Risk Factors for Unfavorable Glycemic Control Trajectory in Type-2 Diabetes Mellitus: A Community-based Longitudinal Study in Urbanslums of Central India.

BACKGROUND: Diabetes mellitus (DM) is a chronic disease, which requires optimal glycemic control to prevent its ensuing vascular complications. Pathway to optimal glycemic control in T2DM has a complex socio-behavioral construct, especially in vulnerable populations, like slum dwellers, who have reduced health-care access and lower prioritization of health needs. OBJECTIVE: The study aimed to map trajectories of glycemic control amongst individuals with T2DM living in urban slums and identify key determinants associated with unfavourable glycaemic trajectory. METHODS: This study was a community-based longitudinal study conducted in an urban slum of Bhopal in Central India. Adult patients diagnosed with T2DM and on treatment for more than one year were included. All 326 eligible participants underwent a baseline interview, which captured sociodemographic, personal behavior, medication adherence, morbidity profile, treatment modality, anthropometric and biochemical measurements (HbA1c). Another 6-month follow-up interview was conducted to record anthropometric measurements, HbA1c and treatment modality. Four mixed effect logistic regression models (through theory-driven variable selections) were created with glycemic status as dependent variable and usage of insulin was considered as random effect. RESULTS: A total of 231 (70.9%) individuals had unfavorable glycemic control trajectory (UGCT), and only 95 (29.1%) had a favorable trajectory. Individuals with UGCT were more likely to be women, with lower educational status, non-vegetarian food preference, consumed tobacco, had poor drug adherence, and were on insulin. The most parsimonious model identified female gender (2.44,1.33-4.37), tobacco use (3.80,1.92 to 7.54), and non-vegetarian food preference (2.29,1.27 to 4.13) to be associated with UGCT. Individuals with good medication adherence (0.35,0.13 to 0.95) and higher education status (0.37,0.16 to 0.86) were found to be protective in nature. CONCLUSION: Unfavorable glycemic control trajectory seems to be an inescapable consequence in vulnerable settings. The identified predictors through this longitudinal study may offer a cue for recognizing a rational response at societal level and adopting strategy formulation thereof.

A study of disability and socio-economic impact of mental morbidities from the state of Madhya Pradesh, India.

Background: Disability associated with mental illness has a disproportionate impact on the work, social, and family responsibilities of an individual toward society. The evidence for disability in mental illnesses would help the clinician, caregivers, policymakers, and various stakeholders to come up with sustainable solutions not only to help fill the existing gaps in care but also to develop new avenues as per the specific needs of the population of Madhya Pradesh (MP). Aim: To estimate the burden of disability related to mental illnesses in the state of MP. Materials and Methods: A multi-site cross-sectional study was conducted in 2015-16 as part of National Mental Health Survey among adults above 18 years of age. Samples were selected using multi-stage, stratified, random cluster sampling based on probability proportionate to size. Six tehsils with one urban metro out of four districts from a total of 50 districts were selected in the state of MP. The Sheehan Disability Scale and socio-economic impact of illness (from selected questions from WHO-Disability Assessment Schedule-2.0) were used to assess mental morbidity and the subjective reporting of disability. Results: The weighted prevalence of disability (n = 1011) was found as 10.2%, 13.1%, and 13.9%, respectively, in work/school, social life, and family/home domains. The weighted prevalence of moderate to extreme disability in the same domains was, respectively, 5.1%, 6.7%, and 7.3%. The presence of common mental disorders (CMDs) increases the odds of self-reported disability in work [odds ratio (OR) 2.48, 95% CI 1.35 to 4.59], social life (OR 2.74, 95% CI 1.50 to 5.07), and family domains (OR 3.03, 95% CI1.62 to 5.74). When combined with common mental disorders, tobacco use disorder further escalates the odds of self-reported disability in all three domains [OR 7.10, confidence interval (CI) 3.15 to 16.37; 4.93, CI 2.19 to 11.28; and 7.10, CI 2.78 to 19.25]. Currently, non-working persons had a higher disability in social life and family life domains (P = 0.003 and P = 0.021), respectively. Conclusion: We report a substantial magnitude of disability in social, work, and family life domains. Participants having CMDs, female gender, and those non-working had more disabilities and would require targeted interventions.

Determinants of behavioural and biological risk factors for cardiovascular diseases from state level STEPS survey (2017-19) in Madhya Pradesh.

BACKGROUND: National and statewide assessment of cardiovascular risk factors needs to be conducted periodically in order to inform public health policy and prioritise allocation of funds, especially in LMICs. Although there have been studies from India which have explored the determinants of cardiovascular risk factors, they have mostly been from high epidemiological transition states. The present study assessed the determinants of cardiovascular (CVD) risk factors in a low epidemiological transition state (Madhya Pradesh) using the WHO STEPwise approach to surveillance (STEPS). METHODS: A total of 5,680 persons aged 18-69 years were selected from the state of Madhya Pradesh through multi-stage cluster random sampling. Key CVD risk factors we sought to evaluate were from behavioural (tobacco, alcohol, physical activity, diet) and biological domains (overweight or obese, Hypertension, Diabetes, and Raised serum cholesterol). Key socio-demographic factors of interest were the caste and tribe groups, and rural vs urban location, in addition to known influencers of CVD risk such as age, gender and education level. RESULTS: Those belonging to the scheduled tribes were more at risk of consuming tobacco (OR 2.13 (95% CI [1.52-2.98]), and a diet with less than five servings of fruits and vegetables (OR 2.78 (95% CI [1.06-7.24]), but had had the least risk of physical inactivity (OR 0.31 (95% CI [0.02-0.54]). Residence in a rural area also reduced the odds of physical inactivity (OR 0.65 (95% CI [0.46-0.92])). Lack of formal education was a risk factor for both tobacco consumption and alcohol intake (OR 1.40 (95% CI [1.08-1.82]) for tobacco use; 1.68 (95% CI [1.14-2.49]) for alcohol intake). Those belonging to schedules tribes had much lower risk of being obese (OR 0.25; 95% CI [0.17-0.37]), but were at similar risk of all other clinical CVD risk factors as compared to other caste groups. CONCLUSION: In the current study we explored socio-demographic determinants of behavioural and biological CVD risks, and found that in Madhya Pradesh, belonging to a scheduled tribe or living in a rural location, protects against being physically inactive or being overweight or obese. Increasing age confers a greater CVD-risk in all domains. Being a male, and lack of formal education confers a greater risk for behavioural domains, but not for most clinical risk domains. Future efforts at curbing CVDs should be therefore two pronged -a population-based strategy targeting biological risk factors, and a more focussed approach directed at those displaying risky behaviour.

Preparedness of primary health care providers for tobacco cessation - Experiences from a non-communicable disease training program.

BACKGROUND: Tobacco use can lead to tobacco/nicotine dependence and serious health problems. Quitting smoking significantly reduces the risk of developing smoking-related diseases. In a low resource setting like India, the role of primary healthcare providers in tobacco cessation is immense. The current study was conducted with the objective of evaluating the preparedness, knowledge and attitude of the primary healthcare providers in tobacco cessation. METHODS: A cross-sectional study involving 289 trainees taking part in a non-communicable disease training in the calendar year 2015, held at All India Institute of Medical Sciences, Bhopal were interviewed with a close-ended questionnaire on the demographic profile of participants, their preparedness, and current knowledge and attitude related with tobacco cessation activities. RESULTS: Among the 289 trainees, majority of the study participants were staff nurses (54.7%) and medical officers (41.2%) with a mean (± Standard Deviation, range) age of 35 (±10, 22-63) years predominantly from district and sub-district hospitals (52.9%). In total, 86.9% counsel their patients regarding tobacco cessation and 13.1% use nicotine replacement therapy in aiding tobacco cessation. 174 (60.2%) participants received on-job training of various duration on tobacco control, and 96 (33.2%) did not receive any training. Preparedness toward tobacco cessation was present in 15.01% (41) of the study participants. CONCLUSION: The study reveals that the majority of the healthcare providers were not prepared, and only half of the participants had favorable attitudes and practices of delivering tobacco cessation activities.

Descriptive profile of risk factors for cardiovascular diseases using WHO STEP wise approach in Madhya Pradesh.

BACKGROUND: Periodic information on risk factor distribution is critical for public health response for reduction in non-communicable disease (NCDs). For this purpose, the WHO has developed STEPs wise approach. State representative population-based STEPS survey was last conducted in 2007-08 in seven states of In India. Since then no such work has been reported from low ETL states. This survey was carried out to assess the prevalence of risk factors associated with NCDs and the prevalence of NCDs in the low ETL state of Madhya Pradesh using the WHO STEPs approach. METHODS: A total of 5680 persons aged 18-69 years were selected from the state of Madhya Pradesh using multi-stage cluster random sampling. Using the WHO STEPs approach, details were collected on demographics, STEP 1 variables (tobacco consumption, alcohol consumption, physical activity, diet), STEP 2 variables (weight, height, waist circumference, blood pressure) and STEP 3 variables (fasting blood glucose, blood cholesterol). RESULTS: We found that 9.4% individuals smoked tobacco, 15.3% were overweight/obese, 22.3% had hypertension, and 6.8% have diabetes mellitus. As compared to women, men were less likely to be overweight or obese, but more likely to smoke tobacco, and have diabetes mellitus. Hypertension was also more common in men. Overall, about a fourth of all adults had three or more risk factors for cardiovascular disease. CONCLUSION: The survey shows that a large section of the population from Madhya Pradesh is either suffering from NCDs or have risk factors which predispose them to acquire NCDs. This state representative survey provides benchmarking information for behavioural and biological risk factor distribution for recently scaled up National Programme for the Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS).

Isoniazid Preventive Therapy among Children Living with Tuberculosis Patients: Is It Working? A Mixed-Method Study from Bhopal, India.

Objective: We assessed uptake of isoniazid preventive therapy (IPT) among child contacts of smear-positive tuberculosis (TB) patients and its implementation challenges from healthcare providers' and parents' perspectives in Bhopal, India. Methods: A mixed-method study design: quantitative phase (review of programme records and house-to-house survey of smear-positive TB patients) followed by qualitative phase (interviews of healthcare providers and parents). Results: Of 59 child contacts (<6 years) of 129 index patients, 51 were contacted. Among them, 19 of 51 (37%) were screened for TB and one had TB. Only 11 of 50 (22%) children were started and 10 of 50 (20%) completed IPT. Content analysis of interviews revealed lack of awareness, risk perception among parents, cumbersome screening process, isoniazid stock-outs, inadequate knowledge among healthcare providers and poor programmatic monitoring as main barriers to IPT implementation. Conclusion: National TB programme should counsel parents, train healthcare providers, simplify screening procedures, ensure regular drug supply and introduce an indicator to strengthen monitoring and uptake of IPT.