Evolving social health scheme for workers in unorganized sector: key evidences from study of cycle rickshaw pullers in Delhi, India.

BACKGROUND: In view of high out-of-pocket costs and low spending even for basic healthcare for the poor employed in the unorganized sector, policy makers in India have turned their attention to developing a financing mechanism for social health insurance with the desire to provide quality care to the poor and economically disadvantaged. OBJECTIVES: This study aims to assess and determine the disease profile, treatment expenditure and willingness to pay for health insurance among rickshaw pullers in Delhi. METHODS: The study was conducted among 500 rickshaw pullers from five zones of the Municipal Corporation of Delhi, taking a sample of 100 from each zone. RESULTS: The average cost of treatment was Rs.505 for outpatient and Rs. 3200 for inpatient care. To finance the treatment expenditure, 27.5% of the respondents spent from their household savings, and 43% had to borrow funds. Any "spell of sickness" and "total expenditure on acute illness" were significantly (p < 0.01) associated with the willingness to pay for health insurance. Overall, the majority (83%) of participants were willing to pay for health insurance. CONCLUSION: The study provides the evidence for the need for urgent policy development by introducing a social health insurance package including wage losses for the vulnerable groups such as rickshaw pullers in the unorganized sector in India, which significantly contribute to pollution free and cheap transportation of community, tourists and commercial goods as well.

Economic and disease burden of dengue illness in India.

Between 2006 and 2012 India reported an annual average of 20,474 dengue cases. Although dengue has been notifiable since 1996, regional comparisons suggest that reported numbers substantially underrepresent the full impact of the disease. Adjustment for underreporting from a case study in Madurai district and an expert Delphi panel yielded an annual average of 5,778,406 clinically diagnosed dengue cases between 2006 and 2012, or 282 times the reported number per year. The total direct annual medical cost was US$548 million. Ambulatory settings treated 67% of cases representing 18% of costs, whereas 33% of cases were hospitalized, comprising 82% of costs. Eighty percent of expenditures went to private facilities. Including non-medical and indirect costs based on other dengue-endemic countries raises the economic cost to $1.11 billion, or $0.88 per capita. The economic and disease burden of dengue in India is substantially more than captured by officially reported cases, and increased control measures merit serious consideration.

Prevention of vertical transmission of HIV in India through service integration: lessons from Mysore District, Karnataka.

Meeting the needs of HIV-positive pregnant women and their offspring is critical to India's political and financial commitment to achieving universal access to HIV prevention, treatment, care and support. This review of the strategy to prevent vertical transmission of HIV in Mysore district, Karnataka, highlights the need to integrate prevention of parent-to-child transmission (PPTCT) and reproductive and child health (RCH) services. All key officials who were involved in the integration of services at the state and district levels were interviewed by use of semistructured protocols. Policy documents and guidelines issued by the Department of Health and Family Welfare and Karnataka State AIDS Prevention Society were reviewed, as were records and official orders issued by the office of District Health and Family Welfare Officer and District HIV/AIDS Programme Office, Mysore. Routine data were also collected from all health facilities. This review found that 4.5 years of PPTCT-RCH integration resulted not only in a rise in antenatal registrations but also in almost all pregnant women counselled during antenatal care undergoing HIV tests. Based on the findings, we propose recommendations for successful replication of this strategy. Integration of PPTCT services with RCH should take place at all levels - policy, administration, facility and community. The increased demand for HIV counselling and testing resulting from service integration must be met by skilled human resources, sufficient facilities and adequate funds at the facility level.

Complete sperm suppression induced by dienogest plus testosterone undecanoate is associated with down-regulation in the expression of upstream steroidogenic enzyme genes in rat testis.

BACKGROUND: We had shown that dienogest (DNG) + testosterone undecanoate (TU) induced complete sperm suppression in rats when administered together every 45 days. On the other hand, individual drugs given alone in a similar fashion failed to achieve the same result. STUDY DESIGN: The present study was therefore undertaken to determine the reason for such a differential sperm suppression and to correlate it with the expression of steroidogenic enzyme genes in the rat testis. RESULTS: Administration of DNG (40 mg/kg body weight [bw]) + TU (25 mg/kg bw) every 45 days for a duration of 90 days induced spermatogenic arrest, leading to a significant reduction in testicular weight and number of precursor germ cells. Flow cytometric analysis further confirmed the same result, leading to a significant shift in the distribution of haploid cells. Measurement of testosterone (serum and intratesticular) was significantly low. Complete sperm suppression coincided with significant down-regulation in the expression of upstream steroidogenic enzyme genes represented serially by cytochrome P450 side-chain cleavage, P450 17α-hydroxylase, 3ß-hydroxysteroid dehydrogenase and steroidogenic acute regulatory protein (StAR) in the testis. On the other hand, rats administered with either DNG or TU alone demonstrated incomplete sperm suppression in which the expression of all the above genes remained characteristically nonuniform. CONCLUSION: Taken together, the above findings corroborate the fact that regulation of expression of three of the upstream steroidogenic enzymes genes and the StAR protein in rat testis is crucial in leading to complete sperm suppression as observed with DNG+TU treatment.

Extended intervention time and evaluation of sperm suppression by dienogest plus testosterone undecanoate in male rat.

BACKGROUND: The potential of using dienogest [DNG, 40 mg/kg body weight (bw)] plus testosterone undecanoate (TU, 25 mg/kg bw) in rats for development of a once-a-month male hormonal contraceptive has been reported earlier in our laboratories. STUDY DESIGN: In the present study, we report a separate efficacy evaluation of the same combination, DNG (40 mg/kg bw) and TU (25 mg/kg bw) in which interval of drug administration has been extended further to 45 and 60 days instead of every 30 days. RESULTS: Complete sperm suppression was observed in rats sacrificed either 60 or 90 days after DNG+TU administration, for two injections at 45-day interval. The neutral α-glucosidase activity in these treated rats remained in the normal range. Germ cell loss due to apoptosis was frequently observed both after 60 or 90 days of combination treatment. Significant decline in serum gonadotropin and testosterone, both serum and intratesticular levels, were observed in the treated rats. Following stoppage of treatment (given at 45-day interval) after two (0 and 45 days) or three injections (0, 45 and 90 days), complete restoration of spermatogenesis was observed by 120 and 165 days, respectively. The sperm suppression, however, could not be sustained when the period of combined drug administration was extended from every 45 to 60 days. CONCLUSIONS: Dienogest plus testosterone undecanoate in the above doses retained contraceptive effectiveness when administered every 45 days but not 60 days. The spermatogenic arrest was completely reversible once drug treatment is stopped. The dose and the frequency of intervention can be extrapolated in future clinical trials.

Self evolution: 1(st) domain of spiritual health.

While measuring physical, mental, and social health as defined by the World Health Organization (WHO), the basis of measurement is in terms of Determinants. Recently with the advent of health promotion activities, the emphasis is on enabling individuals, groups, and societies to have control on these Determinants. To measure the spiritual health, the 4(th) Dimension, a Spiritual Health Scale consisting of 3 Domains, 6 Constructs, and 27 Determinants of spiritual health were identified through a scientific process. A statistically reliable and valid Spiritual Health Scale (SHS 2011) containing 114 items has been developed. Construct validity and test-retest reliability has been established. The 3 Domains are: Self-Evolution, Self-Actualization, and Transcendence. In this article, the process of self evolution in terms of "Wider Perspective" and "Nurturance-Art" have been captured through the Determinants like Commitment, Introspection, Honesty, Creativity, Contemplation, Prayer, Philanthropy, Extending Self, Empathy, Yoga and Exercise, Questioning Injustice, Aesthetics, Value for Time, and Being Away From Comparisons.

Additional cash incentive within a conditional cash transfer scheme: a 'controlled before and during' design evaluation study from India.

BACKGROUND: Conditional Cash Transfer (CCT) schemes have shown largely favorable changes in the health seeking behavior. This evaluation study assesses the process and performance of an Additional Cash Incentive (ACI) scheme within an ongoing CCT scheme in India, and document lessons. MATERIAL AND METHODS: A controlled before and during design study was conducted in Madhya Pradesh state of India, from August 2007 to March 2008, with increased in institutional deliveries as a primary outcome. In depth interviews, focus group discussions and household surveys were done for data collection. RESULTS: Lack of awareness about ACI scheme amongst general population and beneficiaries, cumbersome cash disbursement procedure, intricate eligibility criteria, extensive paper work, and insufficient focus on community involvement were the major implementation challenges. There were anecdotal reports of political interference and possible scope for corruption. At the end of implementation period, overall rate of institutional deliveries had increased in both target and control populations; however, the differences were not statistically significant. No cause and effect association could be proven by this study. CONCLUSIONS: Poor planning and coordination, and lack of public awareness about the scheme resulted in low utilization. Thus, proper IEC and training, detailed implementation plan, orientation training for implementer, sufficient budgetary allocation, and community participation should be an integral part for successful implementation of any such scheme. The lesson learned this evaluation study may be useful in any developing country setting and may be utilized for planning and implementation of any ACI scheme in future.

N-acetyl-L-cysteine counteracts oxidative stress and prevents H2O2 induced germ cell apoptosis through down-regulation of caspase-9 and JNK/c-Jun.

The mechanism of H(2)O(2) induced oxidative stress leading to male germ cell apoptosis was earlier reported from our laboratory. In the present study, we investigated the mechanisms by which N-acetyl-L-cysteine (NAC, which is highly cell specific with strong antioxidant and anti-genotoxic properties), stimulated cell survival under such conditions. Co-incubation with 5 mM NAC significantly (P<0.001) reduced the germ cell apoptosis induced by 10 µM H(2)O(2). Lipid peroxidation was brought down with significant restoration of activities of antioxidant enzymes, SOD, GST, and catalase. Expression of pro-apoptotic marker, Bax up-regulated following H(2)O(2) exposure, was reversed back to control levels. In contrast, expression of anti-apoptotic Bcl-2 and phospho-Akt revealed a completely opposite trend. While caspase-8 activity remained unaffected, NAC successfully attenuated the increased activities of caspase-3 and -9 in the H(2) O(2) treated cells. Simultaneously, the increased expression of caspase-9, phospho-JNK, and phospho-c-Jun after H(2)O(2) treatment was down-regulated by NAC. The above findings indicate that the mechanism of inhibition of H(2)O(2) induced male germ cell apoptosis by NAC is mediated through regulation of caspase-9 and JNK.

Altered levels of seminal nitric oxide, nitric oxide synthase, and enzymatic antioxidants and their association with sperm function in infertile subjects.

OBJECTIVE: To investigate the association between specific reactive nitrogen species and sperm function among infertile subjects. DESIGN: Controlled trial. SETTING: Fertility clinic at the National Institute of Health and Family Welfare, New Delhi, India. PATIENT(S): Proven fertile volunteers and subjects attending the above clinic. INTERVENTION(S): Tests for hypo-osmotic swelling (HOS), nuclear chromatin decondensation (NCD), acrosomal status (AS) were performed, and total nitric oxide (NO), nitric oxide synthase (NOS), superoxide dismutase (SOD), and catalase were assayed in infertile subjects subgrouped on the basis of routine sperm parameters. MAIN OUTCOME MEASURE(S): Correlation between sperm function and total NO, SOD, catalase, and NOS levels in semen. RESULT(S): Most of the infertile subjects were found to possess high NO and NOS activity in the semen. Leukocytospermic subjects, despite having normal sperm motility and viability, demonstrated subnormal sperm function scores. Nitric oxide in semen was inversely associated with sperm function in normospermia, asthenospermia, leukocytospermia, leukocytoasthenospermia, and teratospermia. In oligospermia with normal or subnormal motility, NO was positively associated with sperm function. Attenuated activities of either SOD or catalase or both were observed in all infertile subjects except those with normospermia. CONCLUSION(S): Subnormal sperm function in normospermia, asthenospermia, and leukocytospermia may be due to the cytotoxic effect of increased NO, whereas in oligospermia the same may be due to low or suboptimal levels.

Spiritual health scale 2011: defining and measuring 4 dimension of health.

In the midst of physical comforts provided by the unprecedented developments in all spheres of life, the humanity is at cross roads and looking at something beyond these means. Spirituality has now been identified globally as an important aspect for providing answers to many questions related to health and happiness. The World Health Organization is also keen at looking beyond physical, mental and social dimensions of the health, and the member countries are actively exploring the 4(th) Dimension of the health i.e. the spiritual health and its impact on the overall health and happiness of an individual. National Institute of Health and Family Welfare (NIHFW), realized this need and initiated a research study in this direction. In this study, an effort was made to define this 4(th) Dimension of health from a common worldly person's perspective and measure it. 3 Domains, 6 Constructs and 27 Determinants of spiritual health were identified through a scientific process. A statistically reliable and valid Spiritual Health Scale (SHS 2011) containing 114 items has been developed. Construct validity and test- retest reliability has been established for urban educated adult population. The scale is first of its kind in the world to measure the spiritual health of a common worldly person, which is devoid of religious and cultural bias. Its items have universal applicability.

AR versus ER (α) expression in the testis and pituitary following chronic estrogen administration in adult rat.

Modulation of the testis-pituitary axis has direct relevance to the expression of androgen and estrogen receptors. Androgen receptor (AR) and estrogen receptor (ERα) expression during hypospermatogenesis after chronic estrogen administration to rats was studied in the adult testis and pituitary utilizing immunohistochemistry, western blotting, and RT-PCR. Both organs demonstrated higher AR transcriptional activity gradually increasing from 15 days (d) to 30 d of estrogen treatment. However, the AR protein as measured by either immunostaining or western blotting demonstrated a significant decline. A distinct break down of the AR protein in the pituitary into two specific bands was seen. In contrast, higher ERα transcriptional activity coincided well with the rise in protein and immunoexpression in both organs. FSH and testosterone (serum, intra-testicular testosterone) were found significantly (p < 0.001) lowered compared with raised estradiol levels. Spermatogenesis was adversely affected and was associated with a significant increase in cell apoptosis in both organs. The pituitary demonstrated a higher rate of apoptosis at the end of 30 d of estrogen treatment. Taken together, the above data indicate that chronic estrogenization to adult rats up-regulates ERα but down-regulates AR protein expression in testis and pituitary which probably has a direct association to the marked rise in cell apoptosis in these organs.

N-acetylcysteine counteracts oxidative stress and prevents hCG-induced apoptosis in rat Leydig cells through down regulation of caspase-8 and JNK.

We have earlier reported that following persistent stimulation with hCG, oxidative stress-induced apoptosis in rat Leydig cells was mainly achieved through the extrinsic pathway. In the present study, the role of N-acetylcysteine (NAC) in counteracting the oxidative stress and the mechanisms of inhibition of apoptosis under such conditions were investigated. NAC (1 mM) intervention with repeated hCG stimulation (50 ng/ml, four times, each with 30 min challenge) prevented the decline in Leydig cell viability and the rise in lipid peroxidation and reactive oxygen species. Simultaneously, the activities of the enzymes glutathione-S-transferase, catalase, superoxide dismutase and the intracellular glutathione and antioxidant capacity of the treated cells improved significantly. Apoptotic markers Fas, FasL, and caspase-8, up-regulated following repeated hCG exposure, were significantly down-regulated following NAC co-incubation. While Bcl-2 expression was fully restored, Bax and caspase-9 remained unchanged. NAC treatment induced down-regulation of upstream JNK/pJNK and down-stream caspase-3 in the target cells. Taken together, the above findings indicate that NAC counteracted the oxidative stress in Leydig cells induced as a result of repeated hCG stimulation, and inhibited apoptosis by mainly regulating the extrinsic and JNK pathways of metazoan apoptosis.

Providers' knowledge, attitude and dispensing practices of e-pills in government dispensaries of South district in delhi, India.

BACKGROUND: South Delhi is one of the well developed districts in the capital with best public health care facilities. Knowledge, attitude and dispensing practices of emergency contraceptive pills (E-pills) were assessed among health care providers of government dispensaries in South Delhi. STUDY DESIGN: A descriptive epidemiological study. MATERIALS AND METHODS: Both medical and paramedical (n = 428) providers in 63 government health care facilities were interviewed between August to December 2007 using a semi-structured interview schedule. RESULTS: Among the different categories of the providers, medical officers were observed to be most knowledgeable about E-pills and the pharmacists were the least. The correct prescribed dose of E-pill was known only to 32% of the providers while 49% knew about its right time of intake. Misconceptions and apprehensions for promoting its use were very much prevalent even among medical officers as majority felt that open access to E-pills would increase promiscuity. The dispensing practice of providers was found positively (P < 0.05) correlated with their knowledge. Training resulted a significant (P < 0.05) improvement in knowledge, attitude and dispensing practice of the providers. Knowledge and training combined together contributed 35% to the dispensing practice (R(2) = 0.35). CONCLUSION: Besides knowledge, behavior change communication strategies should form a part of the training curricula of health care providers that would help to improve the dispensing practice of E-pills.

Primary health care and child survival in India.

The Primary Health Care (PHC) has been globally promoted as a comprehensive approach to achieve optimal health status and 'Health for all'. The PHC approach, although, initially received the attention but failed to meet the expectations of the people in India. The child health programs in India had been started for long as verticals programs, which later on integrated and had been planned in a way to deliver the services through the PHC systems. Nevertheless, the last decade has witnessed many new initiatives for improving child health, specially; a number of strategies under National Rural Health Mission have been implemented to improve child survival--Skilled Birth Attendant and Emergency Obstetric Care, Home Based Newborn Care, Sick newborn care units, Integrated Management of Neonatal and Childhood Illnesses, strengthening Immunization services, setting up Nutritional rehabilitation centers etc. However, for a large proportion of rural population, an effective and efficient PHC system is the only way for service delivery, which still needs more attention. The authors note that although there have been improvements in infrastructure, community level health workers, and availability of the funding etc., the areas like community participation, district level health planning, data for action, inter-sectoral coordination, political commitment, public private partnership, accountability, and the improving health work force and need immediate attention, to strengthen the PHC system in the country, making it more child friendly and contributory in child survival, in India.

Sperm function and seminal oxidative stress as tools to identify sperm pathologies in infertile men.

Routine semen analysis, which includes assessment of sperm motility, viability, and morphology, does not always provide complete diagnostic information as men demonstrating standard scores on these specific parameters sometimes remain infertile. In infertile men who had been subgrouped on the basis of sperm count, motility, morphology, and presence of leukocytes, an evaluation of sperm function and reactive oxygen species (ROS) was found to be effective tools to detect sperm pathologies.

Adverse effects associated with persistent stimulation of Leydig cells with hCG in vitro.

The detrimental effects of persistent stimulation with hCG were investigated in rat Leydig cells in vitro. Significant rise in lipid peroxidation and reactive oxygen species (ROS) with concomitant attenuation in the activities of antioxidant enzymes: superoxide dismutase, catalase, and glutathione-S-transferase was observed. Transcripts for catalase and superoxide dismutase were also depleted. Subsequent to each hCG challenge, the total antioxidant capacity in the target cells also declined significantly (P < 0.05). There was an increase in cell apoptosis (23%), which was associated with a rise in caspase-3 activity, PARP cleavage, and Fas, FasL, caspase-8 expression. While Bax and Caspase-9 expression remained unchanged, Bcl-2 demonstrated a marked decline. Taken together, the above data indicate that persistent hCG stimulation of Leydig cells induced adverse effects leading to oxidative stress and apoptosis which was channeled primarily through the extrinsic pathway.