12. Acharya YT, editor. Susrutha Samhita. Varanasi: Chaukhambha 13. Acharya YT, editor. Susrutha Samhita. Varanasi: Chaukhambha 14. Acharya YT, editor. Susrutha Samhita. Varanasi: Chaukhambha 15. Acharya YT, editor. Susrutha Samhita. Varanasi: Chaukhambha 16. Acharya YT, editor. Susrutha Samhita. Varanasi: Chaukhambha 17. Acharya YT, editor. Susrutha Samhita. Varanasi: Chaukhambha 18. Acharya YT, editor. Susrutha Samhita. Varanasi: Chaukhambha 19. Bordens SK, Babott B, editors. Research Design and Methods. India: McGrew Hill Higher Education; 1998. p. 125 6. 20. Bordens SK, Babott B, editors. Research Design and Methods. India: McGrew Hill Higher Education; 1998. p. 418. 21. Gliem JA, Gliem RR. Calculating, Interpreting, and Reporting Cronbach s Alpha Reliability Coefficient for Likert Type Scales. Midwest Research to Practice Conference; 2003. Available from: https://www.scholarworks.iupui.edu/bitstream/handle/1805/344/ Gliem%20 and %20.?sequence=1. [Last cited on 2014 Apr 25]. 22. Lecture 11: Factor Analysis Using SPSS. Available from: http:// www.staff.neu.edu.tr. [Last cited on 2014 Mar 25]. Available from: http://www.staff.neu.edu.tr/~ngunsel/files/lecture%2011.pdf. [Last accessed on 2015 May 19]. Address for correspondence: Dr. H. T. Eswaran, Department of Swasthavritta, Sri Dharmasthala Manjunatheshwara College of Ayurveda and Hospital, Thannirhulla, B.M. Road, Hassan 573 201, Karnataka, India. E mail: drhteswar@gmail.com REFERENCES 1. Park K. Park s Text Book of Preventive and Social Medicine. 21 th ed. Jabalpur: M/s Banarasidas Bhanot Publishers; 2011. p. 16. 2. Acharya YT, editor. Susruta Samhitha. Varanasi: Chaukhambha Sanskrit Sansthan; 2010. p. 75. How to cite this article: Eswaran HT, Kavita MB, Tripaty TB, Shivakumar. Formation and validation of questionnaire to assess Jāṭharāgni. Ancient Sci Life 2015;34:203-9. Source of Support: Nil. Conflict of Interest: None declared. Ancient Science of Life / Apr-Jun 2015 / Vol 34 / Issue 4 207

ANNEXURE 1: ASSESSMENT OF AGNI Name: Age: Gender: Place: Occupation: Answer all the questions with mark on the option you feel right 1. I suffer from bloating of abdomen 2. I feel pain in the abdomen 3. I suffer from loose stools 4. I suffer from distension of abdomen 5. I strain while passing stools 6. I find ups and downs (sometimes yes and sometimes no) in digesting food even when I consume normal amount of food 7. I pass hard stools 8. I feel astringent taste in mouth 9. I feel difficulty in urination 10. I get lots of hiccup in a day 11. I get lots of belching in a day 12. I suffer from constipation frequently 13. I feel difficulty in passing flatus 14. I get sneezing after intake of food 15. I feel hungry frequently even when I have consumed good amount of food 16. I feel indigestion with normal amount of food 17. I feel I lack strength even after having sufficient amount of food 18. I have sense of burning in abdomen 19. I sweat during food 20. I sweat after food 21. I feel sourness in mouth 22. I feel unsatisfied even after intake of normal/ routine quantity of food 23. I feel unsatisfied even after intake of large quantity of food 24. I feel dryness of throat 25. I feel dryness of palate 26. I feel I drink water more frequently 27. I feel yellowish discoloration of eyes 28. I suffer with indigestion even when I eat a little 29. I feel heaviness of abdomen after food even when I eat normal food 30. I feel heaviness of abdomen after food even when I eat less food 31. I feel heaviness of head after food even when I eat normal food 32. I feel heaviness of head after food even when I 208 Ancient Science of Life / Apr-Jun 2015 / Vol 34 / Issue 4

eat less food 33. I get cough after food 34. I find difficulty in breathing after food even when I eat normal food 35. I find difficulty in breathing after food even when I eat less food 36. I get excessive salivation after food 37. I feel nausea after food 38. I feel vomiting after food 39. I take long time for digesting routine food 40. I take long time for digesting little food 41. I get hunger in proper time 42. I consume food in proper time 43. I suffer from indigestion when I take other than routine food 44. I suffer from indigestion when I take food at irregular intervals 45. I feel I have clarity of voice 46. I feel my complexion is improved/maintained 47. I feel my body weight is improved/maintained 48. I feel my strength is improved/maintained 49. I feel desire to take food 50. The food which I consume get digested in proper time 51. I get sleep at proper time 52. I don t get abnormal dreams 53. I don t have any difficulty getting up from sleep (d) Disagree (e) Strongly disagree 54. I can easily wake up from sleep 55. My stool [fecal] evacuation is proper 56. My urination is proper 57. I can easily pass flatus 58. I easily get belching 59. I get clear belching 60. I have normal menstrual cycle/proper ejaculation 61. I feel my mind is stable 62. I feel I don t have fluctuations of thought in my mind 63. I feel I have normal intellect 64. I don t have any difficulty in perceiving sense objects Suggestion if any with regard to formation of questionnaire, the language asked, etc. Ancient Science of Life / Apr-Jun 2015 / Vol 34 / Issue 4 209