Nurturing transformative local structures of multisectoral collaboration for primary health care: qualitative insights from select states in India.

BACKGROUND: Multisectoral collaboration is essential for advancing primary health care (PHC). In low- and middle-income countries (LMICs), limited institutional capacities, governance issues, and inadequate stakeholder engagement impede multisectoral collaboration. India faces similar challenges, especially at the meso-level (districts and subdistricts). Owing to its dependence on context, and insufficient evidence, understanding "How" to improve multisectoral collaboration remains challenging. This study aims to elicit specific recommendations to strengthen meso-level stewardship in India for multisectoral collaboration. The findings from this study may offer lessons for other LMICs. METHODS: Using purposive, maximum variation sampling, the study team conducted semi-structured interviews with 20 diverse participants, including policymakers, implementers, development agency representatives, and academics experienced in multisectoral initiatives. The interviews delved into participants' experiences, the current situation, enablers, and recommendations for enhancing stakeholder engagement and capacities at the meso-level for multisectoral collaboration. RESULTS: Context and power are critical elements to consider in fostering effective collaboration. Multisectoral collaboration was particularly successful in three distinct governance contexts: the social-democratic context as in Kerala, the social governance context in Chhattisgarh, and the public health governance context in Tamil Nadu. Adequate health system input and timely guidance instil confidence among local implementers to collaborate. While power plays a role through local leadership's influence in setting agendas, convening stakeholders, and ensuring accountability. To nurture transformative local leaders for collaboration, holistic, equity-driven, community-informed approaches are essential. The study participants proposed several concrete steps: at the state level, establish "central management units" for supervising local implementers and ensuring bottom-up feedback; at the district level, rationalise committees and assign deliverables to stakeholders; and at the block level, expand convergence structures and involve local self-governments. Development partners can support data-driven priority setting, but local implementers with contextual familiarity should develop decentralised plans collaboratively, articulating rationales, activities, and resources. Finally, innovative training programs are required at all levels, fostering humility, motivation, equity awareness, leadership, problem- solving, and data use proficiency. CONCLUSION: This study offers multiple solutions to enhance local implementers' engagement in multisectoral efforts, advocating for the development, piloting, and evaluation of innovative approaches such as the block convergence model, locally-led collaboration efforts, and novel training methods for local implementers.

Exploring food insecurity and multimorbidity in Indian socially disadvantaged people: cross-sectional findings from LASI, 2017-18.

OBJECTIVES: The present study aimed to examine the association of multimorbidity status with food insecurity among disadvantaged groups such as Scheduled Castes (SCs), Scheduled Tribes (STs), and Other Backward Class (OBCs) in India. METHOD: The data for this study was derived from the first wave of the Longitudinal Ageing Study in India (LASI),2017-18, focusing on 46,953 individuals aged 45 years and over who belong to SCs, STs, and OBCs groups. Food insecurity was measured based on the set of five questions developed by the Food and Nutrition Technical Assistance Program (FANTA). Bivariate analysis was performed to examine the prevalence of food insecurity by multimorbidity status along with socio-demographic and health-related factors. Multivariable logistic regression analysis and interaction models were used. RESULTS: The overall prevalence of multimorbidity was about 16% of the study sample. The prevalence of food insecurity was higher among people with multimorbidity compared to those without multimorbidity. Unadjusted and adjusted models suggested that people with multimorbidity were more likely to be food insecure than people without multimorbidity. While middle-aged adults with multimorbidity and men with multimorbidity had a higher risk of food insecurity. CONCLUSION: The findings of this study suggest an association between multimorbidity and food insecurity among socially disadvantaged people in India. Middle-aged adults experiencing food insecurity tend to reduce the quality of their diet and consume a few low-cost, nutritionally deficient meals to maintain caloric intake, putting them again at risk for several negative health outcomes. Therefore, strengthening disease management could reduce food insecurity in those facing multimorbidity.

Breaking the silence on gendered harassment and assault of community health workers: an analysis of ethnographic studies.

INTRODUCTION: Across a variety of settings, women in tenuous financial circumstances are drawn to community health work as a way to advance themselves in the context of limited employment options. Female Community Health Workers (CHWs) are often preferred because they can more easily access mothers and children; at the same time, gender norms are at the heart of many of the challenges and inequities that these workers encounter. Here, we explore how these gender roles and a lack of formal worker protections leave CHWs vulnerable to violence and sexual harassment, common occurrences that are frequently downplayed or silenced. METHODS: We are a group of researchers who work on CHW programmes in a variety of contexts globally. The examples here are drawn from our ethnographic research (participant observation and in-depth interviews). RESULTS: CHW work creates job opportunities for women in contexts where such opportunities are extremely rare. These jobs can be a lifeline for women with few other options. Yet the threat of violence can be very real: women may face violence from the community, and some experience harassment from supervisors within health programmes. CONCLUSION: Taking gendered harassment and violence seriously in CHW programmes is critical for research and practice. Fulfilling CHWs' vision of health programmes that value them, support them and give them opportunities may be a way for CHW programmes to lead the way in gender-transformative labour practices.

Prevalence of smoking and smokeless tobacco use during breastfeeding: A cross-sectional secondary data analysis based on 0.32 million sample women in 78 low-income and middle-income countries.

Background: Smoking and smokeless tobacco use during the postpartum period is well studied in high-income countries, whereas low-income and middle-income countries (LMICs) lack evidence. Methods: In this cross-sectional study we used data from the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) conducted in 78 LMICs between January 2010 and December 2019 to study tobacco use among 0.32 million sample lactating women. Age-standardized prevalence of smoking and smokeless tobacco use was estimated and presented with a 95% Confidence Interval (CI) for 78 LMICs. Pooled estimates overall and by WHO regions were obtained using random-effects meta-analyses. Country-level and community-level variance to understand contextual factors was also quantified using multilevel modelling. Findings: Pooled prevalence of any tobacco use among breastfeeding women in LMICs was 3.61% (95% CI 3.53-3.70); with the lowest prevalence in regions of the Americas (1.44%, 1.26-1.63) and the highest in the Southeast Asia region (6.13%, 6.0-6.27). The pooled prevalence of tobacco smoking was reported to be 1.16% (1.11-1.21), with the highest prevalence in the Eastern Mediterranean region (4.27%, 3.88-4.67) and the lowest in the African region (0.81%, 0.76-0.86). The pooled prevalence of smokeless tobacco use was reported to be 2.56% (2.49-2.63), with the highest prevalence in the Southeast Asia region (4.92%, 4.80-5.04). Illiterate and poor women in LMICs bore the enormous burden of tobacco use. Interpretation: The prevalence of smoking and smokeless tobacco use among lactating women in LMICs varied considerably across different WHO regions. Considering the cross-sectional design of the study, caution is required while interpreting the results. To improve mothers' and children's health and nutrition outcomes and reduce health inequalities in LMICs, reducing tobacco use through evidence-based interventions is critical. Funding: None.

Assessment of Role and Efficacy of Curcumin and Quercetin in Preventing Lead-Induced Oxidative Stress in Rats.

Lead (Pb) is found in almost all phases in environment and biological systems. Pb stimulated oxidative stress is a state that involves the generation of free radicals beyond the permissible limits, which can deplete the antioxidant reserves and can result in oxidative stress, thus hampering the ability of the biological system to reverse the result. Exposure of rats to Pb (25 mg/kg body weight) for 8 weeks caused an increase in Pb levels in blood and brain. Activity of delta-aminolevulinic acid dehydratase (δ-ALAD) and antioxidant enzymes such as Superoxide dismutase (SOD) and Catalase (CAT) decreased in the blood of Pb-treated group with a concomitant increase in the level of lipid peroxidation (LPO) and no significant change in the level of reduced glutathione (GSH) level was found. Interestingly, co-treatment of Pb-treated rats with curcumin (30 mg/kg body weight) and quercetin (30 mg/kg body weight) for 8 weeks caused a significant decrease in Pb levels of blood and all brain regions versus those treated with Pb alone. A significant improvement in levels of MDA, δ-ALAD, SOD and CAT activities was observed in rats simultaneously treated with curcumin or Quercetin or both with lead. Therefore, the ameliorative impact of curcumin and Quercetin might be due to their antioxidant property hence were able to counter the oxidative stress generated by Pb. These results suggest that combination of curcumin and Quercetin could be utilized as a possible supplement with the relevant therapeutics in the suitable management of Pb toxicity.

Coverage of Quality Maternal and Newborn Healthcare Services in India: Examining Dropouts, Disparity and Determinants.

Background: Abundant research studies has recorded availability, accessibility and quality of antenatal care and safe delivery in India but comparatively less information is known for postnatal care and furthermore limited attempts at capturing the whole spectrum of obstetric and newborn health services. Assessing discontinuity in maternal and child health service utilization provides us holistic information about existing health inequities and barriers in service provision. Objective: Current study evaluated the coverage of quality antenatal care (QANC), delivery care (QDC) and postnatal care (QPNC) in India as a part of a single continuum accounting for significant regional and sub-regional disparities. Methods: This study analyzed nationally representative data obtained from NFHS-4 (2015-16). Included in the data, were 190 898 Indian women who had a recent birth in last five years. Coverage of QANC, QDC and QPNC was examined at the national, state and district level. Bivariate association of key sociodemographic variables with coverage of services was assessed during chi-squared analysis. Multilevel logistic regression analysis examined correlates associated with coverage of services. The output was presented using odds ratios (OR) with 95% CI. Findings: About 23.5% women utilized QANC out of which 92.9% opted for QDC and 35.1% of newborns received QPNC. About 400 and 471 districts out of 640 had less than 30% coverage of QANC and QPNC, respectively. Women residing in rural regions of Bihar and Northeastern states were found with less than 10% coverage of QANC. Regression analysis shows that women with more than 12 years of education and belonging to richest households had increased odds of availing QANC (OR 1.95; 95%CI: 1.84-2.06) and QDC (OR: 2.86; 95%CI: 2.27-3.60), respectively. Conclusion: Focused interventions targeting the delivery of quality services especially ANC and PNC among newborns are imperative to achieve SDG-3 goals to achieve improvement in maternal and newborn health.

An integrated assessment of lead exposure in children: Correlation with biochemical and haematological indices.

BACKGROUND: Lead (Pb) is a worldwide concern due to its persistent property in the environment. However, due to diminutive evidence and elusiveness, the impact of lead exposure on the biochemical and haematological parameter in school-age children is not well established. AIM: This study primarily aimed to investigate blood lead (BL) in children and its association with haematological and biochemical parameter. METHODS: A total of 43 children (4-12 years) were recruited in each control and study group. Furthermore, the study group were subdivided into two groups (group A (<10 µg/dl) and group B (>10 µg/dl)). BL level, haematological parameter including haemoglobin, packed cell volume, red blood cells, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, total leukocytes count, neutrophils, lymphocytes, monocytes, mean corpuscular volume, red cell distribution width, eosinophil's, platelets in the whole blood and biochemical parameter such as liver function test (total bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, total protein, albumin) and kidney function test (sodium, potassium, blood urea nitrogen, creatinine) in serum were measured using anodic stripping voltammeter (ASV), Cell-Dyn Ruby Haematology analyser, Beckman coulter Unicel Dxc 800 Synchron Clinical analyser respectively. RESULTS: The arithmetical mean of BL level was 19.93 ± 9.22 µg/dl (median: 17.5 µg/dl; range 9.1-37.4 µg/dl). Only 21 % children had BL levels <10 µg/dl and there were 79 % children with BL levels >10 µg/dl. Blood mean corpuscular haemoglobin concentration, Neutrophils, Monocytes were significantly higher between the control and study group. Additionally, haemoglobin, packed cell volume, red blood cells, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentration, Lymphocytes and mean corpuscular volume intensities were significantly lower in >10 µg/dl group whereas total leukocytes count, neutrophils, monocytes, red cell distribution width, eosinophil's, platelets levels were statistically higher (p < 0.001). Serum alkaline phosphatase, serum glutamic-oxaloacetic transaminase, total protein, were higher (p < 0.05) and sodium, albumin were significantly lower in the study group. The mean value of sodium, potassium, total bilirubin, alkaline phosphatase, serum glutamic-pyruvic transaminase, total protein and blood urea nitrogen, creatinine in two groups (<10 µg/dl and >10 µg/dl) was not significantly different. Serum glutamic-oxaloacetic transaminase level was significantly higher (p = 0.015) while albumin levels were significantly lower (p = 0.034) in >10 µg/dl group. A statistically significant correlation of BL levels with all haematological parameters was also observed. Creatinine is positively and albumin was negatively correlated with BL levels. CONCLUSION: The outcomes specify that high BL levels were significantly associated with higher haematological and biochemical indices in exposed children. However, lead like noxious metals severely affected the haematological, kidney and liver health of children.

Assessment of MYC/PTEN Status by Gene-Protein Assay in Grade Group 2 Prostate Biopsies.

This study leveraged a gene-protein assay to assess MYC and PTEN status at prostate cancer biopsy and examined the association with adverse outcomes after surgery. MYC gain and PTEN loss were simultaneously assessed by chromogenic in situ hybridization and immunohistochemistry, respectively, using 277 Grade Group 2 needle biopsies that were followed by prostatectomy. The maximal size of cribriform Gleason pattern 4 carcinoma (CRIB), the presence of intraductal carcinoma (IDC), and percentage of Gleason pattern 4 carcinoma at biopsy were also annotated. MYC gain or PTEN loss was present in 19% and 18% of biopsies, respectively, whereas both alterations were present in 9% of biopsies. Tumors with one or both alterations were significantly more likely to have non-organ-confined disease (NOCD) at radical prostatectomy. In logistic regression models, including clinical stage, tumor volume on biopsy, and presence of CRIB/IDC, cases with MYC gain and PTEN loss remained at higher risk for NOCD (odds ratio, 6.23; 95% CI, 1.74-24.55; P = 0.005). The area under the curve for a baseline model using CAPRA variables (age, prostate-specific antigen, percentage of core involvement, clinical stage) was increased from 0.68 to 0.69 with inclusion of CRIB/IDC status and to 0.75 with MYC/PTEN status. Dual MYC/PTEN status can be assessed in a single slide and is independently associated with increased risk of NOCD for Grade Group 2 biopsies.

Mapping the triple burden of smoking, smokeless tobacco and alcohol consumption among adults in 28,521 communities across 640 districts of India: A sex-stratified multilevel cross-sectional study.

National estimates on tobacco and alcohol consumption are insufficient to guide policy at the sub-national level. This study assessed the sex-stratified prevalence of different types of smoking and smokeless tobacco and alcohol consumption among adults aged 15-49 using the National Family Health Survey (2015-16) at sub-national administrative units. Three-level logistic regression models were applied to quantify the variation at district- and community-level in smoking and consumption of smokeless tobacco and alcohol. A higher prevalence of smoking, smokeless tobacco and alcohol consumption was observed among men. The study found that the considerable unexplained variations in two different forms of tobacco and alcohol consumption among men attributed to between-population differences at district-level and community-level. The between-population differences were even larger at the district- and community-level in tobacco and alcohol consumption among women. Continious assessment of tobacco and alcohol consumption at lower administrative units and the development of evidence-based localised cessation interventions must be integrated with health policy to reduce disease burden and preventable deaths.

Evidence of integrated primary-secondary health care in low-and middle-income countries: protocol for a scoping review.

BACKGROUND: Integrated care is a people-centered health delivery approach that ensures the comprehensiveness, quality, and continuity of service across the settings and levels of health systems. The World Health Organization (WHO) recommends integration across levels and building-blocks of health systems as a prerequisite of Universal Health Coverage (UHC). While health systems of low- and middle-income countries (LMICs) are often fragmented and led by siloed service delivery structure, several LMICs-including India-have attempted health system integration. Several systematic reviews of evidence on healthcare integration from developed countries exist, but no synthesis from LMICs was reported to date. This review will overview the existing evidence of primary-secondary care integration (PSI) in the context of LMICs, aiming to support policy decisions for the effective integration of health delivery systems in India. METHODS: The review will be conducted following the six steps recommend by Arksey and O'Malley. Scientific and grey literature will be systematically selected from PubMed, Embase, Scopus, Web of Science, Global Index Medicus, and electronic repositories (such as WHO, World Bank, Health Policy Plus, and OpenGrey). Using a comprehensive search strategy, literature written in English and published between 2000 and 2020 will be selected, and two independent authors will screen their titles and abstracts. The result will be charted using a data extraction form and reported using tables, figures, and narrative forms. DISCUSSION: No ethical approval is necessary for the review. The final report will be developed with the consultation of other stakeholders and disseminated through workshops, conference papers, and peer review articles. The review will serve as a guiding tool to approach, implement, and test the PSI models in India and other LMICs. SCOPING REVIEW REGISTRATION: https://osf.io/kjhzt .

Public health interventions to improve maternal nutrition during pregnancy: a nationally representative study of iron and folic acid consumption and food supplements in India.

OBJECTIVE: Despite a reduction in maternal mortality in recent years, a high rate of anaemia and other nutrient inadequacies during pregnancy pose a serious threat to mothers and their children in the Global South. Using the framework of the WHO-Commission on Social Determinants of Health, this study examines the socioeconomic, programmatic and contextual factors associated with the consumption of iron and folic acid (IFA) tablets/syrup for at least 100 d (IFA100) and receiving supplementary food (SF) by pregnant women in India. DESIGN: We analysed a nationally representative cross-sectional survey of over 190 898 ever-married women aged 15-49 years who were interviewed as part of the National Family Health Survey (NFHS) conducted during 2015-16, who had at least one live birth preceding 5 years of the survey. SETTING: All twenty-nine states and seven union territories of India. PARTICIPANTS: Ever-married women aged 15-49 years. RESULTS: Less than one-third of women were found to be consuming IFA100, and a little over half received SF during their last pregnancy. The consumption of IFA100 was likely to improve with women's education, household wealth, early and more prenatal visits, and in a community with high pregnancy registration. Higher parity, early and more prenatal visits, contact with community health workers during pregnancy, belonging to a poor household and living in an aggregated poor community and rural area positively determine whether a woman might receive SF during pregnancy. CONCLUSIONS: Continuous monitoring and evaluation of provisioning IFA and SF in targeted groups and communities is a key to expanding the coverage and reducing the burden of undernutrition during pregnancy.

Smokeless tobacco control in India: policy review and lessons for high-burden countries.

We examined the magnitude of smokeless tobacco (SLT) use in India and identified policy gaps to ascertain the priorities for SLT control in India and other high SLT burden countries in the Southeast Asia region. We reviewed and analysed the legal and policy framework to identify policy gaps, options and priority areas to address the SLT burden in India and lessons thereof. In India, 21.4% adults, including 29.6% of men, 12.8% of women, use SLT while more than 0.35 million Indians die every year due to SLT use. SLT use remains a huge public health concern for other countries in the region as well. Priority areas for SLT control should include: constant monitoring, increasing taxes and price of SLT products, strengthening and strict enforcement of existing laws, integration of SLT cessation with all health and development programmes, banning of advertisement and promotion of SLT, increasing age of access to tobacco up to 21 years, introducing licensing for the sale of SLT, standardising of SLT packaging and preventing SLT industry interference in the implementation of SLT control policies besides a committed multistakeholder approach for effective policy formulation and enforcement. SLT control in India and the other high SLT burden countries, especially in the Southeast Asia region, should focus on strengthening and implementing the above policy priorities.

Provisions for Health Sector Response to Substance Use Disorders in the Indian Policy: A Critique of the National Policy on Narcotic Drugs and Psychotropic Substances.

This article reviews the provisions of Indian national policy on narcotic drugs and psychotropic substances in context of the health sector services for (illicit) psychoactive substances and substance use disorders (SUD). For the the current review, a checklist was developed based on recommendations from various agencies and organizations. The document on Indian national policy on narcotic drugs and psychotropic substances was reviewed based on the checklist. Themes such as identification in the aims/objectives/vision of the policy, including those highlighting treatment-related needs for SUD; establishment of minimum standards of care for treatment; evaluation of treatment programs for SUD; government regulation of public and private drug treatment services; capacity building for treatment services; and harm reduction services to reduce bloodborne infections were documented in the policy. Others such as transparency of the policy making process; situation analysis; implementation of substance abuse prevention and treatment programs that target key populations; impetus on evidence-based programs and practices were inadequately documented. Finally, integration of treatment into existing health care systems; services for co-occurring disorders (medical and psychiatric); monitoring and performance evaluation of prevention programs; harm reduction services to reduce overdose; budget allocations and provisions for implementation were not documented in the current policy.

Socioeconomic determinants of chronic health diseases among older Indian adults: a nationally representative cross-sectional multilevel study.

OBJECTIVE: Study uses multilevel modelling to examine the effect of individual, household and contextual characteristics on chronic diseases among older Indian adults. DESIGN: Nationally representative cross-sectional study. PARTICIPANTS: Data from the nationally representative, India Human Development Survey conducted in 2011-2012 was used in this study. The survey asked information related to the diagnosed chronic illnesses such as cataract, tuberculosis, hypertension, heart disease and others. The sample size of this study comprised 39 493 individuals who belonged to the age group 50 years and above. MEASURES: Self-reported diagnosed chronic illness. METHOD: Considering the hierarchal structure of the data multilevel logistic regression analysis was applied to attain the study objective. RESULTS: Older adults aged 80 years and older were found with three times more chances (OR: 3.99, 95% CI 2.91 to 5.48) of suffering from a chronic ailment than 50-54 years old. Lifestyle risk factors such as alcohol and tobacco (smoked and smokeless) consumption were noted to be significantly associated with the presence of chronic illness whereas older adults who have never consumed smokeless tobacco stood 20% fewer chances (OR: 0.80, 95% CI 0.68 to 0.94) of having any chronic illness. Contextual level variables such as older adults residing in the rural areas were found with 17% fewer chances (OR: 0.83, 95% CI 0.70 to 0.97) of suffering from a chronic illness. CONCLUSION: Even after controlling for various characteristics at the individual, household and contextual levels, significant variations in chronic illness remain unexplained at the community and state level, respectively. The findings of this study could effectively be utilised to consider more contextual variables to examine the chronic health status among the growing older population of India.

Intrapartum monitoring using partograph at secondary level public health facilities-A cross-sectional study in Odisha, India.

CONTEXT: Partograph is a simple, effective and low-cost intrapartum monitoring tool that helps in early identification of complications if any and helps in prompt intervention to save the life of the mother and the newborn. There is limited study about its usage and challenges in plotting from India particularly Odisha. AIM: To determine the usage of partograph and explore the issues/challenges in its plotting at various levels of health facilities. SETTINGS AND DESIGN: A cross-sectional study was carried out from April to June 2018 in ten different public health facilities from two tribal districts of Odisha, India. Materials and Methods: Quantitative information from 1552 mothers using pre-tested epi-info questionnaire tool and qualitative information through 22 in-depth interviews among health care providers. STATISTICAL ANALYSIS USED: Quantitative data using Ms Excel 10 and IBM SPSS ver. 22 and qualitative data using the inductive content analysis method. RESULTS: Partograph plotting was found in 48.7% (adherence) while its completeness was only 1.03%. Partograph plotting was significantly better at CHCs compared to DHH and SDH (P = 0.000). No significant association of partograph adherence was observed with the birth outcome, complications, referral status and type of delivery. Though majority health care providers knew the importance of the partograph, hardly they use it. The main reasons were increased workload, shortage of staff, cases arriving at a later stage and lack of monitoring from a higher level. CONCLUSIONS: On job training on partograph, regular monitoring and strict policy will improve the adherence and completeness in partograph plotting.

India's health and wellness centres: realizing universal health coverage through comprehensive primary health care.

In common with other countries in the World Health Organization South-East Asia Region, disease patterns in India have rapidly transitioned towards an increased burden of noncommunicable diseases. This epidemiological transition has been a major driver impelling a radical rethink of the structure of health care, especially with respect to the role, quality and capacity of primary health care. In addition to the Pradhan Mantri Jan Arogya Yojana insurance scheme, covering 40% of the poorest and most vulnerable individuals in the country for secondary and tertiary care, Ayushman Bharat is based on an ambitious programme of transforming India's 150 000 public peripheral health centres into health and wellness centres (HWCs) delivering universal, free comprehensive primary health care by the end of 2022. This transformation to facilities delivering high-quality, efficient, equitable and comprehensive care will involve paradigm shifts, not least in human resources to include a new cadre of mid-level health providers. The design of HWCs and the delivery of services build on the experiences and lessons learnt from the National Health Mission, India's flagship programme for strengthening health systems. Expanding the scope of these components to address the expanded service delivery package will require reorganization of work processes, including addressing the continuum of care across facility levels; moving from episodic pregnancy and delivery, newborn and immunization services to chronic care services; instituting screening and early treatment programmes; ensuring high-quality clinical services; and using information and communications technology for better reporting, focusing on health promotion and addressing health literacy in communities. Although there are major challenges ahead to meet these ambitious goals, it is important to capitalize on the current high level of political commitment accorded to comprehensive primary health care.

Comparative assessment of late toxicity in patients of carcinoma cervix treated by radiotherapy versus chemo-radiotherapy - Minimum 5 years follow up.

BACKGROUND: A randomised trial was carried out comparing chemo-radiation (CTRT) vs. radiotherapy (RT) in patients of carcinoma cervix and showed similar rates of pelvic disease control, disease free survival and overall survival. Late toxicity is presented. METHODS: Between December 2000 and July 2006, 180 patients of carcinoma cervix were randomly assigned to RT + weekly cisplatin (n = 94) or RT alone (n = 86). Late toxicity was prospectively scored using RTOG criteria in 156 evaluable patients, 79 and 77 respectively and is presented as crude incidence for rectum, bladder, small intestine, vagina, skin and bone and also as actuarial incidence for rectum and bladder. RESULTS: The median follow up of surviving patients was 10.4 years (minimum - 6.5 years). Crude incidence, CTRT vs. RT, of late toxicities were: rectal (7.5% vs. 5%, p = 0.22), bladder (15% vs. 10.4%, p = 0.76), small bowel (3% vs. 1.2%, p = 0.51), vagina (25% vs. 35%, p = 0.35) while the actuarial risk of grades 3-5 rectal and bladder toxicities by 5 years were 13% vs. 10% (p = 0.698) and 16% vs. 14.8% (p = 0.783) respectively. Bladder toxicity appeared later then rectal toxicity (median 49.4 vs. 21.4 months). Severe bone toxicity (fractures) were higher in the CTRT arm, 5% vs. 0%, p = 0.018. On multivariate analysis vaginal involvement (p = 0.016) and bulky tumor (p = 0.020) were associated with severe vaginal morbidity while rectal point dose > 80% (p = 0.040) was associated with a higher incidence of rectal toxicity. CONCLUSION: Bone toxicity was significantly increased by addition of CT to RT and patients continued to experience toxicity at longer periods of follow up albeit disease free.

Assessment tools for screening and clinical evaluation of psychosocial aspects in addictive disorders.

This article provides an overview of the tools for psychosocial assessment of substance use disorders. Various psychosocial factors need to be assessed for effective management of individuals and to carry out research in the field. These factors include socio-demographic characteristics, neuropsychological functions, psychiatric co-morbidities, psychological vulnerabilities such as personality traits, motivation, and cognitions related to drug use, and the psychosocial functioning of the individual and his family. The various tools used to assess these aspects have been outlined below and the brief descriptions provided can help in choosing the right tool based on the characteristics that need to be measured and logistics.

State of Training, Clinical Services, and Research on Dual Disorders Across France, India, Israel, and Spain.

OBJECTIVE: This article overviews training, clinical services, and research on dual disorders across four countries: France, India, Israel, and Spain. METHODS: The current dual disorders systems in each of the four countries were reviewed, with a focus on strengths and limitations of each. RESULTS: In France, psychiatric care occurs within the public health care system and involves little training of medical graduates for managing dual disorders. Special courses and forums for specialists have recently started to meet the growing interest of physicians in learning how to manage dual disorders. The Indian health care system grapples with a large treatment gap for mental disorders, and while some treatment services for dual disorders exist, specific research and training efforts on dual disorders are just beginning. Israel has both public- and private sector services for patients with dual disorders, with specialized inpatient and emergency care for the acutely ill as well as day care and therapeutic communities for long-term management. Interest by researchers is growing, but training and education efforts in dual disorders are, however, minimal. Similar to the other countries, addiction and psychiatry disciplines are governed by separate divisions within the National Health System in Spain. There are some dual disorders services available, but they are limited in scope. While medical professionals clearly recognize the importance of dual disorders, there is no such recognition by the national and regional governing bodies. CONCLUSIONS: The common thread in various aspects of dual disorder management in each of these four countries is that there is a lower-than-desirable level of attention to dual disorders in terms of care, policy, research, and training. There are growing opportunities for training and continuing education in dual disorders management. We suggest that nations could learn from each other's experiences on how to address the issue of dual disorders.

Time Trends of Cannabis Use Among Treatment-seeking Individuals at Government De-addiction Centers Across India Over a Period of 7 Years.

BACKGROUND: Cannabis continues to be the most commonly used illicit psychoactive substance globally. The National Survey in India conducted in the year 2004 also reported it to be the most commonly used illicit substance in the country. Furthermore, it was reported to be the second most commonly used psychoactive substance by the treatment seekers at de-addiction centers in the country. OBJECTIVES: To assess time trends of cannabis use among treatment-seeking individuals at government de-addiction centers across India over a period of 7 years. MATERIALS AND METHODS: The study utilized data collected through Drug Abuse Monitoring System across India. The data of treatment seekers from de-addiction centers established under the Drug De-addiction Program, Ministry of Health and Family Welfare, Government of India and supported by the Ministry of Social Justice and Empowerment, Government of India (122 in number) across the country were analyzed. RESULTS: A total of 107,469 individuals sought treatment from government de-addiction centers over the 7 years (2007-2013) period. With the exception of an aberration for the year 2012, there has been a steady decline in the proportion of treatment seekers who are not current cannabis users. A significantly greater proportion (Chi-square: 586.30, df: 1, P < 0.001) of individuals with current cannabis use alone or along with tobacco (20.4%) tend to have a co-morbid psychiatric disorder as compared to treatment seekers with current use of substances other than cannabis (6.1%). CONCLUSIONS: It is important to focus on cannabis in clinical service delivery and research in the country.