India marching towards TB elimination: How far we are

Tuberculosis continues to be the leading cause of death worldwide. India shares twenty five percent of total tuberculosis population. Programmatic approach to fight against tuberculosis started in this country in the form of National Tuberculosis Program (NTP). In due course of time India adopted many strategic changes in its fight against tuberculosis. The current program named National tuberculosis elimination program (NTEP) has been set up to eliminate TB by 2025. There are some challenges which India need to overcome to achieve its target five years ahead of the sustainable development goals. Insufficient budget, inadequate diagnostic facilities, under-reporting, low success rate, high dropout rate, social stigma are some of the major challenges in the path to achieve a TB elimination status. Besides that, all the backlogs demand for swift performance in identification, notification, and treatment of TB cases. India has all the potential to eliminate tuberculosis. Strengthening of health system, mainstreaming of private sectors, enhancing diagnostic facilities, inclusion of latest diagnostic techniques, addressing social hindrances, and advocacy for higher budget are some of the program strengthening measures, if followed properly, can take India towards a TB free status.

Prevalence of common mental disorders and treatment gap among patients with non-communicable diseases in the rural areas of East India

BACKGROUND

Mental and physical non-communicable diseases (NCDs) coexist, because they share common environmental and behavioral risk factors. The treatment gap for common mental disorders, such as depression, anxiety, and substance use, is large compared to other NCDs.

OBJECTIVE

To determine the prevalence and treatment gap of common mental disorders among patients with non-communicable diseases.

METHODOLOGY

The community-based cross-sectional study was conducted in the rural parts of East India, in people aged 30 years and older with NCDs. A simple random sample was chosen to select the villages and participants. Eligible participants administered with screening and diagnostic questionnaire for depression, anxiety, and substance use. Those diagnosed with mental disorders were again assessed for treatment status in the last 12 months. Non-receipt of treatment was considered as treatment gap.

RESULTS

A total of 515 participants were included in the analysis. The overall prevalence of common mental disorders among the study population was 46.4% (95% CI 42.0-50.8), and excluding substance use, the prevalence was 11.7% (95% CI 9.0-14.7). The treatment gap for common mental disorders among patients with non-communicable diseases, including and excluding substance use, was 98.3% (95% CI 95.8-99.5) and 93.3% (95% CI 83.8-98.2), respectively.

CONCLUSION

The prevalence and treatment gap of common mental disorders among persons with NCDs was high. Public health interventions need to be emphasized for the integration of mental health care into NCD care.

Effectiveness of peer-led intervention in control of non-communicable diseases in rural areas of Khordha district: study protocol for a cluster randomized controlled trial

BACKGROUND

The main contributors to death and disability from chronic illnesses in developing nations are elevated blood pressure (hypertension), blood sugar (diabetes mellitus), and blood cholesterol (dyslipidaemia). Even though there are affordable treatments, the treatment gap for these conditions is still significant. Few pilot studies from industrialized nations discuss the value of peer-led interventions for achieving community-level management of blood pressure and blood sugar. This study aims to evaluate the effectiveness of peer-led intervention compared to standard care in achieving control of selected non-communicable diseases (NCDs) in Indian context at 1 year of intervention among people of 30-60 years with hypertension and/or diabetes mellitus and/or dyslipidaemia.

METHODS

A cluster-randomized controlled trial will be conducted in villages of two rural blocks of the Khordha district of Odisha from August 2023 to December 2024. A total of 720 eligible participants (360 in the intervention group and 360 in the control group) will be recruited and randomized into two study arms. The participants in the intervention arm will receive a peer-led intervention model for 6 months in addition to standard care. The sessions will be based on the six domains of NCDs - self-care, follow-up care, medication, physical activity, diet, limiting substance use, mental health and co-morbidities. The mean reduction in blood pressure, HbA1C, and blood cholesterol in the intervention arm compared to the standard care arm will be the main outcome.

DISCUSSION

The increasing burden of NCDs demands for newer strategies for management. Peer-led interventions have proven to be useful at the international level. Incorporating it in India will have remarkable results in controlling NCDs.

TRIAL REGISTRATION

Clinical Trial Registry of India (CTRI) CTRI/2023/02/050022. Registered on 23 February 2023.

Anti-SARS-CoV-2 antibody kinetics up to 6 months of follow-up: Result from a nation-wide population-based, age stratified sero-epidemiological prospective cohort study in India

Repeated serological testing tells about the change in the overall infection in a community. This study aimed to evaluate changes in antibody prevalence and kinetics in a closed cohort over six months in different sub-populations in India. The study included 10,000 participants from rural and urban areas in five states and measured SARS-CoV-2 antibodies in serum in three follow-up rounds. The overall seroprevalence increased from 73.9% in round one to 90.7% in round two and 92.9% in round three. Among seropositive rural participants in round one, 98.2% remained positive in round two, and this percentage remained stable in urban and tribal areas in round three. The results showed high antibody prevalence that increased over time and was not different based on area, age group, or sex. Vaccinated individuals had higher antibody prevalence, and nearly all participants had antibody positivity for up to six months.

Health system factors related to COVID-19 mortality in Eastern India: Hospital-based cross-sectional study

Introduction

Mortality from coronavirus disease 2019 (COVID-19) pandemic has left footprints across all ages and socio-economic strata. The deaths because of COVID-19 are usually multi-factorial. The study aimed to assess the health system factors related to COVID-19-related deaths.

Materials and Methods

A hospital-based retrospective study was conducted at a tertiary care hospital of eastern India. A total of 272 COVID-19 deaths that occurred between April and November 2020 were investigated. Data were extracted from Medical Record Department, and telephonic interviews were conducted to assess the different delays related to death. Data were analysed using Statistical Package for Social Sciences. Travel time, travel distance, delay in testing, and delay in receiving quality care were presented as median with inter-quartile range.

Results

Complete information could be collected from 243 COVID deaths of the 272 deaths (89.3%). The duration of hospital stay was 1-7 days for 42% of the deceased. The median travel time was 120 min, and the median distance travelled was 60 km. The median time to receive first attention of health care workers was 10 minutes. There was hardly any delay in reporting of test results, whereas the median time from symptoms to test and the median time from symptoms to admission were 4 days each.

Conclusion

Health system factors related to death of COVID-19 need to be addressed to avoid the avoidable deaths during the pandemic situation. The resilience of the health system can be helpful in reducing death toll in a low-resource country like India.

Effectiveness of Fortified Mid-Day Meal in Reducing Anemia Among School Children in Dhenkanal, Odisha: A Quasi-Experimental Study

BACKGROUND

Iron-deficiency anemia among school-aged children is widespread in India. The efficacy of micronutrient and iron fortified school-served meals in reducing iron deficiency anemia has been demonstrated in randomized controlled trials in other parts of the globe. The current study evaluates its effectiveness in real-world Indian settings.

METHODS

Mid-day-Meal (MDM) programme provides free lunch to students of grade 1 to 8 in all public-funded Indian schools. An implementation research project fortified MDM of all public schools of 4 out of 8 sub-districts ("blocks") of Dhenkanal district of Odisha state with fortified rice kernel (FRK). All the schools of the other 4 blocks fortified with micronutrient powders (MNP)-both FRK and MNP containing equal amounts of supplementary iron and other micronutrients. Schools of 4 matched blocks of neighboring nonimplementing Angul district served as control. Cross-sectional representative samples of students were drawn from the 3 arms, before and after intervention (n = 1764 and n = 1640 respectively). Pre-post changes in anemia prevalence and hemoglobin levels were estimated in the sampled children using difference-in-difference analysis after controlling for inter-arm differences in socioeconomic status, and iron and deworming tablet consumptions.

RESULTS

Factoring in pre-post changes in control and adjusting for potential confounders, the proportion of children without anemia and mean hemoglobin improved by 1.93 (1.38, 2.24, P < .001) times and 0.24 (-0.03, 0.51, P = .083) g/dL in MNP; and 1.63 (1.18, 2.24, P = .002) times and 0.18 (-0.09, 0.45, P = .198) g/dL in FRK arms.

CONCLUSIONS

Fortified MDM could effectively improve anemia status among Indian school-aged children under real-world conditions.

Relationship of Mindfulness with Depression, Self-Management, and Quality of Life in Type 2 Diabetes Mellitus: mindfulness is a Predictor of Quality of Life

Context

Mindfulness interventions have shown promising results in both psychological and clinical outcomes of type 2 diabetes mellitus. Depression, self-management, and quality of life (QOL) have shown improvement with mindfulness interventions; however, little is known about dispositional mindfulness and its relationship with depression, self-management, and QOL in type 2 diabetes mellitus.

Aims

The aim of this study is to assess the relationship of dispositional mindfulness with depression, self-management, and QOL in patients of type 2 diabetes.

Settings and Design

Noncommunicable disease outpatient department of a tertiary care medical center of East India. Cross-sectional study.

Subjects and Methods

Ninety-nine patients with type 2 diabetes completed the Five Facets Mindfulness Questionnaire, Diabetes Self-Management Questionnaire, and World Health Organization QOL BREF questionnaire and Hamilton Rating Scale for depression.

Statistical Analysis Used

Pearson's correlation and hierarchical regression analysis using the SPSS software version 20.0.

Results

Describing, acting with awareness, and nonjudging facets of mindfulness showed a negative correlation with depression (P < 0.05). Acting with awareness and nonreactivity to inner experience were positively correlated with the physical activity domains of self-management (P < 0.05). All facets of mindfulness showed a positive correlation with four domains of QOL. In hierarchical regression analysis, after controlling for sociodemographic and clinical variables, mindfulness predicted the psychological domain of QOL, explaining 31% of the variance (P ≤ 0.001). However, mindfulness did not predict depression or self-management.

Conclusions

Dispositional mindfulness is a strong predictor of QOL in type 2 diabetes mellitus and hence can be targeted with interventions to improve psychological outcomes.

Effectiveness of COVID-19 vaccine (Covaxin) against breakthrough SARS-CoV-2 infection in India

India approved COVID-19 vaccine called Covaxin, developed by the Indian Council of Medical Research and Bharat Biotech Ltd. The primary objective of the study was to estimate the effectiveness of Covaxin in preventing breakthrough SARS-CoV-2 infection in healthcare workers (HCWs). A test-negative matched case-control study was conducted among HCWs of tertiary care hospital in Eastern India. Any HCW who tested positive for COVID-19 using RT-PCR during April and May 2021 was taken as the case. The HCWs who tested negative for COVID-19 by RT-PCR were considered as controls after matching with the date of testing and profession of the cases. Vaccination data were collected from the institution's vaccine database and recall. In case of discrepancy, it was confirmed from the CoWIN portal (cowin.gov.in). The sample size was 670 participants (335 pairs). Conditional logistic regression models were used to calculate the adjusted odds ratio for breakthrough SARS-CoV-2 infection. Vaccine effectiveness was calculated using the following formula: VE = (1-aOR) × 100%. Sensitivity analysis was done for effectiveness of Covaxin, excluding Covishield vaccination. The mean age of participants was 29.1 years (SD = 7.1), and the majority were males (55.2%). Among the study participants, 60% were completely vaccinated, 18.51% were partially vaccinated, and 21.49% were unvaccinated. After adjusting for age, gender, type of household and past history of COVID-19 disease in conditional logistic models, the vaccine effectiveness was 22% (aOR 0.78, 95% CI: 0.52-1.17; p = .233). Sensitivity analysis with Covaxin showed an effectiveness of 29% (aOR 0.71, 95% CI: 0.47-1.08; p = .114) for preventing breakthrough SARS-CoV-2 infection.

Trends in willingness to receive COVID-19 vaccines among healthcare workers in India: Findings from repeated cross-sectional national surveys

Background

COVID-19 vaccination of the healthcare workers (HCWs) is a key priority in the fight against the SARS-CoV-2 pandemic. India launched its COVID-19 vaccination program in January 2021. We aimed to understand the trends in willingness to receive COVID-19 vaccines and its associated factors among HCWs in India.

Methods

Using a repeated cross-sectional survey design, we collected information from HCWs in three critical time points: before (n = 937, October 2020), during (n = 1346, January 2021); and after (n = 812, May 2021) the introduction of COVID-19 vaccines in India. The third survey coincided with the peak of the second wave of COVID-19 pandemic in India.

Findings

Of the study participants, 43.7, 60.2, and 73.2% were willing to receive COVID-19 vaccines during the first, second and third rounds of surveys, respectively. In multivariable logistic regression analysis, participants who trusted the health care system were more likely to report willingness to receive a COVID-19 vaccine; medical trust emerged as a significant factor in all the three rounds of surveys (First survey-aOR: 2.24, 95% CI: 1.67-2.99; Second survey-aOR: 3.38, 95% CI: 2.64-4.33; Third survey-aOR: 2.54, 95% CI: 1.65-3.91). Having confidence in domestic vaccines (Second survey-aOR: 2.21, 95% CI: 1.61-3.02; Third survey-aOR: 2.05, 95% CI: 1.24-3.37); and high perceived risk of contracting COVID-19 (Second survey-aOR: 1.48, 95% CI: 1.13-1.93; Third survey-aOR: 2.02, 95% CI: 1.31-3.13) were found to be associated with willingness to receive vaccines. Among socio-demographic characteristics, being married (aOR: 1.71, 95% CI: 1.08-2.71) and having high socio-economic status (aOR: 3.01, 95% CI: 1.65-5.51) emerged as significant factors associated with willingness to receive COVID-19 vaccines in the third round of the surveys.

Interpretation

Willingness to receive COVID-19 vaccine increased with time, as the severity of the pandemic increased. To increase COVID-19 acceptance and coverage among HCWs, it is important to instill confidence in domestic vaccines and assist in accurate assessment of risk toward contracting COVID-19 infection.

Clinico-Epidemiological Characteristics of Healthcare Workers with SARS-CoV-2 Infection during the First and Second Waves in a Teaching Hospital from Eastern India: A Comparative Analysis

In this retrospective observational study, we have performed a comparative analysis of the demographic, clinical and epidemiological characteristics of the HCWs affected with SARS-CoV-2 infection during first two waves in India. The overall prevalence of SARS-CoV-2 infection among HCWs was found to be 15.24% (14.20-16.33) and 23.38% (22.14-25.65) during first and second waves respectively. The second wave showed an adjusted odds ratio of 0.04(0.02-0.07) and 2.09(1.49-2.93) for hospitalization and being symptomatic, respectively. We detected significantly higher level of C-reactive protein (CRP) among admitted HCWs during the second wave (5.10 -14.60 mg/dl) as compared to the first wave (2.00 - 2.80 mg/dl). Our study found the relative risk of SARS-CoV-2 reinfection among HCWs during the second wave to be 0.68 [0.57-0.82, p < 0.001)]. Although, the prevalence of SARS CoV-2 infection and risk of being symptomatic was higher during second wave, the risk of hospitalization was less when compared with the first wave.

Community health workers willingness to participate in COVID-19 vaccine trials and intention to vaccinate: A cross-sectional survey in India

Background

Vaccine hesitancy is of considerable concern as it threatens the great potential of a vaccine against COVID-19. This study aims to determine factors associated with community health workers’ willingness to participate in clinical trials of COVID-19 vaccine, and their vaccination intention, in India.

Methods

A cross-sectional study was conducted among 377 community health workers using self-administered anonymous questionnaire during the lockdown periods in India. Participant's socio-demographics, willingness-to-participate in COVID-19 vaccine trials, intention to accept COVID-19 vaccine were recorded in a Likert scale. Data were analysed descriptively, and a multivariate logistic regression model was used to investigate factors associated with willingness to participate and accept the vaccine.

Results

Among 377 CHWs, 70 (19%) intended to participate in COVID-19 vaccine trial, 151 (40%) responded positively regarding their intention to get vaccinated. Those with knowledge on development of COVID-19 vaccine [aOR 3.05 (95% CI: 1.18–7.88), p = 0.021], and men [aOR 3.69 (95% CI: 1.51–8.97), p = 0.004] were more willing to participate in clinical-trial, while an undergraduate degree, and trust in domestic vaccines were identified as deterrents for the same. Perceiving COVID-19 as risk [aOR 2.31 (95% CI: 1.24–4.31), p = 0.009], and male gender [aOR 2.39 (95% CI: 1.17–4.88), p = 0.017] were factors associated with intention to get vaccinated. Respondents who had knowledge about COVID-19 virus were less likely to uptake the hypothetical vaccine [aOR 0.32 (95% CI: 0.12–0.88), p = 0.027].

Conclusions

Increasing knowledge regarding COVID-19 is not enough to improve vaccine acceptance rates. Targeted interventions addressing socio-demographic determinants related to COVID-19 vaccination should help improve acceptance.

Development of an EQ-5D Value Set for India Using an Extended Design (DEVINE) Study: The Indian 5-Level Version EQ-5D Value Set

OBJECTIVES

This study aimed to develop the Indian 5-level version EQ-5D (EQ-5D-5L) value set, which is a key input in health technology assessment for resource allocation in healthcare.

METHODS

A cross-sectional survey using the EuroQol Group's Valuation Technology was undertaken in a representative sample of 3548 adult respondents, selected from 5 different states of India using a multistage stratified random sampling technique. The participants were interviewed using a computer-assisted personal interviewing technique. This study adopted a novel extended EuroQol Group's Valuation Technology design that included 18 blocks of 10 composite time trade-off (c-TTO) tasks, comprising 150 unique health states, and 36 blocks of 7 discrete choice experiment (DCE) tasks, comprising 252 DCE pairs. Different models were explored for their predictive performance. Hybrid modeling approach using both c-TTO and DCE data was used to estimate the value set.

RESULTS

A total of 2409 interviews were included in the analysis. The hybrid heteroscedastic model with censoring at -1 combining c-TTO and DCE data yielded the most consistent results and was used for the generation of the value set. The predicted values for all 3125 health states ranged from -0.923 to 1. The preference values were most affected by the pain/discomfort dimension.

CONCLUSIONS

This is the largest EQ-5D-5L valuation study conducted so far in the world. The Indian EQ-5D-5L value set will promote the effective conduct of health technology assessment studies in India, thereby generating credible evidence for efficient resource use in healthcare.

Sociodemographic Determinants of Willingness and Extent to Pay for COVID-19 Vaccine in India

Background

Responding to the fast transmission rates and increasing fatality rates, countries across the world expedited the development and deployment of the vaccine for coronavirus disease 2019 (COVID-19). Evaluation of individuals' willingness to pay (WTP) would provide pertinent information regarding future demand and financing preferences, which shall help to devise the effective payment strategy for COVID-19 vaccination.

Methods

A nationwide, cross-sectional, and self-administered online survey using a structured questionnaire was conducted to identify the sociodemographic determinants of willingness and extent to pay for COVID-19 vaccine in India. A non-probability convenience sampling followed by snowball sampling was employed to recruit participants (n = 3,341). The likelihood of sociodemographic determinants to predict willingness and extent to pay was modeled using the multivariate binary logistic regression analysis.

Results

Out of 3,341 participants, 68% (n = 2,271) were willingness to pay for COVID-19 vaccine. Results showed significantly higher odds for willingness to pay among participants who were single [adjusted odds ratio (aOR) = 1.394, p < 0.01] and having a family size of 4 members (aOR = 1.346, p < 0.01). The adjusted odds ratio sizably increased from 1.396 for participants whose monthly income was between INR 10,000 and 20,000/month to 2.240 for participants whose monthly income was above INR 50,000/month. Further, out of 2,271 of those participants who were willingness to pay for COVID-19 vaccine, majority (n = 1,246, 54.9%) of participants were willingness to pay below 50% of COVID-19 vaccine cost. This study found that those who are single (aOR = 0.688, p < 0.01), having an income between INR 20,000 and 50,000/month (aOR = 0.686, p < 0.05), and those who belonged to socially disadvantaged category (aOR = 0.450, p < 0.01) were estimated to have significantly lower odds of willingness to pay more than 50% of COVID-19 vaccine cost.

Conclusion

This study observed that majority of those participants who willingness to pay for COVID-19 vaccine were willingness to pay only up to 50% of COVID-19 vaccine and income was observed as a precursor predictor of the willingness and extent to pay for COVID-19 vaccine. The understanding on the willingness and extent to pay for COVID-19 vaccine and its sociodemographic determinants will be helpful for making the strategic decisions related to the financing of COVID vaccine in India.

Adverse events following immunization of COVID-19 (Covaxin) vaccine at a tertiary care center of India

The study aimed to assess the adverse events following COVID-19 vaccine (Covaxin) immunization at a tertiary care institution and also assess the predictors of the adverse events following immunization (AEFI). The prospective observational study was conducted in a tertiary care institute among the Covaxin beneficiaries between June 28 and September 6, 2021. A total of 1826 participants were assessed for any local or systemic adverse events after seven days of vaccination. A telephonic interview was conducted, and the beneficiaries were assessed according to the adverse event grading. A total of 1826 participants were assessed for AEFI, and 544 (29.8%) reported at least one of the AEFI. No severe adverse events were reported, and about 1.6% had moderate AEFI. Pain at the injection site (14.6%), fever (9.7%), and myalgia (5.9%) were the common adverse events reported by the participants. AEFI incidence was higher in the first dose (38.1%) when compared to the second dose (26.4%), and this finding was significant with a p < 0.001. The major factors associated with AEFI were female sex, history of an allergic reaction, presence of comorbidities, acute infection in the past 3 months, and intake of chronic medications. Precaution needs to be taken while vaccinating individuals having allergies, comorbidities, acute infection in the last 3 months, and individuals on chronic medication.

Parents' Perceptions and Intention to Vaccinate Their Children Against COVID-19: Results From a Cross-Sectional National Survey in India

Background

Despite the success of adult vaccination against COVID-19, providing vaccines to children remains a challenge for policymakers globally. As parents are primary decision-makers for their children, we aimed to assess parents' perceptions and intentions regarding COVID-19 vaccination in India.

Methods

A cross-sectional web-based study was designed, parents or caregivers (N = 770) were recruited through snowball sampling using Google form. Cross-tabulation was performed by parents' intention to vaccinate their children against COVID-19 virus with sociodemographic characteristics and their risk perception toward COVID-19, trust in the healthcare system, and their history of vaccine hesitancy behavior. Multivariable logistic regression analysis was performed to compute the predictors of child vaccination intention among Indian parents.

Results

Seven hundred and seventy parents across the country have completed the survey. Of the 770 participants, 258 (33.5%) have shown intent to vaccinate their children. The stated likelihood of child vaccination was greater among parents who had a bachelor's degree or higher education (aOR: 1.98, 95% CI: 1.15-3.51); as well as among parents who intended to vaccinate themselves (aOR: 2.35, 95% CI: 1.30-4.67). Parental concerns centered around vaccine safety and side effects.

Conclusion

Indian parents reported high knowledge of the COVID-19 virus and were aware of the development of a vaccine. However, about one-third of parents intended to vaccinate their children, and about half of them were not sure whether to vaccinate their children or not against the COVID-19 virus. The study highlighted the need for health promotion strategies that promote vaccine uptake among parents.

Performance of equations for estimation of 24-hour urinary sodium from morning fasting urine samples in a multisite study in India

Background Dietary salt intake is an important modifiable risk factor for cardiovascular diseases. Estimation of 24-hour salt intake using morning urine samples needs to be validated in the Indian context. We examined the performance of INTERSALT, Tanaka and Kawasaki equations for the estimation of 24-hour urinary sodium from morning fasting urine (MFU) samples. Methods We enrolled 486 adults aged 18-69 years from four regions of India with equal rural/urban and sex representation to provide 24-hour urine samples. The next day, a MFU sample was obtained. Based on the volume and sodium content of the 24-hour urine sample, 24-hour sodium excretion (reference method) was calculated. Sodium levels in the MFU samples were measured along with other parameters required, and the above equations were used to estimate 24-hour urinary sodium levels. Intraclass correlation coefficient (ICC) was used to assess the degree of agreement between the estimates from the reference method and the three equations. Bland-Altman (BA) plots were used to identify systematic bias and limits of agreement. A difference of 1 g of salt (0.39 g of sodium) between the mean salt intake by 24-hour urine and as estimated by equations was considered acceptable. Results A total of 346 participants provided both the samples. The mean (SD) daily salt intake estimated by the 24-hour urine sample method was 9.9 (5.8) g. ICC was low for all the three equations: highest for Kawasaki (0.16; 95% CI 0.05-0.26) and least for Tanaka (0.12; 0.02-0.22). Only Tanaka equation provided estimates within 1 g of measured 24-hour salt intake (-0.36 g). BA plots showed that as the mean values increased, all the three equations provided lower estimates of salt intake. Conclusion Tanaka equation provided acceptable values of 24-hour salt intake at the population level. However, poor performance of all the equations highlights the need to understand the reasons and develop better methods for the measurement of sodium intake at the population level.

Correlation of Serum Retinol and Atherogenic Indices in Type 2 Diabetes Mellitus: A Case-Control Study

Dyslipidemia is an important risk factor for atherosclerosis and coronary heart disease, leading to mortality and morbidity in subjects with T2DM. This risk is higher in subjects with diabetes who are on retinoid therapy for some other indication, where hypercholesterolemia, hypertriglyceridemia, and low serum high-density lipoprotein cholesterol (HDL-C), and sudden cardiovascular deaths have been reported. Our study aimed to find the correlation of serum retinol and atherogenic index (AI) in subjects with T2DM and compare them with healthy controls. We found there was a significant difference in systolic and diastolic blood pressure, body mass index, waist circumference, waist hip ratio, total cholesterol (TC), Triglycerides (TG), non-high density lipoprotein cholesterol (non-HDL-C), the atherogenic ratio of cholesterol (ARC), atherogenic index of plasma (AIP) and AI between the two groups. There was a significant positive correlation of serum retinol with TC, TG, LDL-C, Non-HDL-C, ARC, AIP, and AI. In our study we found an association of serum retinol with atherogenic index and dyslipidemia in subjects with T2DM. Serum retinol can be a novel predictor of cardiovascular risk in subjects with T2DM.

Hospital-Based Contact Tracing of Patients With COVID-19 and Health Care Workers During the COVID-19 Pandemic in Eastern India: Cross-sectional Study

Background

The contact tracing and subsequent quarantining of health care workers (HCWs) are essential to minimizing the further transmission of SARS-CoV-2 infection and mitigating the shortage of HCWs during the COVID-19 pandemic situation.

Objective

This study aimed to assess the yield of contact tracing for COVID-19 cases and the risk stratification of HCWs who are exposed to these cases.

Methods

This was an analysis of routine data that were collected for the contact tracing of COVID-19 cases at the All India Institute of Medical Sciences, Bhubaneswar, in Odisha, India. Data from March 19 to August 31, 2020, were considered for this study. COVID-19 cases were admitted patients, outpatients, or HCWs in the hospital. HCWs who were exposed to COVID-19 cases were categorized, per the risk stratification guidelines, as high-risk contacts or low-risk contacts

Results

During contact tracing, 3411 HCWs were identified as those who were exposed to 360 COVID-19 cases. Of these 360 cases, 269 (74.7%) were either admitted patients or outpatients, and 91 (25.3%) were HCWs. After the risk stratification of the 3411 HCWs, 890 (26.1%) were categorized as high-risk contacts, and 2521 (73.9%) were categorized as low-risk contacts. The COVID-19 test positivity rates of high-risk contacts and low-risk contacts were 3.8% (34/890) and 1.9% (48/2521), respectively. The average number of high-risk contacts was significantly higher when the COVID-19 case was an admitted patient (number of contacts: mean 6.6) rather than when the COVID-19 case was an HCW (number of contacts: mean 4.0) or outpatient (number of contacts: mean 0.2; P=.009). Similarly, the average number of high-risk contacts was higher when the COVID-19 case was admitted in a non–COVID-19 area (number of contacts: mean 15.8) rather than when such cases were admitted in a COVID-19 area (number of contacts: mean 0.27; P<.001). There was a significant decline in the mean number of high-risk contacts over the study period (P=.003).

Conclusions

Contact tracing and risk stratification were effective and helped to reduce the number of HCWs requiring quarantine. There was also a decline in the number of high-risk contacts during the study period. This indicates the role of the implementation of hospital-based, COVID-19–related infection control strategies. The contact tracing and risk stratification approaches that were designed in this study can also be implemented in other health care settings.

Neonatal dermatitis neglecta---Neglect by health system: A case report

A 29 days old female child presented to the general outpatient department of Community Health Center with greenish black crusting over left ear for 7-8days duration without any other signs and symptoms. We report the diagnosis and management of the condition through ad-hoc store and forward tele-dermatology. This is the first reported case of dermatitis neglecta in neo-natal period.

Experience from a COVID-19 screening centre of a tertiary care institution: A retrospective hospital-based study

BACKGROUND

The COVID-19 pandemic continues to be a significant public health concern across the whole world, including India. In the absence of any specific treatment or vaccine against COVID-19, the role of efficient testing and reporting has been uncontested so far as the number of cases is rising daily. In order to strengthen the screening activities and to prevent nosocomial infection, facility-based screening centres have been designed and operated at various levels of healthcare, including tertiary care institutions.

METHODS

The present study has been planned with an objective to understand the patient profile and evaluate the functioning of COVID-19 screening OPD (CS-OPD) at a tertiary care hospital. In this hospital-based retrospective study, data from individuals visiting the COVID-19 screening OPD during the period from 17th March 2020 to 31st July 2020 were collected. We documented and analysed relevant demographic, epidemiological and clinical characteristics of the patients.

RESULTS

A total of 10,735 patients visited the COVID-19 screening OPD during the defined study period of which 3652 individuals were tested. The majority of the patients, i.e., 65.67% (7050) were male and in the 15-59 years age group (84.68%). The most common symptoms among patients visiting CS-OPD was cough (9.86%). Of the total, 17.17% (1843) of patients reported to the CS-OPD with a contact history of COVID-19-positive patient. On the other hand, 13.49% (1448) of patients were with either domestic or international travel history. The overall testing rate and positivity rate for CS-OPD during this period were found to be 34.02% and 7.94%, respectively.

CONCLUSION

The clinical, demographic and epidemiological characteristics of patients visiting CS-OPD varied across the study period depending upon the containment and testing strategy. The CS-OPD played a crucial role in preventing nosocomial infection and maintaining non-COVID care at the tertiary care hospital.

Preparedness of primary and secondary health facilities in India to address major noncommunicable diseases: results of a National Noncommunicable Disease Monitoring Survey (NNMS)

BACKGROUND

The monitoring framework for evaluating health system response to noncommunicable diseases (NCDs) include indicators to assess availability of affordable basic technologies and essential medicines to treat them in both public and private primary care facilities. The Government of India launched the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS) in 2010 to strengthen health systems. We assessed availability of trained human resources, essential medicines and technologies for diabetes, cardiovascular and chronic respiratory diseases as one of the components of the National Noncommunicable Disease Monitoring Survey (NNMS - 2017-18).

METHODS

NNMS was a cross-sectional survey. Health facility survey component covered three public [Primary health centre (PHC), Community health centre (CHC) and District hospital (DH)] and one private primary in each of the 600 primary sampling units (PSUs) selected by stratified multistage random sampling to be nationally representative. Survey teams interviewed medical officers, laboratory technicians, and pharmacists using an adapted World Health Organization (WHO) - Service Availability and Readiness Assessment (SARA) tool on handhelds with Open Data Kit (ODK) technology. List of essential medicines and technology was according to WHO - Package of Essential Medicines and Technologies for NCDs (PEN) and NPCDCS guidelines for primary and secondary facilities, respectively. Availability was defined as reported to be generally available within facility premises.

RESULTS

Total of 537 public and 512 private primary facilities, 386 CHCs and 334 DHs across India were covered. NPCDCS was being implemented in 72.8% of CHCs and 86.8% of DHs. All essential technologies and medicines available to manage three NCDs in primary care varied between 1.1% (95% CI; 0.3-3.3) in rural public to 9.0% (95% CI; 6.2-13.0) in urban private facilities. In NPCDCS implementing districts, 0.4% of CHCs and 14.5% of the DHs were fully equipped. DHs were well staffed, CHCs had deficits in physiotherapist and specialist positions, whereas PHCs reported shortage of nurse-midwives and health assistants. Training under NPCDCS was uniformly poor across all facilities.

CONCLUSION

Both private and public primary care facilities and public secondary facilities are currently not adequately prepared to comprehensively address the burden of NCDs in India.

Prevalence and Psychosocial Correlations of COVID-19-Related Worries in People with Diabetes Mellitus Seeking Services from East Indian Tertiary Care Center: A Cross-Sectional Survey Results

Context

Patients with diabetes are more prone to psychosocial problems which are known to adversely impact clinical outcomes of diabetes. COVID-19 is understood to further worsen the psychosocial problems of patients with diabetes.

Aims

We carried out this cross-sectional telephonic survey of COVID-19-related worries in patients with diabetes mellitus to understand the prevalence and correlates of COVID-19-related worries.

Settings and Design

This was a telephonic survey of patients seeking care from noncommunicable disease clinic of a tertiary care medical center.

Subjects and Methods

We used a structured questionnaire to assess sociodemographic, clinical, psychological variables and COVID-19-related worries.

Statistical Analysis Used

We used SPSS 20.0 for descriptive statistics keeping significance levels at 0.05. Between-group comparisons of continuous variables were made with independent t-test and two-way ANOVA; correlations were carried out with Pearson correlation test.

Results

Two hundred and nine patients completed the telephonic survey conducted from September to November 2020. The prevalence of diabetes-related worries in our sample was 80%. Younger age (P < 0.001), unemployment (P = 0.029), and the presence of mental disorder (P < 0.001) were associated with higher diabetes-related worries. Poor glycemic control (0.008) and symptoms of COVID-19 (0.03) were associated with diabetes-related worries. Diabetes-related worries correlated with diabetes distress (ρ =0.441, P < 0.001), social isolation (ρ =0.401, P < 0.001), and perception of social support (ρ = -0.158, P < 0.001).

Conclusions

A large proportion of our patients with diabetes are at high risk to experience COVID-19-related worries especially, younger people, unemployed and those with mental illness. Furthermore, the presence of diabetes distress and the perception of social isolation increase COVID-19 worries.

Prevalence of diabetes distress and its relationship with self-management in patients with type 2 diabetes mellitus

CONTEXT

Diabetes distress (DD) in India has been studied mainly in the context of depression. Little is known about DD, its determinants, distribution, and its impact.

AIMS

This study aims to estimate the prevalence of DD and identify its socio-demographic and clinical determinants in type 2 diabetes mellitus patients. To assess the relationship of DD with self-management in nondepressed type 2 diabetes mellitus.

SETTINGS AND DESIGN

A cross-sectional descriptive study in noncommunicable disease clinic of a tertiary care medical center.

SUBJECTS AND METHODS

DD Scale was used to assess DD in 200 patients with type 2 diabetes mellitus. Diabetes Self-Management Questionnaire was used to evaluate self-management behavior. Patient Health Questionnaire 9 was used to exclude depression.

STATISTICAL ANALYSIS USED

Sample size calculation was done as per prevailing prevalence estimates. SPSS 20.0 was used for statistical analysis. ANOVA and Independent t-tests were done to compare between groups means. Hierarchical multiple regression analysis was done, keeping self-management as a dependent variable and socio-demographic, clinical variables, and DD as independent variables.

RESULTS

The prevalence of DD was 42% in our sample. The duration of diabetes showed that a significant association with DD. DD was significantly and negatively associated with all four domains of self-management, while statistical significance was reached in three domains: dietary control (β = -0.378, P < 0.01); glucose management (β = -0.181, P < 0.01); and healthcare use (β = -0.244, P < 0.01).

CONCLUSIONS

DD is widespread in our patients and harms self-management. There is a need to address DD to improve disease-specific outcomes.

Baseline risk factor prevalence among adolescents aged 15-17 years old: findings from National Non-communicable Disease Monitoring Survey (NNMS) of India

OBJECTIVE

To generate national estimates of key non-communicable disease (NCD) risk factors for adolescents (15-17 years) identified in the National NCD Monitoring Framework and, study the knowledge, attitudes and practices towards NCD risk behaviours among school-going adolescents.

DESIGN AND SETTING

A community-based, national, cross-sectional survey conducted during 2017-2018. The survey was coordinated by the Indian Council of Medical Research-National Centre for Disease Informatics and Research with 10 reputed implementing research institutes/organisations across India in urban and rural areas.

PARTICIPANTS

A multistage sampling design was adopted covering ages between 15 and 69 years-adolescents (15-17 years) and adults (18-69 years). The sample included 12 000 households drawn from 600 primary sampling units. All available adolescents (15-17 years) from the selected households were included in the survey.

MAIN OUTCOME MEASURES

Key NCD risk factors for adolescents (15-17 years)-current tobacco and alcohol use, dietary behaviours, insufficient physical activity, overweight and obesity.

RESULTS

Overall, 1402 households and 1531 adolescents completed the survey. Prevalence of current daily use of tobacco was 3.1% (95% CI: 2.0% to 4.7%), 25.2% (95% CI: 22.2% to 28.5%) adolescents showed insufficient levels of physical activity, 6.2% (95% CI: 4.9% to 7.9%) were overweight and 1.8% (95% CI: 1.0% to 2.9%) were obese. Two-thirds reported being imparted health education on NCD risk factors in their schools/colleges.

CONCLUSION

The survey provides baseline data on NCD-related key risk factors among 15-17 years in India. These national-level data fill information gaps for this age group and help assess India's progress towards NCD targets set for 2025 comprehensively. Though the prevalence of select risk factors is much lower than in many developed countries, this study offers national evidence for revisiting and framing appropriate policies, strategies for prevention and control of NCDs in younger age groups.

Fear and anxiety among COVID-19 Screening Clinic Beneficiaries of a tertiary care hospital of Eastern India

India is one among the most affected countries in the COVID-19 pandemic. The increasing number of cases in India and the fear of COVID-19 infection is causing fear and anxiety. Fear and anxiety related to COVID-19 the community dwellers are less studied. This study was conducted to assess the fear and anxiety related to COVID-19 among the people seeking COVID-19 screening test. The cross-sectional study was conducted on a sample of 398 participants aged 18 years and above who attended the screening clinic of a tertiary care hospital of eastern India. Participants were assessed using Coronavirus Anxiety Scale (CAS) and Fear of COVID-19 scale which are validated screening scales. Result showed that 20.4 % of the participants were having anxiety due to COVID-19. The mean fear score was 17.87 ± 4.48. Females, Middle aged, housewives, less educated, symptomatic, co-morbid and people under institutional quarantine were having more fear. People with COVID-19 related anxiety faced more fear. These findings suggest the need for screening anxiety in COVID-19 screening clinics. People with high levels of COVID related anxiety and fear are at risk for developing psychiatric disorders hence need targeted approach to address their mental health.

Screening for depression in diabetes in an Indian primary care setting: Is depression related to perceived quality of life?

AIMS

To screen for depression in diabetes and evaluate the contributing factors in a primary care setting in India. To evaluate the relationship of depression with perceived quality of life.

METHODS

We used convenience sampling method in this cross-sectional study. 388 consecutive patients with type 2 diabetes mellitus were enrolled over a period of one year. 50.3% patients screened positive on Patient Health Questionnaire (PHQ-9) out of which 21.4% reported moderate to severe depression. Male gender, middle age and poor glycaemic control were associated with depression. In stepwise linear regression analysis when depression category was included as an independent variable, significant difference in regression equations were found. Other independent variables which were included in regression equation were age, education, gender, income lifestyle, glycosylated haemoglobin and Body Mass Index whereas dependent variables were transformed domains of World Health Organization Quality of Life questionnaire.

RESULTS

There is high prevalence of depression in primary care in type 2 diabetes patients in this Indian setting. Depression was strongly associated with all four domains of quality of life. Highest association with depression was seen in Physical domain (β -0.385, p = 0.000) followed by Social domain (β -0.372, p = 0.000).

CONCLUSIONS

High prevalence of depression and its association with poor quality of life indicates need for improved recognition of depression for improving diabetes outcomes in this centre.

Folic acid and vitamin B12 supplementation in subjects with type 2 diabetes mellitus: A multi-arm randomized controlled clinical trial

OBJECTIVE

This study was conducted to investigate and compare the effects of add-on folic acid and vitamin B12 supplementation on glycaemic control, insulin resistance and serum lipid profile in subjects with type 2 diabetes mellitus.

STUDY DESIGN & INTERVENTION

This study was a randomized, multi-arm, open-label clinical trial. 80 patients with type 2 diabetes and on stable oral antidiabetics were enrolled and 20 patients each were randomly allocated to one of the four groups - Group A: add-on Folic acid (5 mg/day); Group B: add-on Methylcobalamin (500 mcg/day); Group C: add-on Folic acid (5 mg/day) + Methylcobalamin (500 mcg/day) and Group D: Standard oral anti-diabetic drugs. The patients were followed up after 8 weeks.

RESULTS

HbA1c improved significantly in Groups B and C [median changes from baseline - 1.2 % (- 13 mmol/mol) and - 1.5 % (- 16 mmol/mol) respectively, p values 0.04 and 0.02 respectively] compared to Group D. Groups B and C also showed significant improvements in plasma insulin, insulin resistance and serum adiponectin compared to Group D. Serum homocysteine declined significantly in all three groups with add-on supplementation compared to standard treatment. No improvement in the lipid profile was noted in any of the groups.

CONCLUSIONS

Add-on supplementation with vitamin B12 improved glycaemic control and insulin resistance in patients with type 2 diabetes mellitus.

Temporary deterioration of oral health-related quality of life (OHRQoL) in nonextraction and extraction modalities of comprehensive orthodontic treatment in adolescents

OBJECTIVE

To evaluate the effects of nonextraction and all first premolar extraction modalities of orthodontic treatment on oral health-related quality of life (OHRQoL) among adolescents.

MATERIALS AND METHODS

Sixty-eight adolescents of aged 12-18 years were chosen. Subjects who required nonextraction orthodontic treatment were included in group I, and those who required all first premolar extractions for orthodontic treatment were included in group II. Baseline OHRQoL data (T0) were recorded before the start of treatment. To evaluate the impact of orthodontic treatment on OHRQoL, the Oral Health Impact Profile-14 (OHIP-14) questionnaire was presented to all subjects for retrospective evaluation at 1 month (T1), 3 months (T2), 6 months (T3) and 1 year (T4) after the start of orthodontic treatment and 1 week after completion of orthodontic treatment (T5).

RESULTS

At T1 and T2, the physical pain and physical disability domains of OHIP-14 were impacted significantly by comprehensive orthodontic treatment in both groups (P < .001). The negative impact of orthodontic treatment on OHRQoL was maximum at T1 and then slowly recovered to the pretreatment level at T3 in both groups. Recovery of OHIP-14 scores was relatively faster in group I subjects compared to group II subjects. At T1 and T2, social disability and handicap domains were deteriorated significantly in group II subjects compared to group I subjects (P < .01).

CONCLUSIONS

The severity of OHRQoL deterioration was similar in both modalities of orthodontic treatment, but recovery from negative impacts was relatively slower in the first premolar extraction subjects.

Effect of caste on health, independent of economic disparity: evidence from school children of two rural districts of India

Caste, a stratifying axis of the Indian society, is associated with wealth and health. However, to what extent caste-based health inequality is explained by wealth disparities, is not clear. Therefore, we aimed to examine the caste-based differences in anaemia (haemoglobin < 11 gm/dl) and self-reported sickness absenteeism in schoolchildren and the mediating role of economic disparity. Students (n = 1764) were surveyed from 54 government schools of Dhenkanal and Angul, Odisha state. Socioeconomic data, anaemia and absenteeism were recorded. The relative risks of anaemia among Scheduled Tribe (least advantaged) and Scheduled Caste (second least advantaged) students were 1.19 (95% CI: 1.08, 1.26) and 1.13 (1.03, 1.20), respectively, as compared to students of the most advantaged caste and that for sickness absenteeism were 2.78 (2.03, 3.82) and 2.84 (2.13, 3.78); p < 0.05, with marginal attenuation when controlled for inter-caste economic disparities. Caste had an independent effect on anaemia and sickness absenteeism in school children, unexplained by inter-caste economic disparities.

Symptom Recognition to Diagnosis: Pathway to Care for Autism in a Tertiary Care Medical Centre

Objective  There is no systematic report on pathway to care in autism from tertiary care medical centers of India. The present study was aimed to evaluate the pathways to care among parents of children with autism-seeking treatment at a tertiary care medical center.

Methods  Cross-sectional, observational study involving parents of 38 children with autism spectrum disorder diagnosed with INCLEN diagnostic tool. Pathway to care was assessed using World Health Organization Encounter Form.

Statistical Analysis   IBM Statistical Package for Social Sciences (SPSS) 20.0 was used for analysis; categorical variables were assessed using Chi-square test keeping statistical significance at 0.05%.

Results  A total of 74% parents reported going to a general practitioner and 13% reported going to a child psychiatrist as point of first contact. Among them, 71% parents reported seeking care with a child psychiatrist in a tertiary medical center at the fourth point of contact. Also, 84% parents believed in biomedical explanation of autism. Majority of parents sought for speech therapy and medicines for their child with autism which is in tune with their biomedical explanation. Parents were the first to identify developmental concerns, average age of symptom recognition being 2.2 years. Average age of intervention initiation was 40 months, 8 months prior to diagnosis of autism.

Conclusions  Early symptom recognition and initiation of interventions is encouraging. Despite having a biomedical explanation of autism and ability to recognize developmental concerns, there is a lag of 4 years in diagnosis and reaching a specialized child psychiatry setup. This lag is a cause of concern owing to the impact on access to evidence-based interventions.

Affiliate stigma among parents of children with autism in eastern India

Parents of children with autism experience high levels of stigma. They often internalize stigma which results in high psychological distress and has negative impact on seeking and providing care. Qualitative methodology has been used to study stigma in Indian population while quantitative studies have not been reported. The authors report affiliate stigma perception among parents of children with autism in a tertiary care medical centre using Affiliate Stigma Scale. Thirty-eight parents participated in this cross- sectional study. We discuss predictors of stigma in terms of caregiver characteristics and symptom profile. Identification of predictors of stigma perception can help in identifying populations at risk.

Single Intra-articular Platelet-Rich Plasma Versus Corticosteroid Injections in the Treatment of Adhesive Capsulitis of the Shoulder: A Cohort Study

OBJECTIVE

The aim of the study was to compare the effects of single intra-articular platelet-rich plasma (PRP) and corticosteroid (CS) injections in patients with adhesive capsulitis of the shoulder.

DESIGN

Patients aged 18-70 yrs of either sex, diagnosed with adhesive capsulitis of shoulder, with less than 6-mo duration, were included. In intra-articular corticosteroid (IA-CS, control) group, 30 patients received a single injection (4 ml) of IA-CS and in IA-PRP (test) group, 30 patients received single IA-PRP injection (4 ml) into the glenohumeral joint under ultrasound guidance. All patients were prospectively followed for 12 wks.

RESULTS

Twenty-eight patients in IA-PRP group and 27 in IA-CS group finished the entire 12-wk study period. At 12 wks, decrements in visual analog scale and total shoulder pain and disability index scores, in IA-PRP group, were 58.4 and 55.1, compared with 48.7 and 45.8 in IA-CS group. In range of movement, IA-PRP group showed significant improvement in passive abduction (-50.4 vs. -39.4), internal (-36.8 vs. -25.8), and external rotations (-35.4 vs. -25.9) compared with IA-CS group, respectively. No major complications were observed in any patients.

CONCLUSIONS

At 12-wk follow-up, a single dose of IA-PRP injection was found to be more effective than an IA-CS injection, in terms of improving pain, disability, and shoulder range of movement in patients with adhesive capsulitis of the shoulder.

Population Based Cancer Registry of India – the Challenges and Opportunities

Cancer is one of the important causes of morbidity and mortality in India. Globally, out of 14 million diagnosed new cancer cases slightly more than 1 million were from India. Population Based Cancer Registries (PBCRs) plays a vital role in formulating cancer control plans as well as in monitoring their success. The article identifies challenges and opportunities for the PBCRs in India. Major challenges of PBCRs in India are-low coverage, urban dominance, quality assurance in data, less awareness among rural people, lack of follow-up and survival data, timeliness, high cost of registration, non-linkage of PBCR with other PBCRs and Hospital Based Cancer Registries (HBCRs) and generalization of estimates at country level. Expansion of cancer atlas project, real time data collection, entering Aadhar number (UID) during registration and establishing linkage among various PBCRs and PBCRs with HBCRs will improve cancer registration and its quality on a short-term basis. However, the opportunity of development new PBCRs in linkage with existing Health and Demographic Surveillance System (HDSS) will increase coverage as well as sustainability of PBCRs in India.

Physicians' compliance with the National Drug Policy on Malaria in a tertiary teaching hospital, India, from 2010 to 2015: a mixed method study

Background

National drug policies are formulated to encourage rational use of drugs and to reduce drug resistance. This study assessed physicians' compliance with the National Drug Policy on Malaria at a tertiary care hospital in north India.

Methods

This mixed method study extracted data from adult malaria inpatient records of the hospital from 2010-2015, and assessed drug supply at pharmacies. Physicians' practices and perspectives were explored by in-depth interviews. Compliance was assessed by severity, type of species and pregnancy status. Thematic analysis was done for the qualitative data.

Results

A total of 247 case files were reviewed. Vivax malaria (41.0%) was more common than falciparum malaria (37.2%). The majority (90.8%) of cases were severe malaria. Overall compliance for use of schizonticidal drug was 73.0% in severe malaria and was only 9.5% in uncomplicated malaria. Compliance for use of gametocidal drug (primaquine) was 15.3%. Schizonticidal drugs were available in all pharmacies except the public one. Primaquine was available in only one. The main themes emerging in the thematic network analysis were physicians' misconceptions, physician-related factors, and hospital-related and drug access factors.

Conclusions

The degree of compliance for severe malaria treatment was reasonably good but low for radical cure. Raising knowledge and awareness among health care providers, by using written treatment protocols and continuing medical education would improve compliance.

Images of psychiatry: Attitude survey of teaching medical specialists of India

CONTEXT

Attitude of teaching medical specialists shapes those of future doctors. Region-specific data on teaching medical specialists' attitudes toward psychiatry (ATP) are lacking from India.

AIMS

This study aimed to assess the attitudes of teaching medical specialists toward psychiatry and its association with sociodemographic profile and career stage.

SETTINGS AND DESIGN

This is a cross-sectional descriptive survey.

MATERIALS AND METHODS

Attitude towards psychiatry (ATP) was assessed from 188 specialists from All India Institute of Medical Sciences (AIIMS) Bhubaneswar and AIIMS Jodhpur using modified ATP scale-30.

STATISTICAL ANALYSIS

Descriptive statistical analysis was done using SPSS version 16.0. Associations of ATP with sociodemographic status, career stage, and family history of psychiatric illness were done using logistic regression analysis.

RESULTS

Overall response rate was 81.68%, and gender (confidence interval [C.I.]: 2.026-7.410, P = 0.000) and super-specialization (C.I.: 2.167-19.479, P = 0.021) were independent significant predictors for difference in attitudes. Female gender and super-specialization were associated with better attitudes. Ninety percent of participants had favorable attitude toward psychiatric illness. Four-fifth felt psychiatric patients to be as human as other patients and found psychiatric treatments effective. More than half felt that psychiatry does not stand among the three most exciting specialties and psychiatrists get less work satisfaction. Only one third said that they would have liked to be a psychiatrist.

CONCLUSIONS

Attitudes were favorable toward patients and psychiatric interventions whereas unfavorable toward psychiatry as a discipline.

What they think of us: A study of teaching medical specialists' attitude towards psychiatry in India

CONTEXT

Attitudes of teaching medical specialists are important in shaping medical students' attitudes toward psychiatry. Data on attitudes of teaching medical specialists of India toward psychiatry are limited.

AIMS

The aim was to study the attitude of teaching medical specialists of an academic medical center in East India toward psychiatry.

SETTINGS AND DESIGN

This was a cross-sectional descriptive study.

MATERIALS AND METHODS

We administered attitude toward psychiatry-30 (ATP 30) scale to teaching medical specialists of the All India Institute of Medical Sciences, Bhubaneswar, based on convenience sampling. Of 104 specialists contacted, 88 returned the completed questionnaire.

STATISTICAL ANALYSIS

We carried out descriptive statistical analysis and expressed results in mean and standard deviation. We analyzed the association of demographic characteristics, specialization, and duration of professional experience with total ATP scores using Chi-square test. We used subgroup analysis to compare mean ATP scores in different demographic and professional groups. We used independent t-test and ANOVA for between group comparisons.

RESULTS

The response rate was 84.62% with a mean ATP score of 88.60. Female gender and having a family member with mental illness was significantly associated with favorable ATP. Notable findings were that 97% of participants were favorable toward patients with psychiatric illness, 90% felt psychiatric interventions as effective whereas 87% found psychiatry unappealing and 52% said that they would not have liked to be a psychiatrist.

CONCLUSIONS

While favorable attitudes toward patients with psychiatric illness and psychiatric interventions may mean better patient care; unfavorable attitudes toward psychiatry as a career choice may adversely affect postgraduate recruitment rates.

Primary health care teaching to postgraduate public health students, comparison of two models: A natural experiment

Background:

Primary health care as an approach forms an integral part of any public health curricula. The knowledge regarding primary health care can be delivered to public health trainee through conventional or the modular teaching models.

Objectives:

We aimed to observe whether there was any difference in the summative assessment scores between two different modalities of teaching primary health care to public health trainee at School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.

Methods:

The present study was a natural experiment. Students of Masters of Public Health (MPH) and MD (Community Medicine) formed two natural groups. They were taught by modular and conventional methods of teaching respectively. A total of seven MPH students and nine MD students, participated in the study.

Results:

Overall summative assessment score among MPH students was 63.9 ± 10.0 in comparison to 61.1 ± 10.9 among MD students. The difference in total scores was not statistically significant.

Conclusion:

We conclude that approaching a complex topic such as primary health care requires a mix of both modular and non-modular teaching to maximize outputs.

Process evaluation of community monitoring under national health mission at Chandigarh, union territory: Methodology and challenges

BACKGROUND

Community monitoring was introduced on a pilot mode in 36 selected districts of India in a phased manner. In Chandigarh, it was introduced in the year 2009-2010. A preliminary evaluation of the program was undertaken with special emphasis on the inputs and the processes.

METHODOLOGY

Quantitative methods included verification against checklists and record reviews. Nonparticipant observation was used to evaluate the conduct of trainings, interviews, and group discussions. Health system had trained health system functionaries (nursing students and Village Health Sanitation Committee [VHSC] members) to generate village-based scorecards for assessing community needs. Community needs were assessed independently for two villages under the study area to validate the scores generated by the health system.

RESULTS

VHSCs were formed in all 22 villages but without a chairperson or convener. The involvement of VHSC members in the community monitoring process was minimal. The conduct of group discussions was below par due to poor moderation and unequal responses from the group. The community monitoring committees at the state level had limited representation from the non-health sector, lower committees, and the nongovernmental organizations/civil societies. Agreement between the report cards generated by the investigator and the health system in the selected villages was found to be to be fair (0.369) whereas weighted kappa (0.504) was moderate.

CONCLUSION

In spite of all these limitations and challenges, the government has taken a valiant step by trying to involve the community in the monitoring of health services. The dynamic nature of the community warrants incorporation of an evaluation framework into the planning of such programs.

Diagnostic agreement between a primary care physician and a teledermatologist for common dermatological conditions in North India

BACKGROUND

Primary care physicians (PCPs) encounter a large number of patients with dermatological diseases. However, delivering appropriate management is a challenge considering the inadequate dermatology training offered during the undergraduate medical curriculum. Teledermatology is the clinical evaluation of skin lesions by dermatologists and allows patients to be diagnosed and treated from a distant site. It is seen as a potential solution to the shortage of specialists and providing equitable service in remote areas.

AIM

The study was aimed at estimating the diagnostic agreement of common dermatological conditions between a PCP and a teledermatologist.

MATERIALS AND METHODS

Consecutive patients with dermatological ailments who attended a primary health care clinic were recruited into the study, examined by the PCP and offered a diagnosis. The clinical images and patients' history were collected and transferred to a dermatologist at a tertiary center who also made a diagnosis. Agreement between diagnosis made by the PCPs and the teledermatologist was measured using kappa (κ) statistics.

RESULTS

Overall agreement between the diagnoses made by a PCP and the dermatologist was found to be 56%. Poor κ agreement (<0.4) was seen in the diagnosis of psoriasis and eczema.

CONCLUSION

Teledermatology can supplement specialist dermatology service in remote areas. There was poor agreement in the diagnosis of psoriasis, classifying various types of eczematous conditions and fungal infections. Scarce manpower in dermatology at the primary health care level compounded by the burden of skin ailments necessitates training of PCPs in common dermatological conditions.

Compliance monitoring of prohibition of smoking (under section-4 of COTPA) at a tertiary health-care institution in a smoke-free city of India

Background:

India enacted a comprehensive tobacco control law known as cigarettes and other tobacco products act (COTPA) in 2003. However, enforcement of the provisions under the law is still a matter of concern. Compliance survey is an effective tool to measure the status of implementation of the law at various public places. Smoke-free hospital campus demonstrates commitment to good health and sends a pro-healthy signal to the community.

Objective:

The objective of this study was to assess the compliance to the prohibition of smoking at public places (under section-4 of COTPA) in a tertiary health-care institution in a smoke-free city of India.

Materials and Methods:

An observational cross-sectional study was conducted at 40 different venues within a tertiary health-care institution in a smoke-free city of India. These places were observed for certain parameters of assessment by a structured checklist, which included evidence of active smoking, evidence of recent smoking, display of signages, presence of smoking aids, cigarette butts and bidi ends.

Results:

Overall compliance rate for section-4 of COTPA was found to be mere 23%. Evidence of active smoking was observed in 21 (52.5%) venues. Signages were seen at only 8 places (20%). Butt ends and other smoking aids were seen in 37 (92.5%) and 26 (65%) places respectively.

Conclusion:

These dismal findings suggest non-compliance to the provisions under COTPA, which calls for a sensitization workshop and advocacy for all the stakeholders.

Pathway to care of epilepsy patients: Exploratory study from an urban slum in Northern India

INTRODUCTION

Epilepsy is a chronic neurological disorder with major psychosocial correlates. Most epilepsy patients in developing countries are untreated or inadequately treated. It is essential to understand the pathway, to care taken by epilepsy patients in a community, to be able to target appropriate services to them.

MATERIALS AND METHODS

A community based study was conducted on all epilepsy patients in an urban slum in Northern India to study their pathways to care. A list of persons suffering from epilepsy was generated by house to house visits, snowballing, and key informant contacts. In-depth interview and Medical Record Review were used to document their pathway to care.

RESULTS

Thirteen of the twenty two patients had contacted a health-care provider for their first episode. The most common first link of care for the patients was secondary level Government hospitals. The next common was private practitioners, followed by Tertiary Care Hospitals, and registered medical practitioners. Eleven out of twenty two patients had to contact a Tertiary Level Center for seeking care. The number of health-care facilities consulted before arriving at their latest point of care ranged from 0 to 5. Traditional or faith healers were consulted at some point of time for cure.

CONCLUSION

There is a need to focus on strengthening and capacity building of the primary care settings for managing epilepsy to enable their better utilization. This shall prevent unnecessary referrals and hence the load on the already burdened higher facilities.

Reproducibility and validity of a quantitative food frequency questionnaire in an urban and rural area of northern India

Background. Food frequency questionnaires (FFQs) have been used in epidemiological studies across the world to capture the usual food intake of individuals. As food habits vary in different population groups, FFQs should be validated before use. Hence, we determined the reproducibility and validity of FFQs designed for urban and rural populations of northern India. Methods. Separate FFQs, designed for urban and rural populations using standard methods, were administered to a sample of 200 subjects (100 urban and 100 rural) in the age group of 35-70 years in the beginning (baseline FFQ) of the study and after an interval of 1 year (1-year FFQ) to assess their reproducibility. Six 24-hour dietary-recalls, taken at an interval of 2 months over a period of 1 year, were used as a reference method to test the validity. Crude and energy- adjusted nutrient intakes estimated from FFQs and 24-hour dietary-recalls were compared using Pearson correlation coefficients. Bland and Altman plots were also used to test the agreement between the two methods. Results. Nutrient intakes were found to be similar at the baseline and 1-year FFQs in urban and rural areas. The unadjusted Pearson correlation between 24-hour dietary- recalls and 1-year FFQ ranged from 0.22 for vitamin C to 0.63 for iron in the urban area. It ranged from 0.06 for vitamin C to 0.74 for energy in the rural area. The correlations lowered after adjusting for energy and there was a minimal increase after de-attenuation. Conclusion. The FFQs were reproducible and valid for assessing nutrient intakes except for some micronutrients.

Tracking progress toward elimination of iodine deficiency disorders in jharkhand, India

Research question:

What is the current status of Iodine Deficiency Disorders (IDD) in the state of Jharkhand?

Objectives:

(1) To determine the status of iodine deficiency in the state. (2) To determine the availability and cost of adequately iodized salt at the retail shops. (3) To study the perceptions of the community regarding iodine deficiency, salt and iodized salt.

Design:

A cross-sectional community-based survey.

Study setting:

Thirty clusters selected through the probability proportion to size (PPS) sampling in the state of Jharkhand.

Study participants:

Children aged 6-12 years, households, retail shopkeepers and opinion leaders.

Study tool:

Quantitative and qualitative methodology using a pretested questionnaire and focus group discussion used to carry out the community-based survey.

Results:

Total goiter rate (TGR) was 0.9%. Median urinary iodine level was 173.2 µg/L. The proportion of individuals with urinary iodine levels less than 100 and 50 µg/L were 26.4% and 10%, respectively. Slightly less than two-thirds (64.2%) of the households were found to be consuming adequately iodized salt as measured by titration (greater than 15 ppm). Iodized salt was available across the state and the cost varied between Re. 1 and Rs. 8 per kilogram. A common belief among the community was that iodized salt is equivalent to refined packet salt that is further equivalent to expensive salt.

Conclusion:

The results of the present survey show that the iodine nutrition in the state of Jharkhand is optimal. Considering that the consumption of adequately iodized salt should increase from 64.2% to the goal of more than 90%, sustained efforts are required in this place to consolidate the current coverage of adequately iodized salt and increase it to greater than 90%.