Understanding the diabetes self-care behaviour in rural areas: Perspective of patients with type 2 diabetes mellitus and healthcare professionals.

BACKGROUND: Diabetes self-care behaviour plays a crucial role in managing the diabetes effectively and preventing complications. Patients with type 2 diabetes mellitus (T2DM) and health care professionals (HCPs) of rural areas often face unique challenges when it comes to diabetes self-care practices (SCPs). Therefore, this study aim to explore the perspectives of patients with T2DM and HCPs on diabetes SCPs. METHODS: Eight focus group discussions (FGDs) among individuals with T2DM and In-depth interviews (IDIs) with 15 HCPs were conducted in rural areas of Punjab, North India. Capability, Opportunity, Motivation, and Behaviour model (COM-B) was employed for thematic framework analyses. RESULTS: The study participants perceived that a limited understanding of diabetes mellitus (DM), beliefs in alternative therapies, drug side effects, attitudes towards DM (psychological capability), comorbidities (physical capability), family support (social opportunity), financial and time constraints, and weather conditions (physical opportunity) contributed to lack of DM SCPs. Physicians' guidance and support were motivating them to adhere to SCPs, especially when aligned with their sense of self-efficacy (reflective motivation). HCPs constraints in providing patient-centred care are due to training limitations (psychological capability) and a lack of essential resources (physical opportunities). Participants expressed need for comprehensive diabetes care (automatic motivation) through structured diabetes education intervention to improve diabetes SCPs. CONCLUSIONS: The study findings indicate that various factors influence diabetes SCPs from the perspectives of both patients with T2DM and HCPs and emphasizes the need for a multi-faceted approach to improve diabetes SCPs in rural areas. Implementing a structured diabetes self-care intervention strategy in rural areas may help for preventing and mitigating the impact of diabetes-related complications in rural areas.

Contribution of social factors to maternal deaths in urban India: Use of care pathway and delay models.

This paper uses care pathway and delay models to better understand the possible social reasons for maternal deaths in a city with good public and private health infrastructure. The findings can inform programmes to reduce maternal mortality. During 2007-15, 136 maternal deaths were reported in Chandigarh, India. Using World Health Organisation's verbal autopsy questionnaire, interviews were conducted with primary caregivers of 68 (50%) of the 136 deceased women, as majority of the families had returned to their native places. We used process-tracing techniques to construct the care pathways and identify delays, and explored open-ended responses using thematic analysis. The mean age of the deceased women was 27 years, 51% resided in slums, 32% were primigravida, 25% had their deliveries assisted by traditional birth attendants, and 23% had Caesarean section. Eight percent died at home, and 54% died in tertiary level facilities. Post-partum haemorrhage (26.5%), and complications of puerperium (25%) and labour/delivery (14.7%) were the reported medical causes. Male child preference and norms for home delivery were identified as the distal socio-cultural causes. Individual and family level factors included: shame on multiple pregnancies; fear of discrimination from providers; past successful deliveries at home leading to overconfidence and not seeking institutional care; and lack of awareness about family planning, antenatal care, and danger signs of pregnancy. Healthcare system factors were: non-availability of senior doctors at the time of consultation in the emergency that delayed initiation of immediate treatment, and lack of availability of life-saving equipment due to patient load. Empirical evidence was found on social causes of maternal deaths, which could have been prevented by appropriate actions at individual, family, societal, institutional and policy levels. This study identified potential preventable causes of primarily social origin, which could help in taking actionable steps at several levels to further reduce maternal deaths in India.

Access to harm reduction and HIV-related treatment services inside Indian prisons: experiences of formerly incarcerated injecting drug users.

PURPOSE: The authors aimed to examine the incarceration experiences of injecting drug users in accessing harm reduction, and HIV-related services inside prisons in India. DESIGN/METHODOLOGY/APPROACH: The authors conducted three focus groups with a purposive sample of 23 formerly incarcerated male IDUs and four key informant interviews with a former police official, a drug dealer and service providers. Data were analyzed using a constant comparative method. FINDINGS: Participants reported availability of alcohol and injectable or oral drugs such as heroin, dextropropoxyphene, and marijuana inside prisons. Inmates obtained drugs and clean syringes (one syringe bought for 2.5-4 USD) through prison staff, and collected used syringes and needles from the dustbins in prison sickrooms. Needles and syringes were reused and shared. Prisons did not have needle and syringe programmes, detoxification, overdose management or opioid substitution treatment. Drug-using prison inmates faced several challenges in accessing antiretroviral treatment and HIV testing. PRACTICAL IMPLICATIONS: The authors' findings emphasize the need to protect the health of injection drug-using inmates by introducing harm reduction programmes and removing barriers to HIV testing and antiretroviral treatment. ORIGINALITY/VALUE: This study illustrates, for the first time, the contexts behind high risk injecting drug use behaviours among prison inmates in India. It also highlights the lack of availability of harm reduction services such as needle and syringe programmes, drug detoxification and opioid substitution treatment inside prisons. Further, it demonstrates the difficulties faced by HIV-positive prison inmates in getting timely and uninterrupted antiretroviral treatment.

Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India.

The Indian government provides free antiretroviral treatment (ART) for people living with HIV. To assist in developing policies and programs to advance equity in ART access, we explored barriers to ART access among kothis (men who have sex with men [MSM] whose gender expression is feminine) and aravanis (transgender women, also known as hijras) living with HIV in Chennai. In the last quarter of 2007, we conducted six focus groups and four key-informant interviews. Data were explored using framework analysis to identify categories and derive themes. We identified barriers to ART access at the family/social-level, health care system-level, and individual-level; however, we found these barriers to be highly interrelated. The primary individual-level barrier was integrally linked to the family/social and health care levels: many kothis and aravanis feared serious adverse consequences if their HIV-positive status were revealed to others. Strong motivations to keep one's HIV-positive status and same-sex attraction secret were interconnected with sexual prejudice against MSM and transgenders, and HIV stigma prevalent in families, the health care system, and the larger society. HIV stigma was present within kothi and aravani communities as well. Consequences of disclosure, including rejection by family, eviction from home, social isolation, loss of subsistence income, and maltreatment (although improving) within the health care system, presented powerful disincentives to accessing ART. Given the multi-level barriers to ART access related to stigma and discrimination, interventions to facilitate ART uptake should address multiple constituencies: the general public, health care providers, and the kothi and aravani communities. India needs a national policy and action plan to address barriers to ART access at family/social, health care system, and individual levels for aravanis, kothis, other subgroups of MSM and other marginalized groups.

Barriers to free antiretroviral treatment access for female sex workers in Chennai, India.

India's National AIDS Control Organization (NACO) provides free first-line antiretroviral treatment (ART) at government centers for people living with HIV. To assist in developing policies and programs to ensure equity in ART access, we explored barriers to ART access among female sex workers (FSWs) living with HIV in Chennai. Between August and November 2007, we conducted three focus group discussions and two key informant interviews. Data were explored using framework analysis to identify categories and derive themes. We found interrelated barriers at the family/social, health care system/programmatic, and individual levels. Major barriers included fear of adverse consequences of disclosure of HIV status due to stigma and discrimination associated with HIV and sex work, lack of family support, negative experiences with health care providers, lack of adequate counseling services at government centers and by outreach workers employed by nongovernmental organizations (NGOs), perceived biased treatment of FSWs who are not referred by NGOs, lack of adequate knowledge about ART, and fatalism. Barriers can be addressed by: creating effective measures to reduce stigma associated with HIV/AIDS and sex work at the familial, societal, and health care system levels; incorporating information about ART into targeted interventions among FSWs; training counselors at government hospitals and NGO outreach workers on treatment issues; improving infrastructure and staffing levels at government centers to allow adequate time and privacy for counseling; and implementing government mass media campaigns on ART availability. Finally, it is crucial that NACO begin monitoring ART coverage of FSWs and other marginalized populations to ensure equitable ART access.