Socioeconomic and Geographical Inequities in Burden and Treatment seeking Behavior for Hypertension among Women in the Reproductive Age (15-45 years) Group in India: Findings from a Nationally Representative Survey.

BACKGROUND: Socioeconomic disparity changed healthcare seeking and management cascade of hypertension due to inequity in hypertension care cascade pathway. OBJECTIVES: The inequities in burden and treatment-seeking behavior of hypertension among reproductive age group women were studied from National Family Health Survey-4 (NFHS-4) data. MATERIALS AND METHODS: We analyzed the data from NFHS-4 of women of reproductive age group between 15 and 49 years among the selected households contributing to 699,686 women. Socioeconomic inequities were assessed by expenditure quintile. Inequities in burden and treatment-seeking behavior were reported using the concentration curve and concentration index. RESULTS: The prevalence of hypertension in India was 15% (95% confidence interval: 14.9%-15.4%). One-third (32%) of the hypertensive population received treatment and only 28% of the women had controlled blood pressure. Wealth and education-based inequalities were more in high wealth index. The inequity in screening and awareness was in the northern and northeastern regions. CONCLUSION: There was inequity in the overall hypertension care cascade pathway with more inequity in the northern and northeastern region.

Sex-based differences in TB treatment compliance: A mediating factor for sputum conversion among newly diagnosed pulmonary TB patients in Chennai, South India.

Background: Tuberculosis (TB) remains a global health concern, particularly in India, which carries a significant portion of the global burden. The role of sex as a determinant of health is increasingly recognized, impacting various aspects of TB, including treatment compliance and outcomes. This study aimed to determine the mediating role of treatment compliance in the relationship between sex and sputum conversion in newly diagnosed pulmonary TB patients in Chennai, South India. Methods: We conducted a retrospective cohort study among patients newly diagnosed for TB at ESIC Medical College & PGIMSR between April 2020 and April 2022. A causal mediation analysis was performed to identify the direct and indirect effects of sex on sputum conversion via the mediator, treatment compliance. We employed logistic regression models and the "paramed" package for the analysis, with bootstrapping technique for examining the significance of indirect and direct effects. Results: The Marginal Total Effect (MTE) suggested that females were more likely to have sputum positivity compared to males (OR: 6.77; p = 0.003). Direct effect of being female increased the odds of sputum positivity at the end of the intensive phase (OR: 3.42; p = 0.03). The indirect effect of being female via treatment compliance significantly increased the odds of sputum positivity at the end of the intensive phase (OR: 1.98; p = 0.03). Conclusion: The study provides evidence that treatment compliance significantly mediates the relationship between sex and sputum conversion in TB patients, highlighting the necessity to consider gendered dimensions of health in TB control strategies.

Prevalence of Selected Cardiovascular Risk Factors and Their Associated Factors among People Living with HIV/AIDS in India.

Background: Low- and middle-income countries face the dual problem of infectious and non-infectious diseases. Persons living with HIV/AIDS (PLHIV) are also at risk of cardiovascular diseases. Hence, we did this study to determine the prevalence of cardiovascular risk factors (CVRF) among PLHIV and to find the factors associated with it. Methods: We carried out a cross-sectional analytical study among all adults aged ≥18 years registered at a facility-integrated anti-retroviral therapy center in Puducherry, India, from September 2016 to February 2018. After obtaining informed consent, we interviewed the participants to assess physical activity, alcohol, and tobacco use. We measured weight, height, abdominal circumference, and blood pressure, with biochemical investigations such as blood glucose and lipid profile. Results: Of the total 316 adults PLHIV studied, the most common cardiovascular risk factor found was dyslipidemia (82.7%), followed by inadequate physical activity (74.4%). Other behavioral risk factors studied, such as current tobacco use and current alcohol use, showed a prevalence of 12.8% and 5.4%, respectively, among male participants. The prevalence of hypertension among adult PLHIV studied was 15.8%, and diabetes was 12.3%. In the multivariate analysis, diabetes, and hypertension were significantly associated with age and literacy. Obesity was found to be associated with diabetes and abdominal obesity with dyslipidemia. Conclusion: Dyslipidemia was the most common cardiovascular risk factor, followed by inadequate physical inactivity among PLHIV. Regular screening with blood glucose, blood pressure, and lipid profile, and timely cross-referrals can help in the early detection of CVRF among PLHIV and hence improve their quality of life through appropriate treatment.

Self-directed learning for medical graduates: A boon or bane in disguise? A cross-sectional study in Chennai.

BACKGROUND: Self-directed learning (SDL) is an essential aspect of adult education or andragogy, gaining significance in medical education with the introduction of competency-based medical education. The primary objective of this study is to assess the self-directed learning abilities of second-year medical undergraduates in Chennai, South India, and to identify potential challenges and gaps in their learning process. MATERIALS AND METHODS: A cross-sectional study was conducted among 82 second-year medical students attending self-directed learning sessions at a medical college in Chennai. Data were collected using the self-directed learning instrument (SDLI), a standardized questionnaire, administered through Google Forms. Participants' identities were maintained confidential. Data were analyzed using SPSS version 22.0. Descriptive data were presented as proportions and percentages. Normally distributed quantitative data were expressed as mean and standard deviation. Non-normal continuous data were expressed as median and interquartile range (IQR). RESULTS: The majority of the students (61%) demonstrated a high level of SDL ability, with a median score of 76. Students exhibited strong learning motivation (mean score 4.11) but struggled with planning and implementation (mean score 3.07). The maximum mean score was 4.11 for item 3 (constant improvement and excelling in learning), and the minimum mean score was 3.07 for item 11 (arranging and controlling learning time). The students showed high self-monitoring (mean score 3.76) and interpersonal communication skills (mean score 4.00). CONCLUSIONS: SDL emerges as a boon for medical undergraduates in this study. By providing adequate training to faculty members on SDL implementation and guidance to students on planning and time management, SDL can play a pivotal role in enhancing medical education quality and fostering life-long learning among future medical professionals.

Association between domestic violence and unintended, terminated pregnancy and complications during pregnancy among Indian women: Findings from nationally representative survey.

Background: Women experiencing domestic violence might have restrictions in the pregnancy-related decision-making and care-seeking process leading to adverse pregnancy outcomes. We explored the association between domestic violence and undesirable pregnancy events. Methods: 63,796 women aged 18-49 years covered under the domestic violence module of National Family Health Survey-5, 2019-21. Stratification and clustering in the complex sampling design of the survey were accounted in analysis. Using Poisson regression, prevalence ratio (PR) was reported to provide association of domestic violence with undesirable pregnancy events. Results: Prevalence of undesirable pregnancy events was 25.0% (95%CI: 24.4%-25.7%) amongst women aged 18-49 years. Prevalence of unintended, terminated pregnancy and complications during pregnancy was 3.2%, 5.1% and 20.9%, respectively. Women aged ≥35 years, educated, unemployed, primi or multi parity, intimate partner/husband being uneducated, facing problem with access to healthcare, belonging to large number of household members (≥4) and poorest or poorer quintile had significantly higher chance of having undesirable pregnancy events. Sexual violence (aPR: 1.11, p = 0.02) had higher chance of having undesirable pregnancy events. Conclusion: One-fourth of reproductive-age group women had undesirable pregnancy events. Sexual violence was significantly associated with these events. Effective policy should protect women from domestic violence to promote maternal well-being.

Budget impact and cost-utility analysis of prophylactic emicizumab versus on-demand bypassing agents for adolescent severe haemophilia A patients with inhibitors in India.

Introduction: Severe Haemophilia A patients with inhibitors are currently being treated with bypassing agents like activated prothrombin complex concentrates (aPCC) and recombinant factor VIIa. Emicizumab is a recombinant humanized monoclonal antibody, introduced to reduce the bleeding events, improve treatment adherence, and quality of life. However, cost-effectiveness and long-term sustainability of the intervention is not studied in a low middle income setting like India. Aim: The primary objective of this study was to evaluate the cost-utility of Emicizumab compared to traditional bypassing agents in the treatment of severe haemophilia A patients with inhibitors in India. Secondary objective was to analyze the budgetary impact of introducing Emicizumab for this patient population from the perspective of public health system in India. Methods: Markov model was created to compare the prophylactic emicizumab therapy against bypassing agents for a hypothetical cohort of 10-year-old adolescents in India. The time horizon was 10 years and model built based on health system perspective. Cost utility was expressed as costs per quality-adjusted life-years (QALYs) gained. All costs were expressed as 2021 US dollars. Probabilistic sensitivity analysis was performed to check the robustness of the estimates. Results: Prophylactic emicizumab was a cost saving intervention with negative Incremental Cost Utility Ratio (ICUR) against recombinant factor VIIa of -853,573 USD (INR -63,109,773), and negative ICUR of -211,675 USD (INR -15,650,403) against APCC. The estimated total budget for treating all the severe Haemophilia A patients with inhibitors in India was USD 59,042,000 (INR 4,365,329,312) for 10 years' time horizon (per patient cost of USD 295,210 [INR 21,826,646.56]). Conclusion: Prophylactic emicizumab therapy is a cost saving intervention when compared to both the bypassing agents as it is less costly and more effective for severe Haemophilia A patients with inhibitors in India.

Marital status and suicidal behavior in South Asia: A systematic review and meta-analysis.

Background and Aims: The connection between marital status and suicidal behavior has been poorly assessed in South Asia. We aimed to see the proportion of marital status in individuals with suicidal behavior in South Asian countries. Methods: We followed PRISMA guidelines and registered the protocol in advance (PROSPERO 2023 CRD42023399906). A systematic search was conducted in Medline, Embase, and PsycINFO. Meta-analyses were performed to pool the proportion of married individuals with suicidal behavior (total [suicide + suicide attempts], suicide, and suicide attempt) in South Asian countries. We considered suicidal behavior consist of suicide and suicide attempts (nonfatal). Results: Our search identified 47 studies for this review from 6 countries published from 1999 to 2022 with a sample size ranging from 27 to 89,178. The proportion of married individuals was 55.4% (95% CI: 50.1-60.5) for suicidal behavior, 52.7% (95% CI: 44.5-60.7) for suicides, and 43.1 (95% CI: 32.9-53.9) for suicide attempts. The proportion of married persons among suicide attempts varied significantly across countries (p = 0.016) which was highest (61.8%; 95% CI: 57.2-66.2) in India, followed by Bangladesh (52.5%; 95% CI: 41.8%-62.9%) and Pakistan (45.1%; 95% CI: 30.9-59.9). The pooled proportions did not differ significantly in relation to the quality of the studies (p = 0.633). Conclusion: This review identified married persons died more than others by suicide in South Asian countries while single persons attempted suicide than married. As the current study did not assess any cause-and-effect association, a cautious interpretation is warranted while considering married marital status as a risk factor.

Barriers and Facilitators to Implementing the National Patient Safety Implementation Framework in Public Health Facilities in Tamil Nadu: A Qualitative Study.

BACKGROUND: In 2017, the National Patient Safety Implementation Framework (NPSIF) was introduced in India to ensure patient safety at different levels of the health care delivery system by 2025. Evaluating the implementation status, feasibility, and challenges and obtaining suggestions for improvement are key to the successful and sustainable implementation of any national health framework. Hence, we explored the facilitators and challenges in implementing the NPSIF and sought suggestions to address the challenges. METHODS: We adopted a descriptive qualitative approach to inquire about NPSIF implementation. Health care workers were selected using maximum variability sampling from 18 secondary- and tertiary-level public health care facilities in Tamil Nadu, India. From August to October 2021, we conducted a total of 80 key informant interviews and in-depth interviews with the relevant officers in-charge and HCWs of varied cadres. RESULTS: Facilitating factors reported were facilities obtaining/working toward quality certification; availability of standard protocols and checklists; and government rewards for the best-performing hospitals, doctors, and staff. Major implementation challenges reported were staff shortages; lack of infrastructure, facilities, and equipment; lack of awareness about patient safety, noncompliance to standard guidelines, and lack of patient cooperation. Recommendations suggested to overcome these challenges included providing educational materials to patients, offering regular continuing medical education and training, improving record maintenance, having a dedicated staff/team and surveillance system setup for patient safety and dedicated staff for data entry, filling existing staff vacancies, and using a carryover option for funding. CONCLUSION: Based on the current situation of patient safety practices in public health facilities in Tamil Nadu, it will be difficult to achieve full-scale implementation of the NPSIF by 2025. However, as a first step, a core patient safety committee can be formed at the state level to develop a Gantt chart for implementation based on the priorities over the next 2 years.

Hypertension in India: Trends in Wealth-related Inequalities from the National Family Health Surveys.

INTRODUCTION: India depicts a very high prevalence of hypertension. We need to learn more about the effect of wealth-related disparities on the prevalence of hypertension. The primary objective of this study was to assess temporal changes in the epidemiology of hypertension and associated wealth-related disparities among adults using two waves of nationally representative datasets from India. METHODS: We did a secondary data analysis of the National Family Health Survey (NFHS) rounds 4 and 5. We included information from the two rounds from 699,686 and 108,791 males and 92,804 and 677,803 females. Weighted analysis and multivariate binomial regression were used to depict the prevalence and predictors of hypertension. Inequalities were estimated using the concentration index (CI) and concentration curves. RESULTS: The weighted prevalence of hypertension among males increased from 14.6% to 16.7% among males, and from 8.8% to 9.9% among females, between NFHS-4 and NFHS-5. Prehypertension rose from 43.3% to 48.3% for males, and females, from 30.2% to 36.2% between the NFHS rounds. Overall, the CI among the males (0.078 and 0.050) and females (0.102 and 0.059) decreased from rounds 4 to 5, depicting a decrease in pro-poor wealth-related inequalities in hypertension prevalence in India. CONCLUSIONS: To conclude, the current analysis depicts that inequalities due to which hypertension was more prevalent in the wealthier classes in India are slowly disappearing. Therefore, we need to target the already exhausted poor patients with limited access to health-care resources to prevent them from further shifting beyond the line of poverty before these differences narrow down further.