Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study.

BACKGROUND: International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries. METHODS: Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated. FINDINGS: Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations. INTERPRETATION: We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems. FUNDING: The Lowitja Institute.

High Prevalence of Stroke in Rural Gadchiroli, India: A Community-Based Study.

BACKGROUND: In the near future, a majority of strokes are projected to occur in developing countries. However, population-level information on the prevalence of stroke from rural areas of developing countries, including India, is rare. We estimated the prevalence of stroke in a rural area of one of the most underdeveloped districts of India. METHODS: Trained surveyors conducted a house-to-house survey using a validated screening questionnaire in a well-defined population of 45,053 living in 39 villages in a demographic surveillance site in Gadchiroli district. A trained physician and a neurologist evaluated screen-positive patients and diagnosed stroke using the World Health Organization's criteria. RESULTS: In the screened population, 175 patients had stroke. The mean age of patients with stroke was 60.9 ± 14.7 years and 32.5% were women. The crude prevalence rate of stroke was 388.43 (95% CI 335.04-450.33) and the age-standardized prevalence rate of stroke was 535.58 (95% CI 492.41-583.01) per 100,000 population. The crude prevalence rate of stroke was significantly higher among men than among women (520 vs. 255/100,000 population, p < 0.05). CONCLUSION: In this prevalence study, conducted after a gap of 20 years in rural India, the prevalence of stroke was high and was more than twice the prevalence reported from the previous study. The prevalence was double among men compared to women. Stroke is emerging as a public health priority in rural India.

Stroke Is the Leading Cause of Death in Rural Gadchiroli, India: A Prospective Community-Based Study.

BACKGROUND AND PURPOSE: Stroke is an important cause of death and disability worldwide. However, information on stroke deaths in rural India is scarce. To measure the mortality burden of stroke, we conducted a community-based study in a rural area of Gadchiroli, one of the most backward districts of India. METHODS: We prospectively collected information on all deaths from April 2011 to March 2013 and assigned causes of death using a well-validated verbal autopsy tool in a rural population of 94 154 individuals residing in 86 villages. Two trained physicians independently assigned the cause of death, and the disagreements were resolved by a third physician. RESULTS: Of 1599 deaths during the study period, 229 (14.3%) deaths were caused by stroke. Stroke was the most frequent cause of death. For those who died because of stroke, the mean age was 67.47±11.8 years and 48.47% were women. Crude stroke mortality rate was 121.6 (95% confidence interval, 106.4-138.4), and age-standardized stroke mortality rate was 191.9 (95% confidence interval, 165.8-221.1) per 100,000 population. Of total stroke deaths, 87.3% stroke deaths occurred at home and 46.3% occurred within the first month from the onset of symptoms. CONCLUSIONS: Stroke is the leading cause of death and accounted for 1 in 7 deaths in this rural community in Gadchiroli. There was high early mortality, and the mortality rate because of stroke was higher than that reported from previous studies from India. Stroke is emerging as a public health priority in rural India.

Home-based management of neonatal sepsis: 23 years of sustained implementation and effectiveness in rural Gadchiroli, India, 1996-2019.

INTRODUCTION: Although hospitalisation remains the preferred management for neonatal sepsis, it is often not possible in resource-limited settings. The Home-Based Newborn Care (HBNC) study in Gadchiroli, India (1995-1998) was the first trial to demonstrate that neonatal sepsis can be managed in the community. HBNC continues to operate in Gadchiroli. In 2015, WHO recommended community-based management of neonatal sepsis when hospitalisation is not feasible but called for implementation research. We studied the implementation and effectiveness of home-based management of neonatal sepsis over 23 years in Gadchiroli. METHODS: In this cohort study (1996-2019), community health workers (CHWs) visited neonates at home in 39 villages in Gadchiroli, India. CHWs screened, diagnosed sepsis and offered home-based antibiotic treatment if hospitalisation was refused. We evaluated the implementation outcomes of coverage, diagnostic fidelity and adoption. We assessed the association between treatment type and odds of neonatal death using mixed effects logistic regression. Time trends were analysed using the Mann-Kendall test. RESULTS: CHWs screened 93.8% (17 700/18 874) of neonates (coverage) and correctly diagnosed 89% (1051/1177) of sepsis episodes (diagnostic fidelity). Home-based management was preferred by 88.4% (929/1051) of parents (adoption), with 5.6 percent of total neonates receiving antibioties at home. Compared with neonates treated at home, the adjusted odds of death was 5.27 (95% CI 1.91 to 14.58) times higher when parents refused all treatment, 2.17 (95% CI 1.07 to 4.41) times higher when CHWs missed the diagnosis and 5.45 (95% CI 2.74 to 10.87) times higher when parents accepted hospital referral. Implementation outcomes remained consistent over 23 years (coverage p=0.57; fidelity p=0.57; adoption p=0.26; mortality p=0.71). The rate of facility births increased (p<0.01) and the sepsis incidence decreased (p<0.05) over 23 years. CONCLUSION: Implementation of home-based management of neonatal sepsis was sustainable and effective over 23 years. During this period, the need for home-based management in Gadchiroli is declining. Home-based management is advised where sepsis remains a major cause of neonatal mortality and hospital access is limited.

Setting implementation research priorities to reduce preterm births and stillbirths at the community level.

Asha George and colleagues from the GAPPS group report the implementation research priorities to address prematurity and stillbirths at the community level that resulted from their recent expert consensus exercise.

Decline in the Incidence of Neonatal Sepsis in Rural Gadchiroli, India During the Twenty-one Years (1998-2019) Following the Home-based Neonatal Care Field-trial.

BACKGROUND: Sepsis is a leading cause of neonatal mortality globally. The home-based neonatal care (HBNC) field trial (1995-1998) in rural Gadchiroli demonstrated a reduction in the incidence of neonatal sepsis. The current study examines the trend of neonatal sepsis during the twenty-one years (1998-2019) following the trial's completion. METHODS: We conducted a retrospective cohort study based on the HBNC program data in rural Gadchiroli, India, from April 1998 to March 2019. All live-born neonates who spent all or part of the neonatal period in the 39 study villages and received HBNC were eligible for inclusion. Sepsis was diagnosed during regular home visits by trained village health workers if pre-specified clinical criteria were present. Sepsis incidence was computed for seven 3-year periods. Trend analyses were conducted using the Mann-Kendall test. RESULTS: Of the total 17,289 live births, 16,339 (94.5%) home visited were included. In this cohort, 1069 (65 per 1000 live births) neonates were diagnosed with sepsis. The incidence of neonatal sepsis declined from 111 per 1000 live births in 1998 to 2001 to 19 per 1000 live births in 2016 to 2019, an 82.9% decrease (P < 0.0001), mean 4% decrease per year. The incidence of neonatal sepsis declined for early-onset sepsis (P < 0.0001), late-onset sepsis (P < 0.0001), home births (P = 0.006), facility births (P < 0.0001), preterm neonates (P < 0.0001) and full-term neonates (P < 0.0001). CONCLUSIONS: The incidence of neonatal sepsis in rural Gadchiroli has continued to decline during the past twenty-one years. We hypothesize that the decline is due to the ongoing practice of HBNC, improved socioeconomic conditions, and new governmental health policies.

Control of scabies in a tribal community using mass screening and treatment with oral ivermectin -A cluster randomized controlled trial in Gadchiroli, India.

BACKGROUND: Scabies is often endemic in tribal communities and difficult to control. We assessed the efficacy of a community-based intervention using mass screening and treatment with oral ivermectin in controlling scabies. METHODS/ FINDINGS: In this cluster randomised controlled trial, 12 villages were randomly selected from a cluster of 42 tribal villages in Gadchiroli district. In these villages, trained community health workers (CHWs) conducted mass screening for scabies. The diagnosis was confirmed by a physician. Six villages each were randomly allocated to the intervention and usual care arm (control arm). In the intervention arm (population 1184) CHWs provided directly observed oral ivermectin to scabies cases and their household contacts. In the usual care arm (population 1567) scabies cases were referred to the nearest clinic for topical treatment as per the standard practice. The primary outcome was prevalence of scabies two months after the treatment. Secondary outcomes were prevalence of scabies after twelve months of treatment and prevalence of impetigo after two and twelve months of treatment. Outcomes were measured by the team in a similar way as the baseline. The trial was registered with the clinical trial registry of India, number CTRI/2017/01/007704. In the baseline, 2 months and 12 months assessments 92.4%, 96% and 94% of the eligible individuals were screened in intervention villages and 91.4%, 91.3% and 95% in the usual care villages. The prevalence of scabies in the intervention and usual care arm was 8.4% vs 8.1% at the baseline, 2.8% vs 8.8% at two months [adjusted relative risk (ARR) 0.21, 95% CI 0.11-0.38] and 7.3% vs 14.1% (ARR 0.49, 95% CI 0.25-0.98) at twelve months The prevalence of impetigo in the intervention and usual care arm was 1.7% vs 0.6% at baseline, 0.6% vs 1% at two months (ARR 0.55, 95% CI 0.22-1.37) and 0.3% vs 0.7% at 12 months (ARR 0.42, 95% CI 0.06-2.74). Adverse effects due to ivermectin occurred in 12.1% of patients and were mild. CONCLUSIONS: Mass screening and treatment in the community with oral ivermectin delivered by the CHWs is superior to mass screening followed by usual care involving referral to clinic for topical treatment in controlling scabies in this tribal community in Gadchiroli.

Epidemiology of pain in back and extremities in rural population: A community-based estimation of age- and sex-specific prevalence, distribution, duration and intensity of pain, number of painful sites and seasonality of pain during twelve months in rural Gadchiroli, India.

BACKGROUND: Population-based estimates of the burden of pain in back and extremities (PBE) by sex, age, intensity, seasonality and site are lacking from rural India. METHODS: Two villages were randomly selected from a cluster of 39 villages in Gadchiroli district in India. All residents'≥20 years of age were surveyed in January 2010 by trained surveyors by making household visits. Information on PBE in the 12 months prior to survey was obtained using a structured, pretested questionnaire. RESULTS: The 12-month period prevalence of PBE was 75% (95% confidence interval CI = 72.54-77.73) in men and 91% (95% CI = 88.66-92.13) in women. The prevalence of PBE in the participants >50 years was 94% while that in the age group 20 to 50 years was 79% (P < 0.05). The site with the highest prevalence of pain was low back (women 80%, men 59%). The mean number of painful sites per person was 5.42 (95% CI = 5.17-5.67) in women, 3.68 (95% CI = 3.45-3.90) in men, 3.89 (95% CI = 3.71-4.07) in participants aged 20 to 50 years and 6.48 (95% CI = 6.11-6.85) in those >50 years. Among participants across the age and sex groups, the prevalence of mild pain was higher than severe pain at all the anatomical sites. Among various seasons, the highest prevalence of pain was in the rainy season (14%). CONCLUSION: The prevalence and the number of painful sites were higher among women and in those >50 years of age. The public health interventions for PBE need to focus on these two high risk groups.

Burden of pain in back and extremities in rural population: A community-based estimation of 12-month prevalence, distribution and duration of pain in rural Gadchiroli, India.

BACKGROUND: Population based estimates of the burden of pain in back and extremities (PBE) are lacking from rural India. We estimated this burden, measured as a) 12-month prevalence, b) site specific prevalence c) total number of painful sites per adult, d) severity of pain and e) duration of pain in the rural adult population in Gadchiroli, India, over a period of 12 months. METHODS: This population-based, cross-sectional study was conducted in two villages randomly selected from a cluster of 7 eligible villages in Gadchiroli district of India. All adults ≥20 years in these villages were surveyed by the trained community health workers in January 2010 by making household visits. The data were collected using a structured, pretested questionnaire on the history of pain in back and extremities (PBE) at various anatomical sites and its features during the previous 12 months. RESULTS: Out of 2535 eligible adults in two villages, 2259 (89%) were interviewed, of which 1876 (83%) had an episode of PBE in the preceding 12 months. The period prevalence of pain was 76% in back (including lower back, thoracic and neck) and 71% in the extremities. Highest site specific prevalence was at lower back (70%), knee (46%), neck (44%), leg/calf (39%) and mid-back (39%). The mean number of painful sites per adult was 4.57 (standard deviation (SD) = 4.17). The prevalence of severe pain was 15%. The mean number of painful days due to PBE was 166 days. Female gender (odds ratio (OR) = 2.8, 95% confidence interval (CI) = 2.1-3.6), farming/labour occupation (OR = 1.8, 95% CI = 1.4-2.4), increasing age (more than 60 years OR = 6.3, 95% CI = 3.3-11.9) were significantly associated with the risk of PBE. CONCLUSION: Nearly five out of six adults in rural Gadchiroli suffered from pain in back or extremities during the preceding 12 months. Pain was at multiple sites and was present on a mean 166 days in the year. Female gender, farming / manual labor as occupation and increasing age were the key risk factors identified. The pain in back and extremities emerges as a public health priority in rural communities.

Activity limitation and disability due to pain in back and extremities in rural population: A community-based study during a period of twelve months in rural Gadchiroli, India.

BACKGROUND: Population based estimates of the extent of the activity limitation due to back pain and disability due to musculoskeletal pains are lacking from rural India. We estimated this burden as a) extent of activity limitation due to back pain, b) disability due to musculoskeletal pains, c) grading of the limitation of each activity due to back and musculoskeletal pain in the rural adult population in Gadchiroli, India. METHODS: This population-based, cross-sectional study was conducted in two villages randomly selected from a cluster of 7 eligible villages in Gadchiroli district of India. All adults ≥20 years in these villages were surveyed by the trained community health workers in January 2010. Disability due to back pain was evaluated using newly developed questionnaire for women and men which assessed limitations in the gender-specific daily household and occupational activities in a rural area. Disability due to pain in extremities was assessed using the Health Assessment Questionnaire (HAQ). RESULTS: The total population of the two villages was 3735 out of which 2535 (67.9%) were adults ≥20 years of age and were eligible to participate in the study. Of these, 2259 (89%) were interviewed and 1247 participants (55%) had any pain on the day of the survey. Activity limitation questionnaire was filled for 716 (91.4%) out of 783 patients with back pain. HAQ scale was filled for 524 (85.2%) out of 615 patients with pain in extremities. Among men with back pain, respectively 11%, 19%, 60% and 11% had no, mild, moderate to severe difficulty or were completely unable to perform agrarian work, while among women, respectively 6%, 20%, 69% and 4% had no, mild, moderate to severe difficulty or were completely unable to perform household activities. Based on the HAQ score, respectively 1%, 67%, 18% and 14% of the participants had no, mild, moderate to severe disability or were completely unable to perform the activities. CONCLUSIONS: This community-based study in rural Gadchiroli demonstrates significant mild to moderate disability and activity limitation, due to pain in back and extremities in a population involved in hard manual work, especially agricultural and underlines the need to address the problem through appropriate interventions. The study also employs for the first time an indigenously developed questionnaire to identify activity limitation due to back pain, and demonstrates the method as well as the questionnaire.

Clinical patterns and their prevalence among adult population with back pain: A community-based cross-sectional study in rural Gadchiroli, India.

BACKGROUND: Evaluating clinical patterns and their prevalence of back pain, a common problem in rural areas, can help develop treatment strategies to address this leading cause of disability. METHODS: We conducted a population-based study in rural Gadchiroli, India. In this, two-phase study, trained surveyors conducted a door to door survey (Phase 1) to identify individuals with pain in the back and extremities in two villages randomly selected using pre-defined criteria. Those with pain were evaluated by a team of spine surgeons and rheumatologists to diagnose clinical conditions among these patients (Phase 2). RESULTS: Of the 2535 eligible adults, 2259 (89%) were screened, 1247 (55%) reported pain in back and limb and were referred to the specialist clinic. Out of the 906 (73%) participants who attended the clinics, 783 (89%) had back/neck pain. The point prevalence of back/neck pain among adults was 49% (95% confidence interval (CI) = 49%-51%), non-specific low back pain 45% (95% CI = 43.4%-47.5%); non-specific neck pain 21% (95% CI = 18.9-22.4), radiculopathy 12 (95% CI = 10.4-13.1), myelopathy 0.4 (95% CI = 0.1-0.7) and other serious spinal disorders 0.2 (95% CI 0.048-0.45). The prevalence of non-specific back/neck pain and radiculopathy was higher among females. CONCLUSIONS: Non-specific back and neck pain are the commonest diagnoses among those with pain in the back and extremities, followed by radiculopathy. Serious disorders are rare. Given the high prevalence of non-specific back and neck pain, community health workers and physicians working in rural areas need to be trained systematically to manage these conditions.

Stroke Happens Suddenly so It Cannot Be Prevented: A Qualitative Study to Understand Knowledge, Attitudes, and Practices about Stroke in Rural Gadchiroli, Maharashtra, India.

Background Strokes have emerged as one of the leading causes of deaths in rural India but people often remain uninformed about it. This study sought to understand knowledge, attitudes, and healthcare-seeking practices about strokes in rural Gadchiroli, India. Methods A total of 12 focus group discussions were conducted with 34 female and 43 male participants from six villages. Responses were audio recorded, transcribed, coded, and analyzed using inductive method of qualitative data analysis. Results Respondents correctly recognized many symptoms of stroke and were aware of the sudden onset of symptoms. They were unaware of transient ischemic attacks. After stroke, healthcare was sought from private physicians, and physicians in the government run district hospital, or traditional herbal providers depending upon the accessibility, affordability, and perceived effectiveness of the therapy. Most of the respondents thought that stroke is a serious disease associated with disability as well as death and its occurrence in the community is increasing. However, only a few participants could correctly state how stroke occurs and its risk factors. Furthermore, many participants thought that stroke cannot be prevented as it occurs suddenly without any warning. Conclusion Rural people in Gadchiroli were aware of symptoms of stroke but awareness about the etiology and the risk factors was low. Suddenness of symptoms was perceived as a key barrier to taking any preventive action. Understanding such perceptions and addressing them can help improve counseling of patients by physicians and effectiveness of behavioral change communication to prevent stroke in rural areas.

Gaps in secondary prevention among stroke survivors in rural Gadchiroli, India: a community-based cross-sectional study.

Background: With epidemiological transition, stroke has emerged as a public health priority in rural India. However, population-level information on secondary prevention of stroke from rural areas of India and other low- and middle-income countries remains exceedingly rare. Methods: In a cross-sectional community-based survey, trained surveyors screened a well-defined population of 74,095 individuals living in 64 villages in Gadchiroli district of India for symptoms of stroke. A trained physician evaluated screen positive patients, diagnosed stroke, measured blood pressure and collected information on prior diagnosis of risk factors and current use of medications using a structured questionnaire. Results: A total of 265 stroke survivors were identified. Prior diagnosis of hypertension was made in 57.4%, diabetes in 9.8%, hyperlipidaemia in 0.4%, ischaemic heart disease in 1.5%. and atrial fibrillation in 1.1%. Blood pressure was uncontrolled (>140/90) in 46% of stroke survivors. Among men 71.2% used tobacco and 30% used alcohol, while among women 38.2% used tobacco and none used alcohol. Only 40.8% of stroke survivors were receiving antihypertensive medications, while 10.6% were on antiplatelet agents and 4.9% were on statins. In a multivariate analysis, age <50 years (OR 0.2, 95% CI 0.1-0.5), male sex (OR 0.2, 95% CI 0.2-0.8) and lower economic status (no assets vs four assets; OR 0.3, 95% CI 0.1-0.9) were associated with lower odds of receiving medications for secondary prevention of stroke. Conclusions: There were significant gaps in secondary prevention of stroke in rural Gadchiroli. Healthcare programmes for secondary prevention of stroke in rural areas will have to ensure that blood pressure is adequately controlled, alcohol and tobacco cessation is promoted and special attention is paid to those who are younger, men and economically weaker.