Introducing regular behavioural surveillance into the health system in India: its feasibility and validity

BACKGROUND

Illness is affected by human behaviour. However, in most developing countries the risk behaviour of the general population is not assessed. We developed a surveillance system to assess the 'risk factors' at the community level using the routine healthcare system.

METHODS

The Comprehensive Rural Health Services Project at Ballabgarh, Haryana, provides healthcare to a population of 82,933 through 2 primary health centres and 24 health workers. Information on behavioural risk factors for communicable and non-communicable diseases was collected by health workers during the annual health census from December 2003 to February 2004. The information collected pertained to maternal and child health, and household and individual behaviour. We compared the data related to individual behaviour with that ofa survey of non-communicable diseases risk factors done in the same area.

RESULTS

Data were collected from (i) mothers who had delivered during the preceding year (n=1625), (ii) a random sample of individuals (n=2865), (iii) and all households (n=7488). The response rate was 85% for mothers, 91%/ for households and 95% for individuals. Approximately 80% of the households had access to drinking water, 32% to sanitary latrines, 28% of women increased their dietary intake during pregnancy, and 50% of adult men used tobacco. Comparing these results with those from the survey of risk factors for non-communicable diseases revealed no significant differences.

CONCLUSION

It is feasible for health workers to do behavioural surveillance by usingthe routine healthcare system.

Behavioral risk factors for non-communicable disease among factory employees in Faridabad; Haryana

INTRODUCTION

In developing countries like India, in addition to the infectious diseases, non-communicable diseases are emerging as significant causes of morbidity and mortality. Workplaces present a setting which is appropriate for intervention for adults in a community. The aim of this study is to assess the knowledge, attitude and prevalence of selected risk factors for non-communicable diseases.

METHODS

A cross sectional study was conducted among the regular employees of the factories. Smoking, alcohol consumption, dietary intake and physical activity were measured through interview schedules and height, weight and blood pressure were also measured by standard instrument. An awareness generation program was pre-tested.

RESULTS

A total of 545 employees were interviewed. Among them 307 (56.3%) and 238 (43.7%) were manual and non-manual workers respectively. Most of the employees knew [smoking as a risk factor for hypertension (55.2%), heart attack (61.1%) and cancer (78.7%); Alcohol as a risk factor for hypertension (72.1%), heart attack (73.9%), cancer ( 54.9%); Physical inactivity as a risk factor for hypertension (82.6%), heart attack (78.5%), diabetes (60.4%) and high fat diet as a risk factor for hypertension (67.2%), heart attack (64.8%)] that these risk factors lead to different non-communicable diseases. The prevalence (95% CI) of the risk factors is as follows: male current smoker [40.7% (36.4-45.3)], current alcohol consumption [31.0 % (27.2 - 35.1)], sedentary activity [41.2% (37.0 - 45.5)], high fat intake [93.7% (90.2 - 95.5)], over weight [26.9% (23.2 - 30.9)]; and hypertension [21.0% (17.62 - 24.6)]

CONCLUSIONS

This study showed that the risk factors for non-communicable diseases are prevalent in factory employees. Implementation of the risk factors control programme is desirable and there is an interest among employees and management.

Large duodenal GIST with massive liver secondaries melting under Imatinib: a case report

Gastrointestinal stromal tumors(GIST) have become a well established entity and its taxonomy is no more ambiguous. Better understanding of the cell of origin and immunohistochmical markers have made this possible. Their treatment has been revolutionized with the advent of targeted molecular therapy, namely Imatinib mesylate. Herein we report a rare and interesting case of a thirty year old South Indian Lady with an extremely large Duodenal GIST with massive Liver secondaries. The phenomenon of metastatic GIST responding to Imatinib mesylate is not new. What is interesting in this case is the enormous tumor load at the time of presentation as exemplified by the cross sectional images. This kind of tumor response and patient survival deserves documentation

Homelessness: a hidden public health problem

Homelessness is a problem, which affects not only the people who are homeless but the whole society. This problem is not well recognized among the public health professionals. This paper attempts to discuss the issues in the context of homelessness starting from the definition used to methodology of estimation of their numbers as well as their health problems and health care needs. There is lack of data on the health problems of homelessness from India. There is no special health or social programmes or services for this subsection of the society. The existing number of shelters is inadequate and as there are multiple barriers, which prevent them to have proper access to the existing health care system. With the changing social and economic scenario, homelessness is likely to increase. We need to recognize homelessness as a public health problem and attempt to target this group for special care in order to promote equity in health system.

Profile of biochemical risk factors for non communicable diseases in urban, rural and periurban Haryana, India

BACKGROUND

Globalisation and increasing urbanisation in most developing countries including India raises concerns of possibility of a major increase in NCDs in these countries. WHO has recommended a STEPwise approach for NCD risk factor surveillance since risk factors of today are diseases of tomorrow. This paper presents the estimation of biochemical risk factors for NCDs undertaken as a part of the ICMR six centre study.

OBJECTIVE

To estimate the prevalence and levels of bio-chemical risk factors (fasting blood glucose, total cholesterol, HDL and triglyceride levels) in urban, rural and periurban locations in Ballabgarh, Haryana.

METHODOLOGY

A community based cross-sectional study was carried out in urban, rural and periurban areas. A total of 1513 subjects were enrolled (501 in urban, 504 in periurban and 508 in rural areas) with equal distribution by area of residence, sex and age group. Fasting blood glucose and lipids were estimated using enzymatic kits.

RESULTS

The mean levels of fasting blood glucose, cholesterol, TGL and low HDL were the highest in the urban area, though there was not much difference in the rural and periurban areas. There was also an increasing trend of all the parameters as age increased in both men and women. 11.4% of men in urban areas had fasting blood glucose above the cut off levels and 44.3% of urban men and women had high cholesterol levels.

CONCLUSION

This study documents a high burden of biochemical risk factorsnot only in urban areas but also in the periurban and rural population. It has also brought out some technical and operational issues for carrying out biochemical risk factors surveillance in the community. There is a need to scale up from surveys to surveillance mode using appropriate tools and application of this information for policy planning and programme implementation.

Linking undergraduate medical education to primary health care

Under graduate medical education aims at producing doctors who are competent in preventive, promotive and curative knowledge and skills. The community medicine curriculum in All India Institute of Medical Sciences, New Delhi has been designed with this objective in view. Students are given community oriented training in urban and rural settings whereby students are taught to carry out various activities under the guidance of faculty members. This curriculum has evolved over many years and provides ample exposure to the students to understand the health problems, and health system of the country especially at the primary and secondary level. There is a sequential teaching of community medicine, which starts from fourth semester through internship. Successful training in community medicine lies outside the walls of the department and the involvement of other partners like the community, health systems etc contribute largely.

Effect of consumption of micronutrient fortified candies on the iron and vitamin A status of children aged 3-6 years in rural Haryana

OBJECTIVE

To assess the efficacy of micronutrient fortified sugar candies in improving the iron and vitamin A status in children aged 3 to 6 years.

DESIGN

Triple blind randomized controlled trial.

SETTINGS

Anganwadis and preparatory schools in rural Haryana.

METHODS

410 children were randomized in four groups. One group received full dose candy (vitamin A 1000 IU and 14 mg elemental iron) daily, the second group received full dose candy for 3 days a week, the third group received half dose candy (vitamin A 500 IU and 7 mg elemental iron) daily and the fourth received placebo. The candies were provided to children under supervision of field workers. Hemoglobin, S. ferritin, S. retinol and S. retinol binding protein levels were estimated at baseline and after 13 weeks of intervention.

RESULTS

The increase in hemoglobin was least in the placebo group (0.3 g/dL) as compared to the two full dose groups (1.15-1.18 g/dL, P < 0.001). Among anemic children, the increase in hemoglobin was about 2 g/dL in the full dose group and 0.7 g/dL in the placebo group (P < 0.001). S. ferritin levels increased significantly only in the full dose daily group (p < 0.05). The prevalence of anemia decreased from around 50% at baseline to 9.6% in the full dose daily group (p < 0.01). Based on the S. retinol levels, the study area was not vitamin A deficient and the intervention did not result in a significant improvement in the vitamin A status of the children.

CONCLUSION

Micronutrient fortified candies were effective in improving the hemoglobin level and decreasing anemia prevalence. It could serve as a suitable vehicle for micronutrient supplementation in children and other target groups.

Self-medication among residents of urban resettlement colony, New Delhi

A cross-sectional survey on the practice of self-medication was carried out in September 2005, among 1928 residents of urban resettlement colony in New Delhi. Prevalence of self-medication among those who had suffered some illness episode in the last one month was 31.3%. Head/ joint/body ache were the most common symptoms for which self-medication was practiced. Chemists were the main source of prescription for self-medication. Time and money factor were identified as the major reasons for not seeking doctor's advice and taking self-medication instead. It was of concern that about 87% users were not aware of side effects of self-medication.

Are the urban poor vulnerable to non-communicable diseases? A survey of risk factors for non-communicable diseases in urban slums of Faridabad

BACKGROUND

Non-communicable diseases have modifiable risk factors, which are easy to measure and can help in planning effective interventions. We established a community-based sentinel surveillance to estimate the prevalence and level of common risk factors for major non-communicable diseases as part of a joint Indian Council of Medical Research/WHO initiative.

METHODS

This survey was done from February 2003 to June 2004 and included 1260 men and 1 304 women 15-64 years of age living in urban slum areas of Ballabgarh block, Faridabad district, Haryana. A list of all slums in Ballabgarh block was obtained from the Municipal Corporation of Faridabad. Slums were selected by stratified cluster sampling. All households in the selected slums were visited and men and women interviewed in alternate households. The study instrument was based on the STEPS approach of WHO. It included questions related to tobacco use, alcohol intake, diet, physical activity, and history of treatment for hypertension and diabetes mellitus. Height, weight, waist circumference and blood pressure were measured. To estimate prevalence at the population level, age adjustment was done using the urban Faridabad population structure from the 2001 Census of India.

RESULTS

The age-adjusted prevalence of smoking among men was 36.5% compared with 7% in women. Bidi was the predominant form of smoked tobacco used. The use of smokeless tobacco was reported by 10.2% of men and 2.9% of women. While 26% of men reported consuming alcohol in the past 1 year, none of the women did. The mean number of servings per day of fruits and vegetables was 2.7 for men compared with 2.2 for women. Overall, only 7.9% and 5.4% of men and women, respectively took > or = 5 servings per day of fruits and vegetables. Women were more likely to be physically inactive compared with men (14.8% v. 55%); 67% of men and 22.8% of women reported mean physical activity > 150 minutes per week. The mean body mass index (BMI) was lower in men than in women (20.9 v. 21.9 kg/m2). The prevalence of overweight (BMI > or = 25 kg/m2)) was 16% among men and 21.9% among women. The prevalence of hypertension (blood pressure > or = 1 40/> or = 90 mmHg or on an antihypertensive drug) was 17.2% in men and 15.8% in women.

CONCLUSION

The high prevalence of risk factors for noncommunicable diseases across all age groups in this urban slum community indicates the likelihood of a high future burden of illness. Immediate action for prevention and control is required to prevent the situation from worsening.

Lifestyle associated risk factors in adolescents

OBJECTIVE

The data on these risk factors in school age population is deficient in India. The present study was conducted to evaluate the prevalence of lifestyle associated risk factors for non-communicable diseases in apparently healthy school children in an urban school in Delhi using standard criteria.

METHODS

The study was carried out among 510 students of classes 9th-12th of a school in New Delhi and in the age group of 12 to 18 years. The students were surveyed through an age appropriate modified GSHS (Global School Based Student Health Survey) self administered questionnaire. Height and Weight were measured using standardized equipment and procedure. The blood pressure was measured using OMRON electronic B.P apparatus which were standardized daily against a mercury sphygmomanometer. The statistical analysis was done using Epinfo ver.3.3 and SPSS ver11.5.

RESULTS

The study documents the inappropriate dietary practices (fast food consumption, low fruit consumption), low physical activity, higher level of experimentation with alcohol and to a lesser extent smoking, high prevalence of obesity and hypertension in the school children. The study also showed an association between BMI, systolic and diastolic blood pressures amongst children and other lifestyle factors.

CONCLUSION

School based interventions are required to reduce the morbidity associated with non-communicable diseases.

Comparison of epilenticular IOL implantation vs technique of anterior and primary posterior capsulorhexis with anterior vitrectomy in paediatric cataract surgery

PURPOSE

To compare the functional outcome of epilenticular intraocular lens (IOL) implantation vs the technique of anterior continuous curvilinear capsulorhexis (ACCC), posterior continuous curvilinear capsulorhexis (PCCC) with vitrectomy and in-the-bag IOL implantation in paediatric cataract surgery.

METHODS

Forty eyes of 33 children with developmental or traumatic cataract, whose mean age was 2-12 years, were randomly divided into two groups A and B. Group A patients underwent epilenticular IOL implantation while in group B patients, ACCC, PCCC with anterior vitrectomy with in-the-bag IOL implantation was performed. Equal number of eyes (10 each) with developmental cataracts (subgroups A1 and B1) and traumatic cataracts (subgroups A2 and B2) were allotted to both the groups. Postoperative visual acuity, opacification of the visual axis, and possible complications were observed and analysed.

RESULTS

Four eyes in subgroup B2 had fibrous or ruptured capsules, and were managed by epilenticular IOL implantation technique. One eye in subgroup B2 developed central posterior capsular opacification and hence required a secondary capsulotomy. All cases in group A maintained a clear visual axis at the last follow-up. Minimal postoperative inflammation was noticed in all groups, which subsided with anti-inflammatory medication. At the last follow-up, all eyes in group A gained visual acuity >/=6/18. Whereas in group B, visual acuity >/=6/18 was obtained in 85.7% cases with the epilenticular IOL implantation technique and in 83.3% cases with ACCC and PCCC with anterior vitrectomy technique.

CONCLUSION

Epilenticular IOL implantation offers a safe and effective alternative for management of paediatric cataract. In selected cases of traumatic cataract, it is the preferred treatment modality.

Attitude of women towards family planning methods and its use--study from a slum of Delhi

BACKGROUND

To predict the need of family planning methods, family planning managers often rely on unmet need derived from measure of contraceptive demand. However women's intention and her background knowledge of family planning methods not received as much attention as a measure of family planning methods demand.

OBJECTIVE

To know the attitude of women regarding use of family planning methods and to find out the factors that restricts its use, and the change in pattern of use over a period of one year.

METHODS

This was a prospective study. One (Block G) out of eight blocks was selected randomly. Using convenient sample method, families were selected starting from a point in the selected block (Block G). 40 women of childbearing age group (15- 49 years) were enrolled. All women were followed for a period of one year.

RESULTS

Weakness was narrated as the commonest side effect from all family planning methods. More than 70% women told that irregular menstruation from Oral Contraceptive pills and ill health from tubectomy as the other side effects. Demands for more children and for son preferences were the leading reason for not using any methods followed by afraid of side effects and health problems. There was negligible change in the use of family planning methods during the period of the study.

CONCLUSION

Effective family planning methods use should be advocated through adequate counseling about the correct use, side effects and their proper management and their benefit in the back ground of custom and belief.

Declining sex ratio: role of society, technology and government regulation in Faridabad district, Haryana

BACKGROUND

A declining sex ratio at birth has been documented during censuses in India. The decline is especially more in the northern states of Haryana and Punjab. We attempted to assess the role of society (preference for a male child, awareness and acceptability of the practice of sex determination), technology (availability and affordability) and government regulation in the adverse ratio for girls in the Ballabgarh block of Haryana in northern India.

METHODS

The population (about 80 000) in the Ballabgarh block has been under constant demographic surveillance for the past 30 years and the data are stored electronically. This was used to determine the sex ratio at birth in the area since 1990. The data on availability of ultrasound machines was collected from the district authorities, as registration of these machines was made mandatory under the Prenatal Diagnostic Techniques Act, 1994. We interviewed 160 mothers and grandmothers to determine the awareness and acceptability of sex determination methods and practices.

RESULTS

The demographic data for the past 10 years showed a declining sex ratio-from 881 in 1990-91 to 833 in 2000-01. The data support the view that in the initial part of this period, ultrasound was used for sex determination of all-order births but subsequently was used more in higher-order births. Our interviews with the mothers and grandmothers of the area showed that the practice of sex determination is prevalent and the attitude of the society is ambivalent. The increased availability of ultrasound machines in the area in the past 10 years corresponded to the decline in sex ratio. When the government made the practice illegal, the sex ratio improved only to fall again as the law was not implemented. Later years saw a more stringent implementation of the law and the sex ratio improved again.

CONCLUSION

There is a 'demand' for sex determination technology and, therefore, this would continue to be 'supplied'. At most the 'supply' can be regulated. Social engineering efforts need to be targeted at reducing the demand if the sex ratio is to be improved.

Cost of syrup versus capsule form of vitamin A supplementation

The study was done to estimate the cost of each dose of vitamin A (2,00,000 Units) to the health system when delivered as a capsule, applicap or as syrup form. The cost of distribution of vitamin A supplements was estimated for the manufacturers, district and delivery level. The lowest cost per dose was for capsules in plastic jar (Rs. 0.99) and the highest was for the syrup in glass bottle (Rs. 1.29), the option currently being practiced. The distribution costs were least for the capsule, which compensates for its higher production cost. The cost of syrup was also more due to high degree of wastage compared to capsules. While cost is an important issue, other operational factors need also to be considered.

Management of sick children by health workers in Ballabgarh: lessons for implementation of IMCI in India

The aim of this study was to determine the impact of training of health workers in the management of pediatric morbidity in terms of reduction in infant mortality rate (IMR) a 2-year period in rural Ballabgarh with a present IMR of 37 per 1000 live births. The study was designed as a pre- and post-intervention trial. The intervention was started in November 1999 and the outcome measured for the years 2000 and 2001. A sample size of 4000 was estimated for a power of 80 per cent at 5 per cent significance level. The training of the workers was for 4 days and included didactics, video-films, patient demonstrations, etc. Data on under-fives' deaths and their causes using a verbal autopsy tool was done as a part of the routine data collection system. The workers management of pediatric morbidity was assessed based on the post-training knowledge gain, forms filled by them, and referrals seen at the secondary level. The knowledge of the workers on disease and their management improved after the initial training but reached a plateau at a 50 per cent score. A review of 948 forms showed that the workers' disease classification and management was not satisfactory, especially for pneumonia and sick neonates. It was better for fever, measles, dysentery, and diarrhoea. A review of 11 cases referred by workers confirmed this. There was no impact on IMR. A look at the cause of death revealed that malnutrition, diarrhoea, and pneumonia to be the main causes among post-neonatal deaths and birth-asphyxia and prematurity as the main cause of deaths in the neonates. While implementing Integrated Management of Childhood Illnesses (IMCI) in India through the health workers, increased emphasis needs to be placed on training and supervision. Community level issues, such as healthcare seeking, female neglect, etc., may limit the scope of reduction in IMR due to implementation of IMCI.

Use of verbal autopsy by health workers in under-five children

We conducted this study to ascertain whether health workers can routinely administer verbal autopsy (VA) to determine the cause of death in their area. The health workers were trained to administer verbal autopsy tool on the deaths occurring in the population under them. All the verbal autopsies of under-five deaths between January 2000 to December 2001 were reviewed by a pediatrician. There were 262 deaths of children under five years in this period, and 71% of them were infants, out of which 34% were neonatal deaths. The health workers reported PEM, fever, pneumonia, and diarrhea as the leading causes of death, based on the existing system of obtaining information provided by the family members. Verbal autopsy forms reviewed by a pediatrician also showed that apart from fever, the first three causes of death were the same i.e., PEM, diarrhea and pneumonia. This study shows that health workers can be trained to use the verbal autopsy to ascertain the cause of death.

Out-of-pocket expenditure on healthcare in a north Indian village

BACKGROUND

Information on healthcare expenditure at the family or household level is important for the planning and management of health services. It is particularly relevant for health insurance agencies to estimate the amount of premium for initiating a universal health insurance system.

METHODS

Of 800 families in a village, 160 were selected by systematic random sampling. Of these, 156 families were followed up for a period of 12 months (September 1998 to August 1999) by making monthly visits. Responses from each family, as given by the head of the family, were recorded with the help of an interview schedule administered in the local language. The interview schedule covered any morbidity among the family members in the past one month and the out-of-pocket expenditure incurred on the same.

RESULTS

The private health sector was utilized in 59.4% of total episodes. Utilization of the private sector was directly associated with a higher socioeconomic status (p = 0.002). Of the total expenditure on non-hospitalized cases, 83.6% was incurred in the private sector. The mean per capita annual out-of-pocket expenditure on health was Rs 131. The median expenditure per episode was Rs 15.

CONCLUSION

Our study shows that out-of-pocket expenditure is more than the government expenditure on health. There is a need for systems such as health insurance to protect the poor from high medical costs.

HLA associations in P. falciparum malaria patients from Mumbai, western India

In the present study, HLA associations among the cohort of 171 severe P. falciparum malaria patients were compared with that of 101 normal sex, age and ethnically matched control samples. All these individuals lived in Mumbai in an area of low and seasonal P. falciparum transmission. HLA A, B, DRB1 and DQB1 antigens were serologically (A and B) and molecularly (DRB and DQB) determined using isolated lymphocytes and genomic DNA following the microlymphocytotoxicity assay and PCR-SSP techniques. Significant differences were observed between patients with malaria and controls in the following groups of alleles: A3, B27, B49, DRB1*04, and DRB1*0809 were increased, while A19, A34, B18, B37, and DQB1*0203 were decreased. HLA B49 and DRB1*0809 were found to be positively associated with the complicated severe malaria patients (OR = 13.88; p < 0.0001). HLA A19, B5 and B13 were protective in patients with high parasite index (> 2%). These observations revealed the importance of ethnic background, which has to be taken into consideration while developing an ideal malaria vaccine. Further, when compared to HLA associations of other world populations the present study indicates the relative importance of different HLA alleles that may vary in different populations.

Passive malaria surveillance in a low endemic area of India: validation of a clinical case definition

BACKGROUND

In India, 2.55 million cases of malaria were reported during 1997; roughly one-third were due to Plasmodium falciparum. Malaria cases are identified by passive and active surveillance and all patients with fever are treated with chloroquine (10 mg/kg body weight). Since all fevers are not malaria, this results in overtreatment and has a bearing in terms of the parasites developing resistance. We aimed to test the validity of a clinical algorithm for passive malaria surveillance by primary care doctors (fever with pallor or splenomegaly) in a low endemic, Plasmodium vivax-predominant area of Ballabgarh block in Faridabad District, Haryana.

METHODS

Passive surveillance was carried out at the general and paediatric outpatient departments (OPDs) of Ballabgarh hospital. All persons with fever attending the OPD were examined for the presence of fever, pallor and splenomegaly by the treating doctor. A blood smear was prepared and examined in all these cases.

RESULTS

A total of 3119 slides for malaria were made at Ballabgarh hospital but clinical details in the requisition form were available for only 2616 patients who form the subjects of this analysis. A total of 59 malaria cases (30 P. vivax cases and 29 P. falciparum) were diagnosed. The presence of fever with pallor or splenomegaly had a sensitivity of 28.8% (95% CI: 18.1-42.3); specificity of 88.6% (95% CI: 87.3-89.8), positive predictive value of 5.5% (95% CI: 3.3-8.8) and negative predictive value of 98.2% (95% CI: 97.5-98.7).

CONCLUSION

The algorithm did not have sufficient sensitivity to detect malaria cases by passive surveillance.

Consensus and conflicts in health sector reforms in India: a Delphi study

BACKGROUND

Health sector reforms have generated much debate in India, especially in the context of economic liberalization. The World Bank intensified this debate in 1993 when it tried to redefine the role of the public and private sectors in healthcare. The Government of India has recently announced the National Health Policy. We are not aware of any formal exercise by which a consensus has been reached or conflicts in the issues related to health policy have been assessed. We present the results of such an exercise conducted in the format of a Delphi study.

METHODS

Based on a review of the current literature, a 9-domain, 56-item questionnaire was prepared. This was sent to a panel of 132 respondents with diverse backgrounds, from the grassroots workers to policymakers by surface or electronic mall. They were asked to identify the three top priorities and to give their degree of agreement to the statements. The results of the first round were analysed and sent back to the respondents for reconsideration. Consensus was defined as the presence of > or = 75% of the respondents in agreement whereas conflict was said to be present if > 35% of the respondents were on either side of the divide. During the subsequent round, the respondents were also asked to give three suggestions on how to approach the previously identified top three priorities.

RESULTS

Half (66) of the original list of panelists replied to the questionnaire. The three priorities identified and later ratified were: improving the quality of care of the primary healthcare system, improvements in medical education and setting up a disease surveillance system. Other areas of consensus identified were: setting up a formal channel of interaction with the private health sector, instituting cost recovery systems in the government sector, setting up a technology assessment commission and bringing accountability into the system. Conflicts were in continuation of subsidy in medical education, the role of and need for health insurance and the role of health professionals vis-a-vis Panchayati Raj institutions.

CONCLUSION

We have demonstrated, on a small scale, the feasibility of assessing consensus on a wide range of issues. The approach is replicable, cost-effective and ensures that the scope of involvement is widened. Also, there is likely to be a greater feeling of self-involvement in the decisions made which would therefore meet with less resistance from the system during implementation.

Ethical issues in public health policy

Ethics in public health policy is given the least importance and rarely discussed. Resolving ethical issues in public health is often an arduous task as these are complicated and require careful handling. Using four case studies, we discuss issues pertaining to pertussis and brain damage, water fluoridation and dental caries, infection with the human immunodeficiency virus and the right to marriage, and the debate surrounding universal salt iodization. The core issue in all these examples pertains to the relevance of ethics in public health policy.

Neonatal outcomes at a subdistrict hospital in north India

Subdistrict hospitals form the first referral level facilities for essential newborn care services. However, there is a paucity of information on the pattern of neonatal admission and outcomes at this level. The objective of this study was to describe the spectrum of neonatal mortality at a subdistrict hospital. The study was conducted at a 50-bed hospital at Ballabgarh in northern India. The data of the neonates born in this hospital (inborns) and those admitted with sickness after being delivered at home (outborns) were separately analysed for the period 1994-1999. The main outcomes of interests were incidence, distribution, and primary causes of neonatal mortality. Of 6746 inborns and 385 outborns admitted (total 7,137) there were 56 deaths (0.8 per cent) and 38 (0.6 per cent) referrals among inborn and 70 deaths (18.2 per cent) and 37 (9.6 per cent) referrals among outborns. The deaths or referral rates among inborn for different weight groups were 27.7 per cent for < 1,500 g, 7.2 per cent for 1500-1999 g, 1.2 per cent for 2,000-2,499 g, and 0.6 per cent for weight > or = 2,500 g. Most deaths under 7 days of age were related to prematurity [41 per cent (28/69)] and birth asphyxia [38 per cent (26/68)], while those aged between 7 and 27 days were mostly due to sepsis [91 per cent (42/46)]. The results of this study indicate that babies with a birthweight above 1,500 g have a good outcome at this level. Deaths under 7 days of age were mostly due to birth asphyxia and prematurity, while those after 7 days were almost entirely due to sepsis. Referral is an important outcome at this level of service.

Estimation of mortality and morbidity due to strokes in India

In order to control the stroke problem, its magnitude should be assessed. India is ranked among the countries where the information on stroke is minimal. We decided to review the information available in order to estimate the mortality and morbidity due to stroke in India. Information was collected through electronic search, hand search and contact with experts. Each article was reviewed for relevance and epidemiological rigor. The demographic data were as derived from published government figures. The prevalence from individual studies was pooled and weighted based on sample size. Analysis was done separately for males and females at 10-year intervals (20 years onwards). A total of 7 studies was located, but 2 were discarded. All were done in rural areas except 2 which also included urban areas. The prevalence was estimated as 203 per 100,000 population above 20 years amounting to a total of about 1 million cases. The male to female ratio was 1.7. Around 12% of all strokes occurred in population below 40 years. The estimation of stroke mortality was seriously limited by the method of classification of cause of death in the country. The best estimate derived was 102,000 deaths; which represented 1.2% of total deaths in the country. There is need to initiate steps to collect data on morbidity and mortality due to stroke in the country as a first step towards control measures.

Injection use in a village in north India

BACKGROUND

Injections can transmit infections such as human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV), and precipitate poliomyelitis. Complications such as injection abscesses and nerve damage may also occur. It is estimated that 50% of the injections given in developing countries are unsafe. However, limited information is available from India. We planned a pilot study to assess the prevalence of injection use and the knowledge of the community and private medical practitioners (PMPs) about injection use.

METHODS

One in every four houses in the village under study was selected by systematic random sampling. One adult (> 18 years) respondent in the family was asked questions about family members receiving injections in the past 6 months. Nine PMPs were interviewed about their knowledge and practices regarding injection use.

RESULTS

In the past six months, 1280 family members in 285 houses received 1575 injections (2.46 injections per person per year). About 35% had received at least one injection in the past 6 months. Children below 5 years received 3.1 injections/child/year of which about 60% were preventive. On their last visit to a health facility, 55% of the subjects were given injections using disposable syringes. About 45% of the 285 respondents knew that diseases could be spread by improper use of injections. While 18% of the respondents said they would prefer injections, 54% preferred oral medications if both were equally effective. After being told the average cost of disposable needles and syringes, 92% of the respondents were willing to buy them. None of the 9 PMPs practising in the village were formally trained in modern medicine. On the day of observation, 18 of 58 patients (30%) seen by PMPs were given injections. Three injections were observed and though they were all given with disposable syringes, the technique of administration did not follow standard guidelines in any. Two PMPs did not know of any disease transmitted by injections. The syringes were usually thrown in a nearby drain or outside the village. Four PMPs said that patients themselves did not ask for injections.

CONCLUSION

The use of injections in the study area was high. The PMPs were not only giving a high number of injections but the technique of administration was also wrong. The community was less likely to ask for injections on their own but was willing to buy disposable syringes and needles. The awareness about the risk of injections was low.

Microvessel density and p53 overexpression in young women with breast cancer: a case-control study

Several reports have indicated that young women (less than 40 years of age) with breast cancer have a worse prognosis than older women. We performed a case-control study in order to confirm this observation and to determine whether this was attributable to increased microvessel density (MVD) or p53 expression. Twenty-six young women (cases) with stage I-III breast cancer that had adequate paraffin-embedded archival tissue were identified by the Montefiore Medical Center Tumor Registry over a 24-year period. For each case, two or three control subjects at least 40 years of age or older were selected from the registry and matched for nodal status and tumor size. Immunohistochemistry was performed for MVD and p53 overexpression. A Cox proportional hazard model was performed to examine the influence of age, MVD, p53 overexpression, and recognized prognostic factors on disease-free and overall survival. There were 26 cases (median age, 36 years) and 72 controls (median age, 64 years). The groups were well matched for known prognostic variables. There was no significant difference in p53 overexpression or MVD in the cases and controls. In multivariate analysis, the only features associated with an increased risk of recurrence included young age (hazard ratio [HR] = 2.49; 95% confidence interval [CI]: 1.18-5.25; P = 0.02) and positive lymph nodes (HR = 2.44; 95% CI: 1.12-5.30; P = 0.02). We have confirmed previous reports demonstrating a worse prognosis for women younger than 40 years with invasive breast cancer but found no correlation between young age and MVD or p53 overexpression when adjusted for other variables.

Economic evaluation of water iodization program in Thailand

In Thailand, iodine deficiency disorders (IDD) are endemic in 57 out of 75 provinces with an estimated 15 million people at risk of IDD. A three pronged control program with iodized salt, iodized water and iodized oil capsules is being implemented. The water iodization program is both school based and household based. In the household, the residents are given iodine solution, two drops of which is to be added to 10 l of drinking water. In the schools, in addition to this method, an iodinator is used. This releases a fixed amount of iodine into the drinking water. This study examines the cost of the water iodization program in Thailand for the year 1996 in terms of cost per beneficiary, cost per microg iodine consumed daily and cost per goiter person years averted. We used a discount rate of 5%. Field visit and interviews of health personnel from Ministry to village level were conducted to gather primary data. Review of existing papers and reports of the Department of Health, Government of Thailand was done for secondary data. The costs included the capital cost of equipments, initial training and the recurrent costs of potassium iodate, proportional salaries of personnel involved, monitoring and communication activities. The cost per beneficiary of school based iodinator method (US$ 0.72) and school based drop method (US$ 0.64) were similar and much higher than the household based approach (US$ 0.12). The cost per microg of iodine consumed daily was ten times higher in the school based approach (US$ 0.01) compared to the household approach (US$ 0.001). The cost per goiter case averted for the whole strategy of water iodization was US$ 194.50. Water iodization appears to be a low cost intervention. However, the need for behavioral modification raises the issue of long term sustainability.

Scale for identification of "at risk" families for underfive deaths

India currently has an infant mortality rate (IMR) of 73 and aims to reach 60 per 1000 live births by 2000 A.D. The "at risk" approach which has been traditionally used for Maternal and Child Health services could help to reduce costs. The main objective of the study was to identity socio-demographic "risk factors" at family level for underfive deaths and assess the validity and efficiency of a risk index scale for this purpose. A computerised database on about 71,000 individuals in 28 villages in Ballabgarh Block exists since 1987. All the underfive deaths in the study area during the period 1991-95 were compared with age and sex matched controls on socio-demographic variables. All variables which were found significant at 10% level were taken in for logistic regression. The variables found significant were used to construct a ten point scale. This scaling system was applied to all the families with an underfive child during the two year period 1996-97. Validity and efficiency of this approach was calculated. A total of 849 cases and their age and sex matched controls were studied. The variables which were significantly associated with risk of underfive deaths were: not received measles vaccine (2.19; 1.58-3.04), history of sibling death (2.03; 1.19-3.45), maternal illiteracy (1.86; 1.23-2.81), never used a contraceptive (1.59; 1.17-2.14), having more than 4 children (1.46; 1.04-2.05). About 40% of houses were labelled as high risk. The sensitivity and specificity were around 60%. The improvement in efficiency by the risk approach was 33%. Risk approach is helpful in identifying families who are at greater risk of having underfive deaths. It results in a modest increase in the efficiency of services.

"Development" is not essential to reduce infant mortality rate in India: experience from the Ballabgarh project

BACKGROUND

India aims to reduce the infant mortality rate (IMR) to below 60 per 1000 live births by 2000. IMR is higher in northern India as compared with south Indian states like Kerala. Any further reduction in IMR needs identification of new strategies. The Ballabgarh project with an IMR of 36 in 1997 can help identify such strategies.

OBJECTIVE

To see the trend in reduction of neonatal mortality rate (NNMR) and IMR at the Ballabgarh project, compare it with Kerala and rural India's trend and look at the causes of neonatal and infant mortality.

DESIGN

The Comprehensive Rural Health Services Project, Ballabgarh, run by the All India Institute of Medical Sciences, covered an estimated population of 70,079 in 1997. The health care delivery system is on the national pattern. All the deaths are identified during the house visits by the male workers. The cause of death is ascertained by the health assistant based on the symptomatology at the time of death.

RESULTS

The trends in reduction of IMR for Ballabgarh, Kerala and rural India are roughly parallel with the IMR of Ballabgarh lying somewhere in between the two. However, the NNMR of Ballabgarh (10.6 in 1996) was comparable to Kerala's NNMR (10.9 in 1992). The proportion of infant deaths occurring during the neonatal period had fallen from 50% in the early seventies to 30% during 1996-97. In 1992-1994, 33.8% of all neonatal deaths were attributable to low birth weight and 37.3% to infective causes. Acute respiratory infection and diarrhoea continue to be the chief cause of postneonatal mortality.

CONCLUSION

It is possible to bring down neonatal mortality before postneonatal mortality. The Kerala model, which focuses on social development, may not apply to northern India for sociocultural reasons.

Screening for chronic impairments using medical interns in rural Haryana, India

BACKGROUND

With the increase in life expectancy, prevalence of impairments and disabilities are expected to increase in India. However, there have been very few studies to estimate the magnitude of the problem in rural India. This is essential, if appropriate rehabilitation services are to be planned in the country.

METHODS

The study was done in the rural field practice area of the All India Institute of Medical Sciences at Ballabgarh, Haryana. The survey was conducted by successive batches of interns posted at Ballabgarh as a part of their compulsory rotating internship programme. The diagnostic criteria were based on history and simple clinical examination done at the domiciliary level.

RESULTS

A total population of 25,509 in twelve villages were screened. The total impairment rate was 5.4% with no significant men/women difference. The prevalence of physical impairment was 4.7 per 1000 population. The prevalence of corneal opacity in children below 15 years of age was 4.7 per 1000. Prevalence of cataract was almost 35% in the population over 60 years of age and 15% in the population between 45 to 60 years. Auditory impairment was 19.6 per 1000 as ascertained by history. Three-fourths of this was conductive deafness and was found mainly in people above 60 years of age.

CONCLUSION

Utilizing the rural field practice areas of medical colleges for collection of data on issues of national health importance would not only strengthen the health system in the country but also improve medical education. There is a need for a comprehensive preventive, promotive, curative and rehabilitative approach to disabilities in India.