Disabled People's Organisations increase access to services and improve well-being: evidence from a cluster randomized trial in North India.

BACKGROUND: Disabled People's Organisations (DPOs) are the mainstay of disability responses worldwide. Yet there is no quantitative data assessing their effectiveness in low-and middle-income countries (LMICs). The aim of this study was to measure the effectiveness of DPOs as a low-cost intervention to improve well-being and access to services and facilities for people with disabilities. METHODS: We undertook a cluster randomised intervention control trial across 39 distinct rural villages in Uttarakhand State, North India. A total of 527 participants were included from 39 villages: 302 people from 20 villages were assigned to the intervention arm and 225 from 19 villages were assigned to the control group. Over a 2-year period, people with disabilities were facilitated to form DPOs with regular home visits. Participants were also given financial support for public events and exposure visits to other DPOs. Seven domains were used to measure access and participation. RESULTS: DPO formation had improved participation in community consultations (OR 2.57, 95% CI 1.4 to 4.72), social activities (OR 2.46, 95% CI 1.38 to 4.38), DPOs (OR 14.78, 95% CI 1.43 to 152.43), access to toilet facilities (OR 3.89, 95% CI 1.31 to 11.57), rehabilitation (OR 6.83, 95% CI 2.4 to 19.42) and Government social welfare services (OR 4.82, 95% CI 2.35 to 9.91) in intervention when compared to the control. People who were part of a DPO had an improvement in having their opinion heard (OR 1.94, 95% CI 1.16 to 3.24) and being able to make friends (OR 1.63, 95% CI 1 to 2.65) compared to those who were not part of a DPO. All other well-being variables had little evidence despite greater improvement in the DPO intervention group. CONCLUSIONS: This is the first randomised control trial to demonstrate that DPOs in LMICs are effective at improving participation, access and well-being. This study supports the ongoing role of DPOs in activities related to disability inclusion and disability services. This study also suggests that supporting the establishment, facilitation and strengthening of DPOs is a cost-effective intervention and role that non-governmental organisations (NGOs) can play. TRIAL REGISTRATION: ISRCTN36867362, 9th Oct 2019 (retrospectively registered).

Assessment of diabetic retinopathy in type 1 diabetes in a diabetes care center in South India-Feasibility and awareness improvement study.

The prevalence of youth-onset diabetes, both type 1 diabetes (T1D) and young-onset type 2 diabetes (YT2D) are gradually increasing in India. Early and repetitive screening for diabetic retinopathy (DR) is essential to provide timely management, and thereby prevent visual impairment due to the silent sight-threatening microvascular complication of diabetes. A study was undertaken at a diabetes care center in Chennai, south India, to assess the feasibility of screening for DR in T1D in a diabetes clinic and determine the burden of sight-threatening DR (STDR) in individuals with T1D. 315 people with T1D were screened for DR (mean age at onset of diabetes 12.3 ± 6.4 years) by digital retinal color photography, at the urban diabetes center, in a semi-urban and rural diabetes clinic. Counseling about diabetes and the importance of annual screening for retinopathy was provided by diabetes educators. Participants were reviewed after 6 months/1 year based on ophthalmologist's advice. DR was detected in 37.1% (n = 117), 42 (13%) of whom had STDR.Three-quarter participants were compliant with the annual follow-up retinal examination. The peer support group was established for participants with T1D and their families to foster interactions with service providers. The peer group meetings helped to increase the awareness of retinopathy among the parents and individuals with T1D. This narrative provides details of the study that shows that screening for DR among individuals with T1D in a diabetes clinic is a feasible model, irrespective of its location.

Management and referral for high-risk conditions and complications during the antenatal period: knowledge, practice and attitude survey of providers in rural public healthcare in two states of India.

BACKGROUND: Appropriate antenatal care improves pregnancy outcomes. Routine antenatal care is provided at primary care facilities in rural India and women at-risk of poor outcomes are referred to advanced centres in cities. The primary care facilities include Sub-health centres, Primary health centres, and Community health centres, in ascending order of level of obstetric care provided. The latter two should provide basic and comprehensive obstetric care, respectively, but they provide only partial services. In such scenario, the management and referrals during pregnancy are less understood. This study assessed rural providers' perspectives on management and referrals of antenatal women with high obstetric risk, or with complications. METHODS: We surveyed 147 health care providers in primary level public health care from poor and better performing districts from two states. We assessed their knowledge, attitudes and practices regarding obstetric care, referral decisions and pre-referral treatments provided for commonly occurring obstetric high-risk conditions and complications. RESULTS: Staff had sub-optimal knowledge of, and practices for, screening common high-risk conditions and assessing complications in pregnancy. Only 31% (47/147) mentioned screening for at least 10 of the 16 common high-risk conditions and early complications of pregnancy. Only 35% (17/49) of the staff at Primary health centres, and 51% (18/35) at Community health centres, mentioned that they managed these conditions and, the remaining staff referred most of such cases early in pregnancy. The staff mentioned inability to manage childbirth of women with high-risk conditions and complications. Thus in absence of efficient referral systems and communication, it was better for these women to receive antenatal care at the advanced centres (often far) where they should deliver. There were large gaps in knowledge of emergency treatment for obstetric complications in pregnancy and pre-referral first-aid. Staff generally were low on confidence and did not have adequate resources. Nurses had limited roles in decision making. Staff desired skill building, mentoring, moral support, and motivation from senior officers. CONCLUSION: The Indian health system should improve the provision of obstetric care by standardising services at each level of health care and increasing the focus on emergency treatment for complications, appropriate decision-making for referral, and improving referral communication and staff support.

Process of adaptation, development and assessment of acceptability of a health educational intervention to improve referral uptake by people with diabetes in Sri Lanka.

BACKGROUND: One major barrier to uptake of diabetic retinopathy (DR) services is lack of knowledge and awareness of DR among the people with diabetes (PwDM). Targeted health education (HE) can be a key element in improving the uptake of eye care services. Such interventions are lacking in Sri Lanka. METHODS: A local context specific HE intervention (HEI) was developed by adopting available resources and incorporating views from PwDM and key stakeholders. Four sessions of participatory workshops with PwDM (20 Sinhala and 13 Tamil speaking) and two stage 12 stakeholder interviews were conducted to both develop and pre-test the material. The products were a video and a leaflet, delivered at a medical clinic to a sample of 45 PwDM identified as having DR. Semi-structured interviews were conducted after 4 weeks, to evaluate the acceptability and comprehension of the HEI. Additionally, nine interviews were conducted with clinical providers to explore process issues related to delivery of the HEI. Data analysis was conducted using thematic analysis. RESULTS: The lack of knowledge and awareness on DR, and of the importance of regular DR screening and follow up, combined with poor information on referral pathways were key elements identified from the workshops with PwDM. The stakeholders prioritised the importance of using simple language, and the need for emphasis on improving understanding about the asymptomatic phase of DR. The overall acceptability of the HEI material was satisfactory, although there was some difficulty with interpretation of medical images. Overall, although PwDM liked the ideas of the video, the leaflet was seen as a more practical option, given the busy clinic environment. The key issue was both formats required interaction with the provider, in order to support understanding of the messages. CONCLUSIONS: The process of adapting HE material is not simply translation into the appropriate language. Instead, a tailored approach in a country, context and particular health services setting is needed. This study illustrates the value of using a participatory approach and involving PwDM and stakeholders in the adaptation and pilot testing of a HEI to improve uptake of screening for DR in the context of Sri Lanka.

mHealth and the management of chronic conditions in rural areas: a note of caution from southern India.

This article examines challenges facing implementation of likely mHealth programmes in rural India. Based on fieldwork in Andhra Pradesh in 2014, and taking as exemplars two chronic medical 'conditions' - type 2 diabetes and depression - we look at ways in which people in one rural area currently access medical treatment; we also explore how adults there currently use mobile phones in daily life, to gauge the realistic likelihood of uptake for possible mHealth initiatives. We identify the very different pathways to care for these two medical conditions, and we highlight the importance to the rural population of healthcare outside the formal health system provided by those known as registered medical practitioners (RMP), who despite their title are neither registered nor trained. We also show how limited is the use currently made of very basic mobile phones by the majority of the older adult population in this rural context. Not only may this inhibit mHealth potential in the near future; just as importantly, our data suggest how difficult it may be to identify a clinical partner for patients or their carers for any mHealth application designed to assist the management of chronic ill-health in rural India. Finally, we examine how the promotion of patient 'self-management' may not be as readily translated to a country like India as proponents of mHealth might assume.

At the margins of biomedicine: the ambiguous position of 'Registered Medical Practitioners' in rural Indian healthcare.

This analysis challenges a tendency in public health and the social sciences to associate India's medical pluralism with a distinction between biomedicine, as a homogeneous entity, and its non-biomedical 'others'. We argue that this overdrawn dichotomy obscures the important part played by 'informal' biomedical practice, an issue with salience well beyond India. Based on a qualitative study in rural Andhra Pradesh, South India, we focus on a figure little discussed in the academic literature - the Registered Medical Practitioner (RMP) - who occupies a niche in the medical market-place as an informal exponent of biomedical treatment. We explore the significance of these practitioners by tracking diagnosis and treatment of one increasingly prominent medical 'condition', namely diabetes. The RMP, who despite the title is rarely registered, sheds light on the supposed formal-informal sector divide in India's healthcare system, and its permeability in practice. We develop our analysis by contrasting two distinctive conceptualisations of 'informality' in relation to the state in India - one Sarah Pinto's, the other Ananya Roy's.

Prevalence and causes of musculoskeletal impairment in Mahabubnagar District, Telangana State, India: results of a population-based survey.

Background: Musculoskeletal impairments (MSI) are the leading contributor to global years lived with disability. Comparable epidemiological data on MSI is lacking, and are needed to inform health and rehabilitative services. This study aimed to estimate the prevalence and causes of MSI in Telangana State, India. Method: A population-based survey used probability proportionate to size and compact-segment sampling to select 51 clusters of 80 individuals (all ages). Participants were screened using seven questions and any participant who screened positive underwent standardized examination by a physiotherapist for MSI presence, severity and diagnosis. Data were also collected on vision and hearing impairment, depression and self-reported difficulties with physical functioning. Results: The prevalence of MSI was 19.6% (95% CI: 16.7-22.8%) and this increased with age. The majority (82%; 574/699) of MSI was classified as mild, 11% as moderate and 7% as severe. Over half (57%) of MSI diagnoses were acquired non-traumatic causes, with degenerative joint disease being the most common. There was a high unmet need for physiotherapy services (3% attended vs. 40% recommended). One-fifth (21%) of MSI cases also had at least one of vision (10%) or hearing (11%) impairment or depression (3%). Conclusions: MSI is common among persons living in Mahabubnagar District, particularly older adults. These estimates can inform public health initiatives for the planning of health and rehabilitation services.

Transport of pregnant women and obstetric emergencies in India: an analysis of the '108' ambulance service system data.

BACKGROUND: The transport of pregnant women to an appropriate health facility plays a pivotal role in preventing maternal deaths. In India, state-run call-centre based ambulance systems ('108' and '102'), along with district-level Janani Express and local community-based innovations, provide transport services for pregnant women. We studied the role of '108' ambulance services in transporting pregnant women routinely and obstetric emergencies in India. METHODS: This study was an analysis of '108' ambulance call-centre data from six states for the year 2013-14. We estimated the number of expected pregnancies and obstetric complications for each state and calculated the proportions of these transported using '108'. The characteristics of the pregnant women transported, their obstetric complications, and the distance and travel-time for journeys made, are described for each state. RESULTS: The estimated proportion of pregnant women transported by '108' ambulance services ranged from 9.0 % in Chhattisgarh to 20.5 % in Himachal Pradesh. The '108' service transported an estimated 12.7 % of obstetric emergencies in Himachal Pradesh, 7.2 % in Gujarat and less than 3.5 % in other states. Women who used the service were more likely to be from rural backgrounds and from lower socio-economic strata of the population. Across states, the ambulance journeys traversed less than 10-11 km to reach 50 % of obstetric emergencies and less than 10-21 km to reach hospitals from the pick-up site. The overall time from the call to reaching the hospital was less than 2 h for 89 % to 98 % of obstetric emergencies in 5 states, although this percentage was 61 % in Himachal Pradesh. Inter-facility transfers ranged between 2.4 % -11.3 % of all '108' transports. CONCLUSION: A small proportion of pregnant women and obstetric emergencies made use of '108' services. Community-based studies are required to study knowledge and preferences, and to assess the potential for increasing or rationalising the use of '108' services.

Prevalence of disability among adults using Rapid Assessment of Disability tool in a rural district of South India.

BACKGROUND: There are different estimates of disability prevalence reported in India due to the differences in definitions and methodologies. Reliable data is needed to plan effective disability inclusive strategies. OBJECTIVE: The objective of this study was to determine the prevalence and risk factors associated with disability among adults ≥18 years of age in Prakasam district of Andhra Pradesh using the Rapid Assessment of Disability (RAD) tool. METHODS: The RAD survey was conducted in 50 villages (clusters) of Ongole division of Prakasam district. A two-stage cluster random sampling was used. Within each village 80 participants were surveyed. Compact segment sampling was used to determine the houses included. A person was reported as disabled based on their responses to the functioning section of the RAD tool. RESULTS: A total of 4134 adults were included. The overall prevalence of disability was 10.4% (431 adults). The highest prevalence of functional impairment was related to mobility (4.7%) followed by vision (2.1%) and fine motor (1.8%). The prevalence of psychological distress was 2.3%. Disability was significantly more prevalent in the poor socio economic group (OR 2.8; 95% CI: 1.5; 5.0) and among unemployed (OR 3.6; 95% CI: 2.3, 5.5). The prevalence of disability was strongly associated with age where, participants aged 70 years and over were eleven times more likely to report disability than younger age groups. CONCLUSION: The high prevalence of disability in the region points to disability being of public health concern and as a health condition needing urgent attention and specific interventions.

Road traffic injuries to children during the school commute in Hyderabad, India: cross-sectional survey.

BACKGROUND: India is motorising rapidly. With increasing motorisation, road traffic injuries are predicted to increase. A third of a billion children travel to school every day in India, but little is known about children's safety during the school commute. We investigated road traffic injury to children during school journeys. METHODS: We conducted a cross-sectional survey in Hyderabad using a two-stage stratified cluster sampling design. We used school travel questionnaires to record any road injury in the past 12 months that resulted in at least 1 day of school missed or required treatment by a doctor or nurse. We estimated the prevalence of road injury by usual mode of travel and distance to school. RESULTS: The total sample was 5842 children, of whom 5789 (99.1%) children answered the question on road injury. The overall prevalence of self-reported road injury in the last 12 months during school journeys was 17% (95% CI 12.9% to 21.7%). A higher proportion of boys (25%) reported a road injury than girls (11%). There was a strong association between road injury, travel mode and distance to school. Children who cycled to school were more likely to be injured compared with children who walked (OR 1.5; 95% CI 1.2 to 2.0). Travel by school bus was safer than walking (OR 0.5; 95% CI 0.3 to 0.9). CONCLUSIONS: A sixth of the children reported a road traffic injury in the past 12 months during school journeys in Hyderabad. Injury prevention interventions should focus on making walking and cycling safer for children.

Assessing health and rehabilitation needs of people with disabilities in Cameroon and India.

PURPOSE: To assess the association between disability and serious health problems, and the access and uptake of health and rehabilitation services in Cameroon and India. METHODS: We undertook a population-based case-control study, nested within a survey in Fundong Health District, North West Cameroon (August-October 2013) and in Mahbubnagar District, Telangana State, India (February-April 2014). Disability was defined as the presence of self-reported difficulties in functioning or clinical impairments. One control without disability was selected per case, matched by age, gender and cluster. Information was collected using structured questionnaires on: socioeconomic status, health, access to health services and rehabilitation. RESULTS: Cases with disability were significantly more likely to report a serious health problem in the last year compared to controls in both India (OR = 3.2, 95% CI 2.1-4.8) and Cameroon (OR = 1.9, 1.4-2.7). The vast majority of people sought care when seriously ill, and this did not vary between cases and controls. Awareness and use of rehabilitation services was extremely low in both Cameroon and India. CONCLUSIONS: Further focus is needed to improve awareness of rehabilitation services among people with disabilities in India and Cameroon to ensure that their rights are fulfilled and to achieve the goal of Universal Health Coverage. Implications for Rehabilitation People with and without disabilities equally seek health care in India and Cameroon. However, people with disabilities experience more frequent serious health problems than people without. Extremely few people with disabilities were aware of rehabilitation services despite their existence in the study settings.

Human resources for refraction services in Central Nepal.

BACKGROUND: Uncorrected refractive error is a public health problem globally and in Nepal. Planning of refraction services is hampered by a paucity of data. This study was conducted to determine availability and distribution of human resources for refraction, their efficiency, the type and extent of their training; the current service provision of refraction services and the unmet need in human resources for refraction in Central Nepal. METHODS: This was a descriptive cross-sectional study. All refraction facilities in the Central Region were identified through an Internet search and interviews of key informants from the professional bodies and parent organisations of primary eye centres. A stratified simple random sampling technique was used to select 50 per cent of refraction facilities. The selected facilities were visited for primary data collection. Face-to-face interviews were conducted with the managers and the refractionists available in the facilities using a semi-structured questionnaire. RESULTS: Data was collected in 29 centres. All the managers (n=29; response rate 100 per cent) and 50 refractionists (Response rate 65.8 per cent) were interviewed. Optometrists and ophthalmic assistants were the main providers of refraction services (n=70, 92.11 per cent). They were unevenly distributed across the region, highly concentrated around urban areas. The median number of refractions per refractionist per year was 3,600 (IQR: 2,400 - 6,000). Interviewed refractionists stated that clients' knowledge, attitude and practice related factors such as lack of awareness of the need for refraction services and/or availability of existing services were the major barriers to the output of refraction services. The total number of refractions carried out in the Central Region per year was 653,176. An additional 170 refractionists would be needed to meet the unmet need of 1,323,234 refractions. CONCLUSION: The study findings demand a major effort to develop appropriately trained personnel when planning refraction services in the Central Region and in Nepal as a whole. The equitable distribution of the refractionists, their community-outreach services and awareness raising activities should be emphasised.

Assessment of screening practices for gestational hyperglycaemia in public health facilities: a descriptive study in bangalore, India.

BACKGROUND: Screening and timely treatment of gestational hyperglycaemia (GH) is proved to be beneficial and improves maternal and foetal health outcomes. To understand screening practices, we explored the knowledge and perceptions of doctors working in public health facilities in Bangalore, India. We also studied participation factors by examining whether undergoing glucose estimation tests affects morning sickness in pregnant women. DESIGN AND METHODS: We aimed to understand the screening practices and knowledge of doctors. A semi-structured questionnaire was self-administered by the 50 participant doctors, selected from the sampling frame comprising of all the doctors working in public health facilities. We included 105 pregnant women for baseline assessment, in whom a well-structured questionnaire was used. RESULTS: We reported that gestational diabetes mellitus (GDM) screening was done in nearly all the health centres (96%). However, only 12% of the doctors could provide all components of GDM diagnosis and management correctly and 46% would diagnose by using a random blood glucose test. A majority (92%) of the doctors had poor knowledge (68%) about the cut-off values of glucose tests. More than 80% of pregnant women experienced some discomfort mostly due to rapid ingestion glucose in short span of time. CONCLUSIONS: Our study established that screening for GH is done in most public health facilities. Nonetheless, knowledge of doctors on the glucose tests and their interpretation needs improvement. Re-orientation trainings of the doctors can improve their knowledge and thereby can efficiently screen for GH. Further, adequate planning prior to the tests can aid successful completion of them. Significance for public healthRising burden of hyperglycaemia in pregnancy is a cause for concern and is associated with short and long term deleterious consequences for mother and offspring. Hence, there is an urgent need to explore the screening practices for gestational hyperglycaemia (GH). The current study considers patient and doctors' perspectives regarding GH screening. The results from our study indicate several issues during screening of gestational hyperglycaemia in public health facilities in Bangalore, India. These included low awareness levels among doctors, lack of standard operating procedures and lack of adequate care and attention provided to pregnant women. Re-orientation trainings of the doctors within public health facilities can improve their knowledge and thereby can efficiently screen for GH. Further, adequate planning and preparation of the patient prior to the tests can help ensure successful completion of the tests. The findings of the study are comparable with the practices of public health hospitals in India.

FAmily-Led RehabiliTaTion aftEr Stroke in INDia: the ATTEND pilot study.

BACKGROUND: The aim of this pilot study was to determine the feasibility of a multicenter, randomized, controlled trial in India of a family-led, trained caregiver-delivered, home-based rehabilitation intervention vs. routine care. METHODS: A prospective, randomized (within seven-days of hospital admission), blinded outcome assessor, controlled trial of structured home-based rehabilitation delivered by trained and protocol-guided family caregivers (intervention) vs. routine care alone (control) was conducted in patients with residual disability. Key feasibility measures were recruitment, acceptance and adherence to assessment procedures, and follow-up of participants over six-months. CTRI/2014/10/005133. RESULTS: A total of 104 patients from the stroke unit at Christian Medical College, Ludhiana were recruited over nine-months. Recruitment was feasible and accepted by patients and their carers. Important observations were made regarding potential unblinding of the participants, contamination of therapy between the randomized groups, organization of home visits, and resources required for a multicenter study. CONCLUSION: The pilot study established the feasibility of conducting a large-scale study of family-led, trained caregiver-delivered, home-based stroke rehabilitation in a low resource setting. The main phase of the trial 'ATTEND' is currently underway in over 10 centers in India.

Reasons for non-uptake of referral: children with disabilities identified through the Key Informant Method in Bangladesh.

PURPOSE: To identify reasons for the non-uptake of referral for children with disability identified though the Key Informant Method in Bangladesh. METHOD: Core data was collected and analysed using qualitative methodologies. Fifty-one semi-structured interviews were completed with parent(s) of children who had attended a screening camp at the invitation of a Key Informant, but had not taken up their subsequent referral for health or rehabilitative services. Thematic analysis of the interview data resulted in emerging trends that were critically analysed according to the research objective. RESULTS: Seven thematic reasons for non-uptake of referral were identified: severity of the disability; family and community; direct and associated cost; location of referral; negative camp experience; deliberate non-uptake; and procedural problems. Parents often discussed multiple reasons for non-uptake, interrelating socio-cultural, logistical and experiential factors. CONCLUSION: Understanding the reasons for the parents of children with disability not taking up referral is important for the design and implementation of appropriate, relevant and contextual medical and rehabilitative services. The role of Key Informants may be developed from case detection, to include facilitation of effective and efficient uptake of services. IMPLICATIONS FOR REHABILITATION: Programmes to identify children with disability and facilitate subsequent rehabilitation or treatment need to have extensive pre-planned strategies for referral mechanisms and follow up. Although Key Informants were not the focus of investigation, the present study suggests that there is potential for the role of the Key Informants to be extended beyond that of a case detection, to inform and facilitate referral processes and encourage the uptake of services.

Trachoma prevalence in women living in rural northern India: rapid assessment findings.

PURPOSE: Rapid assessment of cicatricial trachoma in adult females aged over 15 years in a previously hyperendemic rural area in Haryana, North India. METHODS: Ten disadvantaged villages each with a population of 3000-5000 were chosen by cluster random sampling. One thousand females, 500 between 15-30 years and the rest over 30 years in the underdeveloped parts of the villages, identified by observation and consultation, were examined for signs of trachomatous scarring (TS), trachomatous trichiasis (TT) and trachomatous corneal opacity (TCO). Examinations of both eyes were performed with the aid of a binocular loupe (2.5x magnification) for signs of trachoma, its complications and other ocular morbidities. RESULTS: Bilateral examination was carried out in all participants. About two-thirds (n = 650; 65%) of subjects did not have any signs of trachoma. The percentages of trachoma stages TS, TT and TCO were found to be 26.4%, 5.4% and 3.2% respectively. Trichiasis was observed in 54 subjects, all in the age group >30 years, and highest in the age group 66-75 years (22.8%). Females in the age group >30 years had significantly higher cicatricial trachoma compared to females <30 years (p < 0.001). Overall 59.3% of affected females had not received any treatment. Epilation and entropion surgery had been performed in 30.3% and 10.4% of affected females, respectively. CONCLUSION: The results of our rapid assessment suggest that the presence of cicatricial trachoma remains an important health issue in females over 15 years of age.

Predictors of referral uptake in children with disabilities in Bangladesh--exploring barriers as a first step to improving referral provision.

PURPOSE: Making services available to children with disabilities in low- and middle-income countries does not guarantee their use. This study aims to identify factors associated with the uptake of referrals in order to investigate barriers to service use. METHODS: Children with impairments identified in two districts of Bangladesh were invited to attend screening camps where their condition was confirmed; they were provided with referrals for rehabilitation and treatment services. Predictors of referral uptake were identified using logistic regression. RESULTS: Overall referral uptake was 47%, 32% in Sirajganj and 61% in Natore. There was no association between age or gender and referral uptake. Factors predictive of referral uptake were higher income in Sirajganj (OR=2.6 95%CI 1.4-5.0), and the districts combined (OR=1.6 95%CI 1.1-2.1); maternal literacy in Natore (OR=1.6 95%CI 1.0-2.5); and epilepsy in all three models (Sirajganj: OR=2.6 95%CI 1.7-4.0; Natore: OR=13.5 95%CI 6.5-28.3; Combined: OR=4.6 95%CI 3.3-6.5). Physical impairment was associated with increased odds of uptake in Sirajganj and in the combined model (OR=2.7 95%CI 1.8-4.1; OR=3.34 95%CI 2.2-5.2). CONCLUSIONS: Even when some logistical and financial assistance is available, children with impairment from low-income families may require additional support to take up referrals. There may be greater willingness to accept treatment that is locally provided, such as medication for epilepsy or therapy at village level.

Barriers to cataract surgery of persons screened at camps in Ibadan, Nigeria.

PURPOSE: To determine barriers to uptake of cataract surgery by outreach patients at the University College Hospital, Ibadan and to make appropriate recommendations for improved cataract surgery uptake METHODS: Consenting cataract blind/visually impaired (presenting vision < 6/18) outreach patients identified from the outreach patient register of the University College Hospital, (UCH) Ibadan during a five months period (January to May 2009) were followed up for a visit in late June and July 2009. A semi-structured questionnaire schedule was used for data collection. People who did not use the services were administered a barriers questionnaire-schedule while those who accepted the services were administered a questionnaire schedule to elicit motivating factors for acceptance of services. Subjects were also examined using standard ophthalmic equipment (pen torch, ETDRS vision charts and ophthalmoscope) and information obtained recorded in a data entry form. RESULTS: A total of 186 subjects comprising 115 who had undergone cataract surgery and 71 who were yet to access cataract surgery services were followed up and included in the study. Reason for accessing surgery included awareness of quality service 63 (57.0%), was referred 32(29.0%) and pressure from family or friends 13(12.0%). Barriers to access included, untreated medical problems 21 (29.0%), not able to afford total (direct and indirect) cost of treatment 15 (21.0%), cataract not mature 10 (14.0%), not able to afford cost of surgery 9 (13.0%) and Dr's appointment 8 (11.0%). CONCLUSION: barriers to surgery uptake by outreach camp patients include cost of services, underlying medical problems and preferred doctors' practice. Adoption and scaling up of health insurance to cover those most in need as well as a change in preferred practice amongst eye care practitioners are possible areas for intervention.

Rapid assessment of trachoma among children living in rural northern India.

PURPOSE: Rapid assessment of active trachoma in children aged 1-9 years in a previously hyperendemic rural area in Haryana, India. METHODS: Ten disadvantaged villages each with a population of 3000-5000 were chosen by cluster random sampling. One thousand children from 500 households in the most underdeveloped parts of the villages--identified by observation and consultation, between the ages of 1-9 years--were examined for signs of Trachomatous inflammation follicular (TF) and Trachomatous inflammation intense (TI). Assessment was done in a health care unit. Examination of both eyes for signs of trachoma and its complications was done with the aid of binocular loupe (2.5X magnification). Tarsal conjunctival swabs from patients of active trachoma were analyzed by direct immunofluorescence assay and polymerase chain reaction for Chlamydia trachomatis antigen. RESULTS: Forty children (males 21, females 19) had signs of active trachoma that included TF (33) and TI (7). At least one ocular morbidity was present in 69% of all children that were examined. Unclean face carried a 2.70 (confidence interval [CI] = 1.30-5.37) times higher risk and poor ocular hygiene had 2.05 (CI = 1.02-4.11) times higher risk for trachoma infection. Among clinically positive cases, direct immunofluorescence assay and polymerase chain reaction assays were positive in 25% and 10%, respectively. CONCLUSIONS: Active trachoma is not a public health problem in previously hyperendemic areas of North India.

Need for optical and low vision services for children in schools for the blind in North India.

CONTEXT: Children admitted in blind schools need low vision assessment for improving functional vision (useful residual vision). AIM: To ascertain the need for spectacles and magnifiers as low vision devices (LVD) in children with useful residual vision, attending blind schools. SETTING AND DESIGN: Cross-sectional study conducted in 13 blind schools in Delhi, North India. MATERIALS AND METHODS: Of a total of 703 children (less than 16 years of age) examined, 133 (18.91%) with useful residual vision were refracted and analyzed. High addition plus lenses (range 5-30 diopters) were used as spectacle magnifiers for near LVD assessment. "World health organization (WHO)/ prevention of blindness (PBL) eye examination record for children with blindness and low vision", was used to collect data. SPSS (statistical package for the social science), version 10.0 was used for analysis. RESULTS: Based on the vision of 133 children at initial examination, 70.7% children were blind and 12.0% were severely visually impaired (SVI). 20.3% children improved by at least one WHO category of blindness after refraction. With best correction, 50.4% children were still blind and 13.5% were SVI. Visual acuity in the better eye after refraction in 47 children (35.3%), improved with spectacles. Children with aphakia (17), coloboma (5), refractive error (5) and microphthalmos (4) benefited from spectacles. Of 124 children with low vision but having useful residual vision, 51 (41.1%) were able to read N-10 unaided or with distance spectacles and 30 children (22.6%) improved to N-10 with spectacle magnifiers and were prescribed the same. CONCLUSION: Visually impaired children with aphakia and congenital anomalies of the eye benefit from refraction and low vision services.