Effect of national cultural dimensions and HIV prevalence rates on stigma towards people living with HIV/AIDS.

This paper examines the main and interactive effects of national culture dimensions and HIV prevalence rates on stigma towards people living with HIV/AIDS (PLHIVA). We examined these various relationships using data from a sample of 68,041 individuals from 49 countries, obtained from the World Values Survey. We used Hierarchical Linear Modeling to conduct our cross-level analyses. Our results indicated that collectivistic societies were positively associated while egalitarian and performance-oriented societies were negatively associated with stigma towards PLHIVA. Additionally, HIV prevalence rates interact with several cultural dimensions to worsen stigma towards PLHIVA. Our findings indicate the need to tailor stigma reduction strategies by taking the national culture dimensions of a given society into consideration when designing and implementing programs.

Effect of gender and clinical-financial vulnerability on mental distress due to COVID-19.

The COVID-19 pandemic has had an enormous impact on people's mental health. This study examines whether gender influences the mental distress in people from at-risk populations (clinically high risk and financially vulnerable). A cross-sectional survey was administered between the 23rd and 28th of April 2020 to 15,691 individuals from 32,596 households in the UK. Our findings confirmed that individuals who are clinically high risk or financially vulnerable or a combination of both experience significantly higher levels of mental distress. Additionally, we also found that females experienced higher levels of mental distress than males across various categories.

Single intravenous bolus versus perioperative continuous infusion of tranexamic acid to reduce blood loss in abdominal oncosurgical procedures: A prospective randomized double-blind clinical study.

BACKGROUND AND AIMS: Intraoperative use of a single bolus dose of tranexamic acid may not be sufficient to prevent bleeding in the early postoperative period. The present study was carried out to compare the effect of two dose regimens of tranexamic acid in reducing perioperative blood loss and the amount of allogenic blood transfusion in abdominal tumor surgery. MATERIAL AND METHODS: In this prospective, controlled, and double-blind investigation, 60 patients electively posted for abdominal oncosurgical procedures were randomly assigned to receive a single bolus dose of tranexamic acid (10 mg/kg) (Group A), a bolus dose of tranexamic acid (10 mg/kg) followed by infusion (1 mg/kg/h) till 4 h postoperatively (Group B), and a bolus followed by infusion of normal saline (group C). Total intraoperative blood loss, amount of allogenic blood transfusion, postoperative drain collections, and hemoglobin and hematocrit levels were recorded at different time intervals. Data obtained after comparing three groups were analyzed by analysis of variance test for variables following normal distribution, Kruskal-Wallis test for nonparametric data, and post-hoc Tukey-Kramer test for intergroup analysis. A probability value of less than 5% was considered significant. RESULTS: There was no significant difference in intraoperative blood loss in all the three groups. Both the tranexamic acid groups showed reduction in postoperative blood collection in drain at 6 h and 24 h in comparison to the control group (P < 0.001). There was also a significant difference in the amount of blood in postoperative drain at 24 h within the tranexamic acid groups, where lesser collection was seen in the infusion group (P = 0.007). Hemoglobin and hematocrit levels measured at different postoperative time intervals showed a significant reduction from the baseline in the control group compared to the tranexamic acid groups together. CONCLUSION: Tranexamic acid causes more effective reduction in post-operative blood loss when used as a bolus followed by an infusion continued in the postoperative period in comparison to its use as a single intravenous bolus in abdominal tumor surgery.

Parkinsonism following bilateral chronic subdural hematoma that presented as orthostatic headache: Highlighting clinical pearls for family physicians and physiotherapists.

Chronic subdural hematoma (CSDH) is a great mimicker. It should be considered in anyone presenting with chronic headaches that show postural variation. Parkinsonism following CSDH, while known, is only rarely reported in the literature. Hyponatremia, rapid correction of hyponatremia, medications, and mechanical pressure are thought to be risk factors. Here, we report a case of a 61-year-old male diagnosed with bilateral CSDH managed by craniotomy and clot evacuation who developed parkinsonism. We share several learnings (clinical pearls) that emerged from the close collaboration and co-learning curve between a family physician and physiotherapist involved in home-based rehabilitation. In conclusion, while managing the postoperative course of patients with CSDH, clinicians should maintain a high index of suspicion for parkinsonism. Early recognition and appropriate management with syndopa with supportive physiotherapy results in significant improvement of function and quality of life. Notably, parkinsonism following SDH is transient and nonprogressive and may not require lifelong therapy.

Promoting South Asian primary care research and projecting family medicine practitioner-scholars: A matter of critical importance.

South Asia, constituting India, Pakistan, Bangladesh, Nepal, Sri Lanka and Bhutan represents the most populous region in the world burdened with significant multilevel poverty. Primary care is well-documented to reduce the burden of diseases (both chronic and acute) and associated morbidity and mortality; be cost-effective and improve health outcomes and health equity for both individuals and populations. Any field, for it to stay relevant and to effectively achieve its stated mission, needs to produce its own knowledge through research. This translates into patient care, practice models, education, and advocacy for health systems strengthening and reform. In primary care, weaving experiential wisdom with clinical evidence lies at the heart of translation. In this editorial, we highlight: a) that local context, in terms of geography, community, culture, language and beliefs, influences the clinical context and practice and therefore research. Thus, relying on primary care research done elsewhere in the globe will not suffice; b) effective primary care is based on a generalist approach that involves certain ways of being, knowing, perceiving, and doing guided by the values of humility and intellectual curiosity, diversity and inclusion, equity, holistic approach to evidence, integrity, transparency, accountability and adaptability, and communication; and c) that the South Asian Region (SAR) has a number of groups experimenting and innovating with various healthcare delivery systems, much of which is not known to the larger field. The WONCA SAR Primary Care Research Network has been set up to facilitate and support scholarship, writing, and publication in primary care especially by practising family physicians. In conclusion, it will be critical to simultaneously promote grounded theory research that integrates both the family medicine/primary care perspective and the voices of families and address the 'hidden curriculum' that shapes the attitudes and aspirations of young doctors at both the undergraduate and postgraduate level. Family Physicians treat a variety of patients on a daily basis, in order to improve the quality of care and impact of primary care, it is imperative that the understanding and application of research is enhanced by specialists of this discipline.

The emergence of family medicine in India-A qualitative descriptive study.

Countries globally are introducing family medicine to strengthen primary health care; however, for many, that process has been slow. Understanding the implementation of family medicine in a national context is complex but critical to uncovering what worked, the challenges faced, and how the process can be improved. This study explores how family medicine was implemented in India and how early cohort family physicians supported the field's emergence. In this qualitative descriptive study, we interviewed twenty family physicians who were among the first in India and recognized as pioneers. We used Rogers's Diffusion of Innovation Theory to describe and understand the roles of family physicians, as innovators and early adopters, in the process of implementation. Greenhalgh's Model of Diffusion in Service Organizations is applied to identify barriers and enablers to family medicine implementation. This research identifies multiple mechanisms by which pioneering family physicians supported the implementation of family medicine in India. They were innovators who developed the first family medicine training programs. They were early adopters willing to enter a new field and support spread as educators and mentors for future cohorts of family physicians. They were champions who developed professional organizations to bring together family physicians to learn from one another. They were advocates who pushed the medical community, governments, and policymakers to recognize family medicine's role in healthcare. Facilitators for implementation included the supportive environment of academic institutions and the development of family medicine professional organizations. Barriers to implementation included the lack of government support and awareness of the field by society, and tension with subspecialties. In India, the implementation of family medicine has primarily occurred through pioneering family physicians and supportive educational institutions. For family medicine to continue to grow and have the intended impacts on primary care, government and policymaker support are needed.

Pioneering family physicians and the mechanisms for strengthening primary health care in India-A qualitative descriptive study.

India has one of the most unequal healthcare systems globally, lagging behind its economic development. Improved primary care and primary health care play an integral role in overcoming health disparities. Family medicine is a subset of primary care-delivered by family physicians, characterized by comprehensive, continuous, coordinated, collaborative, personal, family and community-oriented services-and may be able to fill these gaps. This research aims to understand the potential mechanisms by which family physicians can strengthen primary health care. In this qualitative descriptive study, we interviewed twenty family physicians, identified by purposeful and snowball sampling, who are among the first family physicians in India who received accredited certification in FM and were identified as pioneers of family medicine. We used the Contribution of Family Medicine to Strengthening Primary Health Care Framework to understand the potential mechanisms by which family medicine strengthens primary health care. Iterative inductive techniques were used for analysis. This research identifies multiple ways family physicians can strengthen primary health care in India. They are skilled primary care providers and support mid and low-level health care providers' ongoing training and capacity building. They develop relationships with specialists, ensure appropriate referral systems are in place, and, when necessary, work with governments and organizations to access the essential resources needed to deliver care. They motivate the workforce and change how care is delivered by ensuring providers' skills match the needs of communities and engage communities as partners in healthcare delivery. These findings highlight multiple mechanisms by which family physicians strengthen primary health care. Investments in postgraduate training in family medicine and integrating family physicians into the primary care sector, particularly the public sector, could address health disparities.

Building Indian Biomedical Leadership to Bridge the Gap Between Science, Primary Health Care and Public Health.

The Indian biomedical landscape has been characterized by the existence of somewhat polarized institutional structures and professional growth. While some scientific and public health challenges have been met with existing structures, there is still a large unmet scientific and public health need. Broadly, the physical separation of science, engineering, medical campuses and industry has led to silos of excellence and accomplishment with huge gaps in innovation and implementation. The lack of inter-disciplinary educational options has further reinforced the cultural underpinning of "guilds" that have found it difficult to collaborate. Strikingly, with almost a comparable number of institutions that train doctors in the allopathic or traditional disciplines such as Ayurveda, Unani etc., an "integrative medicine" framework has not emerged, apart from an over reliance on specialization at the expense of primary care. This paper is written by two physician-scientists, the first is located in a basic life science research center. The second, a practicing family physician, from the institutional anchor of a life sciences research institution. In this, we trace our experiences, primarily from a principal investigator's perspective, describing the scientific projects and try to explore the lessons learnt along the way. We will first describe the research in the lab's core area of human cervical cancer progression and our more recent effort with Dengue genomics and vaccine design. We then describe the lab's engagement with medical campuses and other agencies as well as review our various meetings and interactions so far with our colleagues from Africa to grasp what might be the "generalizable lessons" for the future. The Indian council of medical research initiated a program with Africa in health sciences. Building upon those interactions, we have taken some incremental steps in that direction and described our efforts.

Building the foundation for universal healthcare: Academic family medicine's ability to train family medicine practitioners to meet the needs of their community across the globe.

BACKGROUND:  The Declaration of Astana marked a revived global interest in investing in primary care as a means to achieve universal healthcare. Family medicine clinicians are uniquely trained to provide high-quality, comprehensive primary care throughout the lifespan. Yet little focus has been placed on understanding the needs of family medicine training programs. AIM:  This study aims to assess broad patterns of strengths and resource challenges faced by academic programs that train family medicine clinicians. METHODS:  An anonymous online survey was sent to family medicine faculty using World Organization of Family Doctors (WONCA) listservs. RESULTS:  Twenty-nine representatives of academic family medicine programs from around the globe answered the survey. Respondents cited funding for the program and/or individual trainees as one of either their greatest resources or greatest limitations. Frequently available resources included quality and quantity of faculty and reliable clinical training sites. Frequently noted limitations included recruitment capacity and social capital. Over half of respondents reported their program had at some point faced a disruption or gap in its ability to recruit or train, most often because of loss of government recognition. Reflecting on these patterns, respondents expressed strong interest in partnerships focusing on faculty development and research collaboration. LESSONS LEARNT:  This study provides a better understanding of the challenges family medicine training programs face and how to contribute to their sustainability and growth, particularly in terms of areas for investment, opportunities for government policy and action and areas of collaboration.

Effect of national cultural dimensions and consumption rates on stigma toward alcohol and substance use disorders.

BACKGROUND: Despite the notion of stigma as a socio-cultural process with the concept rooted in social space rather than in individual space, global studies examining impact of cultural differences on stigma toward substance use disorders are lacking. AIM: In this study, we aim to study the influence of national culture differences on stigma toward alcohol and substance use disorders. METHODS: We analyzed individual-level data from 68,041 respondents from 49 countries on stigma toward alcohol and substance use disorders. We examined the effect of the national culture dimensions and national alcohol and substance consumption rates on stigma toward alcohol and substance use disorders using hierarchical linear modeling. RESULTS: Our hierarchical linear modeling results indicate that cultural dimensions and consumption rates significantly influence stigma. We found significant positive associations between stigma toward AUD and institutional collectivism and assertiveness, but a negative association with future orientation dimension. Like AUD, stigma toward SUD was also positively associated with institutional collectivism and assertiveness, but negatively associated with power distance. CONCLUSIONS: The study findings have immense implications for national interventions to decrease stigma and influence policy making.

Elder care: The need for interprofessional collaboration between Family Physicians, Clinical Pharmacists, and Physiotherapists in home-based primary care teams.

Background: Elderly patients with pain and falls are commonly seen in family practice. Aims: (1) Highlight the role of a physiotherapist in the primary care team; (2) Discuss the collaboration between a family physician clinical pharmacist dyad and the physiotherapist that emerged; and (3) Share practice tools that emerged from our teamwork. Settings and Design: Home Based Primary Care Practice (a core component of family practice). We have described our home based primary care practice model in earlier publications. Our model utilizes a team based approach to address the prevention of diseases, promotion of health, provision of care for acute and chronic conditions (especially concurrent multi morbidity), and delivery of rehabilitation services in the home setting. Methods and Materials: Selection of three cases from our daily practice. Reflective discussion and learning towards arriving at novel insights and improving our care model. Results: Case discussion from the perspectives of the family physician, clinical pharmacist, and physiotherapist reveal important insights on the roles, responsibilities, benefits and tensions. A process flow to facilitate team based care is also outlined along with a referral communication tool. Conclusion: For our population of the elderly with falls and pain, there was a need for a physiotherapist, as part of the team, instead of a mere referral service. This was felt because of the growing needs of patients, multiple gaps in communication with external referrals, mismatch of values and approaches, and missed opportunities for high quality care. This enhances access, optimizes clinical outcomes, delivers patient centred care, reduces unnecessary hospitalizations, and avoids catastrophic and unwarranted costs. The paper highlights the critical need for interprofessional collaboration between family physicians, clinical pharmacists and Physiotherapist in elder care.

The community health impasse: What can family physicians learn about integration of social determinants of health from the challenges, diversity, and worldview of primary healthcare practices located in Southern India?

CONTEXT: As social position rises, health improves. Alma Ata set the stage for community-oriented primary care (COPC), and family medicine is perfectly positioned to integrate Social Determinants of Health. India presents a unique environment for innovations in family medicine. AIMS: This study aimed to (1) assess the ability of different primary care practices to address the social determinants of health (SDoH); (2) identify key obstacles and supports; and (3) provide practical insights to family physicians and other primary care providers (PCPs) for the integration of SDoH and clinical primary care. SETTINGS AND DESIGN: A diverse sample of primary healthcare practices were selected in southern India for investigation. Data collection involved observation and informal interviews. METHODS AND MATERIAL: The researchers used general observation and informal interviews to collect data. Investigators used a basic interview guide to structure conversations and formal journal entries were recorded immediately following each visit. STATISTICAL ANALYSIS USED: Thematic analysis was conducted with NVIVO software to categorize major themes. RESULTS: Seventeen primary healthcare practices were observed; eleven were formally enrolled for interviews. Four inputs and three outputs of socially oriented primary care practices were identified. The inputs include leadership style, appropriate staffing, funding structures, and patient panels. Social interventions, community contact, and treasuring community empowerment were the major outputs. CONCLUSIONS: Community health lies at the heart of strengthening primary healthcare. Establishing practices that bridge the gap between clinical primary care and SDoH initiatives need to be prioritized. This study fosters agency for family physicians and PCPs to engage with local communities and lead the path toward this integration.

Managing mental health problems in a family and community setting: Reflections on the family physician approach and Re-imagining psychiatric education.

Family Medicine is unique in that it recognizes the central role of the patient's context and the interplay of family dynamics, social relationships, cultural background, and economics in the causation and presentation of any illness and the response to any given treatment. While this is true across the board, it is particularly true of mental health.[3] In this article, using a selection of stories from our daily practices as family physicians, we: (1) reflect on the role of family physicians in addressing mental health needs in the community; (2) contrast between a disease-oriented (specialist approach) and a person-oriented (family physician approach); and (3) suggest a course correction to the existing model of mental health education for both generalists (such a family physicians) and specialists (such as psychiatrists). We conclude that Family Physicians have an extremely important role to play in the promotion of mental well-being and the management of mental illness in the community. Additionally, we highlight several unique facets of the family physician approach that tends to be less disease oriented and more patient-centric. Lastly, we suggest the need for mental health training to occur in the family practice context in the community. Mandatory representation of practicing family physicians on the National Medical Commission (NMC) will facilitate the above.

Antimicrobial resistance (AMR) at the community level: An urban and rural case study from Karnataka.

CONTEXT: The emergence of antimicrobial resistance (AMR) is a major public health crisis in India and globally. While national guidelines exist, the sources of data which form the basis of these guidelines are limited to a few well-established tertiary care centres. There is inadequate literature on AMR and antibiotic mismatch from India at community level and even less literature on AMR patterns from rural India. AIMS: The aims of this study were as follows: 1) to describe the patterns of AMR at an urban tertiary care hospital and a rural 100 bedded hospital; 2) to compare and contrast the AMR patterns noted with published ICMR guidelines; 3) to examine the issue of AMR and antibiotic mismatch; and 4) to identify local factors influencing drug-bug mismatch at the local level. SETTINGS AND DESIGN: The data were obtained from two independently conceived projects (Site 1: Urban tertiary care hospital, Site 2: Rural 100-bedded hospital). METHODS AND MATERIALS: Local antibiograms were made, and the antibiotic resistance patterns were compared between the urban and rural sites and with data published in the 2017 ICMR national guideline for AMR. STATISTICAL ANALYSIS USED: Descriptive statistics including means and medians were used. RESULTS: Our data reveal: a) a significant mismatch between sensitivity patterns and antibiotics prescribed; b) The national guidelines fail to capture the local picture of AMR, highlighting the need for local data; and c) challenges with data collection/retrieval, access and accuracy of diagnostic tools, administrative issues, and lack of local expertise limit antimicrobial stewardship efforts. CONCLUSIONS: Our study finds the burden of AMR high in both rural and urban sites, reinforcing that AMR burden cannot be ignored in rural settings. It also highlights that national data obtained from tertiary care settings fail to capture the local picture, highlighting the need for local data. Mechanisms of linking rural practices, primary health centres, and small hospitals with a common microbiology laboratory and shared data platforms will facilitate antibiotic stewardship at the community level.

What influences adherence among HIV patients presenting with first-line antiretroviral therapy failure (ART failure)? A retrospective, cross-sectional study from a private clinic in Nagpur, India.

BACKGROUND: Multiple reports show increasing occurrences of ART failure in India. Despite the fact that a significant volume of outpatient and on-going healthcare occurs in private clinics, there are very few studies on adherence from private clinics in India. OBJECTIVE: To evaluate the factors influencing adherence to ART in patients with first-line ART failure. MATERIALS AND METHODS: Data were collected from a convenience sample of 139 individuals diagnosed with clinical, immunological or virologic failure from a private HIV clinic in Nagpur, India. A retrospective cross-sectional study was undertaken and data were statistically analysed. RESULTS: Of the 139 patients, 118 (84.9%) were male and 21 (15.1%) were female. 64 (46%) had received pre-treatment and adherence counselling. 81 (58.3%) were not told about the side effects of ART medications and 65 (46.8%) avoided friends and family. Most common reasons for suboptimal adherence by stopping treatment were high cost, alcoholism, choosing non-allopathic medications and depression. Reasons cited for suboptimal adherence due to missed doses included feeling healthy, depression, forgetfulness and busy schedule. A significant association was found between pre-treatment counselling, adherence counselling and being told the importance of lifelong treatment and decreased occurrence of complete stoppage of treatment. CONCLUSION: This study brings to light some of the predictors of ART failure. Counselling, having a strong support system as well as early identification and tackling of reasons for suboptimal adherence plays an important role in preventing ART failure.

Low sensitivity of rapid diagnostic test for influenza.

The QuickVue Influenza A+B Test (Quidel) was used to test nasal swab specimens obtained from persons with influenza-like illness in 3 different populations. Compared with reverse-transcriptase polymerase chain reaction, the test sensitivity was low for all populations (median, 27%; range, 19%-32%), whereas the specificity was high (median, 97%; range, 96%-99.6%).

Does this HIV-positive patient have progressive multifocal leukoencephalopathy or PML-immune reconstitution inflammatory syndrome?

We describe the case of an HIV/AIDS patient with progressive multifocal leukoencephalopathy (PML) associated with immune reconstitution inflammatory syndrome (IRIS) and the diagnostic and management dilemmas in distinguishing between PML and PML-IRIS. This case is relevant to physicians including family physicians who manage immunocompromised patients in their practice.

Reasons for obstetric referrals from community facilities to a tertiary obstetric facility: A study from Southern Karnataka.

CONTEXT: Pregnancy-related preventable morbidity and mortality remain high in India. Safe delivery services should focus on improving neonatal and maternal outcomes while also enabling a positive childbirth experience. However, high rates of intrapartum obstetric referrals are common. OBJECTIVE: To describe the timing and the reasons for obstetric referrals to a public tertiary care hospital in Bangalore and characteristics of the referring facilities. METHODS: We interviewed 320 women who delivered at the tertiary care hospital within a one-month time frame prior to the interview and who originally planned to deliver elsewhere. RESULTS: Ninety four percent of women in the study reported that the decision to transfer to the tertiary hospital was made after the onset of labour. Referrals were made for medical as well as non-medical reasons. About a third (35%) had to take loans to cover the expenses of childbirth. CONCLUSIONS: Referrals frequently occurred after the onset of labour. Our data imply that improving obstetric referral protocols will improve the birth experience and reduce the burden on tertiary care facilities and on the women themselves.

Managing a case of acute calculous cholecystitis at home: Highlighting the role of family physicians in providing home-based care.

Laparoscopic cholecystectomy is the generally recommended management of acute calculous cholecystitis. It is important for family physicians to be taken into consideration that for some patients the surgical risk-benefit profile favors conservative management. Here, we highlight the possibility of safe, home-based, conservative management of acute calculous cholecystitis in a patient-centered and evidence-based manner by a team of family physicians with backup support of their specialist referral network. We use this case to highlight the value of family physicians providing home-based care.