Leveraging health information helpline to sustain health-care delivery during the COVID pandemic: Experiences from a State in Eastern India.

Background: The unprecedented demands on health-care systems due to the COVID-19 pandemic made countries including India to switch toward alternative modes of health-care delivery. Objectives: The aim of this study was to describe the various COVID-related services delivered through 104 health information helpline (HIHL), located in Jharkhand during the pandemic. Methods: The de-identified secondary data from February 2020 to December 2021 related to COVID services delivered through HIHL were analyzed. Results: There was a significant increase in the COVID call volume during the first as well as the second wave. The HIHL has been able to guide the callers on testing, home isolation and follow-up, home-based teleconsultation, vaccination, timely referral, and support with logistic-related information. Conclusion: The 104 HIHL has played a critical role in sustaining health-care delivery during the pandemic, combating the "infodemic" and guiding the general public by providing authentic information.

Understanding the factors leading to high prevalence of teenage pregnancies in the four aspirational Districts of Assam, Namely Goalpara, Barpeta, Dhubri, and darrang.

Background: The prevalence of teenage pregnancy in Assam is higher than the national average as per both NHFS-4 and NHFS-5. Four districts in Assam, falling under the NITI-Aayog Aspiration Districts Transformation program of 2018, namely, Goalpara, Barpeta, Darrang, and Dhubri, have a prevalence of teenage pregnancy at levels higher than the state's average (12% as per NHFS-5). Teenage pregnancy affects several health and nutritional indicators. Objectives: The objective of the study was to identify the factors associated with teenage pregnancies in the Aspirational Districts of Assam in both social and public health contexts. Methods: A comparative cross-sectional study was carried out across these four districts, with sample size of teenage pregnant women as 388 and an equal number of controls. Results: The study presents several factors to be statistically significant, viz., lower level of education of the teenage mothers or their spouses and lesser access to adequate health-related information by teenage mothers. Furthermore, less number of teenage mothers are aware of contraceptive availability and face objection from spouses to use contraception. A unique factor presented by the study is the higher elopement rate among teenage mothers. Conclusion: Many of the factors upheld by the study are rooted in social and cultural fabric of the communities and could be addressed by mobilizing local institutions like panchayat and religious bodies to act as deterrence to teenage marriages in the communities. Men should also be brought into the fold of discussions on this sensitive subject through information and awareness generation.

Cancer Awareness and Stigma in Rural Assam India: Baseline Survey of the Detect Early and Save Her/Him (DESH) Program.

BACKGROUND: India has an estimated incidence of more than one million cancers annually. Breast, oral, and cervical cancers account for over one-third of newly diagnosed cases. With the introduction of pilot cancer screening programs in India, little is known about current sociocultural barriers that may hinder acceptance of screening and treatment. We sought to identify knowledge gaps, misconceptions, and stigmas surrounding cancer diagnosis. PATIENTS AND METHODS: A baseline survey was conducted in Assam, India, as part of the Detect Early and Save Her/Him program, a mobile screening program for breast, oral, and cervical cancer. Data were collected on participants' cancer knowledge, and attitudes towards screening, diagnosis, and treatment. RESULTS: Of the 923 residents who participated, a large majority (92.9%; n = 858) were neither aware of cancer screening availability nor had prior screening. Low-medium awareness was demonstrated regarding the carcinogenic effects of betel nuts (n = 433, 47%). Only one-third of participants recognized oral ulcers and dysphagia as cancer symptoms. Approximately 10% of respondents had misconceptions about cancer etiologies, and 42-57% endorsed statements reflecting a negative stigma towards cancer, including its long-term detrimental effects on personal, occupational, and familial life. However, the majority (68-96%) agreed with statements endorsing positive community support and medical care for cancer patients. CONCLUSIONS: This study identifies actionable targets for intervention in cancer education and awareness within a large rural Indian population. Education to address preventable causes of cancer and to correct misconceptions and stigma is a critical component in ensuring the successful implementation of cancer screening programs.

Revamping village health sanitation and nutrition days for improved delivery of maternal and child health services at village level - Experiences from a pilot phase study.

BACKGROUND: Village health sanitation and nutrition day (VHSND) was conceived under the National Rural Health Mission to deliver maternal and child health and nutrition services at the village level in the anganwadi center. Multiple challenges, including a lack of convergence of frontline workers, were affecting service delivery at VHSND. As a public-private partnership Piramal Foundation proposed to revive the concept of VHSND. OBJECTIVES: The present study was aimed to demonstrate a model of VHSND to provide primary care related to maternal and child health and nutrition at the village level in 25 aspirational districts across seven states of India. METHODS: The descriptive study was undertaken as a pilot phase. Of the purposively identified 506 VHSND sites, monitoring data on delivery of six basic primary care services at VHSND, collected as part of routine operations were compared for 229 sites for the month of September 2018 (baseline) and January 2019 (endline). RESULTS: In model sites, there was the increased availability of drinking water and functional toilets; a significant improvement of availability of equipment for providing antenatal care services, immunization, and growth monitoring. However, the supply of drugs at these sites did not show a statistically significant change. There was also a significant improvement in the engagement of the Village Health Sanitation and Nutrition Committee (VHSNC) in the villages of the model VHSND sites. CONCLUSION: The model demonstrated the significant changes with effective supervision and participation of VHSNC members, demand generation activities complemented with improved supplies and widening range of services at the VHSND are required to be undertaken.

Cardiovascular risk factor reduction by community health workers in rural India: A cluster randomized trial.

BACKGROUND: There is a need to identify and test low-cost approaches for cardiovascular disease (CVD) risk reduction that can enable health systems to achieve such a strategy. OBJECTIVE: Community health workers (CHWs) are an integral part of health-care delivery system in lower income countries. Our aim was to assess impact of CHW based interventions in reducing CVD risk factors in rural households in India. METHODS: We performed an open-label cluster-randomized trial in 28 villages in 3 states of India with the household as a unit of randomization. Households with individuals at intermediate to high CVD risk were randomized to intervention and control groups. In the intervention group, trained CHWs delivered risk-reduction advice and monitored risk factors during 6 household visits over 12 months. Households in the non-intervention group received usual care. Primary outcomes were a reduction in systolic BP (SBP) and adherence to prescribed BP lowering drugs. RESULTS: We randomized 2312 households (3261 participants at intermediate or high risk) to intervention (1172 households) and control (1140 households). At baseline prevalence of tobacco use (48.5%) and hypertension (34.7%) were high. At 12 months, there was significant decline in SBP (mmHg) from baseline in both groups- controls 130.3 ±â€¯21 to 128.3 ±â€¯15; intervention 130.3 ±â€¯21 to 127.6 ±â€¯15 (P < .01 for before and after comparison) but there was no difference between the 2 groups at 12 months (P = .18). Adherence to antihypertensive drugs was greater in intervention vs control households (74.9% vs 61.4%, P = .001). CONCLUSION: A 12-month CHW-led intervention at household level improved adherence to prescribed drugs, but did not impact SBP. To be more impactful, a more comprehensive solution that addresses escalation and access to useful therapies is needed.

Rationale and design of the Primary pREvention strategies at the community level to Promote Adherence of treatments to pREvent cardiovascular diseases trial number (CTRI/2012/09/002981).

INTRODUCTION: Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality in low-income countries including India. There is a need for effective, low-cost methods to prevent CVDs in rural India. One strategy is to identify and implement interventions at high-risk individuals using community health workers (CHWs). There is a paucity of CHW-based CVD intervention trials from low-income countries. METHODS: We designed a multicenter, household-level, cluster-randomized trial with 1:1 allocation to intervention and control arms. The CHWs undertook a door-to-door survey and screened 5,699 households in 28 villages from 3 rural regions in India to identify at-risk households. The households were defined as those with ≥1 individual aged ≥35 years and at moderate or high risk for CVD based on the non-laboratory-based National Health and Nutrition Examination Survey score. All at-risk individuals were invited to attend a physician-led village clinic that provided a CVD risk reduction prescription and education about target risk factor levels for CVD control. All households in which at least 1 member at moderate to high risk for CVD had received a risk reduction prescription were eligible for randomization. Households randomized to the CHW-based intervention will receive 1 household visit by a CHW every 2 months, for 12 months. During these visits, CHWs will measure blood pressure, ascertain and reinforce adherence to prescribed therapies, and modify therapy to meet targets. Households randomized to the control arm do not receive CHW visits. At 12 months after randomization, we will evaluate 2 primary outcomes of systolic blood pressure and adherence to antihypertensive drugs and secondary outcomes of INTERHEART risk score, body mass index, and waist-to-hip ratios. At 18 to 24 months after randomization and 6 to 12 months after the last intervention, we will record these outcomes to evaluate sustainability of intervention. RESULTS: Community health workers screened a total of 5,033 households that included 9,248 individuals and identified 2,571 households with 3,784 at-risk individuals. We randomized 2,438 households (1,219 to intervention and 1,219 to control groups). CONCLUSION: Our large trial of CHWs in rural India will provide important information regarding a promising approach to primary prevention of CVDs.

Cost analysis of a mobile medical unit programme in Andhra Pradesh: a microcosting study protocol.

INTRODUCTION: Offering primary healthcare through mobile medical units is an innovative way to reach the rural and the vulnerable population. With 292 mobile medical units, the Andhra Pradesh mobile medical unit (APMMU) programme is one of the largest health outreach programmes in rural India. However, India lacks reliable cost estimates for the health services delivered through mobile medical platforms. This study aims to estimate the unit cost of providing primary care services through mobile medical units in rural and tribal areas of Andhra Pradesh. METHOD AND ANALYSIS: Cost analysis of 12 mobile medical units will be undertaken. We will use the activity-based microcosting technique from the providers' perspective. A bottom-up approach will be used for cost estimation. Standardised tools will be used to collect data on activities and resources, and on the costs. Capital investments and recurrent costs will be measured and evaluated. Average unit costs, along with 95% CIs, will be reported. Sensitivity analysis will assess the cost estimate uncertainties and other cost assumptions. ETHICS AND DISSEMINATION: Piramal Swasthya Management Research Institute's ethics committee approved the study. The findings of the study will be disseminated through conference presentations, publications in peer-reviewed journals and advocacy with the national and state governments. This study will provide first-hand comprehensive cost estimates of provisioning primary healthcare services using mobile medical units in India.

Shifting research priorities in maternal and child health in the COVID-19 pandemic era in India: A renewed focus on systems strengthening.

BACKGROUND: The remarkable progress seen in maternal and child health (MCH) in India over the past two decades has been impacted by the COVID-19 pandemic. We aimed to undertake a rapid assessment to identify key priorities for public health research in MCH in India within the context and aftermath of the COVID-19 pandemic. METHODS: A web-based survey was developed to identify top research priorities in MCH. It consisted of 26 questions on six broad domains: vaccine preventable diseases, outbreak preparedness, primary healthcare integration, maternal health, neonatal health, and infectious diseases. Key stakeholders were invited to participate between September and November 2020. Participants assigned importance on a 5-point Likert scale, and assigned overall ranks to each sub-domain research priority. Descriptive statistics were used to examine Likert scale responses, and a ranking analysis was done to obtain an "average ranking score" and identify the top research priority under each domain. RESULTS: Amongst the 84 respondents from across 15 Indian states, 37% were public-health researchers, 25% healthcare providers, 20% academic faculty and 13% were policy makers. Most respondents considered conducting systems strengthening research as extremely important. The highest ranked research priorities were strengthening the public sector workforce (vaccine preventable diseases), enhancing public-health surveillance networks (outbreak preparedness), nutrition support through community workers (primary care integration), encouraging at least 4-8 antenatal visits (maternal health), neonatal resuscitation to reduce birth asphyxia (neonatal health) and screening and treatment of tuberculosis (infectious diseases). Common themes identified through open-ended questions primarily included systems strengthening priorities across domains. CONCLUSIONS: The overall focus for research priorities in MCH in India during the COVID-19 pandemic is on strengthening existing services and service delivery, rather than novel research. Our results highlight pivotal steps within the roadmap for advancing and sustaining maternal and child health gains during the ongoing COVID-19 pandemic and beyond.

Bridging the Gaps in Health Service Delivery for Truck Drivers of India Through Mobile Medical Units.

BACKGROUND: Truck drivers in India suffer from many lifestyle-related health problems. Providing primary health care services to truck drivers is essential to improve their overall health and well-being. This paper reports the findings of a community-based mobile medical unit program providing nonemergency and basic primary care services to truck drivers along the major highways of India. Piramal Swasthya Management and Research Institute launched this community-based mobile medical unit program, in partnership with Shriram Transport Finance Corporation Limited (STFCL). MATERIALS AND METHODS: The paper describes the program model, its coverage, the sociodemographic profile, and common health morbidities of the truck drivers availing the program services. 2-year routine program data (April 2017 to March 2019) were accessed and analyzed. RESULTS: A total of 1,167,210 number of unique truck drivers availed the program services during the reference period, of which 61,331 had complete data. The majority of truck drivers were male (99.1%) and just a few women (0.88%) and transgender (0.003%). The mean age was 45.5 years ± 10.91 and nearly half (49%) were in the productive age group (31-45 years). Noncommunicable and other chronic diseases (34.74%), musculoskeletal problems (24.17%), communicable diseases (14.52%), oral cavity-related problems (1.23%), and other minor ailments (17.77%) were the major consultation categories. CONCLUSION: Truck drivers in India have significant health morbidities. Providing primary health care services to truck drivers through mobile medical units is a step toward achieving universal health coverage.

Prevalence and predictors of gestational diabetes mellitus in rural Assam: a cross-sectional study using mobile medical units.

OBJECTIVE: To determine the prevalence and predictors of gestational diabetes mellitus (GDM) in rural Assam, India using a network of Mobile Medical Units. STUDY DESIGN: A field-based cross-sectional study. SETTINGS: Rural areas of Assam state, India. PARTICIPANTS: A total of 1410 pregnant women in gestational age of 24-28 weeks INTERVENTION: Identification of pregnant women in 24-28 weeks of pregnancy from villages and administering them Government of India recommended oral glucose tolerance test for GDM confirmation. PRIMARY AND SECONDARY OUTCOME MEASURES: Presence of gestational diabetes among pregnant women, risk factors and predictors of GDM. RESULTS: A total of 1212 pregnant women underwent the oral glucose tolerance test. One hundred and ninety-eight women were ineligible due to existing chronic diseases or very high blood glucose level before the test. The overall GDM prevalence in Assam was 16.67% (95% CI 14.61% to 18.89%). Women aged 26-30 years (adjusted odds ratio, aOR 1.70; CI 1.14 to 2.52), who passed 10th class (aOR 1.58; CI 1.05 to 2.37), belonging to Muslim religion (aOR 1.52; 95% CI 1.05 to 2.21) and above poverty line (aOR 1.38; 95% CI 1.00 to 1.91) had significantly increased likelihood of developing GDM compared with respective baseline groups (p<0.05). Body mass index, gravida and being non-anaemic were non-significant risk factors for GDM. Family history of diabetes (aOR 1.82; 95% CI 1.08 to 3.06) and smoking (aOR 1.61; 95% CI 1.10 to 2.35) were significant and independent predictors of GDM. CONCLUSION: The prevalence of GDM in rural Assam is high. The mobile medical units may play a significant role in the implementation of GDM screening, diagnosis, treatment to ensure better maternal and foetal health outcomes in rural Assam.

Large-scale mHealth professional support for health workers in rural Maharashtra, India.

Expanding mobile telephony in India has prompted interest in the potential of mobile-telephone health (mHealth) in linking health workers in rural areas with specialist medical advice and other professional services. In 2012, a toll-free helpline offering specialist medical advice to community-based health workers throughout Maharashtra was launched. Calls are handled via a 24 h centre in Pune, staffed by health advisory officers and medical specialists. Health advisory officers handle general queries, which include medical advice via validated algorithms; blood on-call services; grievance issues; and mental health support - the latter calls are transferred to a qualified counsellor. Calls requiring more specialist advice are transferred to the appropriate medical specialist. This paper describes the experience of the first 4 years of this helpline, in terms of the services used, callers, nature of calls, types of queries serviced and lessons learnt. In the first 4 years of the helpline, 669 265 calls were serviced. Of these calls, 453 373 (67.74%) needed medical advice and were handled by health advisory officers. Specialist services were required to address 199 226 (29.77%) calls. Blood-bank-related services accounted for 7919 (1.18%) calls, while 2462 (0.37%) were grievance calls. Counselling for mental health issues accounted for 6285 (0.94%) calls. The large-scale mHealth professional support provided by this helpline in Maharashtra has reached many health workers serving rural communities. Future work is required to explore ways to expand the reach of the helpline further and to measure its effectiveness in improving health outcomes.

Adherence to prescribed medications for chronic illnesses among older adults in a rural community, Karnataka, India.

AIM: To assess adherence to prescribed medications for chronic illnesses and to identify factors associated with it among rural older adults. METHODS: A cross-sectional study was carried out from September to November 2011 in three subcenters in Lakkur PHC, Kolar District, India. All older adults were listed, and those suffering from chronic non-communicable diseases were included in the study. A structured interview schedule comprising of 48 items was used to measure adherence, and to identify factors associated with adherence in the domains of socioeconomic status, therapy, health systems, patient behavior and physical factors. RESULTS: Of the 184 older adults included in the study, 63.6% were fully adherent to their medication. Non-adherence to medication showed a statistically significant relationship with the absence of a medical store within their village, non-availability of drugs at the nearest medical store, inability to understand the doctor's language, failure to explain the consequences of not taking medicines by the healthcare provider, self-alteration of medicine dosage, fear that medicines will lead to the development of dependence to medicines and difficulty in swallowing. Those who led busy lives, those who had been prescribed three or more types of medicines prescribed per day, those who required special skills to take medicines (injections, inhalers), those who had made adjustments to their usual lifestyle to take medicines and those who had knowledge that medicines need to be taken lifelong were more likely to be adherent to their medications. Four factors, namely, the doctor explaining the consequences of not taking medicines, altering the dosage of the medicines by the patients themselves, the number of medicines prescribed per day and having the knowledge that medicines need to be taken lifelong, were critical determinants of adherence to medications. Geriatr Gerontol Int 2016; 16: 1339-1345.

Lifestyle-associated risk for cardiovascular diseases among doctors and nurses working in a medical college hospital in Tamil Nadu, India.

CONTEXT: Globally, about 17 million people die of cardiovascular diseases (CVDs) every year and a substantial number of these deaths are attributed to four major risk factors namely unhealthy diet, physical inactivity, tobacco consumption, and alcohol consumption. Doctors and nurses often have a sedentary lifestyle. AIMS: This study aimed at assessing the lifestyle-associated risk for CVDs among doctors and nurses in a medical college hospital. SETTING AND DESIGN: Cross-sectional study among 250 doctors and nurses, selected using a stratified random sampling, working at a medical college hospital in Tamil Nadu. SUBJECTS AND METHODS: After consenting, each participant answered a questionnaire comprising questions pertaining to the sociodemographic characteristics as well as lifestyle-related risk factors. Risk was categorized into low, moderate, and high based on general risk factors, physical activity risk factors, and dietary risk factors separately. STATISTICAL ANALYSIS: Descriptive statistics and Chi-square analysis were used to analyze the data. RESULTS: It was found that 31.2% of all study subjects and 49.2% of doctors were at high general risk for CVDs; 30.4% of all study subjects and 42.1% of doctors were at high physical activity-related risk for CVDs; 14.4% of all study subjects and 19.8% of all doctors were at high dietary pattern-related risk for CVDs. Advancing age is a statistically significant risk factor across all risk groups. CONCLUSIONS: Doctors are at a higher risk for CVDs as compared to nurses as well as the general population.

Challenges in conducting community-based trials of primary prevention of cardiovascular diseases in resource-constrained rural settings.

Cardiovascular diseases account for almost half of all deaths from noncommunicable diseases, and almost 80% of these deaths occur in low- and middle-income countries such as India. The PrePAre (Primary pREvention strategies at the community level to Promote treatment Adherence to pREvent cardiovascular disease) trial was a primary prevention trial of community health workers aimed at improving adherence to prescribed pharmacological and nonpharmacological therapies in cardiovascular diseases. It was conducted at three geographically, culturally and linguistically diverse sites across India, comprising 28 villages and 5699 households. Planning and implementing large-scale community-based trials is filled with numerous challenges that must be tackled, while keeping in mind the local community dynamics. Some of the challenges are especially pronounced when the focus of the activities is on promoting health in communities where treating disease is considered a priority rather than maintaining health. This report examines the challenges that were encountered while performing the different phases of the trial, along with the solutions and strategies used to tackle those difficulties. We must strive to find feasible and cost-effective solutions to these challenges and thereby develop targeted strategies for primary prevention of cardiovascular diseases in resource-constrained rural settings.