Assessment of community-based education in community health officers' training at a Rural Medical College in Northern Ahmednagar District of Maharashtra, India: A longitudinal study.

We evaluated the Community Health Officer (CHO) training program in northern Ahmednagar district of Maharashtra, India. A longitudinal study was conducted among 110 CHO trainees from August 2019 to January 2020. The trainees undertook field visits and survey with lectures and clinical postings. Evaluation was based on pre- and post-Multiple Choice Question tests, the WHO Education of Health Personnel Checklist, Journals, and Logbooks. MannWhitney U-test, Wilcoxon-rank test were used to compare nonnormal variables while t-test was used for comparison of age. Initially, nursing graduates performed better than Ayurveda graduates, especially in punctuality, grasp on problems, and problem-solving ability. Nursing graduates kept better journals and logbooks. Female trainees performed better than male trainees. Ayurveda and nursing graduates were comparable at the end of the training. Need-based training and upskilling of mid-level healthcare providers can be done at scale by roping in medical colleges.

Metabolic syndrome: The Indian public health perspective.

Metabolic Syndrome (MetS) is a clustering of specific risk factors, namely, central obesity, raised blood pressure, impaired fasting glucose, raised triglycerides, and low levels of high-density lipoprotein-cholesterol (HDL-C). This constellation is triggered by insulin resistance and its resultant hyperinsulinemia. The two most important and universally agreed causes of insulin resistance are increased body fat (particularly central obesity) and physical inactivity. Other causes include certain genetic/pro-genetic factors, unhealthy atherogenic diet, tobacco use, and excessive alcohol intake. Within 3 decades of the initial description of MetS by Reaven, various defining criteria have been developed by now, by leading international professional bodies, the most commonly used being the one given by the Adult Treatment Panel III (ATP III) report of the National Cholesterol Education Program (NCEP) [NCEP-ATP-III], the updated guidelines recently released by the American College of Cardiology (ACC) and the American Heart Association (AHA). MetS has been well documented to increase the risk of ischemic heart disease (IHD) by two to three times and of type 2 diabetes mellitus (T2DM) by five times. The world-wide prevalence is on the increase, with the overall global prevalence estimated to be 20%-25% of the adult population. In our country, various epidemiological studies undertaken across the country have consistently shown a high prevalence, which is likely to be as much as one-quarter of the adult population, with increasing age and female gender being at higher risk. The occurrence has also been recorded among the Armed Forces personnel as well as in adolescents. MetS has therefore become a priority issue for both, the public health providers as well as for the clinicians in our country, and needs concerted, all-round efforts for its prevention, early detection, management, and research. Against this background, the various public health measures for prevention and control of MetS have been suggested in this review.

Trends in antibiotic susceptibility of enteric fever isolates from South India, 2002-2013.

BACKGROUND: Enteric fever is endemic in India. Trends in antibiotic resistance in Salmonella enterica subspecies enterica serovars Typhi and Paratyphi A isolates over the past 12 years were studied. METHODS: A retrospective analysis of consecutive blood culture isolates of Salmonella Typhi and Salmonella Paratyphi A was performed from 2002 to 2013. Antibiotic susceptibility testing was carried out for ampicillin, chloramphenicol, cotrimoxazole, nalidixic acid (NA), ciprofloxacin and ceftriaxone by disc diffusion. The minimum inhibitory concentration of ciprofloxacin and azithromycin was determined using E-test strips. Mantel-Haenszel extended chi-square test was used for analysis of trends across years. RESULTS: Three thousand two hundred ninety-six Salmonella spp. were isolated; of which, 1905 were identified as Salmonella Typhi (58%) and 1393 as Salmonella Paratyphi A (42%). Multidrug resistance (chloramphenicol, ampicillin and cotrimoxazole) was relatively stable throughout the study period. NA resistance increased from 18% in 2007 to 100% in 2013 among Salmonella Paratyphi A isolates and from 67% to 82% among Salmonella Typhi isolates. Complete susceptibility to ceftriaxone and azithromycin was observed in this study. CONCLUSIONS: Knowledge of the local patterns of resistance would help in appropriate therapy for enteric fever. With increasing rates of fluoroquinolone resistance in our hospital setting, it is probably prudent to revert back to the first-line agents for treatment and save azithromycin and third-generation cephalosporins for difficult and non-responsive cases.

Psychometric analysis of Marathi version of an updated European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC QLQ-H&N43).

BACKGROUND: The aim of this study was to perform a psychometric analysis of the Marathi version of an updated European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC QLQ-H&N43) in patients of head and neck squamous cell carcinoma (HNSCC). MATERIAL AND METHODS: After an institutional ethics committee approval and linguistic validation, the Marathi version of EORTC QLQ-H&N43 was served to consecutive eligible, Marathi-speaking HNSCC patients of oral cavity, oropharynx, hypopharynx and larynx, registered from August 2019 to March 2021 and who consented to the study. Performance status scale was used for perceptive assessment of organ function. Psychometric analysis was performed using SYSTAT v. 12 (Cranes software, Bengaluru). RESULTS: A total of 129 patients participated in the study with a median age of 67 years and the man-to-woman ratio of 100:29. The commonest sub-site reported was the oral cavity (61.24%) and the majority were in stage IV disease (69.76%). Ninety patients completed the questionnaire before being started on active oncology treatment at our center. 39 patients completed the questionnaire at pre-treatment and first follow-up. The questionnaire was filled on their own (module) by 32.55% of patients while 67.44% of patients required some kind of assistance (schedule). Internal consistency was moderate to high. The criterion and construct validities were acceptable. The questionnaire was sensitive to change with stage and time. No significant difference was observed in module versus schedule subgroup except for 2 out of 19 item-scales. CONCLUSION: Marathi translation of EORTC QLQ-H&N43 is a sensitive, reliable and valid tool when applied to patients of HNSCC. It can be considered as a schedule.

Need-based training of community health officers for tuberculosis care in Ahmednagar district of Maharashtra, India: A before and after study.

BACKGROUND: Community health officers (CHOs) are a newly introduced cadre of mid-level health-care providers who will man the health and wellness centers under Ayushman Bharat Mission in India. Need-based training will help them fulfil their role in early diagnosis, treatment, and referral of tuberculosis (TB) patients. The present study identified the gaps in the awareness about TB in a heterogeneous group of trainees and addressed them through need-based training. MATERIALS AND METHODS: A before and after the study was carried out in 110 trainee CHOs at Rural Medical College, Loni. In-depth interviews were conducted with public health experts and focus group discussion was conducted with trainees to gain the quality inputs. Structured questionnaires based on training objectives specifically pertaining to TB were designed. Training was provided with an emphasis on addressing the gaps identified in the pretest. Posttest evaluation was done at the end of the training to assess its effectiveness. Data were analyzed using the SPSS software version. 17.0 (Inc., Chicago, IL, USA). RESULTS: The mean pretest score was 15.15 (standard deviation [SD] = 3.55) which improved after 6 months training to 24.01 (SD = 1.223), i.e., from 60% to 96%. There was highly significant improvement in overall knowledge score of trainees (t = 28.124, df = 109, P < 0.001). There was a statistically significant improvement in scores of all topics at the end of 6 months training in both Nursing and Ayurved graduates. Except for knowledge regarding the treatment of multidrug-resistant TB (P = 0.004), knowledge about all other topics was comparable in nursing and Ayurved graduates at the end. CONCLUSIONS: Needs assessment proved effective in identifying the gaps in knowledge and skills of interdisciplinary trainee CHOs. Medical colleges with expertise in teaching, training, and health service provision can work with the public health system to provide a model for rapid upgrading and capacity building to meet health-care challenges such as TB.

Differentials and Determinants of Syndrome 'X' and its Role as Coronary Risk among Healthy Middle Aged Indian Army Personnel.

BACKGROUND: Syndrome 'X', a clustering of impaired glucose tolerance (IGT), raised blood pressure, raised serum triglycerides and low HDL-cholesterol, occurring under the influence of insulin resistance and resultant hyperinsulinaemia, has been hypothesised to be a major risk factor for ischaemic heart disease (IHD). However, there is a lack of research based evidence in this field, in our country. METHODS: The study was a cross-sectional analytical epidemiological design of 614 healthy Indian Army personnel, aged 35 years and above, selected by random sampling. RESULTS: The study indicated that there is a statistically significant (p < 0.001) clustering between fasting hyperinsulinaemia, raised blood pressure, IGT, raised triglycerides and low HDL. The prevalence of syndrome 'X' was 8.47% (95% CI 6.27% to 10.47%). Initial univariate and subsequent multivariate analysis using multiple logistic regression method, indicated that predictors of syndrome 'X' were increasing age, overweight, increasing central (abdominal) obesity, lack of adequate physical exercise and low level of physical fitness. Presence of syndrome 'X' increased the risk of resting ECG changes suggestive of coronary insufficiency (OR = 6.29, p < 0.001). CONCLUSION: Based on the findings, recommendations for prevention of this syndrome have been submitted.

The Curse of HIV: How Well Prepared is our Paramedical Force?

BACKGROUND: HIV patient-care is determined by the knowledge and attitudes of the health care workers (HCWs) towards the disease and towards HIV-positive individuals. With increasing incidence of HIV, a need was felt to assess the preparedness of the health care providers in the Armed Forces. METHODS: A population based, cross-sectional, questionnaire based analytical study was undertaken among para medical workers in the setting of a medical college and tertiary care service hospital to assess the knowledge and attitudes of HCWs towards HIV. RESULTS: The study indicated that contrary to the expectations and general belief, important knowledge gaps regarding modes of transmission, clinical course, diagnosis and management of HIV infection still exist among the paramedical workers of the Armed Forces. CONCLUSIONS: The present study has highlighted the urgent need to review the training curriculum of our paramedical workers at all levels and undertake intensive on the job training. The study recommends that medical officers should take full responsibility for imparting correct knowledge and ensuring correct attitude among the paramedical workers.

Community Based Study of AIDS Awareness and Attitudes among School and College-going Teenagers from Rural Background.

A community based, cross-sectional, analytical study was undertaken among children aged 13 to 19 years, who were currently studying in high school, intermediate or graduate classes, in a rural area of Maharashtra. A sample of 151 girls and 162 boys formed the material for this study. Data was collected by well qualified, centrally trained interviewers, using a pre-tested instrument, administered by personal interview technique. The study indicated that the general awareness about AIDS was very high, with more than 90% of the respondents having heard of AIDS and also identifying it as an important health problem in our country. However, less than 50% knew correctly about the etiology of AIDS, or the difference between HIV and AIDS. Similarly, a very high proportion of the subjects knew about the modes of transmission, though a much lesser proportion had the knowledge about the role of improperly sterilised syringes and needles. Similarly, a general lack of awareness about other sexually transmitted diseases was noticed. Lacunae in knowledge also existed as regards knowledge about high risk groups, like commercial sex workers (CSWs), intravenous drug users (IVDUs), truck drivers and professional blood donors. A very large majority of the subjects had a very positive and healthy attitude about sex, and did not accept pre or extra marital sex, as well as, were desirous of obtaining AIDS education as a part of school / college curriculum. Based on the findings of the study, certain recommendations on AIDS education in the reference population have been submitted.

APPLICATION OF HAZARD ANALYSIS CRITICAL CONTROL POINT SYSTEM : ANALYSIS OF A FOOD POISONING OUTBREAK.

The World Health Organization as well as several experts have recently recommended the use of hazard analysis critical control point system for prevention of food-borne illnesses. The present study proceeded to identify the hazardous operations and their critical control points by investigating, through a case-control design, an outbreak of food poisoning. The predominant presenting symptoms were watery diarrhoea and abdominal cramps. The cumulative incidence during this episode was 28.6 per cent, with a median incubation of 13 hours. Evaluation of food histories indicated a very high and significant odds ratio for mutton dish (OR = 6.45; p < 0.001), which persisted even after adjusting for the consumption of other food items through stratified analysis using the Mantel-Haenszel procedure. Environmental assessment revealed a strong possibility of contamination of raw mutton at the source with animal excreta and prolonged storage at room temperature of cooked mutton dish. Based on these findings, hazardous operations were identified and critical control points and monitoring criteria for prevention of food poisoning have been suggested.

SEXUAL BEHAVIOUR AS A RISK FACTOR IN THE TRANSMISSION OF HIV INFECTION AMONG ADOLESCENTS AND YOUNG MALES IN INDIA.

In order to understand the beliefs and behaviour related to sexual perception and activity of young male adults a multi-centric study was conducted using a structured proforma for a face to face interview. A total of 9845 subjects in the age group 18-25 years were interviewed. 73.78% of the respondents believed that sex with a commercial sex worker (CSW) is an acceptable way of satisfying sex. Sex with an Amateur was considered acceptable by 57.21% of the subjects. Knowledge about condom use was inadequate among 23.67% of the subjects. An information education and communication (IEC) intervention programme with a school set up and peer network education is recommended for developing safe sex practices. Aggressive social marketing for condom usage will reduce the rate of infection and probability of transmission of HIV/AIDS.

HIV SEROPREVALENCE AMONG ADOLESCENTS AND YOUNG ADULT MALES IN INDIA: A LARGE COMMUNITY BASED EPIDEMIOLOGICAL STUDY.

A large number of HIV seroprevalence studies have been conducted on the high-risk groups. However there seems to be a paucity of such studies undertaken in the general population. This study was directed towards the adolescents and young Indian male adults. A representative samples of 19,436 were tested, out of which nine were positive for HIV, thereby giving a HIV seroprevalence rate of 0.46 per 1000 with a clustering of the positive subjects towards the North East of India followed by the Southern states. Those from the North East were younger than those from the South. This calls for a targeted information, education and communication (IEC) programme aimed at the younger group in the East with known greater risk potential for intravenous drug abuse, and older adults in the South. The study also provides an insight for HIV/AIDS mapping and possible future direction of the epidemic in India.

EFFECTIVENESS OF A HEALTH EDUCATIONAL PACKAGE FOR AIDS PREVENTION AMONG ADOLESCENT SCHOOL CHILDREN.

A randomised, controlled, community based intervention trial was undertaken to assess the effectiveness of a Health Education Programme (HEP) for HIV infection and AIDS among school children at Pune. Sample size was calculated on the basis of conventional Type I and Type II errors. School children studying in classes 9th to 12th in six different schools (n=1102) formed the study material. Baseline assessment for knowledge for AIDS/HIV was undertaken and used for formulating the Health education Programme Package. Randomisation was done so as to allocate five schools into trial group (n=803) and one school into control group (n=299). Blinding was also ensured to reduce bias. The study revealed that the HEP was very effective in improving the knowledge, the difference being highly significant as compared to control group. The effect was specially well marked for girls in school level (OR=4.76) followed by boys intermediate level (OR=3.11); there was clear evidence of statistical effect modification as regards this 'sex and educational class' differential (Woolfs'chi square=11.82, p < 0.0001). The study also revealed that the maximum aceceptability of programme was among girls studying in girls school (Stratum OR =2.25) followed by boys in boys school (OR=1.50) compared to students in co-educational system (linear trend chi square=9.35, p < 0.01). Certain recommendations for health education for HIV/AIDS among school children have been submitted.

Cohort Study on the Recurrence Rate of High Altitude Pulmonary Oedema.

Keeping in view the importance of High Altitude Pulmonary Oedema (HAPO) as well as the absence of published evidence as regards recurrence rate of this disease, a cohort study was undertaken, based on data available with the Central Diseases Registry. The inception cohort consisted of all cases of HAPO occurring over a one year period, This cohort was followed up for another 12 months, to observe any recurrence. The study revealed that the recurrence rate of HAPO in terms of Incidence density was 1.83 per 1000 person-months of those who had an initial episode (95% confidence limit 0.53 to 3.13 per 1000 person-months). The cumulative incidence was 32.9 per 1000, over an average follow up of 18 months (95% confidence limit 4.55 to 61.25 per 1000). The time gap between the initial episode and recurrence was 115 to 208 days. All recurrent cases had their initial as well as recurrent episode at the first stage of high altitude (9000 to 12000 feet), with the onset being within 48 hours of entry into high altitude. Based on the findings, some recommendations for prevention of recurrence of HAPO have been submitted.

ARE DOCTORS EFFECTIVE MEDICAL TEACHERS? RESULTS OF A CROSS-SECTIONAL STUDY AT ARMED FORCES MEDICAL COLLEGE, PUNE.

Medical education remains the onerous responsibility of the senior medical fraternity. Not being formally trained calls for periodic introspection to be more effective teachers. This study, involving the fourth year medical students revealed a great need for self-reflection to improve the Style of teaching, ensuring greater involvement of the students and teaching what is appropriate to the stage of study. Aggressive behaviour was inimical to good learning. A better student teacher communication and the ability to run the session' are important indicators of good teaching. A continued self-evaluation by teachers will improve student learning and medical education.

CROSS SECTIONAL ANALYTIC STUDY OF AWARENESS REGARDING FACTORS RELATED TO CHILD SURVIVAL AMONG MARRIED WOMEN IN A SEMI-URBAN COMMUNITY.

A cross sectional analytic study was undertaken on 480 married women living in a semi-urban locality in Pune, with the objective of assessing their awareness regarding factors related to child survival. It was observed that 62.1 per cent of the ladies had adequate knowledge about immunisation. A highly significant trend was evident as regards knowledge about immunisation and formal education and socio-economic status (p<0.01). 93 per cent ladies initiated breast feeding within 24 hours of birth of the new born. Significantly larger proportion of ladies from lower education favoured prolonged breast feeding (p<0.001) and favoured late introduction of top milk (p<0.001). In general, the awareness about growth chart was very poor with only 3.5 per cent ladies having adequate knowledge. Larger family size was significantly associated with declining probability of use of oral rehydration solution (ORS). Certain recommendations for improving the awareness regarding child survival have been submitted accordingly.

A MATHEMATICAL MODEL FOR PREDICTING THE PERSISTENCE AND EFFICACY OF BACILLUS THURINGIENSIS VAR ISRAELENSIS IN RELATION TO WATER POLLUTION.

In a simulated field trial, the bead formulation of Bacillus thuringiensis var israelensis (Bti) was found to be more persistent in moderately polluted as compared to highly polluted water. A mathematical model was built up to study the influence of time (independent variable) on larval reduction (dependent variable) in relation to degree of water pollution. Two predictive models for different grades of water pollution were developed, which estimated that the larval mortality in moderately polluted water was likely to decline by 3.79 as compared to 5.02 on an average, in highly polluted water with each passing day.

A SEARCH FOR UNHAPPY ABDOMEN: PREVALENCE OF IRRITABLE BOWEL SYNDROME IN GENERAL POPULATION.

The irritable bowel syndrome is the commonest gastrointestinal disorder seen in practice but its exact prevalence in India is not known. This study was carried out to determine the prevalence of symptoms compatible with this diagnosis in general population. A cross sectional random sample survey was conducted in various strata of urban population in Wanoworie area of Pune. Survey utilized personal interviews based on a questionnaire. Symptoms were evaluated as per Manning criteria and the diagnosis of irritable bowel syndrome was defined by Kruis diagnostic index. Of the 1010 subjects interviewed, 370 (37%) reported more than 6 episodes of abdominal pain in previous 6 months, with 333 reporting symptoms consistent with the the diagnosis of irritable bowel syndrome. At least one of the Manning's symptoms was present in 307 out of 370 subjects (83%). The male female ratio was 5.3:1. Among males, 288 (35%) and among females 82 (53.2%) persons had at least some degree of abdominal discomfort. Other common symptoms were: excessive passage of wind (42.2%), irregular bowel habits (33%), excessive belching (30.8%), constipation (27.5) and feeling of incomplete evacuation(28.1%). About one third of the symptomatic subjects (134 or 36.2%) had seen a doctor or wanted to be seen by a specialist. Overall prevalence of the symptoms consistent with irritable bowel syndrome thus, is 33 per cent though only about a third of these may possibly consult a doctor. Follow up of all these patients for a mean duration of 8.3 months showed that no case of organic disease was picked up either by the scoring system or by the gastroenterologist. Symptoms consistent with the diagnosis of irritable bowel syndrome are see in almost one third of the study population residing in Wanoworie area of Pune.

CAN WAIST/HIP RATIO BE USED AS A SIMPLE MEASURE OF CARDIOVASCULAR RISK IN THE ARMED FORCES : RESULTS FROM A FIELD EPIDEMIOLOGICAL STUDY.

A cross-sectional analytical epidemiologic study was undertaken in the community setting, on 1080 army personnel in a field formation, to study the association between waist/hip ratio (WHR) and certain physiological and biochemical parameters of cardiovascular risk. The study revealed that Junior Commissioned Officers, personnel aged 35 years and above, and personnel from Services had an increased probability of having higher WHR. WHR was consistently, linearly and significantly associated with increasing mean values of serum cholesterol, blood sugar and blood pressure. The optimum cut-off point of WHR from the findings of this study seems to be 0.91 and above. Beyond this value of WHR, the cardiovascular risk increases significantly and becomes more dramatic at WHR values of 0.96 and above.

ESTIMATES OF EX-SERVICEMEN POPULATION FOR NEXT 30 YEARS: A NEED TO REORIENT OUR HEALTH PLANNING.

A mathematical model, using survival analysis methods has been developed to estimate the total population as well as the populations as per specific age groups of ex-servicemen for the next 30 years. The results indicate that from the present population of 13.75 lakhs., the total population of ex-servicemen would be 15.62 lakhs by 2027 A.D. In addition, there are likely to be noteworthy changes in the population structure. While the population of geriatric age group (65 years and above) is only 21% at present compared to 49% from age group 45-54 years, by 2027 A.D. the geriatric age group would contribute to 34% of the ex-servicemen population while 45-54 years age group would constitute only 36%. There is a need, therefore, to start rethinking on our future plans as regards health services since geriatric health problems are likely to become a leading health issue after the next ten years.