Effectiveness of an oral health education intervention among 6-12-year-old children: A cluster randomized controlled trial.

OBJECTIVES: Literature on the effectiveness of theory-based oral health education on the oral hygiene of children is limited. We aimed to determine the effectiveness of an health behaviour theory-based school oral health education intervention on 1) oral hygiene and 2) oral health-related knowledge, attitude and practices among 6-12-year-old children in Kerala, India. METHODS: Cluster randomized controlled trial. Sixteen class divisions (clusters) were randomized into intervention and control groups of 225 and 228 children respectively. Primary and secondary outcomes were plaque score as measured using the simplified oral hygiene index (OHI-S) and oral health-related knowledge, attitude and practices respectively. The intervention group received structured oral health education classes for three months and materials including pamphlets. Children in the control group were not given the classes or materials. RESULTS: Post-intervention OHI-S scores in the intervention group and control groups were 1.65 and 2.17 respectively (difference = -0.52, 95%CI -0.86, -0.18). All the secondary outcomes improved in the intervention group compared to the control group. CONCLUSIONS: The intervention improved the oral hygiene status, oral health-related knowledge, attitude and practices of the children. Longer term follow-up and economic appraisal are needed to help policymakers plan and develop OHEI based on health behaviour theories.

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.

Multi-morbidity and blood pressure control: Results of a cross-sectional study among school teachers in Kerala, India.

The patterns of concordant and discordant comorbidities of hypertension and their association with hypertension control were ascertained in this cross-sectional study. A total of 402 adults with hypertension were identified from the baseline survey of a randomized controlled trial for hypertension control among school teachers in Kerala. Chronic conditions were captured and categorized into concordant and discordant comorbidities. Nearly 57% of teachers with hypertension reported multimorbidity. Concordant morbidity was reported by 44% and discordant by 21% of participants. The odds of hypertension control was higher among those who reported at least one discordant morbidity (odds ratio [OR]: 2.76, 95% confidence interval [CI]:1.69-4.49) and those who reported at least one concordant morbidity (OR: 2.08, CI: 1.37-3.16), compared to their counterparts. Hypertension control was higher for those who reported any comorbidity (OR: 2.37, CI: 1.51-3.71) compared to those who did not report any. Well-designed large-scale mixed methods studies are required to thoroughly explore multimorbidity and its relationship with hypertension control in India.

Cluster randomised controlled trial of behavioural intervention program: a study protocol for control of hypertension among teachers in schools in Kerala (CHATS-K), India.

BACKGROUND: Control of blood pressure among hypertensives is a major challenge around the world. Interventions for improving hypertension control in India are very limited. This paper describes the protocol for a cluster randomized controlled trial of efficacy of behavioural intervention on control of hypertension among school teachers in Kerala. METHODS: A total of 92 schools are randomised to intervention and control group in Kerala. A baseline survey was conducted in all schools to assess the prevalence of hypertension and its risk factors among school teachers in Thiruvananthapuram district of Kerala state, India. Teachers in both sets of schools will receive a leaflet containing details on the importance of controlling hypertension. With the objective of improving control of hypertension, the intervention schools will additionally receive self-management education and behavioural intervention programs delivered by trained intervention managers along with measurement of weight, waist circumference and blood pressure. This intervention program will be developed based on the findings of the baseline survey and selected components of successful models of hypertension control from previous research done in similar settings. The intervention will be given for 3 months after which a post-survey will be conducted among teachers of both control and intervention schools. The primary outcome is change in control of hypertension and secondary outcome is the change in behavioural risk factors of hypertension both in the control and intervention groups. DISCUSSION: This is the first comprehensive study looking at the efficacy of behavioural intervention on hypertension control among school teachers in Kerala, India. This study is likely to provide an upper estimate of behavioural intervention on hypertension control since teachers are reported to have one of the highest compliance rates of behavioural intervention. TRIAL REGISTRATION: This trial was prospectively registered with the Clinical Trials Registry of India [CTRI/2018/01/011402] on 18 January 2018.

Baseline characteristics of participants in the Kerala Diabetes Prevention Program: a cluster randomized controlled trial of lifestyle intervention in Asian Indians.

AIMS: To describe the baseline characteristics of participants in the Kerala Diabetes Prevention Program. METHODS: The Kerala Diabetes Prevention Program is a cluster randomized controlled trial of lifestyle intervention for prevention of Type 2 diabetes mellitus in India. Participants in the study were those aged 30-60 years who had an Indian Diabetes Risk Score ≥ 60 and who were without Type 2 diabetes on oral glucose tolerance test. Data on demographic, lifestyle, clinical and biochemical characteristics were collected using standardized tools. RESULTS: A total of 2586 individuals were screened with the Indian Diabetes Risk Score, of these 1529 people (59.1%) had a score ≥ 60, of whom 1209 (79.1%) underwent an oral glucose tolerance test. A total of 202 individuals (16.7%) had undiagnosed Type 2 diabetes and were excluded, and the remaining 1007 individuals were enrolled in the trial (control arm, n = 507; intervention arm, n = 500). The mean participant age was 46.0 ± 7.5 years, and 47.2% were women. The mean Indian Diabetes Risk Score was 67.1 ± 8.4. More than two-thirds (69.0%) had prediabetes and 31.0% had normal glucose tolerance. The prevalence of cardiometabolic risk factors was high, including current tobacco use (34.4% in men), current alcohol use (39.3% in men), no leisure time exercise (98.0%), no daily intake of fruit and vegetables (78.7%), family history of diabetes (47.9%), overweight or obesity (68.5%), hypertension (22.3%) and dyslipidemia (85.4%). CONCLUSIONS: The Kerala Diabetes Prevention Program recruited participants using a diabetes risk score. A large proportion of the participants had prediabetes and there were high rates of cardiometabolic risk factors. The trial will evaluate the effectiveness of lifestyle intervention in a population selected on the basis of a diabetes risk score.

Prevalence of coronary artery disease and its risk factors in Kerala, South India: a community-based cross-sectional study.

BACKGROUND: There are no recent data on prevalence of coronary artery disease (CAD) in Indians. The last community based study from Kerala, the most advanced Indian state in epidemiological transition, was in 1993 that reported 1.4% definite CAD prevalence. We studied the prevalence of CAD and its risk factors among adults in Kerala. METHODS: In a community-based cross sectional study, we selected 5167 adults (mean age 51 years, men 40.1%) using a multistage cluster sampling method. Information on socio-demographics, smoking, alcohol use, physical activity, dietary habits and personal history of hypertension, diabetes, and CAD was collected using a structured interview schedule. Anthropometry, blood pressure, electrocardiogram, and biochemical investigations were done using standard protocols. CAD and its risk factors were defined using standard criteria. Comparisons of age adjusted prevalence were done using two tailed proportion tests. RESULTS: The overall age-adjusted prevalence of definite CAD was 3.5%: men 4.8%, women 2.6% (p < 0.001). Prevalence of any CAD was 12.5%: men 9.8%, women 14.3% (p < 0.001). There was no difference in definite CAD between urban and rural population. Physical inactivity was reported by 17.5 and 18% reported family history of CAD. Other CAD risk factors detected in the study were: overweight or obese 59%, abdominal obesity 57%, hypertension 28%, diabetes 15%, high total cholesterol 52% and low level of high density lipoprotein cholesterol 39%. Current smoking was reported only be men (28%). CONCLUSION: The prevalence of definite CAD in Kerala increased nearly three times since 1993 without any difference in urban and rural areas. Most risk factors of CAD were highly prevalent in the state. Both population and individual level approaches are warranted to address the high level of CAD risk factors to reduce the increasing prevalence of CAD in this population.

Balancing expectations amidst limitations: the dynamics of food decision-making in rural Kerala.

BACKGROUND: Food decision-making is a complex process and varies according to the setting, based on cultural and contextual factors. The study aimed to understand the process of food decision-making in households in rural Kerala, India, to inform the design of a dietary behaviour change intervention. METHODS: Three focus group discussions (FGDs) and 17 individual interviews were conducted from September 2010 to January 2011 among 13 men and 40 women, between 23 and 75 years of age. An interview guide facilitated the process to understand: 1) food choices and decision-making in households, with particular reference to access; and 2) beliefs about foods, particularly fruits, vegetables, salt, sugar and oil. The interviews and FGDs were transcribed verbatim and analysed using qualitative content analysis. RESULTS: The analysis revealed one main theme: 'Balancing expectations amidst limitations' with two sub-themes: 'Counting and meeting the costs'; and 'Finding the balance'. Food decisions were made at the household level, with money, time and effort costs weighed against the benefits, estimated in terms of household needs, satisfaction and expectations. The most crucial decisional point was affordability in terms of money costs, followed by food preferences of husband and children. Health and the risk of acquiring chronic diseases was not a major consideration in the decision-making process. Foods perceived as essential for children were purchased irrespective of cost, reportedly owing to the influence of food advertisements. The role of the woman as the homemaker has gendered implications, as the women disproportionately bore the burden of balancing the needs and expectations of all the household members within the available means. CONCLUSIONS: The food decision-making process occurred at household level, and within the household, by the preferences of spouse and children, and cost considerations. The socio-economic status of households was identified as limiting their ability to manoeuvre this fine balance. The study has important policy implications in terms of the need to raise public awareness of the strong link between diet and chronic non-communicable diseases.

Developing a smoke free homes initiative in Kerala, India.

BACKGROUND: Results of the Global Adult Tobacco Survey in Kerala, India found that 42 % of adults were exposed to second hand smoke (SHS) inside the home. Formative research carried out in rural Kerala suggests that exposure may be much higher. Numerous studies have called for research and intervention on SHS exposure among women and children as an important component of maternal and child health activities. METHODS: Community-based participatory research was carried out in Kerala. First, a survey was conducted to assess prevalence of SHS exposure in households. Next, a proof of concept study was conducted to develop and test the feasibility of a community-wide smoke free homes initiative. Educational materials were developed and pretested in focus groups. After feasibility was established, pilot studies were implemented in two other communities. Post intervention, surveys were conducted as a means of assessing changes in community support. RESULTS: At baseline, between 70 and 80 % of male smokers regularly smoked inside the home. Over 80 % of women had asked their husband not to do so. Most women felt powerless to change their husband's behavior. When women were asked about supporting a smoke free homes intervention, 88 % expressed support for the idea, but many expressed doubt that their husbands would comply. Educational meetings were held to discuss the harms of second hand smoke. Community leaders signed a declaration that their community was part of the smoke free homes initiative. Six months post intervention a survey was conducted in these communities; between 34 and 59 % of men who smoked no longer smoked in their home. CONCLUSIONS: The smoke free homes initiative is based on the principle of collective efficacy. Recognizing the difficulty for individual women to effect change in their household, the movement establishes a smoke free community mandate. Based on evaluation data from two pilot studies, we can project that between a 30 and 60 % reduction of smoking in the home may be achieved, the effect size determined by how well the smoke free home steps are implemented, the characteristics of the community, and the motivation of community level facilitators.

Doctors' self-reported physical activity, their counselling practices and their correlates in urban Trivandrum, South India: should a full-service doctor be a physically active doctor?

BACKGROUND: Doctors' self-reported physical activity (PA) is associated with their propensity for prescribing PA. METHODS: We surveyed 146 doctors (median age 42 years; men 58.9%), selected by multistage random sampling. Information on demographic details, self-reported PA and counselling offered to their patients was collected using a pretested, structured, self-administered questionnaire. Multivariate logistic regression analysis was carried out to find the predictors of PA and PA counselling offered to the patients. RESULTS: Moderate PA was reported by 37.7% (95% CI 29.8 to 45.5) of the doctors and the remaining 62.3%reported being inactive. Doctors who were motivated to perform PA (OR 4.01, 95% CI 1.82 to 8.86), who used exercise equipment at home (OR 3.97, CI 1.68 to 9.36) and who used a neighbourhood facility for PA (OR 2.36, CI 1.11 to 5.02) were more likely to perform moderate PA compared with their counterparts. 25% of the doctors always asked and advised their patients on PA. Doctors who believed that their own healthy lifestyle influenced advice practices (OR 9.13, CI 2.49 to 33.41), who consulted less than 30 patients/day (OR 5.35, CI 1.41 to 20.25) and who reported previous participation in sports activities (OR 4.22, CI 1.77 to 10.04) were more likely to always ask and advise their patients on PA compared with their counterparts. CONCLUSIONS: A majority of the doctors in our study were inactive and did not ask or advise their patients on PA. Measures are warranted to enhance doctors' own PA and their counselling practices.

Developing a fully integrated tobacco curriculum in medical colleges in India.

BACKGROUND: This paper describes a pioneering effort to introduce tobacco cessation into India's undergraduate medical college curriculum. This is the first ever attempt to fully integrate tobacco control across all years of medical college in any low and middle income country. The development, pretesting, and piloting of an innovative modular tobacco curriculum are discussed as well as challenges that face implementation and steps taken to address them and to advocate for adoption by the Medical Council of India. METHODS: In-depth interviews were conducted with administrators and faculty in five medical colleges to determine interest in and willingness to fully integrate smoking cessation into the college curriculum. Current curriculum was reviewed for present exposure to information about tobacco and cessation skill training. A modular tobacco curriculum was developed, pretested, modified, piloted, and evaluated by faculty and students. Qualitative research was conducted to identify challenges to future curriculum implementation. RESULTS: Fifteen modules were successfully developed focusing on the public health importance of tobacco control, the relationship between tobacco and specific organ systems, diseases related to smoking and chewing tobacco, and the impact of tobacco on medication effectiveness. Culturally sensitive illness specific cessation training videos were developed. Faculty and students positively evaluated the curriculum as increasing their competency to support cessation during illness as a teachable moment. Students conducted illness centered cessation interviews with patients as a mandated part of their coursework. Systemic challenges to implementing the curriculum were identified and addressed. CONCLUSIONS: A fully integrated tobacco curriculum for medical colleges was piloted in 5 colleges and is now freely available online. The curriculum has been adopted by the state of Kerala as a first step to gaining Medical Council of India review and possible recognition.

Risk factor profile for non-communicable diseases among Mishing tribes in Assam, India: results from a WHO STEPs survey.

BACKGROUND & OBJECTIVES: A comprehensive risk factor profile of non-communicable diseases (NCDs) as suggested by the World Health Organization (WHO) has not been reported from tribal population in India. This survey was carried out to assess the prevalence of NCD risk factors among Mishing tribes in Assam using the WHO STEPs approach. METHODS: A total of 332 individuals of the Mishing tribe (men 54%) aged 25-64 yr were selected from Tinsukia district by multistage cluster sampling. Using the WHO STEPs approach information was collected on demographics, STEP 1 variables (tobacco, alcohol, physical activity, diet) and measured STEP 2 variables (weight, height, waist circumference and blood pressure). Multivariate analysis was used to find the relation between STEP 1 and STEP 2 variables. RESULTS: Overall, tobacco use was 84 per cent (men 94%; women 73%, p0 <0.001) and alcohol use was 67 per cent (men 82%; women 50%, p0 <0.05); 86 per cent reported vigorous physical activity, (men 91%, women 82%; p0 < 0.05). Sixty eight per cent reported to consume unhealthy diet (less than five servings of fruits and vegetables/day), 11 per cent had abdominal obesity, 16 per cent were overweight and 26 per cent had hypertension. Non users of tobacco and those who consumed more fruits and vegetables had higher prevalence of overweight ( p0 <0.05). Among the hypertensives, 24 per cent were aware, 17 per cent treated and 2.4 per cent controlled their hypertension. Older individuals had higher hypertension prevalence ( p0 <0.05) compared to younger individuals. INTERPRETATION & CONCLUSIONS: Tobacco use, alcohol use and unhealthy diet habits were high among men and women in this population and were major NCD risk factors. An integrated approach of culturally appropriate population level and high risk strategies are warranted to reduce these risk factors and to enhance adequate control of hypertension.

Conceptual model for dietary behaviour change at household level: a 'best-fit' qualitative study using primary data.

BACKGROUND: Interventions having a strong theoretical basis are more efficacious, providing a strong argument for incorporating theory into intervention planning. The objective of this study was to develop a conceptual model to facilitate the planning of dietary intervention strategies at the household level in rural Kerala. METHODS: Three focus group discussions and 17 individual interviews were conducted among men and women, aged between 23 and 75 years. An interview guide facilitated the process to understand: 1) feasibility and acceptability of a proposed dietary behaviour change intervention; 2) beliefs about foods, particularly fruits and vegetables; 3) decision-making in households with reference to food choices and access; and 4) to gain insights into the kind of intervention strategies that may be practical at community and household level. The data were analysed using a modified form of qualitative framework analysis, which combined both deductive and inductive reasoning. A priori themes were identified from relevant behaviour change theories using construct definitions, and used to index the meaning units identified from the primary qualitative data. In addition, new themes emerging from the data were included. The associations between the themes were mapped into four main factors and its components, which contributed to construction of the conceptual model. RESULTS: Thirteen of the a priori themes from three behaviour change theories (Trans-theoretical model, Health Belief model and Theory of Planned Behaviour) were confirmed or slightly modified, while four new themes emerged from the data. The conceptual model had four main factors and its components: impact factors (decisional balance, risk perception, attitude); change processes (action-oriented, cognitive); background factors (personal modifiers, societal norms); and overarching factors (accessibility, perceived needs and preferences), built around a three-stage change spiral (pre-contemplation, intention, action). Decisional balance was the strongest in terms of impacting the process of behaviour change, while household efficacy and perceived household cooperation were identified as 'markers' for stages-of-change at the household level. CONCLUSIONS: This type of framework analysis made it possible to develop a conceptual model that could facilitate the design of intervention strategies to aid a household-level dietary behaviour change process.

Smoking cessation among diabetes patients: results of a pilot randomized controlled trial in Kerala, India.

BACKGROUND: India has the second largest diabetic population (61 million) and tobacco users (275 million) in the world. Data on smoking cessation among diabetic patients are limited in low and middle income countries. The objective of the study was to document the effectiveness of diabetic specific smoking cessation counseling by a non-doctor health professional in addition to a cessation advice to quit, delivered by doctors. METHODS: In our parallel-group randomized controlled trial, we selected 224 adult diabetes patients aged 18 years or older who smoked in the last month, from two diabetes clinics in South India. Using a computer generated random sequence with block size four; the patients were randomized equally into intervention-1 and intervention-2 groups. Patients in both groups were asked and advised to quit smoking by a doctor and distributed diabetes specific education materials. The intervention-2 group received an additional diabetes specific 30 minutes counseling session using the 5As (Ask, Advise, Assess, Assist and Arrange), and 5 Rs (Relevance, Risks, Rewards, Roadblocks and Repetition) from a non-doctor health professional. Follow up data were available for 87.5% of patients at six months. The Quit Tobacco International Project is supported by a grant from the Fogarty International Centre of the US National Institutes of Health (RO1TW005969-01).The primary outcomes were quit rate (seven day smoking abstinence) and harm reduction (reduction of the number of cigarettes / bidis smoked per day > 50% of baseline use) at six months. RESULTS: In the intention to treat analysis, the odds for quitting was 8.4 [95% confidence interval (CI): 4.1-17.1] for intervention-2 group compared to intervention-1 group. Even among high level smokers the odds of quitting was similar. The odds of harm reduction was 1.9 (CI: 0.8-4.1) for intervention-2 group compared to intervention-1 group. CONCLUSIONS: The value addition of culturally sensitive diabetic specific cessation counseling sessions delivered by non-doctor health professional was an impressive and efficacious way of preventing smoking related diabetic complications. TRIAL REGISTRATION: Clinical Trial Registry of India (CTRI/2012/01/002327).

Lifestyle change in Kerala, India: needs assessment and planning for a community-based diabetes prevention trial.

BACKGROUND: Type 2 Diabetes Mellitus (T2DM) has become a major public health challenge in India. Factors relevant to the development and implementation of diabetes prevention programmes in resource-constrained countries, such as India, have been under-studied. The purpose of this study is to describe the findings from research aimed at informing the development and evaluation of a Diabetes Prevention Programme in Kerala, India (K-DPP). METHODS: Data were collected from three main sources: (1) a systematic review of key research literature; (2) a review of relevant policy documents; and (3) focus groups conducted among individuals with a high risk of progressing to diabetes. The key findings were then triangulated and synthesised. RESULTS: Prevalence of risk factors for diabetes is very high and increasing in Kerala. This situation is largely attributable to rapid changes in the lifestyle of people living in this state of India. The findings from the systematic review and focus groups identified many environmental and personal determinants of these unhealthy lifestyle changes, including: less than ideal accessibility to and availability of health services; cultural values and norms; optimistic bias and other misconceptions related to risk; and low expectations regarding one's ability to make lifestyle changes in order to influence health and disease outcomes. On the other hand, there are existing intervention trials conducted in India which suggests that risk reduction is possible. These programmes utilize multi-level strategies including mass media, as well as strategies to enhance community and individual empowerment. India's national programme for the prevention and control of major non-communicable diseases (NCD) also provide a supportive environment for further community-based efforts to prevent diabetes. CONCLUSION: These findings provide strong support for undertaking more research into the conduct of community-based diabetes prevention in the rural areas of Kerala. We aim to develop, implement and evaluate a group-based peer support programme that will address cultural and family determinants of lifestyle risks, including family decision-making regarding adoption of healthy dietary and physical activity patterns. Furthermore, we believe that this approach will be feasible, acceptable and effective in these communities; with the potential for scale-up in other parts of India.

Assessing the readiness to integrate tobacco control in medical curriculum: experiences from five medical colleges in Southern India.

BACKGROUND: Making tobacco cessation a normative part of all clinical practice is the only way to substantially reduce tobacco-related deaths and the burden of tobacco-related morbidity in the short term. This study was undertaken because information on receptivity to integrate tobacco control education in the medical curriculum is extremely limited in low- and middle-income countries. METHODS: From five medical colleges (two government) in southern India, 713 (men 59%) faculty and 2585 (men 48%) students participated in our cross-sectional survey. Information on self-reported tobacco use and readiness to integrate tobacco control education in the medical curriculum was collected from both the faculty and students using a pretested structured questionnaire. Multiple logistic regression analysis was done to find the associated factors. RESULTS: Current smoking was reported by 9.0% (95% CI 6.6-12.1) of men faculty and 13.7% (CI 11.8-15.9) by men students. Faculty who were teaching tobacco-related topics [odds ratio (OR) 2.29; 95% CI 1.65-3.20] compared to those who were not, faculty in government colleges (OR 1.69; CI 1.22-2.35) compared to those in private colleges and medical pecialists (OR 1.79; CI 1.23-2.59) compared to surgical and non-clinical specialists were more likely to be ready to integrate tobacco control education in the medical curriculum. Non-smoking students (OR 2.58; CI 2.01-3.33) compared to smokers, and women students (OR 1.80; CI 1.50-2.17) compared to men were more likely to be ready to integrate a tobacco control education in the curriculum. CONCLUSION: Faculty and students are receptive to introduce tobacco control in the medical curriculum. Government faculty, medical specialists and faculty who already teach tobacco-related topics are likely to be early introducers of this new curriculum.

Prevalence of coronary artery disease and coronary risk factors in Kerala, South India: a population survey - design and methods.

BACKGROUND: There is paucity of reliable contemporary data on prevalence of coronary artery disease (CAD) and risk factors in Indians. Only a few studies on prevalence of CAD have been conducted in Kerala, a Southern Indian state. The main objective of the Cardiological Society of India Kerala Chapter Coronary Artery Disease and Its Risk Factors Prevalence Study (CSI Kerala CRP Study) was to determine the prevalence of CAD and risk factors of CAD in men and women aged 20-79 years in urban and rural settings of three geographical areas of Kerala. METHODS: The design of the study was cross-sectional population survey. We estimated the sample size based on an anticipated prevalence of 7.4% of CAD for rural and 11% for urban Kerala. The derived sample sizes for rural and urban areas were 3000 and 2400, respectively. The urban areas for sampling constituted one ward each from three municipal corporations at different parts of the state. The rural sample was drawn from two panchayats each in the same districts as the urban sample. One adult from each household in the age group of 20-59 years was selected using Kish method. All subjects between 60 and 79 years were included from each household. A detailed questionnaire was administered to assess the risk factors, history of CAD, family history, educational status, socioeconomic status, dietary habits, physical activity and treatment for CAD; anthropometric measurements, blood pressure, electrocardiogram and fasting blood levels of glucose and lipids were recorded.

Catastrophic health expenditure & coping strategies associated with acute coronary syndrome in Kerala, India.

BACKGROUND & OBJECTIVES: India contributes a significant number of deaths attributed to coronary artery disease (CAD) compared to the rest of the world. Data on catastrophic health expenditure (CHE) related to acute coronary syndrome (ACS), the major cause of deaths in CAD, are limited in the literature. We estimated the magnitude of CHE and studied the strategies used to cope with CHE. METHODS: Two hundred and ten ACS patients (mean age 56 yr, 83% men) were randomly selected proportionately from six hospitals in Thiruvananthapuram district, Kerala, India. Information on demographics, ACS-related out-of-pocket expenditure and coping strategies was collected using a pre-tested structured interview schedule. CHE, defined as ACS-related expenditures exceeding 40 per cent of a household's capacity to pay, was estimated using the World Health Organization methods. Health security was defined as protection against out-of-pocket expenditure through an employer or government provided social security scheme. Socio-demographic variables, effect on participants' employment, loans or asset sales for treatment purposes, health security coverage and type of treatment were considered as potential correlates of CHE. Multiple logistic regression analyses were conducted to identify the correlates of CHE. RESULTS: CHE was experienced by 84 per cent (95% CI: 79.04, 88.96) of participants as a consequence of treating ACS. Participants belonging to low socio-economic status (SES) were 15 times (odds ratio (OR): 14.51, 95% CI: 1.69-124.41), whose jobs were adversely affected were seven times (OR: 7.21, CI: 1.54-33.80), who had no health security were six times (OR: 6.00, CI: 2.02-17.81) and who underwent any intervention were three times (OR: 3.24, CI: 1.03-10.16) more likely to have CHE compared to their counterparts. The coping strategies adopted by the participants were loans (41%), savings (14%), health insurance (8%) and a combination of the above (37%). INTERPRETATION & CONCLUSIONS: Our findings show that viable financing mechanism for treating ACS is warranted to prevent CHE particularly among low SES participants, those having no health security, requiring intervention procedures and those with adversely affected employment.

Impact of comprehensive cardiovascular risk reduction programme on risk factor clustering associated with elevated blood pressure in an Indian industrial population.

BACKGROUND & OBJECTIVES: Cardiovascular risk factors clustering associated with blood pressure (BP) has not been studied in the Indian population. This study was aimed at assessing the clustering effect of cardiovascular risk factors with suboptimal BP in Indian population as also the impact of risk reduction interventions. METHODS: Data from 10543 individuals collected in a nation-wide surveillance programme in India were analysed. The burden of risk factors clustering with blood pressure and coronary heart disease (CHD) was assessed. The impact of a risk reduction programmme on risk factors clustering was prospectively studied in a sub-group. RESULTS: Mean age of participants was 40.9 ± 11.0 yr. A significant linear increase in number of risk factors with increasing blood pressure, irrespective of stratifying using different risk factor thresholds was observed. While hypertension occurred in isolation in 2.6 per cent of the total population, co-existence of hypertension and >3 risk factors was observed in 12.3 per cent population. A comprehensive risk reduction programme significantly reduced the mean number of additional risk factors in the intervention population across the blood pressure groups, while it continued to be high in the control arm without interventions (both within group and between group P<0.001). The proportion of 'low risk phenotype' increased from 13.4 to 19.9 per cent in the intervention population and it was decreased from 27.8 to 10.6 per cent in the control population (P<0.001). The proportion of individuals with hypertension and three more risk factors decreased from 10.6 to 4.7 per cent in the intervention arm while it was increased from 13.3 to 17.8 per cent in the control arm (P<0.001). INTERPRETATION & CONCLUSIONS: Our findings showed that cardiovascular risk factors clustered together with elevated blood pressure and a risk reduction programme significantly reduced the risk factors burden.

Incidence of hypertension and its risk factors in rural Kerala, India: a community-based cohort study.

OBJECTIVES: To investigate the incidence of hypertension and its risk factors in Kerala, India where the epidemiological transition is more advanced than elsewhere in India. STUDY DESIGN: Prospective cohort study. METHODS: A sample of 297 individuals (aged 15-64 years) in rural Kerala, India, who were free of hypertension at study enrolment, were followed-up from 2003 to 2010. At enrolment, demographic characteristics and behavioural risk factors were determined by interview, and the participants underwent physical (blood pressure, height, weight and waist circumference) and biochemical examinations (fasting plasma glucose and serum lipids). At follow-up, blood pressure readings were repeated using the original tool following the same protocol. RESULTS: Nearly one-quarter (23.6%) of the sample developed hypertension over a mean follow-up period of 7.1 (standard deviation 0.2) years. Age ≥35 years [relative risk (RR) 4.00, 95% confidence interval (CI) 2.37-6.03], current smoking [RR 1.99, 95% CI 1.14-2.97, population-attributable risk percent (PAR%) 13.3%], high-normal blood pressure (RR 3.53 vs optimal blood pressure, 95% CI 2.17-5.28, PAR% 44.0%) and central obesity (RR 2.45, 95% CI 1.45-3.70, PAR% 40.4%) were significantly associated with incident hypertension. Collectively, current smoking, high-normal blood pressure and central obesity accounted for 70.1% of all new cases of hypertension. Awareness, treatment and control rates of incident hypertension were 42.9%, 22.9% and 11.4%, respectively. CONCLUSIONS: This rural sample showed a high incidence of hypertension. This underscores the need for primary prevention of hypertension through lifestyle modification strategies targeting individuals with high-normal blood pressure, central obesity and current smoking. The healthcare system needs to improve the level of awareness, treatment and control of hypertension in this population.

Smokeless tobacco use among patients with tuberculosis in Karnataka: the need for cessation services.

BACKGROUND: India is home to the largest population of patients with tuberculosis and tobacco users in the world. Smokeless tobacco use exceeds smoking and is increasing. There is no study to date that reports smokeless tobacco use before and after the diagnosis and treatment of tuberculosis. We assessed smokeless tobacco use among former patients of tuberculosis in Karnataka, India. METHODS: We conducted a community-based, cross sectional study among 202 men, who had been diagnosed and treated for tuberculosis (mean age 48 years), selected by multistage, random sampling. Using a semi-structured interview schedule, retrospective smoking and smokeless tobacco use were captured at eight time-points before and after the diagnosis and treatment of tuberculosis. RESULTS: Most patients suspended tobacco use during treatment. A high 44% prevalence of smokeless tobacco use 6 months before diagnosis was reduced to just 8% during the intensive phase of treatment and climbed to 27% 6 months after treatment. The tobacco use relapse rate 6 months after completion of treatment was higher for smokeless tobacco use (52%, 95% CI 41%-62%) than for smoking (36%, 95% CI 26%-45%). We also found that many patients who were advised to quit smoking continued using smokeless tobacco after completion of treatment. Additionally, new smokeless tobacco use was documented. Of the 11 new exclusive smokeless tobacco users, 10 shifted from smoking to smokeless tobacco use as a form of harm reduction. CONCLUSION: Patients with tuberculosis are advised by their doctors, at the time of diagnosis, to quit smoking. Several patients shift from smoking to smokeless tobacco use, which needs to be addressed while providing tobacco cessation services.