Challenges of diabetes care in India: Results from a Family Cohort Study.

OBJECTIVES: Diabetes is a significant public health concern in India, with Kerala being labeled as the diabetes capital of the country. The study aims to evaluate the prevalence, treatment, and management of diabetes to examine the unmet need for care to propose cost-effective strategies. DESIGN: A cross-sectional study was conducted on a geographically defined cohort population in Ernakulam. SAMPLE: This paper presents diabetes data of adults ≥30 years enrolled from the community cohort. The interviews were conducted with 997 participants at their residence. MEASUREMENT: Random blood glucose was assessed for each participant using a finger prick test. RESULTS: The overall prevalence of diabetes was 30.1%, of which 4.1% of participants had undiagnosed diabetes. Among those with diabetes, 86.3% were aware of their diagnosis; among those aware, 86.5% were on treatment. Among those on treatment for diabetes, 54% achieved controlled blood sugar. CONCLUSION: The challenge in diabetes management is controlling the blood glucose levels of people who adhere to treatment. Younger employed females from lower-income quartiles have the highest risk. The study also raises questions about quality and strategies for medication compliance. The findings inspire future research on care needs, policies, and program responses to reduce the diabetes disease burden.

Scoping review on the use of South-South learning exchange to scale up evidence-based practices in family planning.

BACKGROUND: South-South learning exchange (SSLE) is an interactive learning process where teams from low-income and middle-income countries exchange knowledge and experience to support one or both team's work towards a change in policies, programmes or practices. SSLE has been used by countries to improve family planning (FP) outcomes such as increased contraceptive prevalence rate and reduced unmet need for FP, but at present, there are no reviews that summarise its use. We conducted a scoping review with stakeholder consultations to summarise the use of SSLE to change FP outcomes. OBJECTIVE: To systematically identify and map the purposes, approaches, outputs, outcomes, enablers and barriers to using SSLE in FP. METHODS: A search was conducted on electronic databases, grey literature sources, websites and the reference list of included studies. The scoping review is based on an adapted version of Arksey and O'Malley's scoping review framework suggested by Levac et al. Experts were interviewed on their experiences in SSLE. RESULTS: The initial search yielded 1483 articles; however, only 29 were selected in the final analysis. The articles were published between 2008 and 2022. Most of the articles were reports, case studies or press releases, only two were peer-reviewed publications. Capacity building of FP providers, policy-makers and community was the most commonly reported purpose of SSLE, with study tours (57%) being the most common approach. Policy dialogue was the most common (45%) output and improved contraceptive prevalence was the most frequently reported outcome. The experiences of the 16 interviewed experts aligned with the scoping review findings. CONCLUSION: The evidence on the effectiveness of SSLE for addressing FP outcomes is very limited and of very low quality. We call on stakeholders conducting SSLE to document their experiences in detail, including the outcomes achieved.

Scoping review protocol to map evidence on South-South learning exchange in family planning.

INTRODUCTION: South-South learning exchange (SSLE) is an interactive learning process where stakeholder teams exchange knowledge and experience to help one, or both to work towards change, by identifying, adopting and/or strengthening implementation of a best practice. SSLE has been conducted between countries to share knowledge on best practices and policies in family planning. To the best of our knowledge, no scoping review has been conducted to synthesise evidence on SSLE in family planning. In this paper, we outline the protocol to conduct scoping review on SSLE in family planning. METHODS AND ANALYSIS: Arksey and O'Malley's scoping review framework with adaptions from Levac et al will be used to guide this scoping review. We will search electronic databases (Medline, Embase, CINAHL, Hinari, ProQuest DB, PUBMED, Web of Science and WorldCat), grey literature sources and reference lists of included studies. We will focus on literature published till August 2022. The abstract and title screening, full-text screening and data charting will be conducted by two independent reviewers. The findings will be summarised into a narrative based on thematic analysis. Stakeholder interviews will be conducted to understand their perception and experiences in applying SSLE in family planning. ETHICS AND DISSEMINATION: The ethics review committee at WHO, Geneva, has exempted this study from ethical approval (ERC.0003752). The findings from the study will provide useful insights into effective approaches, barriers, facilitators to conduct SSLE in family planning. This knowledge will be of significant public health relevance and will help in designing future learning exchanges between countries in the south to accelerate access to quality family planning services. The findings will be disseminated via peer-reviewed journals, conference proceedings, newsletters and workshops.

Strengths and weaknesses of the South-South Learning Exchange: a qualitative analysis of experts' perspectives.

Background: South-South learning exchange (SSLE) refers to an interactive learning process where peers exchange knowledge and experience to work towards a beneficial change. Despite organizations having recently increased the opportunity to run SSLEs, the SSLE support mechanisms and processes are not well documented in the scientific literature. This study explored experts' perspectives on SSLEs, strengths, weaknesses and mechanisms leading to sustainable outcomes. Methods: We conducted a qualitative study using semi-structured interviews on experiences of participants and organizers of SSLEs. Data were collected between 1st September 2021 to 26th November 2021. All data were digitally recorded, transcribed verbatim, and analysed. In the analysis, we adopted an inductive approach derived from thematic analysis. Results: Sixteen experts, who have participated in or facilitated one or more SSLE, were interviewed. The experts' accounts demonstrated an appreciation of participants' empowerment, positive peer-to-peer "mind change" and convincing and powerful hands-on learning of this approach as strengths in the implementation of the SSLE. Being resource heavy, participant and donor reluctance and absence of a validated methodology emerged as main weaknesses of the South-South learning approach, which could impair the effectiveness of this scheme. Conclusions: The strengths of SSLEs are anchored in the theories of experiential and social learning, highlighting SSLE's potential to create an environment that enhances knowledge exchange. the study highlights the challenges SSLE initiatives face. In particular, these include limited commitment and funds, limited evidence of impact, disparate approaches, and the absence of standardized guidelines and evaluation practices.

Determining the Impact of the COVID-19 Pandemic on Availability, Use, and Readiness of Family Planning and Contraceptive Services at Selected Primary Health Care Facilities in Africa and Asia: Protocol for a Mixed Methods Study.

BACKGROUND: The COVID-19 pandemic and the associated social restrictions may have disrupted the provision of essential services, including family planning (FP) and contraceptive services. This protocol is adapted from a generic study protocol titled "Health systems analysis and evaluations of the barriers to availability and readiness of sexual and reproductive health services in COVID-19 affected areas," conducted by the World Health Organization (WHO) Department of Reproductive Health and Research. OBJECTIVE: This study aims to assess the availability and use of FP and contraceptive services in primary health facilities during and after the COVID-19 pandemic; assess the risk perceptions of COVID-19 stigma, barriers to access, and quality of services from clients' and providers' perspectives in the COVID-19-affected areas; and assess the postpandemic recovery of the facilities in the provision of FP and contraceptive services. METHODS: In-depth interviews will be conducted with clients-women in the reproductive age group and their male partners who visit the selected health facilities for FP and contraceptive services-and health providers (the most knowledgeable person on FP and contraceptive service provision) at the selected health facilities. Focus group discussions will be conducted with clients at the selected health facilities and in the community. The in-depth interviews and focus group discussions will help to understand clients' and health service providers' perspectives of FP and contraceptive service availability and readiness in COVID-19-affected areas. A cross-sectional health facility assessment will be conducted in all the selected health facilities to determine the health facility infrastructure's ability and readiness to provide FP and contraceptive services and to capture the trends in FP and contraceptive services available during the COVID-19 pandemic. Scientific approval for this study is obtained from the WHO Research Project Review Panel, and the WHO Ethics Review Committee has given ethical approval in the 3 countries. RESULTS: Using a standardized research protocol will ensure that the results from this study can be compared across regions and countries. The study was funded in March 2021. It received ethics approval from the WHO Ethics Review Committee in February 2022. We completed data collection in September 2022. We plan to complete the data analysis by March 2023. We plan to publish the study results by Summer 2023. CONCLUSIONS: The findings from this study will provide a better understanding of the impact of the COVID-19 pandemic on FP and contraceptive services at the facility level, which will help policy makers and health managers develop and strengthen FP policies and services in health facilities to be more responsive to community needs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/43329.

Improving access to quality family planning services in Nepal and Sri Lanka: insights from a South-South learning exchange.

Nepal and Sri Lanka ministries of health shared best practices and learnings, in a South-South learning exchange (SSLE) to improve access to quality and rights-based family planning services. The SSLE between the two countries followed a five-step methodology designed by the WHO, under the Family Planning Accelerator project. SSLE between the two countries started in January 2020 and is still continuing. Both countries started implementation of the learnings (step 4) at the time of preparing this manuscript (December 2021). An independent consultant from Sri Lanka carried out an evaluation, to inform future SSLEs. The evaluation included a desk review on SSLE and family planning in both countries and key informant interviews with Sri Lanka Ministries Health, WHO CO, external partners. A final evaluation of the outcomes/impact is planned in December 2022. The SSLE resulted in a systematic cross-country transfer of knowledge and implementation of the learnings. Sri Lanka implemented a web-based system for logistics management of family planning commodities and Nepal commenced implementing integrated family planning services in a decentralised environment using a lifecycle approach to improve postpartum family planning uptake. The success of this SSLE is attributed to the rigorous methodology, country-led designing of the learning agenda and process, extensive communication amongst the teams, a focus on outcomes, commitment and leadership by ministries of health in both countries. Learning and technical assistance needs of countries can be met by SSLE if national contexts, availability of resources are considered.

Resiliency Engagement and Care in Health (REaCH): a telephone befriending intervention for upskilled rural youth in the context of COVID-19 pandemic-study protocol for a multi-centre cluster randomised controlled trial.

BACKGROUND: The lockdown associated with the COVID-19 pandemic is likely to impact people's mental health, especially those from economically disadvantaged and vulnerable sections of society. Mental health can be affected by many factors, including fear of disease transmission, from response measures against the pandemic like social distancing, movement restriction, fear of being in quarantine, loneliness, depression due to isolation, fear of losing work and livelihood and avoiding health care due to fear of being infected. Telephonic befriending intervention by non-specialists will be used to provide social and emotional support to the youth from the Deen Dayal Upadhyaya Grameen Kaushalya Yojana (DDUGKY), an initiative of the Government of India. This study aims to promote mental wellbeing and reduce depressive symptoms by assisting participants to mobilise social support from family, friends and significant others by using the telephonic befriending intervention. METHODS: In this article, we report the design and protocol of a multi-centre cluster randomised controlled trial. In total, 1440 participants aged 18-35 years who have recently completed their course out of the DDU-GKY initiative will be recruited in the study from 12 project-implementing agencies (PIAs) across six geographical zones of India. Participants from 6 of these agencies will be assigned to the telephonic befriending intervention arm, and the other six agency participants will be assigned to the general enquiry phone call arm (control). The primary outcomes of this study are mental wellbeing, depressive symptoms and perceived social support. Baseline assessments and follow-up assessments will be carried out 1 month following the intervention using WHO-5, PHQ and MSPSS-12 questionnaires. The befriending intervention will be provided by DDU-GKY staff, whom a virtual training programme will train. DISCUSSION: This trial will help assess whether participants who are offered emotional, social and practical support through befriending will experience lesser symptoms of depression and better mental health compared to participants who do not receive this intervention through mobilised social support from friends, family and others. TRIAL REGISTRATION: Clinical Trial Registry India (ICMR-NIMS) CTRICTRI/2020/07/026834 . Registered on 27 July 2020.

Prevalence, Awareness, Treatment, and Control of Hypertension and Its Associated Risk Factors: Results from Baseline Survey of SWADES Family Cohort Study.

METHODS: In this prospective family-based cohort study, 573 families were included with a total of 997 participants aged 30 years and above. Baseline interviews were conducted in participant's homes using a combination of self-structured and standardized questionnaire. Blood pressure and plasma glucose were assessed for each participant. RESULTS: The prevalence of hypertension was 43%. It was slightly higher in women than men (43.7% vs. 41.4%). The mean systolic blood pressure in the hypertensive population was 141.9 mmHg and mean diastolic blood pressure was 85.3 mmHg. In total, 78% (86.2% in women, 62.9% in men) of the participants were aware of their hypertension. Among those aware, 60.4% (63.5% in women, 52.6% in men) of the participants were on treatment, and hypertension was controlled in 75.1% (77.5% women, 68% in men) of the participants on treatment. The prevalence of hypertension was higher among persons with comorbidities (diabetes 64.5%, transient ischemic attack 54.7%, and heart disease 64.4%). Prevalence was lower among persons who did regular vigorous intensity exercise versus those who did moderate intensity exercise (32% vs. 45.7%) and among nonsmokers versus smokers (42.2% vs. 46.6%). CONCLUSION: The prevalence of hypertension in Kerala is high. Although awareness is quite high, there is a need to improve the number of persons with hypertension taking treatment.

Scoping review to map evidence on mechanism of action, pharmacokinetics, effectiveness and side effects of centchroman as a contraceptive pill.

OBJECTIVE: To systematically identify and map the available evidence on effectiveness, side effects, pharmacokinetics and mechanism of action of centchroman as a contraceptive pill. INTRODUCTION: Centchroman was introduced in the Indian national family planning programme in 2016 as a once-a-week short-term contraceptive pill/oral contraceptive. At present there are no WHO recommendations on this method of contraception. We examined the available evidence through a scoping review. METHODS: A search was conducted inclusive to the years 1970-2019 on electronic databases, grey literature sources and reference lists of included studies to identify studies. The five stages of Arksey and O'Malley's scoping review framework were applied in undertaking this scoping review. RESULTS: The review identified 33 studies conducted between 1976 and 2017. Two studies reported mechanism of action of centchroman. Pharmacokinetics was reported by five studies among non-breastfeeding women and four studies among breastfeeding women. Eight studies reported on effectiveness ranging from 93% to 100%. Pregnancies due to user failure ranged from 2.6% to 10.2%. Although side effects were reported in 13 studies, the incidence varied greatly between the studies. Continuous bleeding and prolonged cycles >45 days were the most commonly reported side effects. All studies conducted had a small sample size and the duration of follow-up of women was 12 months or less. Fifty-five per cent of studies were by the developers of the pill (Central Drug Research Institute) and results of the phase IV clinical trial were unavailable. CONCLUSIONS: The scoping review shows that studies with robust designs and conducted in international context are lacking. Insufficient evidence exists on centchroman use as a postcoital contraceptive pill. The broad uncertainty in range of side effects and effectiveness in the studies implies insufficient evidence to make global recommendations on centchroman that is currently licensed as a contraceptive in India.

Prevalence of disability among adults using Rapid Assessment of Disability tool in a rural district of South India.

BACKGROUND: There are different estimates of disability prevalence reported in India due to the differences in definitions and methodologies. Reliable data is needed to plan effective disability inclusive strategies. OBJECTIVE: The objective of this study was to determine the prevalence and risk factors associated with disability among adults ≥18 years of age in Prakasam district of Andhra Pradesh using the Rapid Assessment of Disability (RAD) tool. METHODS: The RAD survey was conducted in 50 villages (clusters) of Ongole division of Prakasam district. A two-stage cluster random sampling was used. Within each village 80 participants were surveyed. Compact segment sampling was used to determine the houses included. A person was reported as disabled based on their responses to the functioning section of the RAD tool. RESULTS: A total of 4134 adults were included. The overall prevalence of disability was 10.4% (431 adults). The highest prevalence of functional impairment was related to mobility (4.7%) followed by vision (2.1%) and fine motor (1.8%). The prevalence of psychological distress was 2.3%. Disability was significantly more prevalent in the poor socio economic group (OR 2.8; 95% CI: 1.5; 5.0) and among unemployed (OR 3.6; 95% CI: 2.3, 5.5). The prevalence of disability was strongly associated with age where, participants aged 70 years and over were eleven times more likely to report disability than younger age groups. CONCLUSION: The high prevalence of disability in the region points to disability being of public health concern and as a health condition needing urgent attention and specific interventions.

A Mixed-Method Study to Determine the Benefits of Periconceptional Folic Acid Supplementation and Effects of Folic Acid Deficiency in Mothers on Birth Outcomes.

BACKGROUND: Evidence from high income countries shows mothers who are supplemented with folic acid in their periconceptional period and early pregnancy have significantly reduced adverse outcomes like birth defects. However, in India there is a paucity of data on association of birth defects and folic acid supplementation. We identified a few important questions to be answered using separate scientific methods and then planned to triangulate the information. OBJECTIVE: In this paper, we describe the protocol of our study that aims to determine the association of folic acid and pregnancy outcomes like neural tube defects (NTDs) and orofacial clefts (OFCs). We decided to fill the gaps in knowledge from India to determine public health consequences of folic acid deficiency and factors influencing dietary and periconceptional consumption of folic acid. METHODS: The proposed study will be carried out in five stages and will examine the questions related to folic acid deficiency across selected locations in South and North India. The study will be carried out over a period of 4 years through the hierarchical evidence-based approach. At first a systematic review was conducted to pool the current birth prevalence of NTDs and orofacial clefts OFCs in India. To investigate the population prevalence, we plan to use the key informant method to determine prevalence of NTDs and OFCs. To determine the normal serum estimates of folic acid, iron, and vitamin B12 among Indian women (15-35 years), we will conduct a population-based, cross-sectional study. We will further strengthen the evidence of association between OFCs and folic acid by conducting a hospital-based, case-control study across three locations of India. Lastly, using qualitative methods we will understand community and health workers perspective on factors that decide the intake of folic acid supplements. RESULTS: This study will provide evidence on the community prevalence of birth defects and prevalence folic acid and vitamin B12 deficiency in the community. The case-control study will help understand the association of folic acid deficiency with OFCs. CONCLUSIONS: The results from this study are intended to strengthen the evidence base in childhood disability for planning and policy initiatives.

Birth prevalence of neural tube defects and orofacial clefts in India: a systematic review and meta-analysis.

BACKGROUND: In the last two decades, India has witnessed a substantial decrease in infant mortality attributed to infectious disease and malnutrition. However, the mortality attributed to birth defects remains constant. Studies on the prevalence of birth defects such as neural tube defects and orofacial clefts in India have reported inconsistent results. Therefore, we conducted a systematic review of observational studies to document the birth prevalence of neural tube defects and orofacial clefts. METHODS: A comprehensive literature search for observational studies was conducted in MEDLINE and EMBASE databases using key MeSH terms (neural tube defects OR cleft lip OR cleft palate AND Prevalence AND India). Two reviewers independently reviewed the retrieved studies, and studies satisfying the eligibility were included. The quality of included studies was assessed using selected criteria from STROBE statement. RESULTS: The overall pooled birth prevalence (random effect) of neural tube defects in India is 4.5 per 1000 total births (95% CI 4.2 to 4.9). The overall pooled birth prevalence (random effect) of orofacial clefts is 1.3 per 1000 total births (95% CI 1.1 to 1.5). Subgroup analyses were performed by region, time period, consanguinity, and gender of newborn. CONCLUSION: The overall prevalence of neural tube defects from India is high compared to other regions of the world, while that of orofacial clefts is similar to other countries. The majority of studies included in the review were hospital based. The quality of these studies ranged from low to moderate. Further well-designed, high quality community-based observational studies are needed to accurately estimate the burden of neural tube defects and orofacial clefts in India.

Challenges in Developing Competency-based Training Curriculum for Food Safety Regulators in India.

CONTEXT: The Food Safety and Standards Act have redefined the roles and responsibilities of food regulatory workforce and calls for highly skilled human resources as it involves complex management procedures. AIMS: 1) Identify the competencies needed among the food regulatory workforce in India. 2) Develop a competency-based training curriculum for food safety regulators in the country. 3) Develop training materials for use to train the food regulatory workforce. SETTINGS AND DESIGN: The Indian Institute of Public Health, Hyderabad, led the development of training curriculum on food safety with technical assistance from the Royal Society for Public Health, UK and the National Institute of Nutrition, India. The exercise was to facilitate the implementation of new Act by undertaking capacity building through a comprehensive training program. MATERIALS AND METHODS: A competency-based training needs assessment was conducted before undertaking the development of the training materials. RESULTS: THE TRAINING PROGRAM FOR FOOD SAFETY OFFICERS WAS DESIGNED TO COMPRISE OF FIVE MODULES TO INCLUDE: Food science and technology, Food safety management systems, Food safety legislation, Enforcement of food safety regulations, and Administrative functions. Each module has a facilitator guide for the tutor and a handbook for the participant. Essentials of Food Hygiene-I (Basic level), II and III (Retail/ Catering/ Manufacturing) were primarily designed for training of food handlers and are part of essential reading for food safety regulators. CONCLUSION: The Food Safety and Standards Act calls for highly skilled human resources as it involves complex management procedures. Despite having developed a comprehensive competency-based training curriculum by joint efforts by the local, national, and international agencies, implementation remains a challenge in resource-limited setting.

Self-adjustable glasses in the developing world.

Uncorrected refractive errors are the single largest cause of visual impairment globally. Refractive errors are an avoidable cause of visual impairment that are easily correctable. Provision of spectacles is a cost-effective measure. Unfortunately, this simple solution becomes a public health challenge in low- and middle-income countries because of the paucity of human resources for refraction and optical services, lack of access to refraction services in rural areas, and the cost of spectacles. Low-cost approaches to provide affordable glasses in developing countries are critical. A number of approaches has been tried to surmount the challenge, including ready-made spectacles, the use of focometers and self-adjustable glasses, among other modalities. Recently, self-adjustable spectacles have been validated in studies in both children and adults in developed and developing countries. A high degree of agreement between self-adjustable spectacles and cycloplegic subjective refraction has been reported. Self-refraction has also been found to be less prone to accommodative inaccuracy compared with non-cycloplegic autorefraction. The benefits of self-adjusted spectacles include: the potential for correction of both distance and near vision, applicability for all ages, the empowerment of lay workers, the increased participation of clients, augmented awareness of the mechanism of refraction, reduced costs of optical and refraction units in low-resource settings, and a relative reduction in costs for refraction services. Concerns requiring attention include a need for the improved cosmetic appearance of the currently available self-adjustable spectacles, an increased range of correction (currently -6 to +6 diopters), compliance with international standards, quality and affordability, and the likely impact on health systems. Self-adjustable spectacles show poor agreement with conventional refraction methods for high myopia and are unable to correct astigmatism. A limitation of the fluid-filled adjustable spectacles (AdSpecs, Adaptive Eyecare Ltd, Oxford, UK) is that once the spectacles are self-adjusted and the power fixed, they become unalterable, just like conventional spectacles. Therefore, they will need to be changed as refractive power changes over time. Current costs of adjustable spectacles are high in developing countries and therefore not affordable to a large segment of the population. Self-adjustable spectacles have potential for "upscaling" if some of the concerns raised are addressed satisfactorily.