The role(s) of community health workers in primary health care reform in Kerala, before and during the COVID 19 pandemic: a qualitative study.

Background: Accredited Social Health Activists (ASHA) are Community Health Workers (CHWs) employed by the National Health Mission of the Government of India to link the population to health facilities and improve maternal and child health outcomes in the country. The government of Kerala launched primary health reform measures in 2016 whereby Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The COVID-19 pandemic in 2020 impacted essential health service delivery, including primary care services. The CHWs network of Kerala played a crucial role in implementing the primary care reforms and COVID-19 management efforts that followed. We carried out a study to understand the perspectives of the CHWs in Kerala about their role in the recent primary healthcare reforms and during the COVID-19 pandemic management efforts. Methods: We conducted in-depth interviews (IDI) with 16 ASHAs from 8 primary care facilities in Kerala from July to October 2021. We further conducted Focus Group Discussions (FGDs) (N = 34) with population subgroups in these eight facility catchment areas and asked their opinion about the ASHAs working in their community. We obtained written informed consent from all the participants, and interview transcripts were thematically analysed by a team of four researchers using ATLAS.ti 9 software. Results: Our study participants were women aged about 45 years with over 10 years of work experience as CHWs. Their job responsibilities as a frontline health worker helped them build trust in the community and local self-governments. CHWs were assigned roles of outpatient crowd management, and registration duties in FHCs. The COVID-19 pandemic increased their job roles manifold. Community members positively mentioned the home visits, delivery of medicines, and emotional support offered by the CHWs during the pandemic. The CHWs noted that the honorarium of INR 6,000 (US$73) was inconsistent and very low for the volume of work done. Conclusion: The CHWs in Kerala play a crucial role in primary care reforms and COVID-19 management. Despite their strong work ethic and close relationship with local self-governments, low and irregular wages remain the biggest challenge.

Gender-specific inequalities in coverage of Publicly Funded Health Insurance Schemes in Southern States of India: evidence from National Family Health Surveys.

BACKGROUND: Publicly Funded Health Insurance Schemes (PFHIS) are intended to play a role in achieving Universal Health Coverage (UHC). In countries like India, PFHISs have low penetrance and provide limited coverage of services and of family members within households, which can mean that women lose out. Gender inequities in relation to financial risk protection are understudied. Given the emphasis being placed on achieving UHC for all in India, this paper examined intersecting gender inequalities and changes in PFHIS coverage in southern India, where its penetrance is greater and of longer duration. DATA AND METHODS: This study used the fourth (NFHS-4, 2015-16) and fifth (NFHS-5, 2019-21) rounds of India's National Family Health Survey for five southern states: namely, Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, and Telangana. The World Health Organization's Health Equity Assessment Toolkit (HEAT) Plus and Stata were used to analyse PFHIS coverage disaggregated by seven dimensions of inequality. Ratios and differences for binary dimensions; Between Group Variance and Theil Index for unordered dimensions; Absolute and Relative Concentration Index (RCI) for ordered dimensions were computed separately for women and men. RESULTS: Overall, PFHIS coverage increased significantly (p < 0.001) among women and men in Andhra Pradesh, and Kerala from NFHS-4 to NFHS-5. Overall, men had higher PFHIS coverage than women, especially in Andhra Pradesh, Tamil Nadu, and Telangana in both surveys. In both absolute and relative terms, PFHIS coverage was concentrated among older women and men across all states; age-related inequalities were higher among women than men in both surveys in Andhra Pradesh, Kerala, and Telengana. The magnitude of education-related inequalities was twice as high as among women in Telangana (RCINFHS-4: -12.23; RCINFHS-5: -9.98) and Andhra Pradesh (RCINFHS-4: -8.05; RCINFHS-5: -7.84) as compared to men in Telangana (RCINFHS-4: -5.58; RCINFHS-5: -2.30) and Andhra Pradesh (RCINFHS-4: -4.40; RCINFHS-5: -3.12) and these inequalities remained in NFHS-5, suggesting that lower education level women had greater coverage. In the latter survey, a high magnitude of wealth-related inequality was observed in women (RCINFHS-4: -15.78; RCINFHS-5: -14.36) and men (RCINFHS-4: -20.42; RCINFHS-5: -13.84) belonging to Kerala, whereas this inequality has decreased from NFHS-4 to NFHS-5., again suggestive of greater coverage among poorer populations. Caste-related inequalities were higher in women than men in both surveys, the magnitude of inequalities decreased between 2015-16 and 2019-20. CONCLUSIONS: We found gender inequalities in self-reported enrolment in southern states with long-standing PFHIS. Inequalities favoured the poor, uneducated and elderly, which is to some extend desirable when rolling out a PFHIS intended for harder to reach populations. However, religion and caste-based inequalities, while reducing, were still prevalent among women. If PFHIS are to truly offer financial risk protection, they must address the intersecting marginalization faced by women and men, while meeting eventual goals of risk pooling, indicated by high coverage and low inequality across population sub-groups.

Assessing inequalities in publicly funded health insurance scheme coverage and out-of-pocket expenditure for hospitalization: findings from a household survey in Kerala.

BACKGROUND: Increasing financial risk protection is a key feature of Universal Health Coverage and the path towards health for all. Publicly Funded Health Insurance Schemes (PFHIS) have been considered as one of the pathways to safeguard against financial shocks and potentially reduce Out-of-Pocket Expenditure (OOPE). The south Indian state of Kerala has roughly a decade-long experience in implementing PFHIS. To date, there have been very few assessments of the coverage of these schemes and their impact on expenditure. Aiming to fill this gap, we explored the extent of and inequalities in insurance coverage, as well as choice of providers, and median cost of hospitalization in Kerala among insured and uninsured individuals. METHODS: A cross-sectional household survey was conducted in four districts of Kerala as part of a larger health systems research study from July-October 2019. We employed multistage random sampling to collect data from 13,064 individuals covering 3234 households in the catchment area of eight primary health care facilities. We used descriptive statistics, bivariate and multivariate analysis. We evaluated socioeconomic disparities using an absolute measure of inequality-the Slope Index of Inequality (SII) and a relative measure-the Relative Concentration Index (RCI). RESULTS: A substantial proportion of our study respondents reported that they were covered by PFHIS (45.8%). Respondents belonging to lowest and middle wealth quintiles of household had significantly greater odds of being covered by insurance than respondents belonging to the richest wealth quintile. The negative magnitude of RCI [-16.8% (95%CI: -25.3, -8.4)] and SII [-21.5% (95%CI: -36.1, -7.0)] suggest a higher concentration of PFHIS coverage among the poor. Median OOPE for hospitalisation at private health facilities was INR 9000 (approx. USD 108.70) among those covered by PFHIS, whereas it was INR 10500 (approx. USD 126.82) at private health facilities among those not covered by insurance. CONCLUSION: While PFHIS seems to be appropriately targeting poorer populations, among the insured, OOPE for hospitalization persists. Among the uninsured, population subgroups with advantage are spending the greatest amount, raising questions about whether those facing relative disadvantage are forgoing care altogether or seeking care using cheaper, public avenues. Further policy action to more effectively reduce financial burden among left behind eligible populations under PFHIS will be essential to UHC progress in the state.

The Prevalence of Comorbidities and Associated Factors among Patients with Dementia in the Indian Setting: Meta-analysis of Observational Studies.

Background: Patients with dementia usually have multiple comorbidities. The presence of comorbidities may exacerbate the progression of dementia and decreases the patient's ability to participate in health maintenance activities. However, there is hardly any meta-analysis estimating the magnitude of comorbidities among patients with dementia in the Indian context. Methods: We searched PubMed, Scopus, and Google Scholar, and relevant studies conducted in India were included. The risk of bias was assessed and a random-effects meta-analysis model was used in which I2 statistics were calculated to measure heterogeneity among studies. Results: Fourteen studies were included in the meta-analysis based on the inclusion and exclusion criteria. Altogether, we found the coexistence of comorbid conditions such as hypertension (51.10%), diabetes (27.58%), stroke (15.99%), and factors like tobacco use (26.81 %) and alcohol use (9.19%) among patients with dementia in this setting. The level of heterogeneity was high due to differences in the methodologies in the included studies. Conclusions: Our study found hypertension as the most common comorbid condition among patients with dementia in India. The observed lacuna of methodological limitations in the studies included in the current meta-analysis provides the urgent need for good quality research to successfully meet the challenges ahead while devising appropriate strategies to treat the comorbidities among patients with dementia.

On the forms, contributions and impacts of community mobilisation involved with Kerala's COVID-19 response: Perspectives of health staff, Local Self Government institution and community leaders.

BACKGROUND: Kerala, a south Indian state, has a long and strong history of mobilisation of people's participation with institutionalised mechanisms as part of decentralisation reforms introduced three decades ago. This history formed the backdrop of the state's COVID-19 response from 2020 onwards. As part of a larger health equity study, we carried out an analysis to understand the contributions of people's participation to the state's COVID-19 response, and what implications this may have for health reform as well as governance more broadly. METHODS: We employed in-depth interviews with participants from four districts of Kerala between July and October, 2021. Following written informed consent procedures, we carried out interviews of health staff from eight primary health care centres, elected Local Self Government (LSG, or Panchayat) representatives, and community leaders. Questions explored primary health care reforms, COVID responses, and populations left behind. Transliterated English transcripts were analysed by four research team members using a thematic analysis approach and ATLAS.ti 9 software. For this paper, we specifically analysed codes and themes related to experiences of community actors and processes for COVID mitigation activities. RESULTS: A key feature of the COVID-19 response was the formation of Rapid Response Teams (RRTs), groups of lay community volunteers, who were identified and convened by LSG leaders. In some cases, pre-pandemic 'Arogya sena' (health army) community volunteer groups were merged with RRTs. RRT members were trained and supported by the health departments at the local level to distribute medicine and essential items, provided support for transportation to health facilities, and assisted with funerary rites during lockdown and containment period. RRTs often comprised youth cadres of ruling and opposition political parties. Existing community networks like Kudumbashree (Self Help Groups) and field workers from other departments have supported and been supported by RRTs. As pandemic restrictions eased, however, there was concern about the sustainability of this arrangement as well. CONCLUSION: Participatory local governance in Kerala allowed for the creation of invited spaces for community participation in a variety of roles as part of the COVID 19 response, with manifest impact. However, the terms of engagement were not decided by communities, nor were they involved more deeply in planning and organising health policy or services. The sustainability and governance features of such involvement warrant further study.

The Distribution of Lifestyle Risk Factors Among Patients with Stroke in the Indian Setting: Systematic Review and Meta-Analysis.

Background: The burden of stroke is increasing in India, but there is limited understanding of the distribution of reported risk factors in the Indian setting. It is vital to generate robust data on these modifiable risk factors to scale up appropriate strategies for the prevention of cerebrovascular diseases in this setting. Summary: The objective of this study is to estimate the overall proportion of life style risk factors of patients with stroke in the Indian setting. We searched PubMed and Google Scholar and relevant studies published till February 2022 were included. The risk of bias assessment was considered for the study selection criterion in the meta-analysis. The publication bias was evaluated by funnel plots and Egger's test. We identified 61 studies in the systematic review and after quality assessment, 36 studies were included for meta-analysis. Random effect model was used due to the significant inconsistency among the included studies (I2 > 97%). The mean age of the participants was 53.84±9.3 years and patients with stroke were predominantly males (64%). Hypertension (56.69%; 95% CI: - 48.45 - 64.58), obesity (36.61%; 95% CI: - 19.31 - 58.23), dyslipidemia (30.6%; 95% CI: - 22 - 40.81) and diabetes mellitus (23.8%; 95% CI: - 18.79 - 29.83) are the leading intermediate conditions associated with stroke. The Physical inactivity - 29.9% (95% CI: - 22.9 - 37.1), history of tobacco use (28.59 %; 95% CI: - 22.22 - 32.94) and alcohol use (28.15 %; 95% CI: - 20.49 - 37.33) were reported as the behavioral risk factors for stroke in this setting. Key Messages: The current meta-analysis provides robust estimates of the life style related risk-factor of stroke in India based on the observational studies conducted from 1994 to 2019. Estimating the pooled analysis of stroke risk factors is crucial to predict the imposed burden of the illness and ascertain the treatment and prevention strategies for controlling the modifiable risk factors in this setting.

Hidden educational inequalities in high blood pressure and high blood glucose levels in Kerala: evidence from the National Family Health Survey (2019-2021).

OBJECTIVE: This study assesses educational inequalities in measured as well as self-reported high blood pressure (BP) and high blood glucose (BG) in the southern Indian state of Kerala, which is known to have high chronic disease morbidity. DESIGN: The present findings are drawn from a large-scale, nationally representative cross-sectional study. SETTINGS AND PARTICIPANTS: India's Demographic and Health Survey (conducted in 2019-2021) had data on 36 526 individuals aged 15 years and above in the state of Kerala, India. PRIMARY AND SECONDARY OUTCOMES MEASURES: Measured high BP and BG; self-reported high BP and BG; as well as self-reported BP and BG testing. Descriptive statistics, bivariate analysis, along with multivariate statistics, were used. Educational inequalities were assessed through absolute and relative complex measures of inequality, namely the Slope Index of Inequality (SII) and Relative Concentration Index (RCI), respectively, with 95% CIs. RESULTS: The largest margin of inequality in Kerala, between the least and the most educated groups, was observed for measured high BP (57.7% and 17.6%). Measured high BP (SII -45.4% (95% CI -47.3% to -43.4%); RCI -26.6% (95% CI -27.9% to -25.3%)), self-reported high BP (SII -34.5% (95% CI -36.3% to -32.7%); RCI -19.0% (95% CI -20.1% to -17.9%)). High BG levels were concentrated among those with lower educational attainment (SII -26.6% (95% CI -28.6% to -24.7%); RCI -15.7% (95% CI -16.9% to -14.5%)), represented by negative SII and RCI values. CONCLUSIONS: The study findings suggest that research and programme efforts need to be redoubled to determine what is driving greater vulnerability to non-communicable diseases among population with lower educational attainment on the one hand and the possible role that improving education access can be on health outcomes, on the other hand. Further research should explore relevant intersections with low education.

The Psychological Morbidity among Health Care Workers During the Early Phase of Covid-19 Pandemic in India: A Systematic Review and Meta-Analysis.

Across India, there have been multiple studies conducted to address the issues of the mental health of healthcare workers during the COVID-19 pandemic. The present study estimated the pooled prevalence of psychological morbidity among healthcare workers during the early phase of the COVID 19 pandemic in India. We searched the following electronic bibliographic databases: PubMed, ScienceDirect, Wiley online library, and Google scholar for studies conducted from the onset of the COVID 19 pandemic until 25 September 2021. The methodological quality of each study was scored and outcome measures with uniform cut off scores as per various screening measurements were evaluated. According to the current meta analysis, the pooled estimates of depression, anxiety, stress, and insomnia among Indian healthcare workers during the COVID 19 pandemic are 20.1% (95% CI: 15.6 to 24.6%; n = 21 studies), 25.0% (95% CI: 18.4 to 31.6%; n = 20 studies), 36% (95% CI: 23.7 to 48.2%; n = 22 studies) and 18.9% (95% CI: 9.9 to 28.0%; n = 6 studies) respectively. In subgroup analyses, low quality studies based on the JBI checklist (Score < 3/9) and studies using DASS 21 showed a higher pooled prevalence of depression and anxiety. About 20-36% of the healthcare workers in India reported having depression, anxiety, and stress during the early phase of the COVID 19 pandemic. The present study provides a comprehensive review of the overall burden of mental health problems among healthcare workers during the COVID 19 pandemic in India necessitating appropriate intervention strategies to protect these frontline groups before the memory of the pandemic crisis starts to fade.

Who are the vulnerable, and how do we reach them? Perspectives of health system actors and community leaders in Kerala, India.

BACKGROUND: Among the core principles of the 2030 agenda of Sustainable Development Goals (SDGs) is the call to Leave no One behind (LNOB), a principle that gained resonance as the world contended with the COVID-19 pandemic. The south Indian state of Kerala received acclaim globally for its efforts in managing COVID-19 pandemic. Less attention has been paid, however, to how inclusive this management was, as well as if and how those "left behind" in testing, care, treatment, and vaccination efforts were identified and catered to. Filling this gap was the aim of our study. METHODS: We conducted In-depth interviews with 80 participants from four districts of Kerala from July to October 2021. Participants included elected local self-government members, medical and public health staff, as well as community leaders. Following written informed consent procedures, each interviewee was asked questions about whom they considered the most "vulnerable" in their areas. They were also asked if there were any special programmes/schemes to support the access of "vulnerable" groups to general and COVID related health services, as well as other needs. Recordings were transliterated into English and analysed thematically by a team of researchers using ATLAS.ti 9.1 software. RESULTS: The age range of participants was between 35 and 60 years. Vulnerability was described differentially by geography and economic context; for e.g., fisherfolk were identified in coastal areas while migrant labourers were considered as vulnerable in semi-urban areas. In the context of COVID-19, some participants reflected that everyone was vulnerable. In most cases, vulnerable groups were already beneficiaries of various government schemes within and beyond the health sector. During COVID, the government prioritized access to COVID-19 testing and vaccination among marginalized population groups like palliative care patients, the elderly, migrant labourers, as well as Scheduled Caste and Scheduled Tribes communities. Livelihood support like food kits, community kitchen, and patient transportation were provided by the LSGs to support these groups. This involved coordination between health and other departments, which may be formalised, streamlined and optimised in the future. CONCLUSION: Health system actors and local self-government members were aware of vulnerable populations prioritized under various schemes but did not describe vulnerable groups beyond this. Emphasis was placed on the broad range of services made available to these "left behind" groups through interdepartmental and multi-stakeholder collaboration. Further study (currently underway) may offer insights into how these communities - identified as vulnerable - perceive themselves, and whether/how they receive, and experience schemes designed for them. At the program level, inclusive and innovative identification and recruitment mechanisms need to be devised to identify populations who are currently left behind but may still be invisible to system actors and leaders.

Of primary health care reforms and pandemic responses: understanding perspectives of health system actors in Kerala before and during COVID-19.

BACKGROUND: In 2016, the Government of the southern Indian state of Kerala launched the Aardram mission, a set of reforms in the state's health sector with the support of Local Self Governments (LSG). Primary Health Centres (PHCs) were slated for transformation into Family Health Centres (FHCs), with extended hours of operation as well as improved quality and range of services. With the COVID-19 pandemic emerging soon after their introduction, we studied the outcomes of the transformation from PHC to FHC and how they related to primary healthcare service delivery during COVID-19. METHODS: A qualitative study was conducted using In-depth interviews with 80 health system actors (male n = 32, female n = 48) aged between 30-63 years in eight primary care facilities of four districts in Kerala from July to October 2021. Participants included LSG members, medical and public health staff, as well as community leaders. Questions about the need for primary healthcare reforms, their implementation, challenges, achievements, and the impact of COVID-19 on service delivery were asked. Written informed consent was obtained and interview transcripts - transliterated into English-were thematically analysed by a team of four researchers using ATLAS.ti 9 software. RESULTS: LSG members and health staff felt that the PHC was an institution that guarantees preventive, promotive, and curative care to the poorest section of society and can help in reducing the high cost of care. Post-transformation to FHCs, improved timings, additional human resources, new services, fully functioning laboratories, and well stocked pharmacies were observed and linked to improved service utilization and reduced cost of care. Challenges of geographical access remained, along with concerns about the lack of attention to public health functions, and sustainability in low-revenue LSGs. COVID-19 pandemic restrictions disrupted promotive services, awareness sessions and outreach activities; newly introduced services were stopped, and outpatient numbers were reduced drastically. Essential health delivery and COVID-19 management increased the workload of health workers and LSG members, as the emphasis was placed on managing the COVID-19 pandemic and delivering essential health services. CONCLUSION: Most of the health system actors expressed their belief in and commitment to primary health care reforms and noted positive impacts on the clinical side with remaining challenges of access, outreach, and sustainability. COVID-19 reduced service coverage and utilisation, but motivated greater efforts on the part of both health workers and community representatives. Primary health care is a shared priority now, with a need for greater focus on systems strengthening, collaboration, and primary prevention.

Nurse-led brief psycho-education on self-stigma among clients with schizophrenia and affective disorders: - Solomon four-group design.

BACKGROUND: The negative impact of self-stigma among clients with mental illness is well documented. Psychoeducation was found to be an effective measure for managing the treatment gap by reducing the stigma associated with the illness. PURPOSE: The present study investigated the effectiveness of a nurse-led brief psycho-education in reducing self-stigma among clients in the remittent stage of schizophrenia and affective disorders. METHODS: This study used Solomon- four-group design and was carried out at the Institute of mental health, Rohtak, India. A total of 80 participants were consecutively recruited using the block randomization method and as per the sampling criteria. A trained nurse delivered a 30-min individual-based brief psycho-education to the intervention group as per the standard module. The outcome measure was the reduction in the stigma based on a standardized stigma scale during a 1-month follow-up period. RESULTS: The mean age of the participants was 40.48 years (SD = 3.55). Overall, the study observed a significant reduction of stigma scores in the intervention group in the alienation, stereotype endorsement, social withdrawal domain of ISMI during 1-month follow-up (p < 0.001). No interaction effect was found between intervention and pre-test except the social withdrawal domain (p = 0.034). CONCLUSIONS: The nurse-led brief psycho-education has the potential to reduce stigma among clients with mental illness. Our findings open an area of discussion for placing greater attention on nurse-led brief psycho-education in this setting. The study provides pioneer research evidence regarding the involvement of nurses as brief psycho-education therapists among clients attending the tertiary mental health care unit of a lower-middle-income country. Considering the short-term effect of this study, more studies should be conducted in similar settings for an evidence base to advocate supportive nursing care practices in the routine mental health setting.

The prevalence and correlates of comorbidities among patients with cancer attending a tertiary care cancer center in South India: An analytical cross-sectional study.

Background: Comorbidities in patients with cancer can affect treatment, and should, therefore, be prioritized and managed. Objectives: Our primary aim was to assess the prevalence of comorbidities among patients with cancer. The secondary objective was to identify the association of comorbidities with various sociodemographic and clinical variables. Materials and Methods: This was a cross-sectional study conducted between December 2019 and March 2020 among patients with cancer, seeking treatment at Malabar Cancer Center, in Kannur District of northern Kerala in South India. Semi-structured interviews were conducted, and comorbidities were assessed using the Charlson Comorbidity Index. The anthropometric measurements were recorded using a standardized instrument and protocol. Results: We enrolled 242 patients in this study. There were 148 (61.2%) female patients; 106 (43.8%) were aged between 41 and 50 years. Cancers of the head-and-neck and breast accounted for the majority of cases (23.1% each, n = 56), followed by the digestive system (18.6%, n = 45) and female reproductive system (11.2%, n = 27). The most common primary cancers in the head-and-neck, digestive, and female reproductive systems were oral, colorectal, and cervical, respectively. The prevalence of comorbidities among patients with cancer was 70.2% (n = 170). Common comorbidities were hypertension (n = 82 ; 33.9%), arthritis (n = 57; 23.6%), and diabetes (n = 53; 21.6%). After controlling for potential confounders, the factors noted to be independently associated with the presence of comorbidities were advanced age, family history of comorbidity, normal weight or underweight, and cancer treatment for more than 6 months' duration. Conclusions: The high prevalence of comorbidities among patients with cancer suggests the need for an integrated system of care and management as the comorbidities affect the overall management of cancer treatment and care.

Monitoring the Family Health Centres in Kerala, India: Findings from a facility survey.

Introduction: Kerala, a south Indian state, has often been cited globally as a model for better health outcomes at low cost but faces unique challenges in achieving Universal Health Coverage (UHC). To propel the efforts in achieving UHC, the Government of Kerala announced the "Aardram" health reform initiative, emphasising improving the quality of primary care service delivery. The reforms started in 2017, and in the first stage, 170 of 848 Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The facilities were provided with additional doctors, nurses, and paramedical staff; the working hours were extended, and the range of services offered increased. In support of these processes, we carried out a facility assessment to assess differences between upgraded FHCs and existing PHCs. Materials and Methods: We conducted a facility-based cross-sectional assessment in eight primary care facilities of Kerala, FHC (N=4) and PHCs (N=4) from June to October 2019. A structured questionnaire covering utilisation and coverage of selected priority services for various populations and health outcome data was filled out by health staff to report data for the financial year 2018-19. Data were analysed in Microsoft Excel spreadsheets for easy analysis and replication by state stakeholders. Results: Coverage indicators such as full antenatal care and full immunization coverage were not appreciably different in FHCs as compared to PHCs. However, key reform-related differences were observed. On average, FHCs had 0.8 medical officers and one staff nurse per 10,000 population, whereas PHCs had 0.7 medical officers and less than 0.4 staff nurses per 10,000 population, even as the size of populations served by these human resources varied greatly across both types of facilities. The number of outpatient department visits per 10,000 population annually was 11,343 persons in FHCs and 9,580 persons in PHCs. FHCs also provided additional services such as screening for depression and chronic obstructive pulmonary disorders. Conclusion: Aardram primary healthcare reforms are still in their early days and appear to be associated with improved service coverage at the institutional level. However, some patterns are uneven: reforms should be carefully documented, and population-level impacts monitored over time.

Prevalence of Physical and Psychological Impacts of Wearing Personal Protective Equipment on Health Care Workers During COVID-19: A Systematic Review and Meta-Analysis.

Background: The COVID-19 pandemic has necessitated the use of personal protective equipment (PPE) among the frontline health care workers (HCWs). Even though PPE helps in preventing infection, it poses significant physical and psychological impacts at varying levels. Correspondingly, multiple independent studies have brought out the PPE-associated problems. However, there exists a lacuna on comprehensive information of global prevalence related to the same. Aim: To estimate the prevalence and risk factors of PPE among HCWs during COVID-19 across the globe. Design: Systematic review and meta-analysis. Method: The review was undertaken as per the protocol registered in PROSPERO CRD42021272216 following Preferred Reporting Items for Systematic Reviews and Meta-Analysis(PRISMA) guidelines. Two independent reviewers have undertaken the search strategy, study selection, and methodological quality assessment. Discrepancies were addressed by the third reviewer. Heterogeneity was addressed through I2 statistics and forest plots generated by open meta-software. Results: A total of 16 articles conducted across 6 different countries among 10,182 HCWs were included in the review. The pooled prevalence of skin lesions, headache, sweating, breathing difficulty, vision difficulty, thirst/dry mouth, fatigue, and communication difficulty, anxiety, fear were 57 (47-66%), 51 (37-64%), 75 (56-90%), 44 (23-68%), 61 (21-94%), 54 (30-77%), 67 (58-76%), 74 (47-94%), 28 (24-33%), 14 (10-17%), respectively. Moreover, the various risk factors included are the use of PPE for >6 h and young females. In addition, the medical management of new-onset problems created an additional burden on the frontline health care personnel (HCP). Conclusion: The frontline HCWs encountered physical and psychological problems at varying levels as a result of wearing PPE which needs to be addressed to prevent the inadequate use of PPE leading to infections.

Problematic Internet Use Among School-Going Adolescents in India: A Systematic Review and Meta-Analysis.

Background: Problematic internet use (PIU) among school going adolescents constitutes a major area of concern. However, no comprehensive reports are available to determine the magnitude of the problem. This study aimed to estimate the pooled prevalence of PIU among school going adolescents in India. Methods: We conducted a systematic review and meta analysis of 15 studies conducted in various parts of India. Results: The prevalence of moderate and severe PIU among Indian school going adolescents was 21.5% (95% CI: 17.0%-26.8%) and 2.6% (95% CI: 1.6%-4.2%) based on the Young Internet Addiction Test (Y IAT) cutoff points of 50 and 80, respectively. In subgroup analysis, it was found that the year of publication, gender, sampling method, and severity of addiction had a significant effect on the prevalence estimates. Conclusions: Currently, the use of the internet is rampant in India and our findings reflect nationally representative data on the magnitude of PIU among school going adolescents. About one fifth of school going adolescents are at risk of PIU in this setting. There is a need for further research in the reconsideration of cut off points of the Y IAT among Indian adolescents.

Decomposing socioeconomic inequality in blood pressure and blood glucose testing: evidence from four districts in Kerala, India.

BACKGROUND: Non-Communicable Diseases (NCDs) constitute a significant danger to the nation's public health system, both in terms of morbidity and mortality, as well as the financial burden they inflict. Kerala is undergoing an epidemiologic transition, which has significantly impacted the state's morbidity and mortality figures. For decades, the state has been putting in place myriad programs to reduce the burden of NCDs across population groups. Socioeconomic inequalities in NCD testing have been documented in India, although they are understudied in Kerala. The study aimed to estimate and characterize districtwise socioeconomic inequality in Blood Pressure (BP) and Blood Glucose (BG) testing. METHODS: A cross-sectional household survey was conducted between July-October 2019 in Kasaragod, Alappuzha, Kollam and Thiruvananthapuram districts of Kerala, India. A total of 6383 participants aged 30 years and above were interviewed using multistage random sampling. Descriptive statistics were derived district-wise. We computed ratios, differences, equiplots, and Erreygers concentration indices for each district to measure socioeconomic inequality in BP and BG testing. Erreygers decomposition techniques were used to estimate the relative contribution of covariates to socioeconomic inequality. RESULTS: There was a significant concentration of BP and BG testing favouring wealthier quintiles in Alappuzha, Kollam, and Thiruvananthapuram districts. The inequality in BP and BG testing was highest in Thiruvananthapuram (0.087 and 0.110), followed by Kollam (0.077 and 0.090), Alappuzha (0.083 and 0.073) and Kasaragod (0.026 and 0.056). Decomposition analysis revealed that wealth quintile and education contributed substantially to socioeconomic inequality in BP and BG testing in all four districts. It was also found that family history of NCDs significantly contributed to observed socioeconomic inequality in BP testing (29, 11, 16, and 27% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram, respectively). Similarly, in BG testing, family history of NCDs substantially contributed to observed socioeconomic inequality, explaining 16-17% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram respectively of the total inequality. CONCLUSION: While the magnitude of socioeconomic inequality in NCD risk factor testing did not appear to be very high in four Kerala districts, although levels were statistically significant in three of them. Greater exploration is needed on how education and caste contribute to these inequalities and their relationship to NCD risk factors such as family history. From such analyses, we may be able to identify entry points to mitigate inequalities in testing access, as well as burden.

The Quality of Life of Stroke Survivors in the Indian Setting: A Systematic Review and Meta-Analysis.

Background: The significant burden of stroke on the mortality rates of developing countries, including India, is well-documented in the literature. However, robust data regarding the aggregates of evidence on the quality of life (QOL) of stroke survivors is limited. Objective: To gather relevant information for policymakers on the QOL of stroke survivors based on observational studies conducted in the Indian setting. Methods: We searched PubMed, Scopus, and Google Scholar for studies conducted in the Indian setting. The methodological quality of each study was scored, and data were extracted from the published reports. The risk of bias assessment was conducted based on the JBI Critical Appraisal Checklist criteria. The relevant data regarding QOL were analyzed by a random effects model using R software. Results: 16 studies were included in the systematic review in which the majority of the studies recruited study participants in the hospital-based setting with an average duration of 3-6 months following the stroke episode. Our findings suggest that the pooled mean quality of life in the four dimensions of the World Health Organization Quality of Life instrument (WHOQOL-BREF) were ranged from 46.86 to 61.37 and the overall Stroke Specific Quality of Life scale (SS-QOL) mean score was 157.16. There was a significant inconsistency among the included studies as heterogeneity was high (I2 >97%). Conclusion: Assessment of the quality of life among stroke survivors is a crucial step to predict the illness' imposed burden and ascertain the effectiveness of the treatment. The present meta-analysis elucidates the aggregate estimates of quality of life and contributes to the research on the quality of life following a stroke in an Indian context.

COVID-19 and Psychological Distress among the General Population of India: Meta-Analysis of Observational Studies.

Background: There is scanty evidence regarding the magnitude of COVID-19-related psychological distress (PD) among the general population of India. Objectives: This study aimed to estimate the pooled prevalence of PD among the general public of India during the COVID-19 pandemic. Material and Methods: We conducted a meta-analysis of 21 online surveys conducted across the Indian subcontinent and published between 2020 and 2021. Results: Overall estimates of PD among the general public during the COVID-19 pandemic by the random-effects model is 33.3% (95% confidence interval: 23.8%-42.8%; n = 21 studies). The level of heterogeneity was high among the included studies (I2 = 99.67%). In subgroup analysis, it was found that the survey tool and the methodological quality had a significant effect on the overall prevalence estimates. Approximately 33% of the general public reported to have PD during the COVID-19 pandemic in India, although the overall prevalence varied based on survey tools and quality of studies. Conclusion: As the pandemic crisis seems to be ebbing across the world, the current findings are a wake-up call to devise pragmatic strategies to curtail the burden of similar pandemics and to successfully meet the challenges ahead.

The prevalence of alcohol use disorders using alcohol use disorders identification test (AUDIT) in the Indian setting: - a systematic review and meta-analysis.

There is a wide discrepancy in the epidemiology of alcohol use disorders (AUDs) due to diverse scales and survey approaches. We estimated the prevalence of AUDs by comparing the pooled prevalence based on the alcohol use disorders identification test (AUDIT) Vs. non-AUDIT (all scales other than AUDIT). This review searched the community-based prevalence of AUDs in PubMed, Web of Science, PsycINFO, Scopus, Ovid, and Google Scholar. Articles published during the years from 2000 to 2020 were included. The methodological quality of each study was scored, and data were extracted from the published reports. Pooled prevalence was estimated, and the publication bias was evaluated. Twenty-one studies conducted in different states of India included 73997 community-based respondents, which estimated the overall prevalence of AUDs as 12.5% (95% CI: 9 to 17.3%). The pooled prevalence based on AUDIT was 12.4% (AUDIT ≥8; 95% CI: 8.8 to 17.1%) in which the magnitude of hazardous and harmful alcohol use (8.6%; 95% CI: 5.7 to 12.8%; AUDIT 8-19) was significantly higher than dependent alcohol use (2.3%; 95% CI: 1.1 to 4.8%; AUDIT ≥ 20). The pooled prevalence using the non-AUDIT tool was 14.2(95%; CI: 6-30%). Our findings further reveal that about one in twelve of the population of India have AUDs, and there is a gross variation in the patterns of alcohol use across the country. The high prevalence of AUDs suggests developing a national policy to benefit alcohol use, justifying regional variations.