Predictors of recovery in children aged 6-59 months with uncomplicated severe acute malnutrition: a multicentre study.

OBJECTIVE: To identify predictors of recovery in children with uncomplicated severe acute malnutrition (SAM). DESIGN: This is a secondary data analysis from an individual randomised controlled trial, where children with uncomplicated SAM were randomised to three feeding regimens, namely ready-to-use therapeutic food (RUTF) sourced from Compact India, locally prepared RUTF or augmented home-prepared foods, under two age strata (6-17 months and 18-59 months) for 16 weeks or until recovery. Three sets of predictors that could influence recovery, namely child, family and nutritional predictors, were analysed. SETTING: Rural and urban slum areas of three states of India, namely Rajasthan, Delhi and Tamil Nadu. PARTICIPANTS: In total, 906 children (age: 6-59 months) were analysed to estimate the adjusted hazard ratio (AHR) using the Cox proportional hazard ratio model to identify various predictors. RESULTS: Being a female child (AHR: 1·269 (1·016, 1·584)), better employment status of the child's father (AHR: 1·53 (1·197, 1·95)) and residence in a rental house (AHR: 1·485 (1·137, 1·94)) increased the chances of recovery. No hospitalisation (AHR: 1·778 (1·055, 2·997)), no fever, (AHR: 2·748 (2·161, 3·494)) and ≤ 2 episodes of diarrhoea (AHR: 1·579 (1·035, 2·412)) during the treatment phase; availability of community-based peer support to mothers for feeding (AHR: 1·61 (1·237, 2·097)) and a better weight-for-height Z-score (WHZ) at enrolment (AHR: 1·811 (1·297, 2·529)) predicted higher chances of recovery from SAM. CONCLUSION: The probability of recovery increases in children with better WHZ and with the initiation of treatment for acute illnesses to avoid hospitalisation, availability of peer support and better employment status of the father.

Progress Toward Eliminating Mother to Child Transmission of HIV in Kenya: Review of Treatment Guidelines Uptake and Pediatric Transmission Between 2013 and 2016-A Follow Up.

Background Prevention of mother to child transmission of HIV (PMTCT) services are critical to achieve national and global targets of 90% antiretroviral therapy (ART) coverage in PMTCT, and mother to child transmission rates less than 5%. In 2012, Kenya adopted WHO's recommended ART regimen for PMTCT "Option B+". Aims This study assesses progress made in adopting these new guidelines and associated outcomes. Methods We analysed programmatic data of 2604 mother-infant pairs enrolled in the HIV Infant Tracking System (HITSystem) at four government hospitals in Kenya between January, 2013 and December, 2016. We then compared PMTCT trends between 2010 and 2012 and 2013-2016 for the same four government hospitals. Results A total of 2,371 (91.1%) received some ART regimen, however; only 911 (56.2%) mothers received ART regimens compliant with WHO Option B+. From 2013 to 2016, the percent of mothers on WHO Option B + doubled from 42 to 84% (p < 0.001), the mean week of ART initiation decreased from 19.0 to 9.7 weeks (p < 0.001), the percent of pregnant women who were already on ART at the time of PMTCT enrolment increased from 5.8 to 31.7% (p < 0.001), and the paediatric transmission rate decreased from 5.9 to 2.5% (p = 0.002). Conclusion Comparing data at these four Kenyan hospitals indicates significant progress has been made from 2010 to 2016. To continue these positive gains, concerted focus will be needed to target and improve the integration of new guidelines into clinical practice at the facility level, adherence to treatment and retention in care.

A Survey on Factors Affecting Knowledge and Satisfaction with Care Among Persons with Diabetes Mellitus in an Urban Health Centre and its Outreach Clinics in South India.

Objective: To determine the level of knowledge and factors affecting knowledge and satisfaction with diabetes care among persons with diabetes at urban health centre (UHC) and community health worker (CHW)-led outreach clinics (ORC) in South India. Methodology: A cross-sectional study was carried out using a structured questionnaire. One hundred patients at the UHC and 200 patients at the ORC were included. Results: Patients with DM of more than eight years, with co-morbidities and maintained on insulin had good knowledge at the UHC. At the ORC, participants who received education beyond the primary level and belonging to non - Hindu religion had higher knowledge. Patients at the ORC experienced better satisfaction in terms of waiting time for appointments, consultation, registration system and counselling. At the UHC, those who received primary education or those with lower educational attainment had better satisfaction. Overall, knowledge (p = 0.03) and satisfaction (p = 0.00001) of diabetes care was better at the ORC than at the UHC. Conclusions: Our study found better knowledge and satisfaction with diabetes care at the ORC than at the UHC. Whether or not the difference can be attributed to CHW-based clinics in the community needs to be further elucidated.

Protocol for the formative phase of a trial (SHE-CAN) to test co-designed implementation strategies for HPV-based cervical screening among vulnerable women in two diverse settings in India.

BACKGROUND: In view of the WHO's call for the elimination of cervical cancer as a public health problem, and current low screening coverage, Indian policy makers need evidence on how to effectively implement cervical screening programmes, ensuring equity in access. Our study will follow the INSPIRE implementation framework to co-design and test HPV-based screening approaches in two states of India with different health system organisation, based on understanding the status of screening as currently implemented, readiness and challenges to transition to HPV-based screening, and preferences of key stakeholders. Here, we describe our protocol for the formative phase of the study (SHE-CAN). METHODS: The study population includes women from vulnerable populations, defined as residents of tribal areas, rural villages, and urban slums, in the states of Mizoram and Tamil Nadu. The baseline assessment will use mixed methods research, with desktop reviews, qualitative studies, and surveys. A capacity assessment survey of screening and treatment facilities will be done, followed by interviews with healthcare providers, programme managers, and community health workers. Interviews will be conducted with previously screened women and focus group discussions with under and never-screened women and community members. Stakeholder workshops will be held in each state to co-design the approaches to delivering HPV-based screening among 30-49-year-old women. DISCUSSION: The quality and outcomes of existing screening services, readiness to transition to HPV-based screening, challenges in providing and participating in the cervical cancer care continuum, and acceptability of screening and treatment approaches will be examined. The knowledge gained about the current system, as well as recognition of actions to be taken, will inform a stakeholder workshop to co-design and evaluate implementation approaches for HPV-based screening through a cluster randomised implementation trial.

Study protocol: 'a large cohort study of postnatal events in a not-for-profit referral centre in Vellore, South India'.

INTRODUCTION: In a large developing country, with diverse population characteristics and differential access to healthcare, it is important to identify factors that influence postnatal health. This knowledge will help frame recommendations to enhance universal postnatal care. METHODS AND ANALYSIS: A prospective cohort study will be conducted by recruiting all participants who deliver in a referral centre in South India during a 1-year period after written consent is obtained from them. In addition to clinical information pertaining to their delivery and demographics, details of physical health, mental health socioeconomic status and emotional support will also be collected. Every participant will be followed up physically and/or by telephonic consultation at 3, 9 and 18 months of their postnatal period to reassess their status and that of their babies. As there are several independent and dependent variables requiring multivariate analysis, a sample size of 10 000 is considered adequate. Any unplanned visits to a health facility will be enquired into and documented for analysis.During data analysis, the effect of Caesarean section, high-risk characteristics and gestational age of the baby at delivery on various outcome measures and postnatal status will be evaluated. Interpretation of the large volume of collected data will help frame recommendations to improve postnatal care ETHICS AND DISSEMINATION: The study is approved by the Institutional Review Boards (Research and Ethics Committees) of Christian Medical College, Vellore, Tamil Nadu, India (IRB 12178 date 24 June 2020).Women are provided with a detailed information sheet and written consent is obtained. They are reassured that their care will not be compromised if they do not consent to the study. Data will be available on the clinical trial portal to assist in the dissemination of results after the project is published. TRIAL REGISTRATION NUMBER: CTRI/2022/03/041343.

Prevalence of Cervical Cancer Screening and Awareness among Women in an Urban Community in South India-A Cross Sectional Study.

Background: Although the incidence of cervical cancer has declined in developed countries, cervical cancer remains a major problem in those that are developing. Past studies suggest that Indian women, who account for at least one-fourth of the global disease burden, are not routinely screened. Objectives: Among the women living in our low-income urban community in South India, we sought to determine the prevalence of screening and to assess women's knowledge of cervical cancer. Methods: We conducted a community-based cross-sectional survey evaluating cancer screening prevalence among women aged 25-65 living in the communities served by our clinic. We also assessed knowledge of cervical cancer, screening and the HPV vaccine in a subset of 175 women in the same age range. Findings: Prevalence data was available for 1033 women. Of these,14.3% had at least one lifetime pelvic exam and 7.1% had undergone cervical cancer screening. Women who were married below the age of 18, who belonged to non-Hindu religion, and who were from a higher socioeconomic status were more likely to be screened. Women who were single did not undergo screening. With regard to knowledge of cervical cancer, 84.6% of women had poor knowledge, 10.3% had moderate knowledge, and 5.1% had good knowledge. Women aged 41 years or younger had better knowledge of the disease. Conclusions: Very few women are screened for cervical cancer and few have adequate knowledge of the disease within this South Indian community. These findings suggest opportunities for a community-based education and screening campaign to reduce the prevalence of cervical cancer within this population.

Effect of BATHE interview technique on patient satisfaction in an ambulatory family medicine centre in South India.

OBJECTIVE: The objective of the study is to determine the effect of background, affect, trouble, handling and empathy (BATHE) versus usual interview technique on patient satisfaction during regular consultation with family physicians in ambulatory care. DESIGN: The research design was a prospective, randomised control trial. SETTING: The trial took place in a family practice unit in South India, which was one of the clinical service units of the academic Department of Family Medicine of a tertiary hospital. PARTICIPANT: The eligible participants were adults above the age of 18 years, who did not have any acute presenting illness. The participants should have given consent and also not have any cognitive disability. A total of 138 participants took part in the trial, 70 in BATHE group and 68 in the non-BATHE group. All participants entering the trial completed the questionnaire. RESULT: The BATHE group had a significantly higher mean score for questions grouped under professional satisfaction. This included questions on whether the patient felt that the physician treated them as a person and also whether they felt the appropriate clinical examination was communicated to them. The questionnaire used for scoring satisfaction had 18 questions with a maximum possible score of 90. When taking a cut-off of 75% (68) from the total possible score of 90, 72.9% (51) of the participants for whom the BATHE consultation technique was used were satisfied as compared with only 55.9% (30) for whom the routine consultation was carried out. This was statistically significant (χ2=11.15, p value=0.0006) CONCLUSION: The study suggests that using BATHE in this family practice centre is beneficial in improving the perception of person centeredness in the consultation. However, further studies ruling out all possible bias are needed in our setting before the range of probable benefits of the BATHE technique can be fully gauged.

Implementation planning for community-based point-of-care HIV testing for infants: Recommendations from community leaders in Kenya.

BACKGROUND: Early infant diagnosis (EID) establishes the presence of HIV infection in HIV-exposed infants and children younger than 18 months of age. EID services are hospital-based, and thus fail to capture HIV-exposed infants who are not brought to the hospital for care. Point-of-care (POC) diagnostic systems deployed in the community could increase the proportion tested and linked to treatment, but little feasibility and acceptability data is available. METHODS: Semi-structured interviews (n = 74) were conducted by a Kenyan team with community members (Community Health Workers/Volunteers [CHW/CHV], Traditional Birth Attendants [TBAs], community leaders) and parents of HIV-exposed infants at four study sites in Kenya to elicit feedback on the acceptability and feasibility of community-based POC HIV testing. RESULTS: Participants described existing community health resources that could be leveraged to support integration of community-based POC HIV testing; however, the added demand placed on CHW/CHV could pose a challenge. Participants indicated that other potential barriers (concerns about confidentiality, disclosure, and HIV stigma) could be overcome with strong engagement from trusted community leaders and health providers, community sensitization, and strategic location and timing of testing. These steps were seen to improve acceptability and maximize the recognized benefits (rapid results, improved reach) of community-based testing. CONCLUSION: Community members felt that with strategic planning and engagement, community-based POC HIV testing could be a feasible and acceptable strategy to overcome the existing barriers of hospital-based EID.

Prevalence of oral diseases and risks to oral health in an urban community aged above 14 years.

INTRODUCTION: Oral health is a requisite to general health and quality of life. The public health problems associated with oral diseases are a serious burden in every nation around the globe. AIMS: The aim of this study is to assess the prevalence of dental problems and the oral health seeking behavior of an urban south Indian population aged >14 years. MATERIALS AND METHODS: In this population-based cross-sectional study, 101 households were selected through systematic random sampling. About 419 participants were interviewed and information on sociodemographic characteristics, personal, and dental history was obtained and a complete oral cavity examination was performed. RESULTS: The prevalence of dental caries, periodontal problems, and tooth wear were 78.75%, 74.7%, and 72.3%, respectively. The mean number of overall affected teeth in the population by one dental problem is 16 ± 8.13. The mean Decayed, Missing and Filled Teeth (DMFT) score was 4.5. The risk factors that were significantly associated with the poor oral health status were age >31 years (Odds Ratio (OR), 2.88), education less than eighth grade (OR, 2.35), inadequate oral hygiene practices (OR, 1.61), use of any form of tobacco (OR, 2.08), and alcohol consumption (OR, 2.02). Only 185 (44.1%) participants perceived that they had a dental problem at the point of the survey and only 20 of them (10.81%) visited a dentist. CONCLUSION: This study showed a high prevalence of dental caries, periodontal problem, and tooth wear. This emphasizes the need for community-based awareness program on dental health and recommends periodic dental health screening program at the community level for early diagnosis and better treatment.

Quality of Antenatal Care Provided by Nurse Midwives in an Urban Health Centre with Regard to Low-Risk Antenatal Mothers.

BACKGROUND: India contributes to 19% of the global maternal deaths. Good quality antenatal care can prevent maternal deaths by early detection of complications and maintaining maternal health. There are few studies documenting quality of antenatal care in India. This study aimed to document the antenatal services provided by nurse midwives to low-risk pregnant mothers from an urban population. AIMS: The primary objective was to describe the quality of the antenatal care provided by nurse midwives of an urban health centre with regard to low-risk mothers. The secondary objective was to document the maternal and early neonatal outcomes of the enrolled mothers during the period of study. METHODS: This prospective cohort study was done on 200 pregnant women who had antenatal care by nurse midwives between April 2014 and November 2014. The quality of care was assessed by a checklist adapted from World Health Organization (WHO). RESULTS: We report that the quality of antenatal care for all domains was above 90% except for the health education domain, which was poor with regard to breastfeeding and family planning in the enrolled 200 pregnant women. CONCLUSION: Our study concluded that trained nurse midwives when regularly monitored, audited and linked with reliable referral facilities can deliver good quality antenatal care.

Satisfaction of antenatal mothers with the care provided by nurse-midwives in an urban secondary care unit.

BACKGROUND: The satisfaction of antenatal women to antenatal services has rarely been studied in India. In a nation with a maternal mortality ratio of 178/100,000 live births, it is crucial to explore all avenues to reduce it. AIMS: Our study aims to assess the pregnant women's satisfaction with regard to antenatal care services provided by nurse-midwives in an urban health center in South India. METHODS: We administered a satisfaction of care questionnaire to 200 consecutive antenatal women attending the nurse run antenatal clinics from April 2014 to November 2014. The date entry was done using Epi-Data system and the analysis by SPSS version 16. STATISTICAL ANALYSIS USED: The absolute distribution of each of the question in the satisfaction of care questionnaire was calculated as proportions. The relationship between satisfaction of care and parity, number of visits, years of experience of the care provider and mother's education was tested using Mann-Whitney test for two independent groups. RESULTS: The mean age of the mothers was 23.5 years. More than 95% of the mothers expressed satisfaction with the number of antenatal visits components of antenatal care. Only 31.8% of the mothers were satisfied with the health education on family planning. There was no significant relationship between satisfaction of care and parity of mothers or years of experience of care provider. CONCLUSIONS: Pregnant women attending a nurse run antenatal care service have positively expressed satisfaction of care provided therein.

Efficacy of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition: a randomised trial in India.

OBJECTIVE: To assess the efficacy of ready-to-use therapeutic food (RUTF), centrally produced RUTF (RUTF-C) or locally prepared RUTF (RUTF-L) for home-based management of uncomplicated severe acute malnutrition (SAM) compared with micronutrient-enriched (augmented) energy-dense home-prepared foods (A-HPF, the comparison group). METHODS: In an individually randomised multicentre trial, we enrolled 906 children aged 6-59 months with uncomplicated SAM. The children enrolled were randomised to receive RUTF-C, RUTF-L or A-HPF. We provided foods, counselling and feeding support until recovery or 16 weeks, whichever was earlier and measured outcomes weekly (treatment phase). We subsequently facilitated access to government nutrition services and measured outcomes once 16 weeks later (sustenance phase). The primary outcome was recovery during treatment phase (weight-for-height ≥-2 SD and absence of oedema of feet). RESULTS: Recovery rates with RUTF-L, RUTF-C and A-HPF were 56.9%, 47.5% and 42.8%, respectively. The adjusted OR was 1.71 (95% CI 1.20 to 2.43; p=0.003) for RUTF-L and 1.28 (95% CI 0.90 to 1.82; p=0.164) for RUTF-C compared with A-HPF. Weight gain in the RUTF-L group was higher than in the A-HPF group (adjusted difference 0.90 g/kg/day, 95% CI 0.30 to 1.50; p=0.003). Time to recovery was shorter in both RUTF groups. Morbidity was high and similar across groups. At the end of the study, the proportion of children with weight-for-height Z-score (WHZ) >-2 was similar (adjusted OR 1.12, 95% CI 0.74 to 1.95; p=0.464), higher for moderate malnutrition (WHZ<-2 and ≥-3; adjusted OR 1.46, 95% CI 1.02 to 2.08; p=0.039), and lower for those with SAM (adjusted OR 0.58, 95% CI 0.40 to 0.85; p=0.005) in the RUTF-L when compared with the A-HPF group. CONCLUSIONS: This first randomised trial comparing options for home management of uncomplicated SAM confirms that RUTF-L is more efficacious than A-HPF at home. Recovery rates were lower than in African studies, despite longer treatment and greater support for feeding. TRIAL REGISTRATION NUMBER: NCT01705769; Pre-results.

Meningococcal meningitis C in Tamil Nadu, public health perspectives.

Meningococcal meningitis has rarely been reported in Tamil Nadu. We report here two children diagnosed with meningococcal meningitis in Vellore, Tamil Nadu, on May 2014. The causative strain was Neisseria meningitidis serotype C. The role of the primary care physician in early diagnosis, appropriate referral, and preventive measures of this disease to the immediate family and community is stressed.

Primary hypoparathyroidism presenting with new adult onset seizures in family practice.

Hypoparathyroidism commonly presents with paresthesias, fatigue, anxiety, muscle cramps and infrequently with seizures due to hypocalcaemia. Here, we present a case of 27-year-old adult female presenting with new onset convulsions who was subsequently diagnosed to have primary (congenital) hypoparathyroidism.

Early diagnosis of a large vesical calculus complicating pregnancy.

Vesical calculus-complicating pregnancy is rare. This is a case report of a large vesical calculus-complicating pregnancy. The early diagnosis and appropriate surgical management of the large vesical calculus prevented complications like recurrent urinary tract infections and obstructed labor. It enabled the mother to have an uneventful vaginal delivery.

Morbidity Profile of Inpatients in a Secondary Care Center Run by Family Physicians.

BACKGROUND: There is a scarcity of records of morbidity pattern in secondary care centers. Reliable morbidity data will help in proper allocation of human resources. MATERIALS AND METHODS: A retrospective study of inpatient admission records of an urban secondary health center run by family physicians was done between April 2010 and March 2011. RESULTS: Pneumonia and other respiratory illnesses (represented by ICD code J) was the most common diagnosis. This was followed by infectious and viral diseases, circulatory diseases like hypertension, ischemic heart disease and endocrine diseases like non-insulin dependent diabetes mellitus. CONCLUSION: Physicians working in secondary care centres need to be experts in managing respiratory diseases, viral diarrheal illnesses, hypertension, ischemic heart disease and diabetes mellitus and patients with co-morbidities. They also need to be able to manage common obstetrics and neonatal emergencies. As the discipline of family medicine specializes in management of common ailments and multiple co-morbidities with an attitude of patient centeredness, family physicians would be the best managers of such centers. Inclusion of family physicians as specialist in secondary care centers will help in covering the manpower shortage in such centers.