Bringing Sectors Together in Da Nang, Vietnam: Participatory Systems Mapping.

The USAID-funded Building Healthy Cities (BHC) work in Da Nang, Vietnam, engaged 108 multi-sector stakeholders to gather qualitative data across two workshops and three citizen town halls from 2019 to 2021. These data were synthesized with the results from BHC's seven other activities in Da Nang to build systems maps. Contextual findings showed that multi-sector, multi-level participation and collaboration have been the key to moving the city toward their smart and livable city goals. Currently, citizen, nongovernmental organization, and private sector collaboration are low for many government sectors, which results in policy and programs that are mismatched to actual needs and therefore have less powerful impacts. When these policies and programs are implemented, they struggle to demonstrate strong benefits to these stakeholder groups, further decreasing participation. This is central to the systems map that BHC developed, and is expanded upon through additional patterns that fall within four main areas: management quality; vision and leadership; workforce capacity; and community engagement. Stakeholders found four key leverage points within this context that, if included in every action, could help overcome barriers. These leverage opportunities are: (1) investing at all levels; (2) improving function and innovation of information technology; (3) increasing participation and feedback; and (4) creating more responsive policy. As BHC concludes activities in Da Nang, local university students will be trained on systems mapping techniques to embed systems thinking skills into the next generation of workforce, and a set of recommendations will be developed to share with the government to act on these findings.

Designing for a Healthier Indore, India: Participatory Systems Mapping.

In Indore, India, BHC engaged 247 multi-sector stakeholders through a systems mapping approach to gather qualitative data across three workshops and four citizen town halls from 2018 to 2020. These data were synthesized with results from BHC's 18 other city activities to build a systems map and identify high-impact areas for engagement. Contextual findings showed a tension at the heart of Indore's growth-Indore's great success as a city has spurred rapid population growth. This growth creates pressure on municipal systems as population outpaces service delivery capacity. This is central to the systems map that BHC developed and is expanded upon through additional patterns that fall within four main domains: (1) leadership, governance, and financing; (2) essential service delivery and workforce; (3) information systems; and (4) community infrastructure and education. Stakeholders found three key leverage opportunities within this context that, if included in every action, could help overcome barriers. These opportunities are: (1) improving data quality, use, and integration; (2) supporting accountability to, and enforcement of, policies and regulations; and (3) increasing community engagement. Brought together through a better understanding of the key patterns driving system behavior from the context map and leverage opportunities, BHC was able to co-create, with stakeholders, seven "coherent actions" to move Indore to a healthier, more equitable state. When COVID-19 regulations ease, BHC and city officials will reconvene to finalize an implementation plan for these actions.

Designing for a Healthier Makassar, Indonesia: Participatory Systems Mapping.

In Makassar, Indonesia, the USAID-funded Building Healthy Cities (BHC) project engaged 240 multi-sector stakeholders to gather qualitative data across three workshops and two citizen town halls from 2019 to 2021. These data were synthesized with results from BHC's nine other Makassar activities to build maps of the current system and identify high-impact areas for engagement. Contextual findings showed that Makassar leadership has actively innovated and used new technology to improve the city, resulting in improved connectivity and responsiveness. However, this drive toward innovation has strained existing infrastructure and workforce capacity. When this strain fails to meet promised results, citizens are less likely to engage and support the innovations. This is central to the systems map that BHC developed, and is expanded upon through additional patterns that fall within four main areas: (1) leadership, governance, and financing; (2) infrastructure and workforce; (3) collaboration and data; and (4) community cohesion and awareness. Stakeholders found three key leverage points within this context that, if included in every action, could help overcome barriers. These leverage opportunities are: (1) increasing data-driven decision-making; (2) ensuring equitable policy and leadership; and (3) increasing community participation. By combining key patterns discovered in the Context Map with the leverage opportunities, BHC was able to co-create with stakeholders six "coherent actions" that can move Makassar to a healthier, "Sombere (kind-hearted and hospitable) and Smart City." BHC has been working with the city planning office to incorporate the map findings into its bottom-up planning processes and the 5-year mid-term plan for Makassar.

Engaging Citizens Via Journey Maps to Address Urban Health Issues.

Effectively addressing urban health challenges requires engagement of citizens. However, citizens often face barriers providing feedback, and city officials likewise face difficulties incorporating feedback in a meaningful and systematic way. This paper shares one innovative approach to capturing citizens' stories about urban health concerns, developed by the Building Healthy Cities (BHC) project in 2 Asian cities (Indore, India, and Makassar, Indonesia). Using ethnographic methods, BHC developed "journey maps" as a monitoring tool to follow key service issues over time. Several urban health-related issues were identified in each city. For this paper, we focus on wastewater management, which was a serious health issue in both cities. Qualitative data were collected from citizens in one neighborhood and city officials quarterly starting in early 2018; these data were supplemented by city spending data, usage statistics, photos and news articles. In both cities, the journey maps captured notable changes during the first 2 years of the project. At the start of the journeys (2018), informal settlement citizens in Indore reported poor drainage which was compounded by trash, narrow roads blocking vehicular removal of waste, and unsafe infrastructure leading to waterborne diseases and injuries (including several child deaths). Likewise in Makassar, dirty water overflowed from open drains due to frequent flooding and garbage. Citizens reported exposure to diarrhea, dengue and skin symptoms due to the drains, which was confirmed by the local health post. By the end of Year 2 (2019), these journeys captured increasing dialogue between citizens and the city, which resulted in several improvements. In Indore, changes included garbage vans built for narrow streets and construction of a safer bridge. In Makassar, while they still suffer from seasonal flooding, the city has increased garbage pickup, included drainage activities in the village-level budgeting process, and a slum improvement project has pledged funding to improve drainage and street issues in 41 neighborhoods. Journey maps work on the premise that capturing a community's experience and relaying it to government officials can bring about positive change. They also provide crucial grassroots level evidence to support more traditional research findings, which can lead to effective urban health solutions. As this work continues, BHC is training citizens to collect and share their own journeys.

Resource and Infrastructure-Appropriate Management of ST-Segment Elevation Myocardial Infarction in Low- and Middle-Income Countries.

The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world's population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment-elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.

Factors affecting adherence to treatment in children living with HIV.

BACKGROUND: With the successful introduction of ART, the life expectancy of children living with HIV (CLHIV) is substantially increased. However, strict compliance is a necessary step to begin with as noncompliance is again associated with its own demerits of incomplete suppression and decreasing the overall survival of the patients. AIMS: The aim of this study was to measure factors associated with adherence to ART among CLHIV. MATERIALS AND METHODS: This is a 1-year follow-up study conducted from November 2012 to December 2013. A total of 171 children between 18 months and 15 years living with HIV and on ART attending the two ART centers of Delhi were enrolled in the study. Adherence and factors affecting adherence were obtained from the study participants using a semi-structured interview schedule. STATISTICAL ANALYSIS USED: Collected data were transformed into variables and analyzed into SPSS. All observations were in terms of mean, median, standard deviations, percentages, and proportions. Tests of significance such as Chi-square test and t-test were applied wherever required. RESULTS: In nearly 89% of the study participants, adherence to ART was ≥95% at the end of the study. The most common reason for nonadherence was forgetfulness (59%), and 57% of the parents/caretakers were facing monetary problems. Long distance, greater duration to reach center, and unavailability of the parents/caretakers were also quoted as problems. CONCLUSION: Adherence is genesis to successful treatment outcome and is strongly associated with availability of support by their parents/caretakers. Professional help along with guidance and encouragement is required not only at the caretaker level but also to the family as a whole.

Prevalence of anemia among elderly persons residing in old age homes in national capital territory, Delhi, India.

BACKGROUND: Anemia is a common morbidity in elderly persons (aged 60 years or above). In India, in recent years, the number of old age homes (OAHs) and the residents living in them has increased significantly. OBJECTIVE: The aim of this study was to estimate the prevalence of anemia among elderly persons living in OAHs. METHODS: This was a cross-sectional study among individuals living in OAH in Delhi, India. Using combination of location and type of OAH, 28 clusters of almost equal sizes were created, of which 13 clusters were randomly selected, and all elderly persons living therein were selected for the study. Sociodemographic profile was recorded using a self-designed, semistructured interview schedule. Hemoglobin (Hb) was estimated using HemoCue Hb 201+ system. Binary Logistic regression was used to assess the socioeconomic determinants of anemia. RESULTS: The study included 334 elderly persons, with a mean (standard deviation [SD]) age of 75.2 (8.6) years and mean (SD) Hb of 11.6 (1.7) g/dL. The mean (SD) Hb in men was 12.1 (1.7) g/dL compared to 10.9 (1.5) g/dL among women (P < 0.0001). The overall prevalence of anemia was 68.7% (95% confidence interval 63.9, 73.4); among those who were anemic, 47.4% had mild anemia, 47.0% had moderate anemia, and 5.6% had severe anemia. The prevalence of mild anemia was 45% in men compared to 24.8% in women. The odds of anemia among ≥80 years was 2 times that among 60-69 years (P < 0.029). CONCLUSIONS: The prevalence of anemia among elderly persons in OAHs is high in Delhi, India and increased with age.

Students' perception of lacunae in medical education in India, and suggestions for reforms.

Background: The methods of classroom and clinical teaching in the MBBS course in India have not seen major modifications or innovations in recent decades, leading to dissatisfaction among students. Lack of conclusive data in this regard and absence of a mechanism for students' feedback are also areas of concern. We aimed to assess the satisfaction levels and identify lacunae in undergraduate medical education in India. Methods: We used an 8-item questionnaire to identify lacunae in medical education. A total of 336 undergraduate medical students from second and third professional years and interns of Delhi voluntarily participated in the study. Data were analysed using SPSS 17 version. Results: Eighty-one per cent of students were not satisfied with teaching methods due to lack of coordination between different departments and lack of problem-based learning. Sixty-five per cent of students did not find the classroom environment conducive to learning due to large sizes of teaching batches and inadequate maintenance of infrastructure. Eighty-six per cent of students were not satisfied with learning experience during clinical postings attributing it to 'doctors being too busy to teach in clinics'. Conclusion: There is dissatisfaction among students indicating their desire for improved methods in medical education. Suggestions include short-term reforms such as encouraging interdepartmental planning and introducing problem-based learning, coupled with long-term measures such as improving infrastructure.

Childhood Morbidity and Mortality in India - Analysis of National Family Health Survey 4 (NFHS-4) Findings.

National Family Health Survey (NFHS)-4 report was recently released for health-related data. This review compares the child health indicators across NFHS-3 and NFHS-4 with a background of existing health programs catering to child health. Reports of NFHS-4 and NFHS-3, along with ministry reports and existing literature were reviewed to understand the current status of child health. Child health indicators were compared between the two rounds of NFHS and among Empowered Action Group states of India. National Health Policy 2017 and National Health Programs related to child health were also analyzed. There has been an improvement in almost all child health indicators from NFHS-3 to NFHS-4. The infant mortality rate has reduced to 41 per 1000 live births. The immunization rate is 62%, and has almost doubled in the states of Uttar Pradesh, Rajasthan and Madhya Pradesh. Despite existence of many health programs, there is still a substantial lack of achievement in most of the indicators.

Prevalence of fall, and determinants of repeat incidents of fall in older persons living in old age homes in the National Capital Territory of Delhi, India.

Background: Fall is a common morbidity in older persons. In India, the number of old age homes and persons living in them are increasing. We studied the prevalence of fall among older persons living in old age homes. Methods: We did a cross-sectional survey among persons aged 60 years or above, living in old age homes of Delhi, India. Information on location, type and bed-strength was collected for old age homes, and using their combination, 28 clusters of almost equal sizes (25-35) were created, of which, 13 were selected randomly to meet an estimated sample size of 340. All residents of the selected old age homes were recruited for the study. A self-developed, semi-structured interview schedule was used for recording the sociodemographic profile and history of fall in the past 6 months. Logistic regression was used to explore factors that might be associated with fall. Poisson regression was used to model the frequency of incidents of fall. Results: A total of 335 older persons, with mean (SD) age of 75.2 (8.6) years were studied. At least 1 episode of fall was reported by 55 (16.4%), of whom, injury and disability were sustained by 54.5% and 23.3%, respectively. On multivariate logistic regression, for each additional morbidity, odds ratio of fall was 1.5 (95% confidence interval [CI] 1.09-1.95). Multivariate Poisson regression showed that age and tobacco use were significantly associated with the incidents of fall. For each unit increase in age, the incident rate ratio increased by 1.02 times (95% CI 1.01-1.03). Being a past user of tobacco had a statistically significant incident rate of 1.57 times (95% CI 1.01-2.45) compared to non-users of tobacco. Conclusion: One-sixth of individuals living in old age homes had experienced a fall in the past 6 months. Measures should be taken to prevent falls in old age home settings in India.

Socio-Demographic, Reproductive and Clinical Profile of Women Diagnosed with Advanced Cervical Cancer in a Tertiary Care Institute of Delhi.

INTRODUCTION: Cervical cancer is one of the leading cancers among Indian women with estimated 123,000 new cases and 67,477 deaths in 2012. Cervical cancer is a multi-etiological disease. Factors such as low socioeconomic status, tobacco use, sexual and reproductive factors, HIV and other sexually transmitted diseases and long-term oral contraceptive use have been suggested as determinants. Assessment of socio-demographic profile and reproductive history gives a better picture of the determinants of cervical carcinoma in low-resource settings. METHODS: This hospital-based cross-sectional study was undertaken at a tertiary healthcare institute at New Delhi, India. Sixty-seven newly diagnosed women with advanced cervical cancer (stage 2B-4B), who were undertaking radio- and/or chemotherapy, were included to assess their socio-demographic, reproductive and clinical profile. RESULTS: The mean age of women at the time of detection of cervical cancer was 52.28 ± 11.29 years (range 30-75 years). More than 60 % of patients were illiterate and belonged to middle socioeconomic status. Thirty-nine percentage of the study subjects had their first sexual experience before 15 years of age. Nearly 54 % women had 5 or more pregnancies. Nearly 73 % of women had all deliveries at home. Majority (69 %) of women had symptoms suggestive of reproductive tract infection. Among them, unusual discharge from vagina (73.13 %) followed by bleeding after menopause (55.10 %) and pain in abdomen (44.77 %) were the most common presenting complaints. Pallor was present in nearly two-third (63.93 %) study subjects. More than half (56.72 %) study subjects had moderate anemia, and 7.46 % had severe anemia before treatment. Mean hemoglobin level of the study subjects was 10.35 ± 1.72 gm% before treatment and 9.69 ± 1.29 gm% after treatment. This difference was statistically significant. Around 97 % of the study subjects had squamous cell carcinoma of the cervix. Majority (53.73 %) of the study subjects were in stage 3B of cervical cancer. Combination of radiotherapy and chemotherapy was the most common (77.67 %) modality of treatment. CONCLUSIONS AND RECOMMENDATIONS: Illiteracy, low socioeconomic status, early sexual debut, high fertility, home delivery, reproductive tract infections, use of insanitary clothes during menstruation and anemia were observed in majority of women with advanced cancer cervix. Presence of these factors indicates possible risk of cervical cancer and should be kept in mind when women seek health services. Early diagnosis through high risk or opportunistic screening and timely management of cervical cancer needs to be ensured for better outcomes.

Thalassemia Major: how do we improve quality of life?

BACKGROUND: Thalassemia Major is a preventable genetic disorder characterized by abnormal hemoglobin synthesis and lifelong blood transfusions. The children suffering from Thalassemia Major have poor quality of life. This study was conducted to assess the factors influencing quality of life of these children and how it can be improved. METHODS: A descriptive cross sectional study was conducted in 2014 at Thalassemia Day Care Centre of a tertiary level children's hospital in Delhi, to assess quality of life of children suffering from Thalassemia Major. A total of 241 eligible children (age 2-18 years) were enrolled in the study. Socio demographic and clinical characteristics were collected from interview and existing medical records. The PedsQL 4.0 generic core scale was used for assessing the quality of life of the children. RESULTS: The mean age of children was 8.69 ± 4.98 years. Two-thirds (63.5%) were boys. The total mean QoL score of the children was 82.0 ± 14.4. The quality of life scores were better for boys as compared to girls. The most affected domain was the emotional domain which showed statistically significant (p = 0.025) difference between boys and girls. The total QoL scores were significantly affected by the current age of the child (p = 0.000) and presence of co-morbidity (p = 0.026). Children not on any form of iron chelation therapy (p = 0.003) and fewer hospital visits (p = 0.044) had better QoL scores. CONCLUSIONS: Factors improving the quality of life were control of iron overload and adverse effects of ICTs, management of co morbidities and fewer hospital visits.

Quality of Life of Patients with Advanced Cervical Cancer before and after Chemoradiotherapy.

BACKGROUND: Cervical cancer is the most frequently diagnosed cancer among women in India. Understanding quality of life (QOL) in women undergoing chemoradiotherapy for cervical cancer will help in introducing interventions for better care and outcomes in these women. This study assessed QOL before and after chemo radiotherapy in cervical cancer patients. MATERIALS AND METHODS: This followup study covered sixtyseven newly diagnosed women with advanced cervical cancer (stages 2b to 4b). Structured questionnaires (the European Organization for Research and Treatment of Cancer, EORTC QLQC30 and EORTC QLQCX24) were used to assess the change in QOL after 6 months of treatment. RESULTS: The mean age of women at the time of detection of cervical cancer was 52.3±11.29 years (Range 3075 years). Six months survival was 92.53%. The mean global health score of cervical cancer patients after six months of treatment was 59.52, which was significantly higher than the pretreatment score of 50.15 (p=0.00007). Physical, cognitive and emotional functioning improved significantly (p<0.05) after treatment. Fatigue, pain, insomnia and appetite loss improved but episodes of diarrhea increased after treatment. The mean "symptoms score" using EORTC QLQCX24 post treatment was 20.0 which was significantly lower as compared to the pre treatment score 30.0 (p<0.00001). Sexual enjoyment and sexual functioning decreased significantly after treatment. CONCLUSIONS: QOL of newly diagnosed cervical cancer patients improved significantly following chemoradio therapy. Enhancement was also demonstrated on three of the five functional scales of EORTC QLQC30. To further improve QOL, interventions focusing on social and psychological support and physical rehabilitation may be needed.