Leveling the Research Playing Field: Decolonizing Global Health Research Through Web-Based Platforms.

Global health research has traditionally been rooted in colonialism, with some investigators in high-income countries leading and managing research and investigators in low- and middle-income countries serving as implementing partners. The Community Health Worker-Led Intervention for Vaccine Information and Confidence (CIVIC) Project, conducted in India and led jointly by India- and US-based investigators, leveraged web-based platforms to facilitate a more horizontal, inclusive, and balanced approach to partnerships between researchers and the community. Using web-based platforms to conduct research was found to be an effective strategy to engage researchers at all levels and combat systemic barriers associated with in-person activities such as power, economic, social, and gender dynamics. Connecting online for research meetings created a more equitable environment for community members to engage meaningfully with research. Further, by conducting research through web-based platforms, we found that we were able to strengthen the diversity of participants, provide a space for more marginalized groups to speak up, and minimize logistical barriers to attendance. Harnessing web-based approaches in research provides a pathway toward opportunities to promote equity and contribute to the decolonization of global health spaces.

Community perceptions of vaccination among influential stakeholders: qualitative research in rural India.

BACKGROUND: In India and other low- and middle-income countries, multiple family and community members are influential in caregivers' perceptions of vaccination. Existing literature indicates the primary caregiver, typically the mother, is instrumental in vaccine decision-making, but this may vary in contexts. We investigated the role of stakeholders in India who influence caregivers' vaccination perceptions, as this is essential to developing strategies to promote vaccine acceptance and improve uptake. METHODS: This research was conducted in 2019 in Mewat District in Haryana, an area in India with extremely low vaccination coverage. We conducted six focus group discussions with 60 participants in the following categories: fathers of children under-5 years old, expectant mothers, mothers-in-law, community health workers, and community influencers such as locally elected officials and religious leaders. RESULTS: Our results highlighted four themes that influence vaccine uptake. First, while caregivers associated vaccination with reductions in specific diseases, they also noted that vaccination services brought broad health gains, including improved nutrition, antenatal guidance, and social support. Second, community health workers critically influenced, positively or negatively, caregivers' vaccination perceptions. Third, community health workers faced gaps in their education such as limited training on vaccine side-effects, placing them at a disadvantage when dealing with families. Finally, we found that mothers-in-law, fathers, and religious leaders influence caregivers' perceptions of vaccination. CONCLUSIONS: Communication of broader benefits of vaccines and vaccination services by community health workers could be impactful in increasing vaccine acceptance. Vaccine uptake could potentially be improved by facilitating community health workers' ownership over vaccine acceptance and uptake by involving them in the design and implementation of interventions to target mothers and mothers-in-law. A 'bottom-up' approach, leveraging community health workers' knowledge to design interventions, and giving a voice to key members of the household and society beyond mothers alone, may sustain health improvement in low vaccine coverage areas.

Adapting Child Development Assessment Tools to the Rural Indian Context.

BACKGROUND: Child development assessment tests serve many purposes, including educational placement, identifying cognitive weaknesses, and initiating early interventions. Much of the research associated with developmental testing has been conducted in high-income countries, offering limited guidance on adapting these tests to other settings. OBJECTIVES: As part of the first phase of a study exploring the impact of childhood vaccines on cognition and school attainment, we aimed to assess the feasibility of enrolling children from the community, documenting immunization, and conducting child development assessments for children between 18 months and 8 years of age in a rural setting in Haryana, India. METHODS: To ensure assessments are optimally tailored to the context, child development assessment tests require valid translation and cultural adaptation. This report describes the rigorous seven-step adaptation process we designed for the contextually appropriate adaptation of the following three child development assessment tests: the Bayley Scales of Infant Development-IV, the Stanford Binet Intelligence Scale Fifth Ed. for Early Childhood, and the Wechsler Intelligence Scale for Children IV. RESULTS: This process involved translating tests into the local language, back-translating them for accuracy, adapting them to the rural context via several iterations, and field-testing to refine and validate adaptation quality. CONCLUSIONS: This adaptation process may be beneficial for other researchers involved in adapting child development assessment tests to other settings. Further, this adaptation process may inform other researchers involved in adapting tests for diverse settings.

The Indian Academy of Pediatrics and Directorate General of Health Services, Government of India White Paper on Transition of Care for Youth with Special Health Care Needs.

Over the years, survival of children with chronic diseases has significantly improved and a large proportion of them now are entering into adulthood. Transition of Care (ToC) of such patients with having childhood onset of chronic diseases to the adult health care system is well organized in developed countries, although it is an emerging concept in India. In situations where the systems for ToC are not in place, such cases are fraught with unsatisfactory health outcomes. With proper ToC in place, these patients are likely to receive uninterrupted care by the adult care physicians and hence reach their full potential. This document highlights the need, rationale and way forward for ToC of youth with special health care needs (YSHCN) across the country. It also describes the standard operating procedures to develop the ToC at a hospital level for clinicians and administrators.

Access to health and rights of children in street situations and working children: a scoping review.

BACKGROUND: Street and working children (SWC) and young people (YP) are highly vulnerable to violence, exploitation, hazardous environments and human rights violations. While the UN Committee on the Rights of the Child and the International Labour Organisation provide some guidance, there is limited information on their right to healthcare. This study aims to identify enablers and barriers to healthcare access for SWC and document associated rights violations. METHODS: From 2000 to the present, we conducted systematic searches for SWC (0-18 years) in databases including MEDLINE, PsycINFO, EBSCO, PUBMED and PROQUEST, using broad search terms related to street children, working children, healthcare access and rights. The searches were supplemented by grey literature and hand searches. Two independent reviewers finalised the included studies, and data were analysed using a rights-based framework with narrative analysis and thematisation. RESULTS: The initial search yielded 7346 articles (5972 for street children and 1374 for working children), with 35 studies (18 for street children and 17 for working children) included in the review. Most studies on working children (13/17) focused on trafficking/commercial exploitation. Studies were predominantly from Africa, followed by the USA, Asia, the UK and Canada, with only two employing a rights framework. SWC face barriers such as cost, distance, visibility/accessibility of services, stigma, seclusion, threats of violence, lack of legal documents, crisis-oriented healthcare use and self-medication. Enablers included agency, self-efficacy, positive relationships with adults and proactive healthcare use when accessible. Emergency departments are frequently accessed by SWC, indicating a need for healthcare professionals to be trained and sensitised. Holistic and comprehensive healthcare is essential. CONCLUSION: Significant research gaps exist, with many SWC populations under-represented. SWC share healthcare access barriers with other marginalised groups. Healthcare for SWC must be tailored to their unique needs and strengths and be holistic and trauma-informed.

Leading from the frontlines: community-oriented approaches for strengthening vaccine delivery and acceptance.

BACKGROUND: Although immunization is one of the most successful public health interventions, vaccine hesitancy and the COVID-19 pandemic have strained health systems, contributing to global reductions in immunization coverage. Existing literature suggests that involving community members in vaccine interventions has been beneficial, but efforts to facilitate community ownership to motivate vaccine acceptance have been limited. METHODS: Our research leveraged community-based participatory research to closely involve the community from conception to implementation of an intervention to facilitate vaccine acceptance in Mewat District in Haryana, an area in India with extremely low vaccination coverage. Through the development of a community accountability board, baseline data collection on vaccination barriers and facilitators, and two human-centered design workshops, our team co-created a six-pronged intervention with community leaders and community health workers. This intervention included involving religious leaders in vaccine discussions, creating pamphlets of local vaccine champions for dissemination to parent and child caregivers, creating short videos of local leaders advocating for vaccines, implementing communication training exercises for community health workers, and implementing strategies to strengthen coordination between health workers and supervisors. RESULTS: Post-intervention data suggested parents and child caregivers had improvements in knowledge of the purpose of vaccines and side effects of vaccines. They noted that the involvement of religious leaders was beneficial, they were more willing to travel to vaccinate their children, and they had fewer non-logistical reasons to refuse vaccination services. Interviews with community leaders and community health workers who were involved in the creation of the intervention suggested that they experienced higher levels of ownership, they were better equipped to address community concerns, and that vaccine misinformation decreased in the post-intervention period. CONCLUSION: Through this unique intervention to strengthen vaccine uptake that incorporated the needs, interests, and expertise of local community members, we developed a community-driven approach to strengthen vaccine acceptance in a population with low uptake. This comprehensive approach is essential to amplify local voices, identify local concerns and advocates, and leverage bottom-up strategies to co-design successful interventions to facilitate long-term change.

Caregiver perceptions of the broader societal benefits of vaccination: A path toward sustainable vaccine advocacy in India.

Over the last decade growing public health evidence suggests that, in addition to health-related benefits, there are also social and economic benefits of vaccination. Research to understand how caregivers in low-and-middle-income countries perceive these social and economic benefits, or if these benefits factor into their vaccination decisions for their children, has been limited. Leveraging qualitative strategies to gain more nuanced insights into caregiver perceptions of vaccination benefits has also been significantly underexplored. We conducted in-depth interviews with 13 caregivers of children, at which point we reached saturation, in Mewat District, Haryana, an area in India with low vaccination coverage. Interview results suggest that caregivers of children associate positive health outcomes with vaccination programs, and some additional social and economic benefits beyond improved health outcomes. Caregivers also shared how local advocacy and gaps in vaccination programs can affect their perceptions of vaccination benefits. Qualitatively exploring the perceived benefits provides a unique understanding of the value that caregivers assign to vaccination and complements existing knowledge on factors that dissuade caregivers from vaccination. These insights will allow researchers to better identify and design context-specific advocacy strategies to strengthen vaccination programs in communities with low vaccine uptake and acceptance.

Vaccine acceptance in rural India: Engaging faith leaders as vaccine ambassadors.

Introduction: Religious faith is a key marker of identity and shapes community perspectives and trust. Faith leader involvement in vaccine campaigns in India have been beneficial to counter misinformation regarding infectious diseases such as polio. Faith leaders are influential stakeholders who bear potential to enhance public confidence in vaccine campaigns. Context: While vaccine coverage has been increasing in India, inequities abound, especially in populations with historically low vaccine confidence. The COVID-19 pandemic has led to major disruptions in delivery of routine immunization services for children. To address these challenges, we co-designed interventions aimed at contextual communication strategies and peer support. Engaging faith leaders was an important part of this intervention. In this report we describe our experience and highlight the perspectives of faith leaders and their expectations of the outcomes for this intervention. Programmatic elements: The CIVIC Project, conducted from January to December 2021 aimed to engage caregivers, community health workers and key stakeholders, particularly, faith leaders in co-designing interventions to address vaccine hesitancy in Mewat. The project, deeply rooted in community based participatory research, used a three-E approach (Exploration of community perspectives, Establishment of vaccine trust and awareness, Engagement in vaccine promotion activities) to successfully engage faith leaders in the design and dissemination of media messages advocating for vaccine acceptance and uptake. Lessons learned: The involvement of faith leaders in the intervention benefited the community in two ways. First, faith leaders were spotlighted via videos, often disseminating advice and personal anecdotes about vaccines, thus reassuring caregivers and community members who previously expressed distrust in vaccines. Second, involvement of trusted faith leaders provided a platform for a two-way dialogue for the community to openly discuss and address myths and misconceptions regarding vaccines. This project provided the learning that co-creating interventions with faith leaders who are often gatekeepers of close-knit communities can lead to the development of vaccine positive messaging that community members relate with, motivating increased vaccine confidence.

Impact of COVID-19 on the lives of vulnerable young people in New Delhi, India: a mixed method study.

Background: India is home to the largest child population in the world. India also has faced a devastating burden of COVID-19 infections. During the first wave of COVID-19, the Indian government's lockdown measures brought loss of livelihoods for millions. We aimed to explore the social, psychological and health impacts of the government's pandemic measures on children and young people (CYP), and their families. Methods: Bal Umang Drishya Sanstha (BUDS) is a non-profit organisation providing child health and welfare services to marginalised urban slum communities in New Delhi, India. As part of formative evaluation of BUDS's COVID-19 pandemic relief efforts, the team conducted a rapid survey of 60 children (10-17 years) and 62 young adults (18-25 years) who were beneficiaries of the relief programme. The team also undertook semi-structured interviews with nine young women attending BUDS's second-chance education programme. Results: Almost all respondents had some understanding of COVID-19 (54 children (90%) and 53 young adults (85%)) and the reasons for public health measures (59 children (98%) and 56 young adults (90%)). Over 80% of girls and 60% of boys experienced financial strains and food shortages. Gender discrepancies were particularly evident in areas of family stress, with girls and young women disproportionately experiencing distress and family violence. Girls were more likely to be fearful of contracting the disease, while boys were more concerned about getting back to school. In-depth interviews with young women revealed that government ration schemes were insufficient to support vulnerable families; there were interesting cultural understandings of and responses to the pandemic. Young women reported high rates of anxiety and distress. Conclusions: The lockdown had a multitude of adverse social, health and psychosocial effects on marginalised CYP, disproportionately affecting girls and young women. A tailored response based on equity and child rights is urgently required to address concerns voiced by CYP.

Urinary tract infection due to Group B Streptococcus: A case series from Eastern India.

Group B Streptococcus (GBS) or Streptococcus agalactiae is an uncommon causative agent of urinary tract infection (UTI). We present a series of seven cases of UTI due to GBS from a tertiary care hospital of Eastern India, highlighting its emerging role in a hitherto less commonly described clinical entity.

Ending violence against children: What can global agencies do in partnership?

Globally, the range, scale and burden of all forms of violence against children (VAC) have visibly increased. Yet VAC as a physical, mental, public and social health concern is only recently gaining the prominence it deserves. Addressing VAC is critical. Violence experienced early in life can result in short, medium, long-lasting, and/or even inter-generational negative health outcomes. Ample evidence shows that VAC is widespread and the most common forms are usually perpetrated by people with whom children interact every day in their homes, schools and communities. We report on an innovative collaboration between global agencies, led by the International Society for Social Pediatrics and Child Health (ISSOP), the International Society for Prevention of Child Abuse and Neglect (ISPCAN), and the International Pediatric Association (IPA), who were galvanized to respond to VAC using a child-rights and public health lens. This collaboration led to a position statement on VAC with an implementation plan. The strength of the position statement was the explicit incorporation of a rights-based expansive understanding of VAC, with a description of typologies of violence pertinent to children globally, including child labor, children in armed conflict, trafficking of children and gender-based violence; and the identification of strategies both in preventing violence from occurring and ameliorating the effects in its aftermath. We report on the challenges and successes of our collaborative action at regional and supra-national levels, including opportunistic action.

COVID-19-related disruptions to routine vaccination services in India: a survey of paediatric providers.

The COVID-19 pandemic has led to disruptions in essential health services globally. We surveyed Indian paediatric providers on their perceptions of the impact of the pandemic on routine vaccination. Among 424 (survey 1) and 141 (survey 2) respondents representing 26 of 36 Indian states and union territories, complete suspension of vaccination services was reported by 33.4% and 7.8%, respectively. In April-June 2020, 83.1% perceived that vaccination services dropped by half, followed by 32.6% in September 2020, indicating slow resumption of services. Concerns that vaccine coverage gaps can lead to mortality were expressed by 76.6%. Concerted multipronged efforts are needed to sustain gains in vaccination coverage.

Assessment of optic nerve cup-to-disk ratio changes in patients receiving multiple intravitreal injections of antivascular endothelial growth factor agents.

PURPOSE: To assess whether the transient intraocular pressure rise, frequent intraocular pressure fluctuations, or antivascular endothelial growth factor (VEGF) effects of repeated intravitreal injection of anti-VEGF agents can lead to changes in the optic nerve vertical cup-to-disk ratio (C/D). METHODS: Patients with a known history of glaucoma and those receiving triamcinolone acetonide were excluded from the study. Fundus photographs were cropped to optic disk images only, which were then randomized and independently graded by two glaucoma specialists. In patients who received treatments in only one eye, the fellow eye was used as a control. RESULTS: Twenty-three eyes of 21 patients met inclusion criteria. The mean change in C/D was -0.012 (95% confidence interval [CI], -0.053 to 0.029) for the treated group and -0.006 (95% CI, -0.106 to 0.095) for the control group, with no statistically significant difference (P = 0.90). The mean change in C/D for eyes receiving < or =5 injections (n = 9) was 0.003 (95% CI, -0.089 to 0.095) in the treated group and 0.054 (95% CI, -0.033 to 0.142) in the control group, with no statistically significant difference (P = 0.33). In eyes receiving >5 injections (n = 14), the mean change in C/D was -0.021 (95% CI, -0.095 to 0.052) in the treated group and -0.057 (95% CI, -0.231 to 0.116) in the control group, with no statistically significant difference (P = 0.70). CONCLUSION: There was no statistically significant change in the vertical C/D of optic nerves in patients receiving multiple intravitreal injections of anti-VEGF agents, regardless of whether they received fewer or more than five total injections. This suggests that the short-term intraocular pressure rise and frequent intraocular pressure fluctuation, as well as the anti-VEGF properties of these drugs, do not adversely change the optic nerve C/D. Additional prospective studies are warranted to confirm these conclusions.

Mobile Phone Incentives for Childhood Immunizations in Rural India.

OBJECTIVES: Young children in resource-poor settings remain inadequately immunized. We evaluated the role of compliance-linked incentives versus mobile phone messaging to improve childhood immunizations. METHODS: Children aged ≤24 months from a rural community in India were randomly assigned to either a control group or 1 of 2 study groups. A cloud-based, biometric-linked software platform was used for positive identification, record keeping for all groups, and delivery of automated mobile phone reminders with or without compliance-linked incentives (Indian rupee Rs30 or US dollar $0.50 of phone talk time) for the study groups. Immunization coverage was analyzed by using multivariable Poisson regression. RESULTS: Between July 11, 2016, and July 20, 2017, 608 children were randomly assigned to the study groups. Five hundred and forty-nine (90.3%) children fulfilled eligibility criteria, with a median age of 5 months; 51.4% were girls, 83.6% of their mothers had no schooling, and they were in the study for a median duration of 292 days. Median immunization coverage at enrollment was 33% in all groups and increased to 41.7% (interquartile range [IQR]: 23.1%-69.2%), 40.1% (IQR: 30.8%-69.2%), and 50.0% (IQR: 30.8%-76.9%) by the end of the study in the control group, the group with mobile phone reminders, and the compliance-linked incentives group, respectively. The administration of compliance-linked incentives was independently associated with improvement in immunization coverage and a modest increase in timeliness of immunizations. CONCLUSIONS: Compliance-linked incentives are an important intervention for improving the coverage and timeliness of immunizations in young children in resource-poor settings.

Social Determinants of Child Marriage in Rural India.

BACKGROUND: Child marriage represents a grave violence against children and deprives them of their rights to health, education, and a livelihood. Because child marriage should be recognized as a social and medical emergency, the social determinants of child marriage in India need to be mapped. The aim of this qualitative case study was to document social determinants of child marriage identified by the authors while providing community mobile health services in rural Mewat District, India. CASE REPORT: We present qualitative participatory medical histories and assessments of two clinical cases: an adolescent who is waiting to get married and a young woman who was married as an adolescent but developed multiple health complications after her husband abandoned her. CONCLUSION: Patriarchy, coercion, social customs, and norms were identified as major social determinants. The two cases demonstrate that social norms influence intergenerational norms and lead to uninformed decision-making and child marriage. In low- and middle-income countries, medical professionals should urgently address child marriage as a major public health problem. Primary care physicians and medical professionals should implement preventive measures and provide anticipatory guidance to prevent child marriage.

Cataract secondary to electrical shock from a Taser gun.

A 35-year-old man presented with traumatic iritis, angle-recession glaucoma, and a retinal dialysis secondary to blunt trauma from a Taser gun in the right eye and a unique electrical cataract in the left eye. Taser guns, which can also function as stun guns, can lead to electrical cataract formation. Given the increasing use of Taser guns by law enforcement and citizens, blunt mechanical and electrical sequelae of Taser gun injuries should be recognized.

Choroidal neovascularization associated with West Nile virus chorioretinitis.

A case of late-onset choroidal neovascularization in a patient with a history of West Nile virus chorioretinitis is described. An 86-year-old man with a history of diabetes mellitus developed bilateral West Nile virus chorioretinitis in 2001, after which his vision improved to baseline. Approximately 5 years later, the patient was found to have choroidal neovascularization in his left eye, for which he received an intravitreal injection of bevacizumab. After one injection, there was good anatomical response. Choroidal neovascularization may be a late-onset complication of West Nile virus chorioretinitis, and bevacizumab may be a good therapeutic option.

Change in head posture and character of nystagmus in a patient with neurological upbeat nystagmus.

PURPOSE: To report a case of a patient with chin-up head posture and presumed congenital toxoplasmosis chorioretinal scars, who had a change in the character of the nystagmus and therefore the head posture following treatment for a neurological upbeat nystagmus. CASE REPORT: A 5 month old female presented with a chin up head posture and upbeat nystagmus. Magnetic resonance imaging of the brain revealed an arachnoid cyst in the area of the pineal gland. Nine months after cyst-peritoneal shunt surgery, the upbeat nystagmus was dampened but change in character to a rotary nystagmus worse on the left gaze. The patient had assumed a left face turn, shifting the null point from the vertical to the horizontal plane. The left face turn was successfully corrected at age eight years with a Kestenbaum procedure. CONCLUSION: This case emphasizes the possibility of having two distinct types of nystagmus associated with two etiologies. In this case, an acquired upbeat nystagmus secondary to an arachnoid cyst, and a congenital left rotary nystagmus from the chorioretinal scars. Furthermore, there can be a change in head position and character of nystagmus after treating the cause of the central motility disorder, thereby affecting the choice and timing of surgical intervention to correct the head positioning.