'IHPBA-APHPBA clinical practice guidelines': international Delphi consensus recommendations for gallbladder cancer.

BACKGROUND: The Delphi consensus study was carried out under the auspices of the International and Asia-Pacific Hepato-Pancreato-Biliary Associations (IHPBA-APHPBA) to develop practice guidelines for management of gallbladder cancer (GBC) globally. METHOD: GBC experts from 17 countries, spanning 6 continents, participated in a hybrid four-round Delphi consensus development process. The methodology involved email, online consultations, and in-person discussions. Sixty eight clinical questions (CQs) covering various domains related to GBC, were administered to the experts. A consensus recommendation was accepted only when endorsed by more than 75% of the participating experts. RESULTS: Out of the sixty experts invited initially to participate in the consensus process 45 (75%) responded to the invitation. The consensus was achieved in 92.6% (63/68) of the CQs. Consensus covers epidemiological aspects of GBC, early, incidental and advanced GBC management, definitions for radical GBC resections, the extent of liver resection, lymph node dissection, and definitions of borderline resectable and locally advanced GBC. CONCLUSIONS: This is the first international Delphi consensus on GBC. These recommendations provide uniform terminology and practical clinical guidelines on the current management of GBC. Unresolved contentious issues like borderline resectable/locally advanced GBC need to be addressed by future clinical studies.

Disabled People's Organisations increase access to services and improve well-being: evidence from a cluster randomized trial in North India.

BACKGROUND: Disabled People's Organisations (DPOs) are the mainstay of disability responses worldwide. Yet there is no quantitative data assessing their effectiveness in low-and middle-income countries (LMICs). The aim of this study was to measure the effectiveness of DPOs as a low-cost intervention to improve well-being and access to services and facilities for people with disabilities. METHODS: We undertook a cluster randomised intervention control trial across 39 distinct rural villages in Uttarakhand State, North India. A total of 527 participants were included from 39 villages: 302 people from 20 villages were assigned to the intervention arm and 225 from 19 villages were assigned to the control group. Over a 2-year period, people with disabilities were facilitated to form DPOs with regular home visits. Participants were also given financial support for public events and exposure visits to other DPOs. Seven domains were used to measure access and participation. RESULTS: DPO formation had improved participation in community consultations (OR 2.57, 95% CI 1.4 to 4.72), social activities (OR 2.46, 95% CI 1.38 to 4.38), DPOs (OR 14.78, 95% CI 1.43 to 152.43), access to toilet facilities (OR 3.89, 95% CI 1.31 to 11.57), rehabilitation (OR 6.83, 95% CI 2.4 to 19.42) and Government social welfare services (OR 4.82, 95% CI 2.35 to 9.91) in intervention when compared to the control. People who were part of a DPO had an improvement in having their opinion heard (OR 1.94, 95% CI 1.16 to 3.24) and being able to make friends (OR 1.63, 95% CI 1 to 2.65) compared to those who were not part of a DPO. All other well-being variables had little evidence despite greater improvement in the DPO intervention group. CONCLUSIONS: This is the first randomised control trial to demonstrate that DPOs in LMICs are effective at improving participation, access and well-being. This study supports the ongoing role of DPOs in activities related to disability inclusion and disability services. This study also suggests that supporting the establishment, facilitation and strengthening of DPOs is a cost-effective intervention and role that non-governmental organisations (NGOs) can play. TRIAL REGISTRATION: ISRCTN36867362, 9th Oct 2019 (retrospectively registered).

Process of adaptation, development and assessment of acceptability of a health educational intervention to improve referral uptake by people with diabetes in Sri Lanka.

BACKGROUND: One major barrier to uptake of diabetic retinopathy (DR) services is lack of knowledge and awareness of DR among the people with diabetes (PwDM). Targeted health education (HE) can be a key element in improving the uptake of eye care services. Such interventions are lacking in Sri Lanka. METHODS: A local context specific HE intervention (HEI) was developed by adopting available resources and incorporating views from PwDM and key stakeholders. Four sessions of participatory workshops with PwDM (20 Sinhala and 13 Tamil speaking) and two stage 12 stakeholder interviews were conducted to both develop and pre-test the material. The products were a video and a leaflet, delivered at a medical clinic to a sample of 45 PwDM identified as having DR. Semi-structured interviews were conducted after 4 weeks, to evaluate the acceptability and comprehension of the HEI. Additionally, nine interviews were conducted with clinical providers to explore process issues related to delivery of the HEI. Data analysis was conducted using thematic analysis. RESULTS: The lack of knowledge and awareness on DR, and of the importance of regular DR screening and follow up, combined with poor information on referral pathways were key elements identified from the workshops with PwDM. The stakeholders prioritised the importance of using simple language, and the need for emphasis on improving understanding about the asymptomatic phase of DR. The overall acceptability of the HEI material was satisfactory, although there was some difficulty with interpretation of medical images. Overall, although PwDM liked the ideas of the video, the leaflet was seen as a more practical option, given the busy clinic environment. The key issue was both formats required interaction with the provider, in order to support understanding of the messages. CONCLUSIONS: The process of adapting HE material is not simply translation into the appropriate language. Instead, a tailored approach in a country, context and particular health services setting is needed. This study illustrates the value of using a participatory approach and involving PwDM and stakeholders in the adaptation and pilot testing of a HEI to improve uptake of screening for DR in the context of Sri Lanka.

Management and referral for high-risk conditions and complications during the antenatal period: knowledge, practice and attitude survey of providers in rural public healthcare in two states of India.

BACKGROUND: Appropriate antenatal care improves pregnancy outcomes. Routine antenatal care is provided at primary care facilities in rural India and women at-risk of poor outcomes are referred to advanced centres in cities. The primary care facilities include Sub-health centres, Primary health centres, and Community health centres, in ascending order of level of obstetric care provided. The latter two should provide basic and comprehensive obstetric care, respectively, but they provide only partial services. In such scenario, the management and referrals during pregnancy are less understood. This study assessed rural providers' perspectives on management and referrals of antenatal women with high obstetric risk, or with complications. METHODS: We surveyed 147 health care providers in primary level public health care from poor and better performing districts from two states. We assessed their knowledge, attitudes and practices regarding obstetric care, referral decisions and pre-referral treatments provided for commonly occurring obstetric high-risk conditions and complications. RESULTS: Staff had sub-optimal knowledge of, and practices for, screening common high-risk conditions and assessing complications in pregnancy. Only 31% (47/147) mentioned screening for at least 10 of the 16 common high-risk conditions and early complications of pregnancy. Only 35% (17/49) of the staff at Primary health centres, and 51% (18/35) at Community health centres, mentioned that they managed these conditions and, the remaining staff referred most of such cases early in pregnancy. The staff mentioned inability to manage childbirth of women with high-risk conditions and complications. Thus in absence of efficient referral systems and communication, it was better for these women to receive antenatal care at the advanced centres (often far) where they should deliver. There were large gaps in knowledge of emergency treatment for obstetric complications in pregnancy and pre-referral first-aid. Staff generally were low on confidence and did not have adequate resources. Nurses had limited roles in decision making. Staff desired skill building, mentoring, moral support, and motivation from senior officers. CONCLUSION: The Indian health system should improve the provision of obstetric care by standardising services at each level of health care and increasing the focus on emergency treatment for complications, appropriate decision-making for referral, and improving referral communication and staff support.

Neurodevelopmental disorders in children aged 2-9 years: Population-based burden estimates across five regions in India.

BACKGROUND: Neurodevelopmental disorders (NDDs) compromise the development and attainment of full social and economic potential at individual, family, community, and country levels. Paucity of data on NDDs slows down policy and programmatic action in most developing countries despite perceived high burden. METHODS AND FINDINGS: We assessed 3,964 children (with almost equal number of boys and girls distributed in 2-<6 and 6-9 year age categories) identified from five geographically diverse populations in India using cluster sampling technique (probability proportionate to population size). These were from the North-Central, i.e., Palwal (N = 998; all rural, 16.4% non-Hindu, 25.3% from scheduled caste/tribe [SC-ST] [these are considered underserved communities who are eligible for affirmative action]); North, i.e., Kangra (N = 997; 91.6% rural, 3.7% non-Hindu, 25.3% SC-ST); East, i.e., Dhenkanal (N = 981; 89.8% rural, 1.2% non-Hindu, 38.0% SC-ST); South, i.e., Hyderabad (N = 495; all urban, 25.7% non-Hindu, 27.3% SC-ST) and West, i.e., North Goa (N = 493; 68.0% rural, 11.4% non-Hindu, 18.5% SC-ST). All children were assessed for vision impairment (VI), epilepsy (Epi), neuromotor impairments including cerebral palsy (NMI-CP), hearing impairment (HI), speech and language disorders, autism spectrum disorders (ASDs), and intellectual disability (ID). Furthermore, 6-9-year-old children were also assessed for attention deficit hyperactivity disorder (ADHD) and learning disorders (LDs). We standardized sample characteristics as per Census of India 2011 to arrive at district level and all-sites-pooled estimates. Site-specific prevalence of any of seven NDDs in 2-<6 year olds ranged from 2.9% (95% CI 1.6-5.5) to 18.7% (95% CI 14.7-23.6), and for any of nine NDDs in the 6-9-year-old children, from 6.5% (95% CI 4.6-9.1) to 18.5% (95% CI 15.3-22.3). Two or more NDDs were present in 0.4% (95% CI 0.1-1.7) to 4.3% (95% CI 2.2-8.2) in the younger age category and 0.7% (95% CI 0.2-2.0) to 5.3% (95% CI 3.3-8.2) in the older age category. All-site-pooled estimates for NDDs were 9.2% (95% CI 7.5-11.2) and 13.6% (95% CI 11.3-16.2) in children of 2-<6 and 6-9 year age categories, respectively, without significant difference according to gender, rural/urban residence, or religion; almost one-fifth of these children had more than one NDD. The pooled estimates for prevalence increased by up to three percentage points when these were adjusted for national rates of stunting or low birth weight (LBW). HI, ID, speech and language disorders, Epi, and LDs were the common NDDs across sites. Upon risk modelling, noninstitutional delivery, history of perinatal asphyxia, neonatal illness, postnatal neurological/brain infections, stunting, LBW/prematurity, and older age category (6-9 year) were significantly associated with NDDs. The study sample was underrepresentative of stunting and LBW and had a 15.6% refusal. These factors could be contributing to underestimation of the true NDD burden in our population. CONCLUSIONS: The study identifies NDDs in children aged 2-9 years as a significant public health burden for India. HI was higher than and ASD prevalence comparable to the published global literature. Most risk factors of NDDs were modifiable and amenable to public health interventions.

At the margins of biomedicine: the ambiguous position of 'Registered Medical Practitioners' in rural Indian healthcare.

This analysis challenges a tendency in public health and the social sciences to associate India's medical pluralism with a distinction between biomedicine, as a homogeneous entity, and its non-biomedical 'others'. We argue that this overdrawn dichotomy obscures the important part played by 'informal' biomedical practice, an issue with salience well beyond India. Based on a qualitative study in rural Andhra Pradesh, South India, we focus on a figure little discussed in the academic literature - the Registered Medical Practitioner (RMP) - who occupies a niche in the medical market-place as an informal exponent of biomedical treatment. We explore the significance of these practitioners by tracking diagnosis and treatment of one increasingly prominent medical 'condition', namely diabetes. The RMP, who despite the title is rarely registered, sheds light on the supposed formal-informal sector divide in India's healthcare system, and its permeability in practice. We develop our analysis by contrasting two distinctive conceptualisations of 'informality' in relation to the state in India - one Sarah Pinto's, the other Ananya Roy's.

mHealth and the management of chronic conditions in rural areas: a note of caution from southern India.

This article examines challenges facing implementation of likely mHealth programmes in rural India. Based on fieldwork in Andhra Pradesh in 2014, and taking as exemplars two chronic medical 'conditions' - type 2 diabetes and depression - we look at ways in which people in one rural area currently access medical treatment; we also explore how adults there currently use mobile phones in daily life, to gauge the realistic likelihood of uptake for possible mHealth initiatives. We identify the very different pathways to care for these two medical conditions, and we highlight the importance to the rural population of healthcare outside the formal health system provided by those known as registered medical practitioners (RMP), who despite their title are neither registered nor trained. We also show how limited is the use currently made of very basic mobile phones by the majority of the older adult population in this rural context. Not only may this inhibit mHealth potential in the near future; just as importantly, our data suggest how difficult it may be to identify a clinical partner for patients or their carers for any mHealth application designed to assist the management of chronic ill-health in rural India. Finally, we examine how the promotion of patient 'self-management' may not be as readily translated to a country like India as proponents of mHealth might assume.

Transport of pregnant women and obstetric emergencies in India: an analysis of the '108' ambulance service system data.

BACKGROUND: The transport of pregnant women to an appropriate health facility plays a pivotal role in preventing maternal deaths. In India, state-run call-centre based ambulance systems ('108' and '102'), along with district-level Janani Express and local community-based innovations, provide transport services for pregnant women. We studied the role of '108' ambulance services in transporting pregnant women routinely and obstetric emergencies in India. METHODS: This study was an analysis of '108' ambulance call-centre data from six states for the year 2013-14. We estimated the number of expected pregnancies and obstetric complications for each state and calculated the proportions of these transported using '108'. The characteristics of the pregnant women transported, their obstetric complications, and the distance and travel-time for journeys made, are described for each state. RESULTS: The estimated proportion of pregnant women transported by '108' ambulance services ranged from 9.0 % in Chhattisgarh to 20.5 % in Himachal Pradesh. The '108' service transported an estimated 12.7 % of obstetric emergencies in Himachal Pradesh, 7.2 % in Gujarat and less than 3.5 % in other states. Women who used the service were more likely to be from rural backgrounds and from lower socio-economic strata of the population. Across states, the ambulance journeys traversed less than 10-11 km to reach 50 % of obstetric emergencies and less than 10-21 km to reach hospitals from the pick-up site. The overall time from the call to reaching the hospital was less than 2 h for 89 % to 98 % of obstetric emergencies in 5 states, although this percentage was 61 % in Himachal Pradesh. Inter-facility transfers ranged between 2.4 % -11.3 % of all '108' transports. CONCLUSION: A small proportion of pregnant women and obstetric emergencies made use of '108' services. Community-based studies are required to study knowledge and preferences, and to assess the potential for increasing or rationalising the use of '108' services.

Road traffic injuries to children during the school commute in Hyderabad, India: cross-sectional survey.

BACKGROUND: India is motorising rapidly. With increasing motorisation, road traffic injuries are predicted to increase. A third of a billion children travel to school every day in India, but little is known about children's safety during the school commute. We investigated road traffic injury to children during school journeys. METHODS: We conducted a cross-sectional survey in Hyderabad using a two-stage stratified cluster sampling design. We used school travel questionnaires to record any road injury in the past 12 months that resulted in at least 1 day of school missed or required treatment by a doctor or nurse. We estimated the prevalence of road injury by usual mode of travel and distance to school. RESULTS: The total sample was 5842 children, of whom 5789 (99.1%) children answered the question on road injury. The overall prevalence of self-reported road injury in the last 12 months during school journeys was 17% (95% CI 12.9% to 21.7%). A higher proportion of boys (25%) reported a road injury than girls (11%). There was a strong association between road injury, travel mode and distance to school. Children who cycled to school were more likely to be injured compared with children who walked (OR 1.5; 95% CI 1.2 to 2.0). Travel by school bus was safer than walking (OR 0.5; 95% CI 0.3 to 0.9). CONCLUSIONS: A sixth of the children reported a road traffic injury in the past 12 months during school journeys in Hyderabad. Injury prevention interventions should focus on making walking and cycling safer for children.

Development and validation of a self-administered questionnaire to estimate the distance and mode of children's travel to school in urban India.

BACKGROUND: Although some 300 million Indian children travel to school every day, little is known about how they get there. This information is important for transport planners and public health authorities. This paper presents the development of a self-administered questionnaire and examines its reliability and validity in estimating distance and mode of travel to school in a low resource urban setting. METHODS: We developed a questionnaire on children's travel to school. We assessed test re-test reliability by repeating the questionnaire one week later (n = 61). The questionnaire was improved and re-tested (n = 68). We examined the convergent validity of distance estimates by comparing estimates based on the nearest landmark to children's homes with a 'gold standard' based on one-to-one interviews with children using detailed maps (n = 50). RESULTS: Most questions showed fair to almost perfect agreement. Questions on usual mode of travel (κ 0.73- 0.84) and road injury (κ 0.61- 0.72) were found to be more reliable than those on parental permissions (κ 0.18- 0.30), perception of safety (κ 0.00- 0.54), and physical activity (κ -0.01- 0.07). The distance estimated by the nearest landmark method was not significantly different than the in-depth method for walking , 52 m [95 % CI -32 m to 135 m], 10 % of the mean difference, and for walking and cycling combined, 65 m [95 % CI -30 m to 159 m], 11 % of the mean difference. For children who used motorized transport (excluding private school bus), the nearest landmark method under-estimated distance by an average of 325 metres [95 % CI -664 m to 1314 m], 15 % of the mean difference. CONCLUSIONS: A self-administered questionnaire was found to provide reliable information on the usual mode of travel to school, and road injury, in a small sample of children in Hyderabad, India. The 'nearest landmark' method can be applied in similar low-resource settings, for a reasonably accurate estimate of the distance from a child's home to school.

Psychological well-being of parents and family caregivers of children with hearing impairment in south India: influence of behavioural problems in children and social support.

Parents of children with hearing impairment are at increased risk of mental health morbidities. We examined the predictive factors associated with caregiver's strain and psychological morbidities in parents and family caregivers of children with hearing impairment. In total, n = 201 parents and family caregivers of children with and without hearing impairment aged 3 to 16 years were recruited. Caregiver's strain and psychological morbidities were measured using the Zarit Burden scale and the World Health Organization's Self-Reporting Questionnaire (SRQ-20). Presence of behavioural problems in children was measured using the Strengths and Difficulties Questionnaire. After adjustment, low educational attainment and domestic violence were found to be associated with caregiving strain, whereas dissatisfaction with social support from family, behavioural problems in children, and domestic violence strongly predicted psychological morbidities. Addressing the mental healthcare needs of parents may help in downsizing the impact of psychological morbidities on the well-being of children with hearing impairment.

Undesirable Levels of Practice Behaviours and Associated Knowledge amongst Community Health Workers in Rural South India Responsible for Type 2 Diabetes Screening and Management.

BACKGROUND: Type 2 diabetes (T2DM) poses an enormous global health care challenge, especially among rural communities. Healthcare in these areas can be inadequate and inaccessible due to socio-demographic barriers. To overcome this situation, many low- and middle-income countries are resorting to task shifting, using community health workers (CHWs) for diabetes management. However, its successful implementation depends on the practice behaviours and knowledge of these workers. OBJECTIVE: This cross-sectional study aimed to evaluate the proficiency of CHWs involved in diabetes screening and management in rural South India by identifying the existing practice behaviours and knowledge gaps. METHODS: Employing a customised questionnaire, developed through inputs from experts and government officials, we assessed practice behaviours and the corresponding knowledge base of 275 CHWs. Analytical methodologies consisted of descriptive statistics, logistic regression, and mosaic plots for comprehensive data interpretation. RESULTS: The study showcased significant deficiencies in both practice behaviours (97%) and knowledge (95%) with current mean levels ranging from 48 to 50%, respectively, among the participants. The identified areas of insufficiency were broadly representative of the core competencies required for effective diabetes management, encompassing diabetes diagnosis and referral, HbA1c testing, diabetes diet, diabetes type and self-management, microvascular complications and their screening, peripheral neuropathy management, and diabetes risk assessment. In several areas, correct practice behaviour was reported by a relatively large number of CHWs despite incorrect answers to the related knowledge questions such as referral to the health centres, self-management, and calculation of diabetes risk assessment. CONCLUSION: This study highlights widespread deficiencies (97% CHWs) in diabetes management practices and knowledge (95% CHWs). To overcome these deficiencies, a thorough needs assessments is vital for effective CHW training. Training of CHWs should not only identify prior knowledge and/or behaviour but also their interrelationship to help create a robust and flexible set of practice behaviours.

Training of Community Health Workers in Diabetes Lead to Improved Outcomes for Diabetes Screening and Management in Low- and Middle-Income Countries: Protocol for a Systematic Review.

BACKGROUND: Diabetes is a growing concern worldwide, particularly in low- and middle-income countries (LMICs). Type 2 diabetes mellitus constitutes a significant proportion of cases and is associated with debilitating microvascular complications. Type 2 diabetes mellitus is steadily increasing among the LMICs where many barriers to health care exist. Thus, task shifting to community health workers (CHWs) has been proposed as a solution to improve diabetes management in these settings. However, CHWs often lack the necessary training to manage diabetes effectively. Thus, a systematic review is required to present evidence of the highest degree for this intervention. OBJECTIVE: This study aims to establish the protocols for a systemic review. METHODS: Using the Participants Intervention Comparator Outcome Time Study Design (PICOTS) framework, this study outlines a systematic review aiming to evaluate the impact of training programs for CHWs in diabetes management in LMICs. Quantitative studies focusing on CHWs, diabetes training, focusing on diabetes management outcomes like hemoglobin A1c levels and fasting blood glucose levels, between January 2000 and December 2023 and found on databases such as PubMed, Ovid MEDLINE, Evidence Based Medicine Reviews, BASE, Google Scholar, and Web of Science will be included. We will include randomized controlled trials but will also include observational studies if we find less than 5 randomized controlled trials. An author committee consisting of 3 reviewers will be formed, where 2 reviewers will conduct the review independently while the third will resolve all disputes. The Cochrane Methods Risk of Bias Tool 2 will be used for assessing the risk of bias and the Grading of Recommendations, Assessment, Development and Evaluation approach for the meta-analysis and narrative synthesis analysis will be used. The results will be presented in a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram. RESULTS: The review will begin in May 2024 and conclude in 3 months. CONCLUSIONS: The review will synthesize existing evidence and provide insights into the effectiveness of such programs, informing future research and practice in diabetes care in LMICs. TRIAL REGISTRATION: PROSPERO CRD42022341717; https://tinyurl.com/jva2hpdr. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/57313.

Projected cancer burden, challenges, and barriers to cancer prevention and control activities in the state of Telangana.

BACKGROUND AND AIM: The Telangana cancer care program is a proactive, comprehensive initiative encompassing infrastructure development, human resource skilling and ensuring financial protection to those below poverty line. The broad aim of this exercise was to identify modalities to augment the Telangana State Cancer Control Plan to implement a sustainable comprehensive cancer care model for Telangana. METHODS: We conducted in-depth interviews of stakeholders (17 patients and 25 health care providers) to identify barriers and challenges to access existing cancer care system in Telangana; calculated the magnitude of cancer and commensurate workload (in terms of visits to tertiary cancer care system for cancer management and human and equipment requirement) for the next 15 years (from 2022 to 2037). Using the anecdotal evidence and information from stakeholders' interviews, we developed patient-journey funnels for oral, breast, and cervical cancer patients to highlight patient leakages at various levels of cancer care. RESULTS: We estimated a 13%, 28%, and 44.7% increase in the number of new cancer cases and the resultant workload (number of visits to health care centre, chemotherapy sessions, radiotherapy sessions, surgeries, specialized human resources and equipment), for the year 2027, 2032, and 2037, respectively, compared to the year 2022. The stakeholders mentioned 'delayed access' to healthcare system as the main reason for the poor prognosis of patients. The common reasons cited for 'delayed access' were: poor cancer-literacy including prevailing myths and misconception, financial barriers, and rural residence. The patient journey funnel for cancer care revealed a major leakage from 'screened-positive' to 'diagnosis confirmation' step. The estimated patient leakage varied from ~70% to 90% from 'screened-positive' till 'treatment completion'. CONCLUSION: In this study, we anticipated a steady increase in the number of new cancers cases and resultant workload for the state of Telangana from the year 2022 to 2037. This may further be accompanied with limited access or utilization of cancer care system. To manage this public health issue, government should take appropriate measures to improve cancer literacy at the community level as well as increase human resources and necessary equipment.

What cut-off(s) to use with the Washington Group short set of questions?

The Washington Group short set (WG-SS) questions are increasingly integrated into national household surveys, censuses, and international survey programs. They enable the monitoring of disability rights and the production of internationally comparable statistics. Disability statistics on prevalence and inequalities can be estimated using different cut-offs on the degree of functional difficulties based on the WG-SS. This commentary discusses what cut-offs to adopt for the purpose of investigating and monitoring disability gaps. We recommend a three-way disaggregation comparing persons with (a) no difficulty, (b) some difficulty and (c) a lot of difficulty or unable to do. In cases where sample sizes are small for disaggregated analysis, we recommend comparing persons with no difficulty to persons with any level of difficulty (i.e. persons with any disability).

Barriers to cataract surgery of persons screened at camps in Ibadan, Nigeria.

PURPOSE: To determine barriers to uptake of cataract surgery by outreach patients at the University College Hospital, Ibadan and to make appropriate recommendations for improved cataract surgery uptake METHODS: Consenting cataract blind/visually impaired (presenting vision < 6/18) outreach patients identified from the outreach patient register of the University College Hospital, (UCH) Ibadan during a five months period (January to May 2009) were followed up for a visit in late June and July 2009. A semi-structured questionnaire schedule was used for data collection. People who did not use the services were administered a barriers questionnaire-schedule while those who accepted the services were administered a questionnaire schedule to elicit motivating factors for acceptance of services. Subjects were also examined using standard ophthalmic equipment (pen torch, ETDRS vision charts and ophthalmoscope) and information obtained recorded in a data entry form. RESULTS: A total of 186 subjects comprising 115 who had undergone cataract surgery and 71 who were yet to access cataract surgery services were followed up and included in the study. Reason for accessing surgery included awareness of quality service 63 (57.0%), was referred 32(29.0%) and pressure from family or friends 13(12.0%). Barriers to access included, untreated medical problems 21 (29.0%), not able to afford total (direct and indirect) cost of treatment 15 (21.0%), cataract not mature 10 (14.0%), not able to afford cost of surgery 9 (13.0%) and Dr's appointment 8 (11.0%). CONCLUSION: barriers to surgery uptake by outreach camp patients include cost of services, underlying medical problems and preferred doctors' practice. Adoption and scaling up of health insurance to cover those most in need as well as a change in preferred practice amongst eye care practitioners are possible areas for intervention.

Cohort profile: maternal antecedents of adiposity and studying the transgenerational role of hyperglycaemia and insulin (MAASTHI).

PURPOSE: The Maternal Antecedents of Adiposity and Studying the transgenerational role of Hyperglycaemia and Insulin cohort in Bengaluru, South India, aims to understand the transgenerational role of increased circulating glucose levels or hyperglycaemia and other nutrients and psychosocial environment, on the risk of childhood obesity, as an early marker of chronic diseases. PARTICIPANTS: Through this paper, we describe the baseline characteristics of the cohort participants and their children, along with plans and challenges. A total of 5694 pregnant women were screened, with 4862 (85.4%) eligible pregnant women recruited at baseline. We assessed anthropometry, Haemoglobin status, Oral Glucose Tolerance Test (OGTT), dietary practices, depressive symptoms using the Edinburgh Postnatal Depression Scale and social support in all women. Follow-up visits involved assessing anthropometry and the health profile of mothers and children. FINDINGS TO DATE: Among 4862 eligible participants recruited, 3260 (67%) underwent OGTT, while 2962 participants completed OGTT (90.9%). During the pregnancy, 9.7% of women were obese (>90th percentile of skinfold thickness), and 14.3% had gestational diabetesmellitus. Moreover, 6.2% and 16.8% of women had symptoms suggestive of depression during pregnancy and the immediate postnatal period, respectively. We found that 3.3% of children were small for gestational age, 10.8% were large for gestational age and 9.7% of children were obese at birth. FUTURE PLANS: We have completed recruitment and baseline data collection in 2019, and are conducting annual follow-ups until age 4 of the participant's children. For delineating causal pathways of childhood obesity, blood aliquots are stored in the biorepository. The study will inform policy formulation and community awareness in the prevention and control of non-communicable diseases and health promotion.

Evaluation of the Impact of the First Wave of COVID-19 and Associated Lockdown Restrictions on Persons with Disabilities in 14 States of India.

BACKGROUND: There is a paucity of data to assess the impact of the COVID-19 pandemic on persons with disabilities (PwDs) in India. About 27.4 million cases were reported as of 27 May 2021. The continuing pandemic in the form of subsequent waves is expected to have negative repercussions for the disabled globally, particularly in India, where access to health, rehabilitation, and social care services is very limited. Therefore, this study aimed to assess the impact of the COVID-19 pandemic and lockdown restrictions on PwDs in India. OBJECTIVE: To determine the level of disruption due to COVID-19 and the associated countrywide lockdown restrictions on PwD in India during the first wave. METHODS: Using a cross-sectional, mixed-methods approach, data were collected from a representative sample of 403 persons with disabilities in 14 states in India during the COVID-19 first wave at two different points in time (Lockdown and post-lockdown phase). Factors associated with the negative impact were examined using the Chi-square test for associations. The paired comparisons between 'lockdown' with the 'post-lockdown' phase are presented using McNemar's test and the marginal homogeneity test to compare the proportions. Additionally, a subsample of the participants in the survey was identified to participate in in-depth interviews and focus group discussions to gain in-depth insights on the study question and substantiate the quantitative findings. The framework approach was used to conduct a thematic analysis of the qualitative data. RESULTS: About 60% of the PwDs found it difficult to access emergency medical services during the lockdown, and 4.6% post lockdown (p < 0.001). Likewise, 12% found it difficult to access rehabilitation services during the lockdown, and 5% post lockdown (p = 0.03). About 76% of respondents were apprehensive of the risk of infection during the lockdown, and this increased to 92% post lockdown (p < 0.001). Parents with children were significantly impacted due to lockdown in the areas of Medical (p = 0.007), Rehabilitation (p = 0.001), and Mental health services (p = 0.001). The results from the qualitative study supported these quantitative findings. PWDs felt that the lockdown restrictions had negatively impacted their productivity, social participation, and overall engagement in everyday activities. Access to medicines and rehabilitation services was felt to be extremely difficult and detrimental to the therapeutic benefits that were gained by them during the pre-pandemic time. None of the pandemic mitigation plans and services was specific or inclusive of PWDs. CONCLUSIONS: COVID-19 and the associated lockdown restrictions have negatively impacted persons with disabilities during the first wave in India. It is critical to mainstream disability within the agenda for health and development with pragmatic, context-specific strategies and programs in the country.

The association of sun exposure, ultraviolet radiation effects and other risk factors for pterygium (the SURE RISK for pterygium study) in geographically diverse adult (≥40 years) rural populations of India -3rd report of the ICMR-EYE SEE study group.

PURPOSE: To determine the prevalence and risk factors for pterygium in geographically diverse regions of India. METHODS: A population-based, cross-sectional multicentric study was conducted in adults aged ≥40 years in plains, hilly and coastal regions of India. All participants underwent a detailed questionnaire-based assessment for sun exposure, usage of sun protective measures, exposure to indoor smoke, and smoking. Detailed ocular and systemic examinations were performed. Pterygium was diagnosed and graded clinically by slit-lamp examination. Association of pterygium with sociodemographic, ophthalmological, and systemic parameters was assessed. Physical environmental parameters for the study period were estimated. RESULTS: Of the 12,021 eligible subjects, 9735 (81% response rate) participated in the study. The prevalence of pterygium in any eye was 13.2% (95% CI: 12.5%-13.9%), and bilateral pterygium was 6.7% (95% CI: 6.2-7.2). The prevalence increased with age (<0.001) irrespective of sex and was highest in those aged 60-69 years (15.8%). The prevalence was highest in coastal (20.3%), followed by plains (11.2%) and hilly regions (9.1%). On multi-logistic regression, pterygium was positively associated with coastal location (P<0.001), illiteracy (P = 0.037), increasing lifetime sun exposure (P<0.001), and negatively associated with BMI ≥25 kg/m2 (P = 0.009). CONCLUSION: Pterygium prevalence is high in the rural Indian population. The association of pterygium with several potentially modifiable risk factors reflects its multifactorial etiology and provides targets for preventive measures.

Situational analysis of diabetic retinopathy screening in India: How has it changed in the last three years?

Of all the eye conditions in the contemporary Indian context, diabetic retinopathy (DR) attracts the maximum attention not just of the eye care fraternity but the entire medical fraternity. Countries are at different stages of evolution in structured DR screening services. In most low and middle income countries, screening is opportunistic, while in most of the high income countries structured population-based DR screening is the established norm. To reduce inequities in access, it is important that all persons with diabetes are provided equal access to DR screening and management services. Such programs have been proven to reverse the magnitude of vision-threatening diabetic retinopathy in countries like England and Scotland. DR screening should not be considered an endpoint in itself but the starting point in a continuum of services for effective management of DR services so that the risk of vision loss can be mitigated. Till recently all DR screening programs in India were opportunistic models where persons with diabetes visiting an eye care facility were screened. Since 2016, with support from International funders, demonstration models integrating DR screening services in the public health system were initiated. These pilots showed that a systematic integrated structured DR screening program is possible in India and need to be scaled up across the country. Many DR screening and referral initiatives have been adversely impacted by the COVID-19 pandemic and advocacy with the government is critical to facilitate continuous sustainable services.