Awareness about brain death and attitude towards organ donation in a rural area of Haryana, India.

INTRODUCTION: Awareness about brain death influences organ donation behaviour of community. There is huge gap in the demand and availability of organs in India. This study was carried out with the objective of assessing awareness about brain death and attitude towards organ donation in a rural community. MATERIAL AND METHODS: A community based cross-sectional study was carried out among 1050 adults in a rural area of district Faridabad, Haryana. Data were collected through a pre-tested interview schedule and analysed using SPSS v17. RESULTS: 80% of the study participants had heard about organ donation. Among them, about 40% were aware of brain death. Majority of the study participants (71.5%) were willing to donate organ irrespective of circumstances. Totally, 94.6% participants had the perspective that special facility should be there for organ donors and their families. Awareness was significantly more among men and among those educated above primary level. CONCLUSION: Knowledge about brain death is crucial in convincing people into organ donation. Hence more efforts should be made to educate and make people aware about brain death and its implications for organ donation.

Feasibility and validity of using WHO adolescent job aid algorithms by health workers for reproductive morbidities among adolescent girls in rural North India.

BACKGROUND: High prevalence of reproductive morbidities is seen among adolescents in India. Health workers play an important role in providing health services in the community, including the adolescent reproductive health services. A study was done to assess the feasibility of training female health workers (FHWs) in the classification and management of selected adolescent girls' reproductive health problems according to modified WHO algorithms. METHODS: The study was conducted between Jan-Sept 2011 in Northern India. Thirteen FHWs were trained regarding adolescent girls' reproductive health as per WHO Adolescent Job-Aid booklet. A pre and post-test assessment of the knowledge of the FHWs was carried out. All FHWs were given five modified WHO algorithms to classify and manage common reproductive morbidities among adolescent girls. All the FHWs applied the algorithms on at least ten adolescent girls at their respective sub-centres. Simultaneously, a medical doctor independently applied the same algorithms in all girls. Classification of the condition was followed by relevant management and advice provided in the algorithm. Focus group discussion with the FHWs was carried out to receive their feedback. RESULTS: After training the median score of the FHWs increased from 19.2 to 25.2 (p - 0.0071). Out of 144 girls examined by the FHWs 108 were classified as true positives and 30 as true negatives and agreement as measured by kappa was 0.7 (0.5-0.9). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 94.3% (88.2-97.4), 78.9% (63.6-88.9), 92.5% (86.0-96.2), and 83.3% (68.1-92.1) respectively. DISCUSSION: A consistent and significant difference between pre and post training knowledge scores of the FHWs were observed and hence it was possible to use the modified Job Aid algorithms with ease. Limitation of this study was the munber of FHWs trained was small. Issues such as time management during routine work, timing of training, overhead cost of training etc were not taken into account. CONCLUSIONS: Training was successful in increasing the knowledge of the FHWs about adolescent girls' reproductive health issues. The FHWs were able to satisfactorily classify the common adolescent girls' problems using the modified WHO algorithms.

Teaching community medicine to medical undergraduates-learning by doing: our experience of rural posting at All India Institute of Medical Sciences, New Delhi, India.

BACKGROUND: The goal of medical education is to ensure that the medical graduate has acquired broad public health competencies needed to solve the health problems of the community. We present the current teaching of community medicine to medical students of the All India Institute of Medical Sciences (AIIMS), New Delhi during their 5-week posting at the rural centre at Ballabgarh, Haryana. METHODS: The teaching activities consist of field visits to different levels of health facilities and meeting with health workers, epidemiological exercises, a community-based exercise, posting in inpatient and outpatient departments of a secondary hospital, and domiciliary visits to families of patients. These are spread over 80 sessions of about 200 hours. There is very little didactic teaching and the assessment is broad-based. The evaluation of the posting was based on comparison of blinded pre- and post-posting assessments as well as anonymous feedback of the posting by the students. RESULTS: There was a significant increase in the mean scores of all components of the posting-epidemiology (5.1 to 8.4), health systems (6.8 to 9.3) and clinical (8.0 to 10.8). The posting did not result in a better understanding of a public health approach as compared to a clinical approach. The feedback provided by students was generally positive for all activities with 94% of them rating it as good or very good. CONCLUSION: The teaching of community medicine can be made more practical and interesting without compromising on learning. However, despite such a programme, getting medical students to develop a public health approach is a daunting task.

Non-specific sex-differential effect of DTP vaccination may partially explain the excess girl child mortality in Ballabgarh, India.

OBJECTIVE: To test the hypothesis that a gender differential exists in the effect on child mortality of BCG, DTP, measles vaccine as administered under programme conditions in Ballabgarh HDSS area. METHODS: All live births in 28 villages of Ballabgarh block in North India from 2006 to 2011 were followed until 31 December 2011 or 36 months of age whichever was earlier. The period of analysis was divided into four time periods based on eligibility for vaccines under the national immunisation schedule (BCG for tuberculosis, primary and booster doses of diphtheria-tetanus-pertussis and measles). Cox proportional hazards regression was used to assess the association between sex and risk of mortality by vaccination status using age as the timescale in survival analysis and adjusting for wealth index, access to health care, the presence of a health facility in the village, parental education, type of family, birth order of the child and year of birth. RESULTS: 702 deaths (332 boys and 370 girls) occurred among 12,142 children in the cohort in the 3 years of follow-up giving a cumulative mortality rate of 57.5 per 1000 live births with 35% excess girl child mortality. Age at vaccination for the four vaccines did not differ by sex. There was significant excess mortality among girls after immunisation with DTP, for both primary (HR 1.65; 95% CI:1.17-2.32) and DTPb (2.21; 1.24-3.93) vaccinations. No significant excess morality among girls was noted after exposure to BCG 1.06 (0.67-1.67) or measles 1.34 (0.85-2.12) vaccine. CONCLUSION: This study supports the contention that DTP vaccination is partially responsible for higher mortality among girls in this study population.

Contributions of ancient Indian physicians--implications for modern times.

Ayurveda traces its origins to contributions of mythological and real physicians that lived millennia earlier. In many respects, Western medicine also had similar origins and beliefs, however, the introduction of anatomical dissection and progressive application of scientific evidence based practices have resulted in divergent paths taken by these systems. We examined the lives, careers, and contributions made by nine ancient Indian physicians. Ancient texts, translations of these texts, books, and biographical works were consulted to obtain relevant information, both for Indian traditional medicine as well as for Western medicine. Ayurveda has retained principles enunciated by these physicians, with minor conceptual advances over the centuries. Western medicine separated from ancient Indian medicine several hundred years ago, and remains the foundation of modern medicine. Modern medicine is evidence based, and randomized clinical trials (RCTs) are the gold standard by which efficacy of treatment is evaluated. Ayurvedic medicine has not undergone such critical evaluation to any large extent. The few RCTs that have evaluated alternative medical treatment recently have shown that such therapy is no better than placebo; however, placebo treatment is 30% effective. We suggest that foreign domination, initially by Mughals, and later by the British, may have contributed, in part, to this inertia and protracted status quo.

Introducing regular behavioural surveillance into the health system in India: its feasibility and validity.

BACKGROUND: Illness is affected by human behaviour. However, in most developing countries the risk behaviour of the general population is not assessed. We developed a surveillance system to assess the 'risk factors' at the community level using the routine healthcare system. METHODS: The Comprehensive Rural Health Services Project at Ballabgarh, Haryana, provides healthcare to a population of 82,933 through 2 primary health centres and 24 health workers. Information on behavioural risk factors for communicable and non-communicable diseases was collected by health workers during the annual health census from December 2003 to February 2004. The information collected pertained to maternal and child health, and household and individual behaviour. We compared the data related to individual behaviour with that ofa survey of non-communicable diseases risk factors done in the same area. RESULTS: Data were collected from (i) mothers who had delivered during the preceding year (n=1625), (ii) a random sample of individuals (n=2865), (iii) and all households (n=7488). The response rate was 85% for mothers, 91%/ for households and 95% for individuals. Approximately 80% of the households had access to drinking water, 32% to sanitary latrines, 28% of women increased their dietary intake during pregnancy, and 50% of adult men used tobacco. Comparing these results with those from the survey of risk factors for non-communicable diseases revealed no significant differences. CONCLUSION: It is feasible for health workers to do behavioural surveillance by usingthe routine healthcare system.

Intensified pulse polio immunization: time spent and cost incurred at a primary healthcare centre.

BACKGROUND: Despite launching the polio eradication initiative in 1995, India is among the world's largest reservoir of wild poliovirus with 559 cases of poliomyelitis reported in 2008. This continued failure has been criticised for its negative impact on routine healthcare delivery. We assessed the impact of the pulse polio immunization programme at the primary health level in terms of services, time and cost. METHODS: All activities during a single round of intensified pulse polio immunization were modelled on actual requirements at the primary health centre at Dayalpur in Haryana. Total person-hours and cost per child vaccinated at the primary health centre were computed. RESULTS: Almost all routine healthcare services at the primary health centre were suspended during the round. Total person-hours consumed were 4446 and the total direct cost was Rs 24.2 per child vaccinated during a single round of the intensified pulse polio immunization programme. CONCLUSION: A single round of intensified pulse polio immunization consumes a substantial number of person-hours and leads to a temporary suspension of routine services provided at the primary health centre. This should be factored in while planning any future strategy of polio eradication or control and suggests the need to re-think the 'intensified pulse polio strategy'.

From reorientation of medical education to development of medical educators.

Re-orientation of medical education in India has not been fully successful because the development of medical teacher, a critical component has not been adequately addressed. Faculty development is a key factor. We have identified six shifting trends in faculty development that can contribute to the development of a medical educator in India. These include a shift from: One time training to continuing professional development; information based approach to project based approach; training to scholarship; lack of accountability to accountability and recognition; individual efforts to networking; and role of treatment providers to health promoters. We have discussed how these shifts are in tune with the global trends. We recommend that the initiatives taken in India in the recent past, viz., constitution of a Task Force by the Ministry of Health and Family Welfare, establishment of several medical education centers should be harnessed by forming a national working group. Such a group would provide policy directions for faculty development which will lead to a concrete plan for implementation and thereby addressing a critical component of the re-orientation of medical education.

Public health strategies to stem the tide of chronic kidney disease in India.

It is estimated that 10-15% of the population has chronic kidney disease (CKD), resulting in significant health expenditure, which is largely met by out-of-pocket by the patient in India. However, the seriousness of this public health problem has remained largely under-recognized so far. Luckily the preventive measures are simple and not difficult to implement. Public health strategies are essential to control the burgeoning problem. Lifestyle modifications can reduce the incidence of obesity, hypertension and diabetes. These diseases account for a significant proportion of CKD cases. Active involvement of the primary care physicians is vital for early detection of CKD with retardation of its progress, since nephrologists do not see the patients in the early stages. The role of community health specialists is essential to organize health education programs and screening camps, form active patient support groups; and incorporate the prevention program in the various tiers of the health-care system. Availability of optimal nephrology services in peripheral hospitals can rehabilitate most cases of end-stage renal disease, and also prevent the illegal organ trade, which keeps rearing its ugly head at regular intervals in India.

Tracking progress towards sustainable elimination of iodine deficiency disorders in Orissa.

OBJECTIVE: To assess the status of iodine deficiency in the population of Orissa and track progress of the elimination efforts. METHODS: A community based field survey was conducted. Data was collected using quantitative and qualitative research methods. Standard internationally recommended protocol and methodology was followed. Thirty clusters were selected using population proportionate to size sampling technique. School children aged 6 to 12 years were selected as target group. Goiter prevalence, urinary iodine excretion in the target group and iodine content of the salt at household were used as outcome variables. RESULTS: A total of 1200 children were studied. The total goiter rate was found to be 8.0%, of which 7.6% were grade I and 0.4% was grade-II goiter. The median urinary iodine excretion was found to be 85.4 microg/L and 32.2% of the subjects had urinary iodine levels less than 50 microg/L. Estimation of iodine content by titration method revealed that in only 45% of households salt was found to be adequately iodised. (Salt with iodine level 15 ppm). CONCLUSION: Iodine deficiency continues to be a public health problem in Orissa and the need to accelerate efforts to iodine sufficiency cannot be overemphasized.

Tracking progress towards sustainable elimination of iodine deficiency disorders in Bihar.

OBJECTIVES: To assess the status of the iodine deficiency in the population of Bihar and track progress of the elimination efforts. METHODS: A community based field survey was conducted. Using quantitative and qualitative research methods, data was collected by following internationally recommended protocol and methodology. Thirty clusters were selected using population proportionate to size technique. School age children (6 to 12 years) were the target group studied. Urinary iodine in target children and iodine content of salt at households were the indicators used. RESULTS: Total of 1169 children were studied. The median urinary iodine concentration was found to be 85.6 microg/L. Urinary iodine concentration was less than 50 microg/L in 31.5% of the subjects. Only 40.1% of the household salt samples were found to be adequately iodised as determined by titration method (> or =15 ppm iodine). CONCLUSIONS: Study results show existence of iodine deficiency in the state. There is need to accelerate our efforts to achieve iodine sufficiency and this should be done on a war-footing.

Methods for establishing a surveillance system for cardiovascular diseases in Indian industrial populations.

OBJECTIVE: To establish a surveillance network for cardiovascular diseases (CVD) risk factors in industrial settings and estimate the risk factor burden using standardized tools. METHODS: We conducted a baseline cross-sectional survey (as part of a CVD surveillance programme) of industrial populations from 10 companies across India, situated in close proximity to medical colleges that served as study centres. The study subjects were employees (selected by age and sex stratified random sampling) and their family members. Information on behavioural, clinical and biochemical determinants was obtained through standardized methods (questionnaires, clinical measurements and biochemical analysis). Data collation and analyses were done at the national coordinating centre. FINDINGS: We report the prevalence of CVD risk factors among individuals aged 20-69 years (n = 19 973 for the questionnaire survey, n = 10 442 for biochemical investigations); mean age was 40 years. The overall prevalence of most risk factors was high, with 50.9% of men and 51.9% of women being overweight, central obesity was observed among 30.9% of men and 32.8% of women, and 40.2% of men and 14.9% of women reported current tobacco use. Self-reported prevalence of diabetes (5.3%) and hypertension (10.9%) was lower than when measured clinically and biochemically (10.1% and 27.7%, respectively). There was marked heterogeneity in the prevalence of risk factors among the study centres. CONCLUSION: There is a high burden of CVD risk factors among industrial populations across India. The surveillance system can be used as a model for replication in India as well as other developing countries.

Iodine nutrition status of exclusively breast-fed infants and their mothers in New Delhi, India.

OBJECTIVE: To assess the iodine nutrition status of exclusively breast-fed infants and their mothers. HYPOTHESIS: In the presence of environmental and maternal iodine deficiency, an exclusively breast-fed baby is likely to receive a suboptimal iodine supply during the period of rapid brain growth. METHODS: Spot urinary iodine (UI) and serum TSH levels were measured in 175 healthy, exclusively breast-fed infants and their mothers. Iodine content of salt used by participants for domestic consumption was also analyzed. RESULTS: The median UI levels in mothers and infants was 124 microg/l and 162 microg/l, respectively. 34% of mothers and 21% of infants had UI levels <100 microg/l indicating iodine deficiency. Serum TSH was elevated in 29% of mothers and 2% of infants. No correlation was observed between individual mother-infant UI or serum TSH levels (r = -0.036, r = -0.1 for UI excretion and serum TSH, respectively). 96% of the salt samples tested had adequate iodine concentration, i.e. >15 ppm. CONCLUSION: The present study demonstrated significant iodine deficiency in both mothers and infants despite consumption of adequately iodized salt. The iodine nutrition status of the infants was better compared to the mothers, indicating a preferential iodine supply to the infants over the mothers.