Education Intervention on 'Hearing Impairment - Its Assessment and Management' among Medical Practitioners in Sikkim, India.

BACKGROUND: Health care providers must be aware of the choices in aural rehabilitation methods and assessment procedures available presently to those with hearing impairment in order to facilitate early identification and intervention and ensure quality of care to those hearing impaired individuals. The referrals from the medical fraternities for the audiological services are not uniform across India. Part of reason may be that awareness about the roles of and responsibilities of audiologist's is poor among medical practitioners. In some regions of India medical practitioners may be only grossly be aware of audiologists per se. They may not know enough to refer all individuals with hearing or balance disorders for the required audiological services. AIM: To evaluate changes in pre survey and post survey after education intervention specifically planned for medical practitioners in the state of Sikkim, India. Education intervention included awareness about hearing impairment and its assessment and management by audiologists. METHOD: A pre and post survey comparison research design with purposive convenient sampling technique was applied. Participants were medical practitioners working in geographical area of Sikkim at the time of the study. Inspection of demographic data of respondents showed that they were in their age range of 24 and 60 years and with work experience ranging 1-40 years. Participants were invited for an awareness talk which included, information about hearing loss, early identification and early intervention, tests and management of hearing loss in different age groups, need for hearing aids/cochlear implants, auditory training, and the role of an audiologist in the management of hearing loss and ways to prevent hearing loss. A pre and post awareness program responses were collected from all the participants using a customized questionnaire tool. RESULTS: Respondents exhibited, in the pre-survey questionnaire, lack of awareness in many aspects of audiology, including assessing hearing impairment, diagnosing hearing loss, and the role of an audiologist. There was an overall, statistically significant difference in the level of performance on the pre-awareness and post-awareness responses. CONCLUSION: Following an awareness campaign among the medical professionals in Sikkim, there was a considerable change in their level of awareness of hearing impairment, its assessment, and management by audiologists. The reach of the awareness campaign was significant as around 70% of subjects showed significant change in their knowledge and attitude towards hearing impairment, its management.

Operational feasibility of lot quality assurance sampling (LQAS) as a tool in routine process monitoring of filariasis control programmes.

Lot quality assurance sampling (LQAS) with two-stage sampling plan was applied for rapid monitoring of coverage after every round of mass drug administration (MDA). A Primary Health Centre (PHC) consisting of 29 villages in Thiruvannamalai district, Tamil Nadu was selected as the study area. Two threshold levels of coverage were used: threshold A (maximum: 60%; minimum: 40%) and threshold B (maximum: 80%; minimum: 60%). Based on these thresholds, one sampling plan each for A and B was derived with the necessary sample size and the number of allowable defectives (i.e. defectives mean those who have not received the drug). Using data generated through simple random sampling (SRSI) of 1,750 individuals in the study area, LQAS was validated with the above two sampling plans for its diagnostic and field applicability. Simultaneously, a household survey (SRSH) was conducted for validation and cost-effectiveness analysis. Based on SRSH survey, the estimated coverage was 93.5% (CI: 91.7-95.3%). LQAS with threshold A revealed that by sampling a maximum of 14 individuals and by allowing four defectives, the coverage was >or=60% in >90% of villages at the first stage. Similarly, with threshold B by sampling a maximum of nine individuals and by allowing four defectives, the coverage was >or=80% in >90% of villages at the first stage. These analyses suggest that the sampling plan (14,4,52,25) of threshold A may be adopted in MDA to assess if a minimum coverage of 60% has been achieved. However, to achieve the goal of elimination, the sampling plan (9, 4, 42, 29) of threshold B can identify villages in which the coverage is <80% so that remedial measures can be taken. Cost-effectiveness analysis showed that both options of LQAS are more cost-effective than SRSH to detect a village with a given level of coverage. The cost per village was US dollars 76.18 under SRSH. The cost of LQAS was US dollars 65.81 and 55.63 per village for thresholds A and B respectively. The total financial cost of classifying a village correctly with the given threshold level of LQAS could be reduced by 14% and 26% of the cost of conventional SRSH method.

Cost of mass annual single dose diethylcarbamazine distribution for the large scale control of lymphatic filariasis.

Economic analysis of the revised strategy to control lymphatic filariasis with mass annual single dose diethylcarbamazine (DEC) at 6 mg/kg body weight launched in one of the districts of Tamil Nadu in 1996 was carried out. This exploratory study, proposed for five years in 13 districts under 7 states on a pilot scale through the Department of Public Health is an additional input of the existing National Filaria Control Programme in India. A retrospective costing exercise was undertaken systematically from the provider's perspective following the completion of the first round of drug distribution. The major activities and cost components were identified and itemized cost menu was prepared to estimate the direct (financial) and indirect (opportunity) cost related to the implementation of the Programme. The total financial cost of this Programme to cover 22.7 lakh population in the district was Rs. 22.05 lakhs. The opportunity cost of labour and capital investment was calculated to be Rs. 7.98 lakhs. The total per capita cost was Rs. 1.32, with Rs. 0.97 and Rs. 0.35 as financial and opportunity cost respectively. Based on these estimates, the implementation cost of the Programme at Primary Health Centre (PHC) level was calculated and projected for five years. The additional financial cost for the existing health care system is estimated to be Rs. 27,800 per PHC every year. DEC tablets (50 mg) was the major cost component and sensitivity analysis showed that the cost of the Programme could be minimized by 20 per cent by switching over to 100 mg tablets. The analysis indicates that this Programme is a low-cost option and the results are discussed in view of its operational feasibility and epidemiological impact.

Development of rapid assessment procedures for the delimitation of lymphatic filariasis-endemic areas.

Lymphatic filariasis caused by Wuchereria bancrofti is a major public health problem in 73 tropical and subtropical countries including India. Delimitation of endemic areas is essential to plan control operations. The current method of night blood survey (NBS) for delimitation is cumbersome, time-consuming and expensive. Therefore, there is a need to develop assessment procedures which can rapidly delimit endemic areas. For this purpose we evaluated three procedures: direct interviewing of key informants using structured questionnaires, an indirect method of a self-administered questionnaires to key informants and physical examination by health workers for the presence of chronic filarial disease. Thirty rural communities in a filariasis-endemic region in Cuddalore district in Tamil Nadu State in southern India constituted the study population. The determination of filariasis endemicity in the village communities assessed by the above procedures was compared in terms of rapidity, specificity, sensitivity and cost with the microfilaria rate and disease rate obtained by night blood sample survey and clinical examination by physicians. Prevalence score, control preference score and weighted mean number of cases with filarial disease per village were calculated using the key informant questionnaire techniques. While the prevalence and control preference score showed low sensitivity and moderate specificity, weighted mean number of cases showed high sensitivity and moderate specificity in identifying endemic villages. The prevalence of disease as determined by the physical examination of a sample population by health workers was highly sensitive in identifying communities endemic for filariasis. The degree of association between the disease rates estimated by physician and trained health workers was significant (r = 0.56; P < 0.05). These observations suggest that the weighted mean number of cases per village obtained through key informant techniques may be considered at a primary level to crudely identify endemic areas, followed by physical examination by health workers for filariasis, since it is relatively cheap and rapid.

Rapid assessment procedures (RAP) for lymphatic filariasis.

BACKGROUND: New strategies are emerging for control of filariasis in terms of chemotherapy and vector control. Field application of these tools requires mapping and prioritization of filaria-endemic areas and quantification of the infection/ disease burden. Available procedures are time-consuming, costly and have poor sensitivity. Therefore, rapid assessment procedures need to be developed to assess the disease burden as well as monitor and evaluate control programmes. METHODS: Data collected on different variables from 25 areas in India and elsewhere were used. The relationship between prevalence of human infection and vector infection rate was analysed quantitatively. Due to lack of independent samples, only qualitative analysis was carried out between other epidemiological variables such as infection and disease prevalence in relation to age, gender and manifestation. RESULTS: There was a significant positive correlation between vector infection rate and infection prevalence in humans, suggesting that vector infection can be used as an indicator in the rapid assessment of infection prevalence. Scatter plots showed that community screening may be limited to the age group of 11-30 years for infection prevalence and 20-50 years for disease prevalence. Further, clinical surveys may be limited to only hydrocele prevalence which may be sufficient to predict the total disease. This can also be used as an alternative method by the community itself for delimiting endemic areas. CONCLUSIONS: Vector infection rate may be used as an indicator for rapid assessment of human infection. Alternatively, blood smear examination could be limited to the age group of 11-30 years. For a rapid survey of the diseases, males in the age group of 20-50 years could be examined only for hydrocele.