Knowledge, Attitude and Practices of Contraceptives Among Married Women of Rural Vellore.

Introduction: Ensuring reproductive health is central to the process of developing and improving the health of women and children and is linked to the issues such as sexually transmitted diseases, poverty, education, gender equality, and human rights. This community-based cross-sectional study was conducted to assess the knowledge, attitude, and practices of contraceptives of married women aged 18-49 years in rural Vellore, Tamil Nadu. Methods: This study was conducted in Kaniyambadi block in Vellore, Tamil Nadu. Two-stage cluster sampling was used. A total of 200 households were selected. From each household, one eligible woman was selected. Results: Two hundred women participated in the study. Nine percent had good knowledge, 52.5% had a good attitude and 67.5% had good practices as defined by this study. Education, belonging to non-scheduled caste, age, type of family, and the number of living children were significantly associated with knowledge, attitude, and practices in both bivariate analysis and multivariate analysis. The main reasons for not using contraception were the desire to have a child and the fear of side effects of contraceptives. Conclusion: Despite poor knowledge levels and moderate levels of good attitude, modern contraceptive usage in this study population was high. Women thought traditional methods were more effective than modern contraceptives. Permanent sterilization in women was the widely practiced modern contraceptive method. Strategies and methods to improve knowledge, and adoption of modern contraceptive usage among women and men need to be designed, implemented and studied.

Impact of the COVID-19 National Lockdown on a Rural and Tribal Population of Tamil Nadu, Southern India: A Mixed-Methods Survey.

We assessed the impact of the national lockdown on a rural and tribal population in Tamil Nadu, southern India. A mixed-methods approach with a pilot-tested, semi-structured questionnaire and focus group discussions were used. The impact of the lockdown on health, finances, and livelihood was studied using descriptive statistics. Multivariable logistic regression was carried out to identify factors associated with households that borrowed loans or sold assets during the lockdown, and unemployment during the lockdown. Of the 607 rural and tribal households surveyed, households from comparatively higher socioeconomic quintiles (adjusted odds ratio [aOR], 1.84; 95% CI, 1.01-3.34), with no financial savings (aOR, 2.91; 95% CI, 1.17-7.22), and with larger families (aOR, 1.76; 95% CI, 1.22-2.53), took loans or sold assets during the lockdown. Previously employed individuals from rural households (aOR, 5.07; 95% CI, 3.30-7.78), lower socioeconomic households (aOR, 3.08; 95% CI, 1.74, 5.45), and households with no savings (aOR, 1.78; 95% CI, 1.30-2.44) became predominantly unemployed during the lockdown. Existing government schemes for the elderly, differently abled, and widows were shown to be accessible to 89% of the individuals requiring these schemes in our survey. During the focus group discussions, the limited reach of online classes for schoolchildren was noted and attributed to the lack of smartphones and poor Internet connectivity. Although the sudden, unannounced national lockdown was imposed to flatten the COVID-19 curve, aspects related to livelihood and financial security were affected for both the rural and tribal populations.

Risk Factors and Hazards in the Household Environment for Elevated Blood Lead Levels in Urban Preschool Children of Vellore: A Case-Control Approach in the MAL-ED Birth Cohort.

OBJECTIVES: To study the household environmental risk factors and hazards associated with elevated blood lead levels (EBLLs) in preschool children in an urban setting of Vellore, South India. METHODS: A case-control study within the MAL-ED (Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development) birth cohort was conducted between January 2014 and January 2015. The study included 153 pre-school children: 87 cases and 66 controls with elevated and normal BLLs, respectively. A structured questionnaire was used to assess the sociodemographic profile, household environment, breastfeeding practices, children's habits, and the use of cosmetics in them. Household environmental samples of wall and door paint, floor dust, drinking water, and cosmetics were estimated for lead levels using gas flame atomic absorption spectrometry (FAAS). RESULTS: Children born with low birth weight, those living in houses painted at least once in the last five years and those residing in houses older than ten years had a higher odds of EBLLs [OR (95% CI) = 3.79 (1.24-11.1); 4.84 (1.42-16.53); 5.07 (2.06-12.46), and 2.58 (0.99-6.69)], respectively. Drinking water samples from both cases (88%) and controls (95%) had lead levels more than the Environmental Protection Agency (EPA), USA recommendation of 0.015 ppm. CONCLUSIONS: Low birth weight and the household environment pose important risk factors/hazards for elevated blood lead levels in urban preschool children. Multipronged interventions that include government legislations, household environmental modification, safe water supply, and community education are pivotal in reducing lead exposure in young children.

Primary care for the urban poor in India during the pandemic: Uninterrupted management of non-communicable diseases and home-based care of patients with COVID-19 infection.

Problem: The two waves of COVID-19 severely affected the healthcare system in India. The government responded to the first wave with a strict nationwide lockdown which disrupted primary care, including the management of non-communicable diseases (NCDs). The second wave overwhelmed healthcare facilities leading to inadequate access to hospital services. Collectively, these issues required urgent responses, including the adaptation of primary care. Approach: The Low-Cost Effective Care Unit (LCECU) of Christian Medical College, Vellore (CMC) has a network of community volunteers, community health workers, an outreach nurse, social workers and doctors who operate clinics in six poorer areas of Vellore. The network adapted quickly, responding to the lockdown during the first wave and ensuring ongoing primary care for patients with non-communicable diseases. During the second wave, the team developed a system in collaboration with other CMC departments to provide home-based care for patients with COVID-19. Local setting: The LCECU is a 48-bed unit of the Department of Family Medicine, part of the 3,000-bed CMC. It originated in 1982, aiming to care for the poor populations of Vellore town. It has been actively working among urban communities since 2002, with a focus on delivering Community Oriented Primary Care (COPC), for six poor urban communities since 2016. Relevant changes: During the first wave of COVID the LCECU team ensured patients with NCDs had uninterrupted primary care and medications by visiting them in their homes. The team also addressed food insecurity by organizing a daily lunch service for 600 people for over 2 months. In the second wave, the team responded to community needs by organizing and delivering home-based care to monitor patients affected by COVID-19. Lessons learned: The COVID-19 pandemic raises many questions about the preparedness of health systems for disasters that disproportionately affect marginalized populations globally. COVID-19 is only one of the many potential disasters, including non-communicable diseases, mental health problems, pollution, climate change, and lifestyle illness. There is an urgent need to study models of care that support vulnerable communities in an accessible, cost-effective, and patient-oriented way, particularly in low- and middle-income countries. This paper outlines lessons on how the LCECU team addressed disaster management:1. The COVID-19 pandemic has highlighted the importance of primary care-based rapid response interventions in disaster management.2. The LCECU model demonstrated the effectiveness of a primary care intervention based on pre-existing networks and familiarity between primary care teams and the community.3. Establishing community-based health care via interdisciplinary teams, including community health workers, community volunteers, outreach nurses, and doctors, is key.4. Addressing other social determinants of health, such as food insecurity, is an important component of care delivery.

Screening practices for breast and cervical cancer and associated factors, among rural women in Vellore, Tamil Nadu.

BACKGROUND: Population-based screening coverage for breast and cervical cancer screening in the community is inadequately reported in India. This study assessed screening rates, awareness, and other factors affecting screening, among rural women aged 25-60 years in Vellore, Tamil Nadu. METHODS: Women aged 25-60 years, from five randomly selected villages of a rural block were included in this cross-sectional study in Vellore, Tamil Nadu. Households were selected by systematic random sampling, followed by simple random sampling of eligible women in the house. A semi-structured questionnaire was used to assess screening practices, awareness, and other factors related to cervical and breast cancer. RESULTS: Although 43.8% and 57.9% were aware of the availability of screening for cervical and breast cancer respectively, screening rates were only 23.4% (95% confidence interval [CI]: 18.4-28.4%) and 16.2% (95% CI: 11.9-20.5%), respectively. Adequate knowledge (score of ≥50%) on breast cancer was only 5.9%, with 27.2% for cervical cancer. Only 16.6% of women had ever attended any health education program on cancer. Exposure to health education (breast screening odds ratio [OR]: 6.89, 95% CI: 3.34-14.21; cervical screening OR: 6.92, 95% CI: 3.42-14.00); and adequate knowledge (breast OR: 4.69, 95% CI: 1.55-14.22; cervix OR: 3.01, 95% CI: 1.59-5.68) were independently associated with cancer screening. CONCLUSION: Awareness and screening rates for breast and cervical cancer are low among rural women in Tamil Nadu, a south Indian state with comparatively good health indices, with health education being an important factor associated with screening practices.

The insulin sharps disposal study: Evaluation of a structured patient education initiative in an urban community health centre in India.

CONTEXT: India has witnessed an increase in people suffering from diabetes mellitus and also those on insulin. The issue of handling used sharps in the community is an area of concern. AIMS: Our study aimed to assess the change in knowledge and practise concerning the disposal of used insulin sharps in patients with diabetes, pre- and post-evaluation, a structured, health provider-initiated, patient-centred insulin-use health education (PIHE). SETTINGS AND DESIGN: A pre- and post-evaluation study of PIHE set in an urban health centre in south India. METHODS AND MATERIALS: A pre-evaluation study was done on a cross-sectional sample of type II diabetes patients, who visited the urban health centre and were on insulin for at least 1 year. A semi-structured pilot-tested questionnaire was used for the study. For 18 months, PIHE was provided to all insulin users at outpatient contact, after which a post-evaluation study among another cross-sectional sample of patients in the same centre, was done to assess change in knowledge and practise. STATISTICAL ANALYSIS USED: Univariate analysis followed by logistic regression. RESULTS: The participants in the pre- and post-evaluation studies had a mean (SD) age of 54.9 (11.33) years and 57.2 (11.01) years, respectively. The baseline characteristics of gender, socioeconomic status and diabetes duration were similar. There was a statistically significant (P < 0.001) difference in knowledge (19 [19%] to 81 [81%]) and practise (7 [7%] to 73 [73%]) of participants regarding the correct disposal method of used insulin syringes and sharps before and after PIHE. CONCLUSIONS: PIHE over an 18-month period for diabetic patients on insulin significantly improved knowledge and practises relating to insulin use and correct disposal of syringes and sharps.

Low head circumference during early childhood and its predictors in a semi-urban settlement of Vellore, Southern India.

BACKGROUND: Stunting in developing countries continues to be a major public health problem. Measuring head circumference (HC) during clinical anthropometric assessment can help predict stunting. The aim of this study was to assess burden and determine the predictors of low HC (<- 2 SD) at birth and during first 2 years of life in a semi- urban settlement of Vellore. METHODS: The study uses baseline data and serial HC measurements from the birth cohort of MAL-ED study, where 228 children from Vellore completed follow-up between March 2010 to February 2014. Analysis of baseline, maternal and paternal characteristics, micro-nutrient status and cognition with HC measurements was performed using STATA version 13.0 software. RESULTS: The mean HC (±SD) at 1st, 12th and 24th month were 33.37 (1.29) cm, 42.76 (1.23) cm and 44.9 (1.22) cm respectively. A third of the infants (75/228) had HC less than - 2 SD at first month of life, and on follow-up, 50% of the cohort had HC ≤ -2 SD both at 12th and 24th month. Low HC measurements at all three time-points were observed for 21.6% (46/222) infants. Low HC was significantly associated with stunting in 37.3% (OR = 10.8), 57.3% (OR = 3.1) and 44.4% (OR = 2.6) children at 1st, 12th and 24th month respectively. Bivariate analysis of low HC (<- 2 SD) at 12th month showed a statistically significant association with lower socioeconomic status, low paternal and maternal HC and low maternal IQ. Multivariable logistic regression analysis showed maternal (AOR = 0.759, 95% CI = 0.604 to 0.954) and paternal (AOR = 0.734, 95% CI = 0.581 to 0.930) HC to be significantly associated with HC attained by the infant at the end of 12 months. CONCLUSIONS: One-third of the children in our cohort had low head circumference (HC) at birth, with one-fifth recording low HC at all time-points until 2 years of age. Low HC was significantly associated with stunting. Paternal and maternal HC predicted HC in children. HC measurement, often less used, can be a simple tool that can be additionally used by clinicians as well as parents/caregivers to monitor child growth.

Unintentional injuries among children aged 1-5 years: understanding the burden, risk factors and severity in urban slums of southern India.

BACKGROUND: Globally, 5.82 million deaths occurred among children under the age of five years in 2015 and injury specific mortality rate was 73 per 100,000 population. In India, injury specific mortality rate is around 2.1 per 1000 live births contributing to 4% of the total under 5 mortality rate. This study aims to estimate the burden and understand factors associated with unintentional injuries among children aged 1-5 years residing in urban slums of Vellore, southern India. We also attempted to assess the hazards posed by the living environment of these children and study their association with unintentional injury patterns. METHODS: This cross-sectional study was conducted in eight urban slums of Vellore, southern India and primary caregivers of children aged 1-5 years were interviewed with a questionnaire to obtain the details of injuries sustained in the past three months. Environmental hazard risk assessment was conducted at places frequented by these children and their scores calculated. Baseline prevalence and incidence rates of unintentional injuries were estimated. Multivariate logistic regression and poisson regression analysis were performed to examine factors associated with unintentional injuries and repeated injuries respectively. Association between environmental hazard risk and unintentional injuries was estimated. RESULTS: Prevalence of unintentional injuries was 39.1% (95% CI 35.4-42.9%) and incidence rate was 16.5 (95% CI 14.7-18.3) per 100 child months (N = 662). Bivariate analysis revealed that children of working mothers (OR 1.48; 1.01-2.18) and children from overcrowded families (OR 1.78; 1.22-2.60) had increased odds of sustaining unintentional injuries. Multivariate regression analysis revealed that children from overcrowded families had increased odds of sustaining unintentional injuries (AOR 1.66, 95% CI 1.14-2.41). Boys (IRR 1.33, 95% CI 1.07-1.66) and children from overcrowded families (IRR 1.50; 1.14-1.98) were at increased risk of having repeated injuries. There is an increase in incidence rate of injuries with an increased environmental hazard risk, although not statistically significant. CONCLUSIONS: The burden of unintentional injuries was very high among study children when compared to studies in other urban slums in India. Environment plays an important role in the epidemiology of unintentional injuries; providing safe play environment and adequate supervision of children is important to reduce its burden.

Effects of elevated blood lead levels in preschool children in urban Vellore.

OBJECTIVE: To study the burden and associated risk factors for elevated blood lead levels among pre-school children (15-24 months) in urban Vellore, and to study its effects on child cognition and anemia. DESIGN: An investigative study through Mal-ED cohort. SETTING: Eight adjacent urban slums in Vellore, Tamil Nadu. PARTICIPANTS: 251 babies recruited through Mal-ED Network. OUTCOME MEASURES: Blood lead levels using Graphite Furnace Atomic Absorption Spectrophotometry method at 15 and 24 mo; hemoglobin estimation by azidemethemoglobin method; cognitive levels using Bayley Scales of Infant Development III. RESULTS: Around 45% of children at 15 months and 46.4% at 24 months had elevated blood lead levels (>10 µg/dL). Among children who had elevated blood lead levels at 15 months, 69.2% (45/65) continued to have elevated levels at 24 months. After adjusting for potential confounders, children from houses having a piped drinking water supply and houses with mud or clay floors were at significantly higher risk of having elevated blood lead levels at 15 months. Thirty one percent (21/67) of the children with elevated blood lead levels had poor cognitive scores. Children with elevated blood lead levels at 15 months had higher risk (Adjusted OR 1.80; 95% CI 0.80 - 3.99) of having poorer cognitive scores at 24 months. More than half of the children (57%) were anemic at 15 months of age, and elevated blood lead levels were not significantly associated with anemia. CONCLUSIONS: Elevated blood lead levels are common among preschool children living in urban slums of Vellore. Poorer conditions of the living environment are associated with elevated lead levels.

Nature, prevalence and risk factors of alcohol use in an urban slum of Southern India.

BACKGROUND: There is a paucity of data on the use of alcohol in urban slums of southern India. METHODS: We screened 2811 men for alcohol use via a household-level census in an urban slum in Vellore, Tamil Nadu, and interviewed 220 age- and area-matched pairs of men drinkers and non-drinkers to examine factors associated with alcohol use. Alcohol Use Disorder Identification Test (AUDIT), a standard instrument, was used to assess risk levels of drinking of 354 drinkers. Prevalence rates were calculated using age- adjusted direct standardization. Odds ratios (ORs) of drinking status and higher-risk drinking were calculated using conditional logistic regression and ordinal logistic regression, respectively. RESULTS: Among all men, we estimated that 46.1% consumed alcohol and 31.4% were hazardous drinkers (19% increased-risk, 7.7% high-risk and 4.7% dependent drinkers). Factors associated with alcohol use were: manual labour occupations (OR 2.08); presence of a common mental disorder (OR 1.50) and smoking (OR 2.08); while Muslim religion was protective (OR 0.43). Factors associated with higher-risk alcohol use were: being reported as a non-drinker during the census (OR 3.96); presence of a common mental disorder (OR 3.83); smoking (OR 1.78); drinking before legal age of 21 years (OR 2.71); spending more than `100 per day on alcohol (OR 6.17); and mainly drinking Indian-made foreign liquor (OR 5.45). CONCLUSION: High prevalence of hazardous drinking and the factors associated with it suggest the need for population- wide interventions and further investigations to effectively reduce hazardous alcohol use and its harmful effects.

Reported healthcare utilisation for childhood respiratory illnesses in Vellore, South India.

A 30-cluster survey using a modified WHO method was performed to assess the healthcare utilisation patterns for respiratory illnesses in Indian children < 5 years of age. Families of 600 children were interviewed to assess respiratory illness and healthcare utilisation during the previous month as well as hypothetical healthcare-seeking behaviour in the future. Based on parental report, 381 children (63.5%) had experienced a respiratory illness 1 month prior to the interview; 10 children were reported to have had severe pneumonia, 49 non-severe pneumonia and 322 upper respiratory illnesses (URI), extrapolating to 0.20 (95% CI 0.1-0.4), 0.98 (0.7-1.3) and 6.44 (6.0-6.9) cases per child-year, respectively. Five severe pneumonia cases (50%) were reported to have directly accessed care at a secondary or tertiary care centre, whilst 18 children (36.7%) with non-severe pneumonia and 56 children (17.4%) with URI were reported to have been seen at secondary or tertiary centres. The remaining respiratory illnesses were reported to have been seen by primary care physicians, pharmacists, traditional healers and friends or were not seen by a healthcare professional. This community-based Indian study suggests that, in this community, tertiary care surveillance alone may not accurately sample community disease, even for severe illnesses.

The challenge of patients with severe psychiatric illness who do not access care - a way forward.

Psychiatric illnesses are a significant cause of morbidity all over the world. In India many people with mental disorders are unable to access psychiatric care for a variety of reasons. This article describes the successful management of a person with schizophrenia in the community through a primary care team in liaison with psychiatrist services.