Integrating Narrative Medicine Through Story-Telling: A Feasibility Study in a Community Medicine Curriculum for Undergraduate and Postgraduate Students.

Introduction The routine curriculum of community medicine includes clinico-social case-taking with a focus on the physical, biological, and psychosocial determinants of health. There is an opportunity to integrate narrative medicine with this for undergraduate and postgraduate medical students using story-telling. The objective of the current study was to assess its feasibility, challenges, and opportunities. Methods We conducted a need assessment cross-sectional survey of the teaching faculty of community medicine across India using Google Forms. Considering an 80% positive response in a pilot within the department, a relative error of 10%, and a 20% non-response rate, the sample size was 120. The questionnaire included closed-ended questions with a Likert scale that dealt with affective, cognitive, and communication domains and open-ended questions for insights into opportunities and challenges. The results of the former were expressed as descriptive statistics, in frequencies and proportions. Open-ended questions were summarized to guide the refinement of further implementation. Results Of the 120 participants, 92 (77%) quoted low/medium empathy quotient in students, and 107 (89.2%) felt that the listening skills of students can improve with the introduction of story-telling. A hundred and twelve (93.4%) participants felt that their history-taking skills can improve with story-telling, and all agreed that the language of medicine can be improved. One hundred nine (90.8%) felt that it will lead to better student-patient interaction. Opportunities included a better understanding of social determinants, patient-/family-centered care, improved communication skills, and better mental health. The key challenges included time, motivation, the need for training/capacity building, and streamlining of assessment metrics. Conclusion We conclude that story-telling may help medical students investigate various social determinants of health, disease, and lived environments that create vulnerabilities.

Nutritional status of Indian adolescents (15-19 years) from National Family Health Surveys 3 and 4: Revised estimates using WHO 2007 Growth reference.

BACKGROUND: The National Family Health Surveys (NFHS) in India apply adult cutoffs of nutritional status for the estimation of undernutrition/overweight in the 15-19 age group. The prevalence of thinness in boys and girls thus estimated is 58.1% and 46.8% in NFHS-3, and 45% and 42% in NFHS-4 respectively. But the WHO recommends using age and sex-specific reference for adolescents. We reanalyzed the nutritional status of the adolescents using the WHO 2007 Growth Reference to obtain revised estimates of thinness, overweight and stunting across states, rural-urban residence, and wealth quintiles. METHODS AND FINDINGS: Demographic information, anthropometric data, and wealth index were accessed from the Demographic and Health Survey (DHS) database. We re-analyzed the anthropometric data using WHO AnthroPlus software which uses the WHO 2007 Growth reference. The revised estimates of thinness assessed by BMI-for-age z-scores in boys and girls was 22.3% (95%CI: 21.6, 23.0) and 9.9% (95%CI: 9.5, 10.3) in NFHS-3 and 16.5% (95%CI: 16.0,17.0) and 9% (95%CI: 8.9, 9.2) in NFHS-4 respectively. Stunting was found to be 32.2% (95% CI: 31.6, 32.9) in boys and 34.4% (95% CI: 34.2, 34.7) in girls in NFHS-4. This was higher than that in NFHS-3; 25.2% (95% CI: 24.4, 26) in boys and 31.2 (95% CI: 30.6, 31.8) in girls. There was a clear socioeconomic gradient as there were higher thinness and stunting in rural areas. There was wide variation among the states with pockets of a double burden of malnutrition. CONCLUSION: Using the adult cutoffs significantly overestimates thinness in adolescents in the age group of 15-19 years old in India. Stunting, which is an indicator of long term nutrition is also widely prevalent in them. Future editions of DHS and NFHS should consider adolescents as a separate age group for nutritional assessment for a better understanding of nutritional transition in the population.

Tuberculosis deaths are predictable and preventable: Comprehensive assessment and clinical care is the key.

The goal of reducing tuberculosis (TB) mortality in the END TB Strategy can be achieved if TB deaths are considered predictable and preventable. This will require programs to examine and address some key gaps in the understanding of the distribution and determinants of TB mortality and the current model of assessment and care in high burden countries. Most deaths in high-burden countries occur in the first eight weeks of treatment and in those belonging to the age group of 15-49 years, living in poverty, with HIV infection and/or low body mass index (BMI). Deaths result from extensive disease, comorbidities like advanced HIV disease complicated with other infections (bacterial, fungal, bloodstream), and moderate-severe undernutrition. Most early deaths in patients with TB, even with TB-HIV co-infection, are due to TB itself. Comprehensive assessment and clinical care are a prerequisite of patient-centered care. Simple independent predictors of death like unstable vital signs, BMI, mid-upper arm circumference, or inability to stand or walk unaided can be used by programs for risk assessment. Programs need to define criteria for referral for inpatient care, address the paucity of hospital beds and develop and implement guidelines for the clinical management of seriously ill patients with TB, advanced HIV disease and severe undernutrition as co-morbidities. Programs should also consider notification and audit of all TB deaths, similar to audit of maternal deaths, and address the issues in delays in diagnosis, treatment, and quality of care.

Universal health coverage and tuberculosis care in India in the times of Covid-19: Aligning Ayushman Bharat (National Health Assurance Scheme) to improve case detection, reduce deaths and catastrophic health expenditure.

India has the largest global burden of new cases of tuberculosis (TB) and deaths due to TB. These occur predominantly in the poor who suffer catastrophic costs during diagnosis and treatment. The National Tuberculosis Elimination Programme has ambitious goals of 80% reduction of incidence of TB, 90% reduction in mortality due to TB by 2025 and 0% occurrence of catastrophic costs to households affected by TB by 2020. The Covid-19 pandemic and the resulting disruption to TB services are expected to worsen the situation. There are gaps in case finding at the peripheral level and access to care at the higher level for patients with TB. An estimated 32% patients with active TB do not access diagnostic services, while catastrophic costs associated with hospitalization are a barrier to access for seriously ill patients. Deaths due to TB in India occur largely at home and not in medical facilities, and are preventable with appropriate inpatient care. The Ayushman Bharat scheme with its Health and Wellness Centres (HWCs) and coverage for inpatient care under the Pradhan Mantri Jan Arogya Yojana (PM-JAY) can facilitate, the achievement of the goals of TB elimination. The HWCs provide an opportunity to close the case-finding gap as first point of contact by enabling sputum transport services to the designated microscopy centres. This will facilitate case detection, reduce diagnostic delays, and decrease community transmission and the incidence of TB. The benefit package of PM-JAY can cover patients with pulmonary TB, inpatient evaluation for other forms of TB, enhance the allocation for treatment and cover management of comorbid conditions such as severe undernutrition, anaemia, HIV and diabetes.

N-TB: A mobile-based application to simplify nutritional assessment, counseling and care of patients with tuberculosis in India.

Undernutrition is the most prevalent comorbidity in patients with tuberculosis (TB) in India. Undernutrition is often severe and results in higher risk of death, drug toxicity during treatment, poor functional status at end of treatment and a higher risk of relapse after successful treatment. A World Health Organization guideline has recommended nutritional assessment, counseling, and care as integral parts of TB care. The Revised National Tuberculosis Control Programme has recognized undernutrition as a significant comorbidity, released a guidance document for improving nutritional care and support, and launched a scheme for direct bank transfer of monthly cash benefit to TB patients. However, there are gaps at the provider level on nutritional assessment, due to challenges in calculation and interpretation of body mass index (BMI). A mobile based application has been developed for use in the programme, which makes estimation of BMI possible, classifies the severity of undernutrition, suggests triage and clinical actions based on the BMI, indicates desirable body weight corresponding to a BMI of 21 kg/m2, and the daily caloric and protein intake for underweight patients with active TB. The app also provides tips for dietary counseling for TB patients, information on the major food groups, emphasizes an adequate and balanced diet from locally available foods for nutritional recovery of TB patients.

Water, sanitation and hygiene survey - Use of hydrogen sulfide strip at field level as a point-of-care test: A pilot study.

Safe drinking water is a basic element of primary health care. The government of India in its Indian Public Health Standards recommends the hydrogen sulfide (H2S) strip test as a desirable component at primary health centers for screening water for fecal coliforms. The objective of the present study was to conduct a water, sanitation and hygiene (WASH) survey followed by a H2S strip test of drinking water in a village with ninety households. The test was positive in 88% at the source and the point of consumption, with 100% concordance between both the points of test. A subsample of water samples was subjected to testing in microbiology laboratory, and fecal contamination was confirmed in all of them. To conclude, H2S strip test can be conveniently used at field level, and its ease of use and visual nature of results make it a useful point-of-care test of environmental and public health.

Overweight and Obesity in School Children of a Hill State in North India: Is the Dichotomy Urban-Rural or Socio-Economic? Results from a Cross-Sectional Survey.

INTRODUCTION: Overweight and obesity are a public health problem in India not only in adults but also in children. The authors sought to estimate the prevalence of overweight and obesity in school-going children of 6-17 years of age and examine its demographic and dietary correlates in context of their urban-rural status and socio-economic status. METHODS: In this cross-sectional survey height and weight were measured in 1266 school children in government and private schools of urban and rural areas. Dietary assessment was done using single day 24-hour dietary recall method. The data were analyzed using SPSS (IBM SPSS Statistics Version 19) and WHO AnthroPlus Software. Factorial ANOVA was used for testing interaction within and between subgroups for continuous variables and Chi-square test was used for categorical variables. RESULTS: It was found that the overall prevalence of overweight was 15.6% of which 5.4% were obese, with maximum prevalence in boys attending urban private schools. The mean caloric intake in the study population with 24-hour dietary recall method was 1558.2 kilocalories (SD: 428 kilocalories). CONCLUSION: Overweight and obesity is a significant problem in school-going children. Higher socio-economic status continues to remain an important driver of this epidemic in the younger generation and affects demographic and dietary determinants of this problem.

Can social interventions prevent tuberculosis?: the Papworth experiment (1918-1943) revisited.

RATIONALE: There is consensus on the need to address social determinants of tuberculosis (TB) to achieve TB control, but evidence based on interventions is lacking. OBJECTIVES: We reanalyzed data from the sociomedical experiment performed at the Papworth Village Settlement in England, where the impact of stable employment and adequate housing and nutrition on the incidence of TB infection and disease in children living with parents with active TB was documented during 1918-1943. METHODS: Information on 315 children of patients, who lived at Papworth, was abstracted from a published monograph. Overall and age-specific occurrence of TB infection, disease, and deaths among children born in the settlement (village-born cohort) were compared with those of children born outside and admitted later (admitted cohort) to Papworth. MEASUREMENTS AND MAIN RESULTS: The annual risks of infection in the village-born and admitted cohorts were 20 and 24%, respectively. Of 24 children who developed TB disease, only one was village-born. Among children 5 years of age or less, there was zero incidence of TB in the village-born, compared with five cases (1,217/100,000 person-years) among children born outside Papworth. In the admitted cohort, among children 13 years of age and older, the incidence of TB before admission to Papworth was 5,263/100,000 person-years, whereas it was 341/100,000 person-years while living in Papworth. CONCLUSIONS: At Papworth social interventions including adequate nutrition did not reduce TB transmission but did reduce the incidence of TB disease in children living with parents with active TB. These results are relevant today for prevention of TB in children of patients with active TB, particularly with multidrug-resistant TB in high-burden settings.