The Patient's Perspective on the Functioning of the Primary Healthcare Centres in Bangalore, India: An Illustrated Guide.

India's healthcare system is, for a large part, organized around a vast network of Primary Healthcare Centres (PHCs) that form the pillar on which the public healthcare sector functions. The World Health Organization (WHO) has emphasized the important role that PHCs play in strengthening community health and the provision of healthcare. Although a few studies have assessed specific elements of services offered by PHCs, only a few have studied the patients' perspectives on the functioning and performance of PHCs in the Indian context. A qualitative research methodology was employed to explore the opinions of 188 patients attending one of three PHCs in Bengaluru (India), using in-depth interviews and thematic analysis. Results showed that patients assessed PHC based on the nine themes that broadly can be classified into components of the center, and that of the personnel. The patients valued the behavioural aspects of the personnel during service delivery and should be configured into the PHC performance.

["Mummy, can I join a sports club?" a qualitative study on the impact of health-promoting schools on health behaviours in the home setting]. / 'Mam, dat is eigenlijk niet zo gezond'.

OBJECTIVE/DESIGN: Information regarding school-based health-promoting interventions' potential effects in the home environment is scarce. Gaining more insight into this is vital to optimise interventions' potential. The Healthy Primary School of the Future (HPSF) is a Dutch initiative aiming to improve children's health and well-being by providing daily physical activity sessions and healthy school lunches. This qualitative study examines if and how HPSF influenced children's and parents' physical activity and dietary behaviours at home. METHOD: In 2018-2019, 27 semi-structured interviews were conducted with parents from two HPSF schools. Interviews were recorded and transcribed, and data were coded and interpreted through thematic analysis. RESULTS: HPSF resulted in various behavioural changes at home, initiated by both children and parents. Parents reported improvements in healthy behaviours, as well as compensatory, unhealthy behaviours. Reasons for behavioural change included increased awareness, perceived support to adopt healthy behaviours, and children asking for the same healthy products at home. Barriers to change included no perceived necessity for change, lack of HPSF-related information provision, and time and financial constraints. CONCLUSION: Both child-to-adult intergenerational learning and parent-initiated changes play an important role in the transfer of health behaviours from school to home and are therefore key mechanisms to maximise school-based health-promoting interventions' impact.

Battling the obesity epidemic with a school-based intervention: Long-term effects of a quasi-experimental study.

BACKGROUND: School-based health-promoting interventions are increasingly seen as an effective population strategy to improve health and prevent obesity. Evidence on the long-term effectiveness of school-based interventions is scarce. This study investigates the four-year effectiveness of the school-based Healthy Primary School of the Future (HPSF) intervention on children's body mass index z-score (BMIz), and on the secondary outcomes waist circumference (WC), dietary and physical activity (PA) behaviours. METHODS AND FINDINGS: This study has a quasi-experimental design with four intervention schools, i.e., two full HPSFs (focus: diet and PA), two partial HPSFs (focus: PA), and four control schools. Primary school children (aged 4-12 years) attending the eight participating schools were invited to enrol in the study between 2015 and 2019. Annual measurements consisted of children's anthropometry (weight, height and waist circumference), dietary behaviours (child- and parent-reported questionnaires) and PA levels (accelerometers). Between 2015 and 2019, 2236 children enrolled. The average exposure to the school condition was 2·66 (SD 1·33) years, and 900 participants were exposed for the full four years (40·3%). After four years of intervention, both full (estimated intervention effect (B = -0·17 (95%CI -0·27 to -0·08) p = 0·000) and partial HPSF (B = -0·16 (95%CI-0·25 to -0·06) p = 0·001) resulted in significant changes in children's BMIz compared to control schools. Likewise, WC changed in favour of both full and partial HPSFs. In full HPSFs, almost all dietary behaviours changed significantly in the short term. In the long term, only consumption of water and dairy remained significant compared to control schools. In both partial and full HPSFs, changes in PA behaviours were mostly absent. INTERPRETATION: This school-based health-promoting intervention is effective in bringing unfavourable changes in body composition to a halt in both the short and long term. It provides policy makers with robust evidence to sustainably implement these interventions in school-based routine.

Providers' perspectives on the performance of primary healthcare centres in India: The missing link.

BACKGROUND: Primary healthcare centres (PHCs) form the foundation of the Indian public health system, and thus their effective functioning is paramount in ensuring the population's health. The World Health Organisation (WHO) has set six aspects of performance assessment for general health systems, which are hardly applicable to the PHC setup in a low- and middle-income country. The Primary Health Care Performance Initiative (PHCPI) has prescribed a framework with five domains consisting of 36 indicators for primary healthcare performance assessment from a policy point of view. For the assessment to be realistic, it should include inputs from stakeholders involved in care delivery, so this study examines the perspectives of healthcare providers at PHCs in India. METHODOLOGY: The authors used qualitative research methodology in the form of responsive evaluations of healthcare provider's interviews to understand the indicators of PHC performance. RESULTS AND CONCLUSION: The study results showed that healthcare providers considered efficient teamwork, opportunities for enhancing provider skills and knowledge, job satisfaction, effective PHC administration, and good community relationship as PHC performance assessment. These domains of performance could be considered the 'missing link' in PHC assessment, since they are deemed important by providers and did not coincide with the WHO aspects and the PHCPI performance assessment framework.

[Effects and costs of The Healthy Primary School of the Future]. / De effecten en kosten van de Gezonde Basisschool van de Toekomst.

OBJECTIVE: To study school lifestyle interventions for elementary school children (The Healthy Primary School of the Future). RESEARCH QUESTION: What are the effects of the introduction of increased physical activity with or without healthy nutrition on health behaviour and BMI of young children and what are the costs of this program? DESIGN: Prospective controlled non-randomized study with nearly 1700 children in Parkstad (South-East Netherlands). RESULTS: Preliminary results after two years show that the combination of increased physical activity and healthy nutrition result in a decreased BMIz-score (-0.036), increased physical activity alone in hardly any change (-0.10) while in the control group the BMIz-score increased (0.052). The net societal costs of the combination of physical activity and health nutrition costs were 1 euro per child per day. CONCLUSION: The study contributes to the increasing amount of evidence proving that lifestyle interventions are effective in reducing the obesity epidemic. Future studies will show whether a weight reduction in children will result in the prevention of chronic disease later on in life and what the cost reduction related to this result will be.

Non-response and external validity in a school-based quasi-experimental study 'The Healthy Primary School of the Future': A cross-sectional assessment.

Limited evidence is available about (non)-representativeness of participants in health-promoting interventions. The Dutch Healthy Primary School of the Future (HPSF)-study is a school-based study aiming to improve health through altering physical activity and dietary behaviour, that started in 2015 (registered in ClinicalTrials.gov on 14-06-2016, NCT02800616). The study has a response rate of 60%. A comprehensive non-responder analysis was carried out, and responders were compared with schoolchildren from the region and the Netherlands using a cross-sectional design. External sources were consulted to collect non-responder, regional, and national data regarding relevant characteristics including sex, demographics, health, and lifestyle. The Chi-square test, Mann-Whitney U test, or Student's t-test were used to analyse differences. The analyses showed that responders (n = 494) were comparable with non-responders (n = 348) and regional data (n = 6172) with regard to sex and health. Responders did not significantly differ from regional data with regard to lifestyle. Responders had significantly higher educated parents compared to non-responders and were more often of autochthonous ethnicity compared to regional data. Major differences were observed between responders and schoolchildren in the Netherlands, regarding, among others sex, ethnicity, and parental employment rates. We conclude that a potential healthy-volunteer effect in the HPSF-sample is limited. External validity is high when compared to the regional population but low when compared to the national sample. For future intervention studies, we advise to evaluate outcome measures according to regional/national standards and to cooperate with external parties in early stages of research to be able to assess and enhance generalisability.

Primary health Centres' performance assessment measures in developing countries: review of the empirical literature.

BACKGROUND: It is universally accepted that primary healthcare is essential for achieving public health and that assessment of its performance is critical for continuous improvement. The World Health Organization's (WHO's) framework for performance assessment is a comprehensive global standard, but difficult to apply in developing countries because of financial and data constraints. This study aims to review the empirical literature on measures for Primary Health Centre (PHC) performance assessment in developing countries, and compare them for comprehensiveness with the aspects described by the WHO Framework. METHODS: Research articles published in English scientific journals between January 1979 and October 2016 were reviewed systematically. The reporting quality of the article and the quality of the measures were assessed with instruments adapted for the purpose of this study. Data was categorized and described. RESULTS: Fifteen articles were included in the study out of 4359 articles reviewed. Nine articles used quantitative methods, one article used qualitative methods exclusively and five used mixed methods. Fourteen articles had a good description of the measurement properties. None of the articles presented validity tests of the measures but eleven articles presented measures that were well established. Mostly studies included components of personnel competencies (skilled/ non-skilled) and centre performance (patient satisfaction/cost /efficiency). CONCLUSIONS: In comparison to the WHO framework, the measures in the articles were limited in scope as they did not represent all service components of PHCs. Hence, PHC performance assessment should include system components along with relevant measures of personnel performance beyond knowledge of protocols. Existing measures for PHC performance assessment in developing countries need to be validated and concise measures for neglected aspects need to be developed.

The effect of financial incentives on top of behavioral support on quit rates in tobacco smoking employees: study protocol of a cluster-randomized trial.

BACKGROUND: Stimulating successful tobacco cessation among employees has multiple benefits. Employees who quit tobacco are healthier, more productive, less absent from work, and longer employable than employees who continue to use tobacco. Despite the evidence for these benefits of tobacco cessation, a successful method to stimulate employees to quit tobacco is lacking. The aim of this study is to evaluate whether adding a financial incentive to behavioral support (compared with no additional incentive) is effective and cost-effective in increasing abstinence rates in tobacco smoking employees participating in a smoking cessation group training. METHODS/DESIGN: In this cluster-randomized trial employees in the intervention and control group both participate in a smoking cessation group training consisting of seven weekly counseling sessions of ninety minutes each. In addition to the training, employees in the intervention group receive a voucher as an incentive for being abstinent from smoking at the end of the training (€50), after three months (€50), after six months (€50), and after one year (€200). The control group does not receive any incentive. The primary outcome is carbon monoxide validated 12-month continuous abstinence from smoking (Russel's standard). Additionally, an economic evaluation is performed from a societal and an employer perspective. DISCUSSION: The present paper describes the methods and design of this cluster-randomized trial in detail. We hypothesize that the financial incentive for abstinence in the form of vouchers increases abstinence rates over and above the group training. The results of this study can provide important recommendations for enhancement of employee tobacco cessation. TRIAL REGISTRATION: Dutch Trial Register: NTR5657 . First received 27-01-2016.

The Healthy Primary School of the Future: study protocol of a quasi-experimental study.

BACKGROUND: Unhealthy lifestyles in early childhood are a major global health challenge. These lifestyles often persist from generation to generation and contribute to a vicious cycle of health-related and social problems. This design article presents a study evaluating the effects of two novel healthy school interventions. The main outcome measure will be changes in children's body mass index (BMI). In addition, lifestyle behaviours, academic achievement, child well-being, socio-economic differences, and societal costs will be examined. METHODS: In close collaboration with various stakeholders, a quasi-experimental study was developed, for which children of four intervention schools (n = 1200) in the southern part of the Netherlands are compared with children of four control schools (n = 1200) in the same region. The interventions started in November 2015. In two of the four intervention schools, a whole-school approach named 'The Healthy Primary School of the Future', is implemented with the aim of improving physical activity and dietary behaviour. For this intervention, pupils are offered an extended curriculum, including a healthy lunch, more physical exercises, and social and educational activities, next to the regular school curriculum. In the two other intervention schools, a physical-activity school approach called 'The Physical Activity School', is implemented, which is essentially similar to the other intervention, except that no lunch is provided. The interventions proceed during a period of 4 years. Apart from the effectiveness of both interventions, the process, the cost-effectiveness, and the expected legal implications are studied. Data collection is conducted within the school system. The baseline measurements started in September 2015 and yearly follow-up measurements are taking place until 2019. DISCUSSION: A whole-school approach is a new concept in the Netherlands. Due to its innovative, multifaceted nature and sound scientific foundation, these integrated programmes have the potential to form a template for primary schools worldwide. The effects of this approach may extend further than the outcomes associated with well-being and academic achievement, potentially impacting legal and cultural aspects in our society. TRIAL REGISTRATION: The study protocol was registered in the database ClinicalTrials.gov on 14-06-2016 with the reference number NCT02800616 .

Overweight and obesity prevalence among Indian women by place of residence and socio-economic status: Contrasting patterns from 'underweight states' and 'overweight states' of India.

Evidence from developing countries demonstrates a mixed relationship of overweight/obesity with socioeconomic status (SES) and place of residence. Theory of nutrition transition suggests that over the course of development, overweight first emerges among rich and urban people before spreading among rural and poor people. India is currently experiencing a rapid rise in the proportion of overweight and obese population especially among adult women. Under the backdrop of huge socio-economic heterogeneity across the states of India, the inter-state scenario of overweight and obesity differs considerably. Hence, this paper investigates the evolution over time of overweight and obesity among ever-married Indian women (15-49 years) from selected 'underweight states' (Bihar, Orissa and Madhya Pradesh, where underweight proportion is predominant) and 'overweight states' (Kerala, Delhi and Punjab, where overweight is the prime concern), in relation to a few selected socio-economic and demographic indicators. This study analysed National Family Health Surveys- NFHS-2 (1998-99) and NFHS-3 (2005-06) following Asian population specific BMI cut-offs for overweight and obesity. The results confirm that within India itself the relationship of overweight and obesity with place of residence and SES cannot be generalized. Results from 'overweight states' show that the overweight problem has started expanding from urban and well-off women to the poor and rural people, while the rural-urban and rich-poor difference has disappeared. On the other hand in 'underweight states' overweight and obesity have remained socially segregated and increasing strongly among urban and richer section of the population. The rate of rise of overweight and obesity has been higher in rural areas of 'OW states' and in urban areas of 'UW states'. Indian policymakers thus need to design state-specific approaches to arrest the rapid growth of overweight and its penetration especially towards under-privileged section of the society.

Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit.

Chronic obstructive pulmonary disease (COPD), lung cancer, asthma and pulmonary tuberculosis are common pulmonary diseases that are caused or worsened by tobacco smoking. Growing observational evidence suggests that symptoms and prognosis of these conditions improve upon smoking cessation. Despite increasing numbers of (small) randomised controlled trials suggesting intensive smoking cessation treatments work in people with pulmonary diseases many patients are not given specific advice on the benefits or referred for intensive cessation treatments and, therefore, continue smoking.This is a qualitative review regarding smoking cessation in patients with COPD and other pulmonary disorders, written by a group of European Respiratory Society experts. We describe the epidemiological links between smoking and pulmonary disorders, the evidence for benefits of stopping smoking, how best to assess tobacco dependence and what interventions currently work best to help pulmonary patients quit. Finally, we describe characteristics and management of any "hardcore" smoker who finds it difficult to quit with standard approaches.

Combining intensive practice nurse counselling or brief general practitioner advice with varenicline for smoking cessation in primary care: study protocol of a pragmatic randomized controlled trial.

INTRODUCTION: Combining behavioural support and pharmacotherapy is most effective for smoking cessation and recommended in clinical guidelines. Despite that smoking cessation assistance from the general practitioner can be effective, dissemination of clinical practice guidelines and efforts on upskilling has not lead to the routine provision of smoking cessation advice among general practitioners. Intensive counselling from the practice nurse could contribute to better smoking cessation rates in primary care. However, the effectiveness of intensive counselling from a practice nurse versus usual care from a general practitioner in combination with varenicline is still unknown. MATERIALS AND METHODS: A pragmatic randomized controlled trial was conducted comparing: (a) intensive individual counselling delivered by a practice nurse and (b) brief advice delivered by a general practitioner; both groups received 12-weeks of open-label varenicline. A minimum of 272 adult daily smoking participants were recruited and treated in their routine primary care setting. The primary outcome was defined as prolonged abstinence from weeks 9 to 26, biochemically validated by exhaled carbon monoxide. Data was analysed blinded according to the intention-to-treat principle and participants with missing data on their smoking status at follow-up were counted as smokers. Secondary outcomes included: one-year prolonged abstinence, short-term incremental cost-effectiveness, medication adherence, and baseline predictors of successful smoking cessation. DISCUSSION: This trial is the first to provide scientific evidence on the effectiveness, cost-effectiveness, and potential mechanisms of action of intensive practice nurse counselling combined with varenicline under real-life conditions. This paper explains the methodology of the trial and discusses the pragmatic and/or explanatory design aspects. TRIAL REGISTRATION: Dutch Trial Register NTR3067.

Methodological considerations in service use assessment for children and youth with mental health conditions; issues for economic evaluation.

Economic evaluations are increasingly used in decision-making. Accurate measurement of service use is critical to economic evaluation. This qualitative study, based on expert interviews, aims to identify best approaches to service use measurement for child mental health conditions, and to identify problems in current methods. Results suggest considerable agreement on strengths (e.g., availability of accurate instruments to measure service use) and weaknesses, (e.g., lack of unit prices for services outside the health sector) or alternative approaches to service use measurement. Experts also identified some unresolved problems, for example the lack of uniform definitions for some mental health services.

State-wise dynamics of the double burden of malnutrition among 15-49 year-old women in India: how much does the scenario change considering Asian population-specific BMI cut-off values?

This article assesses the gravity of the "double burden of malnutrition" across 21 states of India, through a comparative analysis of traditional and Asian population-specific BMI categorizations for overweight and obesity. This study analyzes data on ever-married women (15-49 years) from the National Family Health Survey (NFHS-2, 1998-1999; NFHS-3, 2005-2006). Findings depict that Indian women tilt toward high BMI resulting in a co-existence of under- and overweight populations, which portray a regional pattern. With Asian population-specific cut-offs, 11 states can be classified as "double burden states"; however, following traditional categorization, only 4 states face such dual pressure.

Stimulating program implementation via a Community of Practice: a responsive evaluation of care programs for frail older people in the Netherlands.

Evaluation is often used as a vehicle to improve program implementation. To evaluate the implementation of programs that provide care for frail older people a Community of Practice (CoP) was developed in the Netherlands. The purpose of this paper is to describe and reflect on the role of a CoP in the implementation of these programs. Using a responsive evaluation approach this study was based on interviews with participating stakeholders and transcripts of the CoP meetings with 13 professionals, project managers and patient representatives. Findings showed that CoP members had unanticipated concerns regarding the pro-active approach of the programs and older people not being open to receiving care. The heterogenic composition was appreciated and fostered learning. A social infrastructure was created for active learning inside and outside the CoP. We conclude that a CoP is a useful strategy as part of an evaluation aimed at improving program implementation. Lessons learned include the importance of creating ownership among CoP members by sharing responsibilities and paying attention to the heterogenic group composition and professional language spoken to involve all members.

[Pharmacogenetics in the treatment of tobacco addiction]. / Farmacogenetica bij de behandeling van tabaksverslaving.

BACKGROUND: Smokers vary in their genetic susceptibility to become addicted to smoking and probably also in their reaction to smoking cessation pharmacotherapies. AIM: To provide an overview of the developments on the pharmacogenetics of the treatment of tobacco addiction. METHOD: Review article describing the biological processes associated with tobacco addiction, and the influence of genetic variants on smoking behavior and the efficacy of smoking cessation therapies. RESULTS: Several (combinations of) genetic variants in smoking-related genes influence nicotine dependence. Moreover, several genetic variants in smoking- and treatment-related genes seem to influence the efficacy of smoking cessation therapies which are distinctive for the different forms of pharmacotherapy, especially when they have a different mechanism-of-action. CONCLUSION: Much progress has been made in unraveling the (pharmaco)genetics of tobacco addiction, but much still remains to be done before genetically tailored smoking cessation therapy can be implemented in clinical practice.

Investigating international time trends in the incidence and prevalence of atopic eczema 1990-2010: a systematic review of epidemiological studies.

The prevalence of atopic eczema has been found to have increased greatly in some parts of the world. Building on a systematic review of global disease trends in asthma, our objective was to study trends in incidence and prevalence of atopic eczema. Disease trends are important for health service planning and for generating hypotheses regarding the aetiology of chronic disorders. We conducted a systematic search for high quality reports of cohort, repeated cross-sectional and routine healthcare database-based studies in seven electronic databases. Studies were required to report on at least two measures of the incidence and/or prevalence of atopic eczema between 1990 and 2010 and needed to use comparable methods at all assessment points. We retrieved 2,464 citations, from which we included 69 reports. Assessing global trends was complicated by the use of a range of outcome measures across studies and possible changes in diagnostic criteria over time. Notwithstanding these difficulties, there was evidence suggesting that the prevalence of atopic eczema was increasing in Africa, eastern Asia, western Europe and parts of northern Europe (i.e. the UK). No clear trends were identified in other regions. There was inadequate study coverage worldwide, particularly for repeated measures of atopic eczema incidence. Further epidemiological work is needed to investigate trends in what is now one of the most common long-term disorders globally. A range of relevant measures of incidence and prevalence, careful use of definitions and description of diagnostic criteria, improved study design, more comprehensive reporting and appropriate interpretation of these data are all essential to ensure that this important field of epidemiological enquiry progresses in a scientifically robust manner.

House dust mite avoidance measures for perennial allergic rhinitis: an updated Cochrane systematic review.

BACKGROUND: To assess the benefits and harms of measures designed to reduce house dust mite (HDM) exposure in the management of house dust mite-sensitive allergic rhinitis. METHODS: Systematic review of randomized controlled trials was made, in which HDM control measures have been evaluated in comparison with placebo or other HDM avoidance measures, in patients with clinically proven allergic rhinitis. RESULTS: Nine trials involving 501 participants satisfied the inclusion criteria. These trials have investigated the effectiveness of bedroom environmental control programmes involving the use of HDM impermeable bedding covers (n = 4), acaricides (n = 2), high-efficiency particulate air filters (n = 2) and, using a factorial design, acaricide and HDM impermeable bedding covers in isolation and combination (n = 1). Seven of the nine trials reported that, when compared with control, the interventions studied resulted in significant reductions in HDM load. Of the interventions studied to date, acaricides appear to be the most promising, although the findings from these studies need to be interpreted with care because of their methodological limitations. House dust mite impermeable bedding as an isolated intervention is unlikely to offer benefit. CONCLUSIONS: Trials have tended to be small and of poor methodological quality, making it difficult to offer any definitive recommendations. Interventions that achieve substantial reductions in HDM load may offer some benefit in reducing rhinitis symptoms. Isolated use of HDM impermeable bedding is unlikely to prove effective.