Qualitative research methods in psychiatry in India: Landscaping the terrain.

BACKGROUND: Qualitative research methods (QRMs) bear a critical role in psychiatry as they explore the phenomenology of psychiatric illness and its sociocultural dimensions. However, there is limited evidence regarding its use in psychiatric research in India. AIM: This study, under the aegis of mapping qualitative health research in India initiative, attempted to landscape the use of QRMs in psychiatry and elicited expert opinion on its potential, perceived quality, and scope for improvement. MATERIALS AND METHODS: We reviewed studies using qualitative methodology published in the Indian Journal of Psychiatry (IJP) and the abstracts presented at the Annual Conference of the Indian Psychiatric Society (ANCIPS) between 2010 and 2019. Titles and abstracts were screened and shortlisted; full-text articles were checked to identify the relevant ones. In addition, ten experts comprising psychiatry journal reviewers, editors, and conference scientific committee members were interviewed to elicit their views and suggestions. RESULTS: Out of 356 papers published in IJP between 2010 and 2019, only 12 papers used QRMs: five qualitative and seven mixed methods. Out of 2297 abstracts published between 2010 and 2019 in ANCIPS, only 28 had used QRMs, consisting of 20 qualitative and eight mixed methods. The findings reveal that qualitative research is still an understudied domain in Indian psychiatry with a substantial need for rigor and quality. CONCLUSIONS: To catalyze the use of qualitative research in Indian psychiatry, continuing medical education programs through workshops or webinar mode need to be imparted. These trainings should aim at building skills on qualitative study design, data collection, analysis, and writing.

Water, Sanitation, and Hygiene (WaSH) practices and morbidity status in a rural community: findings from a cross-sectional study in Odisha, India.

INTRODUCTION: Global evidence indicates an association between poor WaSH practice and inferior health outcomes. In rural areas, this practice is predominantly compromised with limited access to safe drinking water, knowledge gaps, and unhealthy socio-behavioural practices. Suboptimal WaSH practice leads to increased vulnerability of various infections, thereby posing a challenge to the primary health care system. METHODS: A community based cross-sectional study was conducted among 879 participants of two villages in Tigiria block, Cuttack district, Odisha, India. Information pertaining to socio-demography, WaSH practices and self-reported morbidities were captured and analysed. Bi-variate analysis was done to assess the association between WaSH practices and any acute illnesses. Differences were considered statistically significant if p-value was less than 0.05. RESULTS: Tube well was the main source of drinking water (49.3%) followed by dug well (46.6%). Only 7.1% of participants reported to purify drinking water and around 40% were still practicing open defecation. The prevalence of acute and chronic illnesses was 9.2% and 19.1% respectively. Major acute illnesses were respiratory diseases, diarrhoeal disorders, and musculoskeletal problems, while major chronic illnesses were gastrointestinal problems, musculoskeletal problems, and hypertension. After adjusting for age, gender, and education, a significant odds ratio of 3.79 [CI = (1.23-11.70)] was observed between drinking water source (surface water Vs tube well water) for acute illnesses. CONCLUSIONS: Poor WaSH practices among rural people make them vulnerable to acute and chronic morbidities. Health awareness and socio behavioural changes pertaining to WaSH practices need utmost priority to ensure better health for rural people of Odisha.

Multimorbidity and Its Outcomes Among Patients Attending Psychiatric Care Settings: An Observational Study From Odisha, India.

Background: Multimorbidity, the presence of two or more chronic health conditions is linked to premature mortality among psychiatric patients since the presence of one can further complicate the management of either. Little research has focused on the magnitude and effect of multimorbidity among psychiatric patients in low-and middle-income settings. Our study, provides the first ever data on multimorbidity and its outcomes among patients attending psychiatric clinics in Odisha, India. It further explored whether multimorbidity was associated with higher medical expenditure and the interaction effect of psychiatric illness on this association. Methods: This cross-sectional study included 500 adult patients presenting to the psychiatric clinic of a medical college hospital in Odisha over a period of 6 months (February 2019-July 2019). A validated structured questionnaire, "multimorbidity assessment questionnaire for psychiatric care" (MAQ-PsyC) was used for data collection. We used multinomial logistic model for the effect estimation. Odds ratios (OR) and 95% confidence intervals (CI) for high healthcare utilization and expenditure were calculated by number and pattern of multimorbidity. Data was analyzed by STATA 14. Results: Half (50%) of the psychiatric outpatients had multimorbidity. The relative probabilities of having one additional condition were 5.3 times (RRR = 5.3; 95% CI: 2.3, 11.9) and multiple morbidities were 6.6 times (RRR = 6.6; 95%CI: 3.3, 13.1) higher for patients in 60+ age group. Healthcare utilization i.e., medication use and physician consultation was significantly higher for psychiatric conditions such as mood disorders, schizophrenia, schizotypal and delusional disorders, and for hypertension, cancer, diabetes, among somatic conditions. Out of pocket expenditure (OOPE) was found to be highest for laboratory investigations, followed by medicines and transport expenditure. Within psychiatric conditions, mood disorders incurred highest OOPE ($93.43) while hypertension was the most leading for OOPE in physical morbidities ($93.43). Psychiatric illnesses had a significant interaction effect on the association between multimorbidity and high medical expenditure (P = 0.001). Conclusion: Multimorbidity is highly prevalent in psychiatric patients associated with significantly high healthcare utilization and medical expenditure. Such disproportionate effect of psychiatric multimorbidity on healthcare cost and use insinuates the need for stronger financial protection and tailor-made clinical decision making for these vulnerable patient subgroups.

Treatment by untrained providers among sick infants in rural Odisha, India.

AIM: This study assessed the diagnosis, treatment and referral service provided by untrained providers for sick infants. BACKGROUND: In rural India, lack of trained providers causes inopportune treatment of sick infants and results in increase in child morbidity and mortality. The untrained providers deliver a significant proportion of health care for rural infants; however, there is a paucity of information on their treatment practice. METHOD: A cross-sectional study was conducted in three rural blocks of Odisha. A total of 337 prescriptions recommended for sick infants were collected from the 15 untrained providers using pre-designed prescription form - designed as per the Integrated Management of Neonatal and Childhood Illness (IMNCI) guideline. The forms were collected through the periodic visit and regular follow-up to the providers. FINDINGS: A total of 68% of infants were diagnosed with the possible serious bacterial infection, 56% fever, 10% feeding problems, 9% dysentery and 9% local bacterial infection. A total of 61% of sick infants prescribed antibiotics - cephalosporin was commonly prescribed (56%). Among severe persistent diarrhea-diagnosed infants, 76% prescribed oral rehydration salt (ORS), 48% zinc and 62% of them received various antibiotics. The untrained providers referred 23% of sick infants to trained providers/facilities. In rural settings, most of the sick infants sought care from untrained providers; however, none of them followed any standard treatment protocol. This study suggests there is a need for training on common disease algorithm and treatment using a standard guideline for untrained providers to reduce inopportuneness in the treatment of sick infants, promoting early diagnosis and referral services to public health systems.

Use of Animal and Animal Products for Rheumatoid Arthritis Treatment: An Explorative Study in Odisha, India.

Severe fatigue, pain, deformity, and disability, are the major concerns for rheumatoid arthritis (RA). The extreme pain experienced by the patients often force them to experiment with various indigenous substances including animals and animal products. However, there is little evidence on the use of animals or animal products as traditional medicine in RA. Hence, this study was aimed to explore the experience and perception of patients toward the use of animals and animal products for the treatment of RA. A qualitative, explorative study was conducted at the out-patient-department of Rheumatology of a tertiary care medical college and hospital at Cuttack, Odisha, India. Out of 113 patients with RA, 18 patients gave history of use of animal and/or animal products and were selected for in-depth interviews. The content analysis methods were used for data analysis. Four major categories emerged: (1) prevailing patterns of traditional treatment of RA using animals, (2) beliefs and values behind the traditional treatment of RA, (3) sources and traditional learning pathway of indigenous practices on RA, and (4) ethical aspects of the indigenous practice of using animals and/or animal products in the treatment of RA. This study revealed the practice of eating dead animals to get relief from RA. However, there was hardly any perceived positive outcome of the practice; which indicates the lack of awareness of rational, scientific, treatment, and prevalence of irrational and unethical practices for the treatment of RA. Hence, community awareness, social mobilization, and newer screening tools are necessary to improve the timely detection and prevention of irrational treatment practices among RA patients.

Care-seeking pathways, care challenges, and coping experiences of rural women living with rheumatoid arthritis in Odisha, India.

AIM: The aim of the study was to explore the care-seeking pathway of rural women living with rheumatoid arthritis (RA) and attending a tertiary health-care facility in Odisha, India. BACKGROUND: RA is the third leading chronic health condition and causes severe pain and immense psychosocial stress. The prevalence of RA is three to four times higher in women than in men. Furthermore, in India, women delay care seeking due to the prevailing sociocultural norms. Women report more severe symptoms and greater disability; however, there is a lack of information on their care-seeking pathways. METHOD: We conducted 113 in-depth interviews among RA patients those who visited specialists at the outpatients' Department of Rheumatology, SCB Medical College Hospital, a tertiary care hospital in Cuttack, Odisha, India. The grounded theory approaches were used for data analysis. FINDINGS: The key findings included physical pain and psychosocial stress in relation to RA, cultural issues in relation to RA, mapping of the health-care providers for RA, the first point of cares and changes in care-seeking pathways, the perceived challenge for seeking health-care, and coping strategies of patients and social supports. This study explored that the RA patients seek care from multiple providers - untrained, trained and specialist without any gatekeeping. However, the primary health centers were the first point of care for maximum patients due to accessibility and affordability. Furthermore, follow-up care is significant to prevent complication among RA patients; the primary health centers are the gateway for keeping RA patients. Hence, the availability of RA trained providers at primary health center including interprofessional care, such as physiotherapy providers, and proper referral system is essential to convalesce care-seeking pathways.