The Health Impact of mHealth Interventions in India: Systematic Review and Meta-Analysis.

Background: Considerable use of mobile health (mHealth) interventions has been seen, and these interventions have beneficial effects on health and health service delivery processes, especially in resource-limited settings. Various functionalities of mobile phones offer a range of opportunities for mHealth interventions. Objective: This review aims to assess the health impact of mHealth interventions in India. Methods: This systematic review and meta-analysis was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies conducted in India, and published between April 1, 2011, and March 31, 2021, were considered. A literature search was conducted using a combination of MeSH (Medical Subject Headings) terms in different databases to identify peer-reviewed publications. Thirteen out of 1350 articles were included for the final review. Risk of bias was assessed using the Risk of Bias 2 tool for RCTs and Risk Of Bias In Non-randomised Studies - of Interventions tool (for nonrandomized trials), and a meta-analysis was performed using RevMan for 3 comparable studies on maternal, neonatal, and child health. Results: The meta-analysis showed improved usage of maternal and child health services including iron-folic acid supplementation (odds ratio [OR] 14.30, 95% CI 6.65-30.75), administration of both doses of the tetanus toxoid (OR 2.47, 95% CI 0.22-27.37), and attending 4 or more antenatal check-ups (OR 1.82, 95% CI 0.65-5.09). Meta-analysis for studies concerning economic evaluation and chronic diseases could not be performed due to heterogeneity. However, a positive economic impact was observed from a societal perspective (ReMiND [reducing maternal and newborn deaths] and ImTeCHO [Innovative Mobile Technology for Community Health Operation] interventions), and chronic disease interventions showed a positive impact on clinical outcomes, patient and provider satisfaction, app usage, and improvement in health behaviors. Conclusions: This review provides a comprehensive overview of mHealth technology in all health sectors in India, analyzing both health and health care usage indicators for interventions focused on maternal and child health and chronic diseases. Trial Registration: PROSPERO 2021 CRD42021235315; https://tinyurl.com/yh4tp2j7.

Death, Disability, and Premature Life Years Lost Due to Cigarettes, Bidis, and Smokeless Tobacco in India: A Comparative Assessment.

Background: Due to the staggering number of tobacco users in India, it is important to determine the exact mortality and morbidity rates due to tobacco use. This study aimed to estimate deaths, disability-adjusted life years (DALYs), and years of life lost (YLLs) attributable to cigarettes, bidis, and smokeless tobacco (SLT) in India. Methods: Data pooling and meta-analysis were done using case-control studies available on the three types of tobacco products. Health burden was estimated by applying the population attributable fraction (PAF) value to the total disease burden. Findings: A total of 33 studies were included. PAF was calculated for oral and lung cancer as well as ischemic heart disease (IHD) due to cigarettes, oral and lung cancer, IHD, and chronic obstructive pulmonary disease due to bidi, and oral and stomach cancer and IHD due to SLT. Cigarettes resulted in 8.4 million DALYs, 8.26 million YLLs, and 341 deaths; bidis led to 11.7 million DALYs, 10.7 million YLLs, and 478 thousand deaths, and SLTs accounted for 4.38 million DALYs, 4.3 million YLLs, and 171 thousand deaths annually. Conclusion: Evidence of measurable health burden and methodology for calculation for individual states was provided in the study. The generated evidence could be utilized for policy recommendations and revision of the existing taxation norms.

Competence-Based Assessment of Biomedical Equipment Management and Maintenance System (e-Upkaran) Using Benefit Evaluation Framework.

Introduction To establish a centralized inventory management system for the efficient functioning of all healthcare facilities, e-Upkaran (equipment management and maintenance system) was launched in 2015 in the state of Rajasthan. This study is conducted to assess the functioning of e-Upkaran in Rajasthan. Methods The assessment of the e-Upkaran system for primary and secondary healthcare centers was carried out using a systematic review of the literature and a multi-indicator stakeholder questionnaire. The benefits evaluation framework focused on the system quality, information and service quality, use and user satisfaction, and net benefits utilized for the assessment. A review of the literature was done to highlight the importance of computerized medical equipment management and maintenance systems and appraise the challenges and benefits associated with such systems as compared to the traditional pen-paper register. Information was gathered based on available documents, field observation, and data obtained from specific hospital staff, including the bioengineers and other users of e-Upkaran. Results The finding of this study suggests that e-Upkaran efficiently improves documentation, reporting, maintenance, and management of medical equipment. It is more efficient than the traditional paper-pen system. It is designed to minimize downtime and maintain equipment in good operating condition and has potential benefits in terms of improving information quality, use, and net benefit. The cost of service ratio is within the benchmark value. This system has also considerably reduced out-of-pocket expenditure. Computer proficiency and the workload of other e-health programs pose a challenge in the implementation of this program. Conclusion The e-Upkaran system is competent in terms of improving information quality, use, and net benefit. Other Indian states could also adopt this system to improve their biomedical equipment management and maintenance system.

Assessment of e-aushadhi program (drug inventory e-health initiative in Rajasthan) using benefit evaluation framework.

Background: E-aushadhi is a drug supply chain management initiative of the Rajasthan government. This study is conducted to assess this e-health program as evidence is lacking in this context. Methods: A mix-method study was conducted. Primary data were recorded from key stakeholders using qualitative interviews. Secondary data were collected from internet-based searches, reports, documents, and available literature. Findings were contextualized into the Benefit-Evaluation framework using six dimensions. Results: E-aushadhi provides a systematic approach for sourcing, storing, and re-distribution of essential medicine through its three-tier structure. Its user-friendly dashboard entails accurate entries, customizable reports, and easy tracking. It has reduced workload and improved information management with timely drug supply while allowing monitoring with key performance indicators. Conclusions: E-aushadhi has been successful in improving beneficiary access at public health facilities and may act as a backbone architecture for various digital interventions in the National Digital Health Mission that supports the universal health coverage.

Economic analysis of ASHA-soft programme (online payment and monitoring system) in Jodhpur, Rajasthan.

Context: The Government of India under a performance-based payment scheme is providing remuneration as per the activities completed by the Accredited Social Health Activists (ASHA) health workers. Each state in India has a differentperformance-based payment system for ASHAs. The state of Rajasthan developed the ASHA-Soft system in 2014 for providing incentives to ASHAs. Aims: This study is planned to analyze the performance of ASHA-Soft considering the economic aspects as there is a paucity of studies in this context. Settings and Design: This study was conducted in Jodhpur, Rajasthan. Methods and Material: Economic analysis of ASHA-Soft program was performed based on Incentive paid to ASHA workers; Number of beneficiaries; Overall contribution of ASHAs in the health services; and unit cost per health service under ASHA-Soft program. Data of five financial years, that is, from the inception of ASHA-Soft was analyzed. Results: Consolidated incentive for maternal health, child health, and Immunization services provided to ASHAs through ASHA-Soft in the year 2015--16 was $96794.22, $35348.32, and $49016.83 which increased to $200285.00, $116320.52, and $101686.48 in the year 2019-20, respectively. Family planning and national program services were provided to 6,259 and 4,061 beneficiaries, respectively, in the year 2015--16 which markedly increased to 16,360 and 9,552 in the year 2019--20. Unit-cost of service provided by ASHAs in the National Programme ($1.13) was the lowest and for Family Planning Services ($5.71) were the highest. Conclusions: ASHA-Soft program seems a potential program to attract ASHA workers for delivering health care services. The findings of this study could assist policymakers in guiding further decision-making.

Tobacco Use Pattern, Dependence, Oral Cancer Awareness and Health Education needs Among Urban Slum Dwellers of Jodhpur City.

Background: The rapid migration from rural to urban region results in mushrooming of slums in India. Urban-slums are comparatively poor vulnerable groups which are mostly affected with oral cancer due to higher exposure to risk factors like tobacco use. Aims: To assess pattern of tobacco consumption, awareness about oral cancer and related health education needs in urban slums of Jodhpur city. Methods: Study was conducted during July 2018Nov 2018 in slum of Jodhpur city. On the basis of cluster sampling strategy data were collected from 1200 participants regarding tobacco use and perception regarding oral cancer to identify health education needs in urban slums. Descriptive statistics, Chi-square test, multivariate logistics analysis were used and P < 0.05 was considered statistically significant. Results: A total of 1200 participants were surveyed, out of which 48.5% were males. Among the study population, 58.5% (n = 462/789) males and 41.45% (n = 327/789) females were consuming tobacco in one or more forms. The statistical association between: age and bidi, gutka, zarda consumption; gender and bidi, cigarette, gutka consumption was found to be significant (P < 0.001). The younger population (1530 years) has more willingness to quit tobacco than the older population. (OR = 1.52, 95% CI = 1.092.11). Almost 56% were aware of oral cancer. Conclusions: An effective information, education and communication (IEC) strategy for tobacco cessation should be designed with focus on different education needs according to age, gender, and education status of slum population.

Assessment of Epidemiological Implications Due to Serial Tropical Cyclones in India: Introspecting the Recent Sanitation Interventions.

OBJECTIVES: The Indian subcontinent is prone to tropical cyclones that used to originate in the North Indian Ocean. Through this study, an inventory of disease outbreaks for the tropical cyclone-affected regions from 2010 to 2018 has been compiled. This inventory is used to assess the success of recent sanitation intervention, Swachh Bharat Mission, also known as the Clean India Mission. METHODS: Meteorological parameters from the Indian satellites were used to demarcate the cyclone-affected area. Disease outbreaks and epidemics during the tropical cyclones were compiled from the Integrated Disease Surveillance Program and other relevant sources. The inventory has been used to track the effect of recent sanitation interventions on disease outbreaks. RESULTS: Districts in the eastern coast of India are frequently affected due to tropical cyclones that have originated from the North Indian Ocean. Infectious diseases like the acute diarrheal diseases, vector-borne diseases, viral fevers, enteric fevers, and food poisoning have recursively occurred during the cyclonic events and persisted up to 2 weeks from the cyclonic episode. The effectiveness of the Clean India Mission is evident during the recent cyclones, Ockhi, Titli, and Gaja, where a significantly lower number of infectious disease outbreaks were recorded. CONCLUSIONS: The Clean India Mission has exhibited positive results on the public health consequences associated with tropical cyclones.

Assessment of monitoring and online payment system (Asha Soft) in Rajasthan using benefit evaluation (BE) framework.

CONTEXT: e-Health programs are implemented assuming that e-health/digital health can prove beneficial but pieces of evidence for assessing the actual benefits of e-health programs are lacking. AIMS: To utilize the benefit evaluation (BE) framework to assess Asha Soft, which is an online payment and performance monitoring system initiative taken by Rajasthan. SETTINGS AND DESIGN: BE of Asha Soft in Rajasthan. METHODS AND MATERIALS: BE of ASHA Soft was done using scoping review with consultation exercise. The rationale behind using this methodological framework is to contextualize knowledge of the current state of understanding within BE framework practice contexts. The themes used for data compilation and analysis were based on three broad dimensions of BE framework namely, health information technology quality, use, and net benefits. RESULTS: The state of Rajasthan has been the first in the country to start an online system of payment and monitoring of ASHA workers, through Asha Soft. It has administrative and supportive functions. Its simple and easy to use graphical user interference helps users to make accurate data entries and obtain desired monitoring and analytical reports. It has attributed to the availability of data on various parameters which help decision-maker to decide about the performance of ASHA worker and has brought a positive impact on the work performance of ASHAs. This online payment and monitoring mechanism has argumented motivational level and intention of use. The program has optimally utilized available human resources and no apparent monetary cost was involved in developing this software. CONCLUSIONS: This scoping study using the BE framework has provided evidence on the potential benefits of Asha Soft adoption in Rajasthan. It is recommended that future in-depth assessment of other e-health initiatives could be undertaken to guide the decision making.

Economic Burden of Acute Stroke Care in Beneficiaries and Non-Beneficiaries under Social Security Schemes at Tertiary Care Hospitals of Western Rajasthan.

OBJECTIVE: A cost of illness study was conducted with aims to asses various cost of acute stroke care and its determinants among beneficiary (patients enrolled in any social security scheme) and non beneficiary (patients not enrolled in any social security scheme) of various social security schemes. METHOD: A cross-sectional study was conducted at government hospitals in western Rajasthan from March to May 2019. All consecutive stroke patients were enrolled during study period. Data related to socio-demographic, disease-related and cost-related data was collected by direct patient and main caregiver's interview. Primary study outcome was description of direct and indirect cost of acute stroke care among beneficiary and non beneficiary patients. Secondary outcome was description of determinants of cost or significant cost-driven variables. RESULTS: Total of 126 stroke patients were enrolled in 3 months. Mean age was 57.67 ± 15.0 and male: female ratio was 82:44. Both beneficiary and non-beneficiary patients were similar in baseline characteristic except monthly income (P < 0.01) Mean hospital stay was 6.52 ± 2.23 Total out of pocket direct cost among beneficiary was INR 12727.21 [95% C.I. 8658.50, 16795.92] and among non beneficiary was INR 23649.68 [95%C.I. 18591.37, 28707.99]. There was significant difference indirect cost of beneficiary and non-beneficiary patients (P < 0.01). Mean Indirect cost (wages loss) among beneficiary was INR 12414.75 [95% C.I. 9691.13, 15138.37] and among non-beneficiary was INR 16460 [95% C.I. 13044.81, 19875.19]. There was no significant difference in Indirect cost of beneficiary and non-beneficiary patients (P = 0.06). Monthly income, stroke severity (modified Rankin score) and hospital stay were significant direct cost determinants. CONCLUSION: Public health insurance scheme reduces direct cost of acute stroke care significantly. Severity of stroke and prolonged hospital stay were main cost-driven variables.