Strategies for primary HPV test-based cervical cancer screening programme in resource-limited settings in India: Results from a quasi-experimental pragmatic implementation trial.

BACKGROUND: In order for low and middle income countries (LMIC) to transition to Human Papilloma Virus (HPV) test based cervical cancer screening, a greater understanding of how to implement these evidence based interventions (EBI) among vulnerable populations is needed. This paper documents outcomes of an implementation research on HPV screening among women from tribal, rural, urban slum settings in India. METHODS: A mixed-method, pragmatic, quasi-experimental trial design was used. HPV screening on self-collected cervical samples was offered to women aged 30-60 years. Implementation strategies were 1) Assessment of contextual factors using both qualitative and quantitative methods like key informant interviews (KII), focus group discussions (FGDs), pre-post population sample surveys, capacity assessment of participating departments 2) enhancing provider capacity through training workshops, access to HPV testing facility, colposcopy, thermal ablation/cryotherapy at the primary health care centers 3) community engagement, counselling for self-sampling and triage process by frontline health care workers (HCWs). Outcomes were assessed using the RE-AIM (Reach, Effectiveness, adoption, implementation, maintenance) framework. RESULTS: Screening rate in 8 months' of study was 31.0%, 26.7%, 32.9%, prevalence of oncogenic HPV was 12.1%, 3.1%, 5.5%, compliance to triage was 53.6%, 45.5%, 84.6% in tribal, urban slum, rural sites respectively. Pre-cancer among triage compliant HPV positive women was 13.6% in tribal, 4% in rural and 0% among urban slum women. Unique challenges faced in the tribal setting led to programme adaptations like increasing honoraria of community health workers for late-evening work and recalling HPV positive women for colposcopy by nurses, thermal ablation by gynaecologist at the outreach camp site. CONCLUSIONS: Self-collection of samples combined with HCW led community engagement activities, flexible triage processes and strengthening of health system showed an acceptable screening rate and better compliance to triage, highlighting the importance of identifying the barriers and developing strategies suitable for the setting. TRIAL REGISTRATION: CTRI/2021/09/036130.

Nature, prevalence, and risk factors for self-neglect among older people: a pilot study from Vellore, South India.

Changes in demography in developing countries haves led to new issues among older rural populations, such as self-neglect which is under researched.Self-neglect identified as poor self-care, unsafe living quarters, inadequate medical care and poor utilization of services increase the odds of morbidity and mortality.Methods Our study was conducted in Kaniyambadi, a rural block in Vellore district in the state of Tamil Nadu, India. Ten villages were randomly selected. The study was conducted among people older than 60 years who were selected by random sampling using a computer-generated list. The following assessments were done: (i) A 19-item questionnaire was used to assess self-neglect, (ii) Katz index of daily living to assess functional activity, (iii) Mini Mental State Examination to evaluate cognition, (iv) Geriatric Depression Scale to identify depression, (v) Duke Social Support Index to measure social supports. Clinical data and anthropometric data were also collected. Data were entered into Epidata v3.1. All analyses were performed using SPSS v23.0.Results One hundred fourteen people above 60 years of age participated. The prevalence of self-neglect was 21.1% (95% CI 14.9%-29%); about half of the elderly population (47.38%) refused to seek or follow medical advice. Lower levels of education (OR 3.678, 95% CI 1.017 - 13.301), lower social class (OR 4.455, 95% CI 1.236 - 16.050) and functional impairment (3.643, 95% CI 1.373 - 9.668) were found to be significant factors associated with self-neglect. Though prevalence of comorbidities (70%) and depression (27%) were high, there was no statistical evidence of association with self-neglect.

A proposed methodology of health education for inherited genetic disorders: Bag and Ball technique.

The life-threatening genetic blood disorder, thalassaemia, which causes decreased haemoglobin production, is preventable. Sociocultural determinants and the level of public health awareness must be used to adopt control measures of prevention. Identifying information gaps and educating the community about screening should be a priority, especially in areas with high disease burdens. A relevant health education technique, with which the audience can identify, can effectively bring understanding necessary effectively to sensitise the community. We propose the 'Bag and Ball' method, which includes role-play for health education specifically concerning inherited genetic disorders.

Impact of the COVID-19 National Lockdown on a Rural and Tribal Population of Tamil Nadu, Southern India: A Mixed-Methods Survey.

We assessed the impact of the national lockdown on a rural and tribal population in Tamil Nadu, southern India. A mixed-methods approach with a pilot-tested, semi-structured questionnaire and focus group discussions were used. The impact of the lockdown on health, finances, and livelihood was studied using descriptive statistics. Multivariable logistic regression was carried out to identify factors associated with households that borrowed loans or sold assets during the lockdown, and unemployment during the lockdown. Of the 607 rural and tribal households surveyed, households from comparatively higher socioeconomic quintiles (adjusted odds ratio [aOR], 1.84; 95% CI, 1.01-3.34), with no financial savings (aOR, 2.91; 95% CI, 1.17-7.22), and with larger families (aOR, 1.76; 95% CI, 1.22-2.53), took loans or sold assets during the lockdown. Previously employed individuals from rural households (aOR, 5.07; 95% CI, 3.30-7.78), lower socioeconomic households (aOR, 3.08; 95% CI, 1.74, 5.45), and households with no savings (aOR, 1.78; 95% CI, 1.30-2.44) became predominantly unemployed during the lockdown. Existing government schemes for the elderly, differently abled, and widows were shown to be accessible to 89% of the individuals requiring these schemes in our survey. During the focus group discussions, the limited reach of online classes for schoolchildren was noted and attributed to the lack of smartphones and poor Internet connectivity. Although the sudden, unannounced national lockdown was imposed to flatten the COVID-19 curve, aspects related to livelihood and financial security were affected for both the rural and tribal populations.

Risk Factors and Hazards in the Household Environment for Elevated Blood Lead Levels in Urban Preschool Children of Vellore: A Case-Control Approach in the MAL-ED Birth Cohort.

OBJECTIVES: To study the household environmental risk factors and hazards associated with elevated blood lead levels (EBLLs) in preschool children in an urban setting of Vellore, South India. METHODS: A case-control study within the MAL-ED (Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development) birth cohort was conducted between January 2014 and January 2015. The study included 153 pre-school children: 87 cases and 66 controls with elevated and normal BLLs, respectively. A structured questionnaire was used to assess the sociodemographic profile, household environment, breastfeeding practices, children's habits, and the use of cosmetics in them. Household environmental samples of wall and door paint, floor dust, drinking water, and cosmetics were estimated for lead levels using gas flame atomic absorption spectrometry (FAAS). RESULTS: Children born with low birth weight, those living in houses painted at least once in the last five years and those residing in houses older than ten years had a higher odds of EBLLs [OR (95% CI) = 3.79 (1.24-11.1); 4.84 (1.42-16.53); 5.07 (2.06-12.46), and 2.58 (0.99-6.69)], respectively. Drinking water samples from both cases (88%) and controls (95%) had lead levels more than the Environmental Protection Agency (EPA), USA recommendation of 0.015 ppm. CONCLUSIONS: Low birth weight and the household environment pose important risk factors/hazards for elevated blood lead levels in urban preschool children. Multipronged interventions that include government legislations, household environmental modification, safe water supply, and community education are pivotal in reducing lead exposure in young children.

Effect of lock down due to COVID-19 pandemic on the alcohol use and abuse among a tribal community in South India.

Background: Alcohol consumption in the tribal communities is found to be rising, as Indian-made foreign liquor (IMFL) is easily accessible through state-run outlets. During the first coronavirus disease (COVID-19) lockdown, despite IMFL being non-available, there were not any reports of alcohol withdrawal among the tribal men who were enrolled in our substance abuse clinic. Methodology: This is a community-based, mixed-method study to document the changes during the lockdown in the drinking pattern and behavior of families and communities of men who consume alcohol. The quantitative part of the study was done by interviewing 45 alcohol-dependent men and documenting their alcohol use disorders identification test (AUDIT) scores during the lockdown. The qualitative part captured the changes in familial and social behavior. Focused group discussions (FGDs) were conducted among community members and leaders. In-depth interviews (IDs) were done among men with harmful drinking patterns and their spouses. Results: There was a significant reduction in the consumption of IMFL among the men interviewed as depicted by the low mean AUDIT score (16.42, P < 0.001). Trivial withdrawal symptoms were found among them (67%). Around 73.3% could access arrack. The community perceived that arrack was brewed and sold at a higher cost within days of lockdown. Familial conflicts reduced. Certain community leaders and members could proactively curb the brewing and selling of arrack. Conclusion: The study uniquely brought out in depth the information at the individual, familial, and community contexts. It is imperative to develop policies to protect indigenous populations by different rules governing the sales of alcohol.

Hazardous use of alcohol among men in the tribal population of Jawadhi Hills, Tamil Nadu: Nature, prevalence, and risk factors.

BACKGROUND: Worldwide, hazardous use of alcohol is common among many cultures and societies and adversely impacts families and communities, with significant morbidity and mortality. Scheduled Tribes (STs) who are socially deprived and marginalised have higher rates of alcohol use. AIM: We attempted to determine the nature, prevalence, and risk factors associated with hazardous consumption of alcohol in the tribal community. METHODOLOGY: A cross-sectional study was conducted among adult male and permanent residents of Jawadhi hills. A total of 1200 men were interviewed. Study participants were chosen by Probability Proportionate to Size (PPS) sampling method. The questionnaire that documented socio-demographic characteristics and patterns of alcohol use was used. AUDIT tool was used to assess the hazardous use of Alcohol. Data were analysed using SPSS. RESULTS: Majority of the men were middle-aged, married, and were from lower socio-economic strata. A large proportion of men (65%) had a history of alcohol consumption in the last one year using one-year, of whom a quarter showed hazardous use (29%) and another quarter exhibited alcohol dependency (24%). Tobacco use, higher income and local alcohol production were found to be significant risk factors for Hazardous alcohol use. CONCLUSION: Alcohol consumption needs to be treated as a social problem and has to be tackled at the policy level. Population-based interventions, legislation, taxation, policies regarding the manufacture and sale of alcohol, are some of the ways to address this problem.

A One Health Approach to Defining Animal and Human Helminth Exposure Risks in a Tribal Village in Southern India.

The high burden of soil-transmitted helminth infections has been studied in India; however, little data exist on zoonotic helminths, and on animal-associated exposure to soil-transmitted helminths. Our study took place in the Jawadhu Hills, which is a tribal region in Tamil Nadu, India. Using a One Health approach, we included animal and environmental samples and human risk factors to answer questions about the associations among infected household soil, domestic animals, and human risk factors. Helminth eggs were identified by microscopy in animal and soil samples, and a survey about risk factors was administered to the head of the household. Contact with animals was reported in 71% of households. High levels of helminth infections were found across domestic animal species, especially in goats, chickens, and dogs. Helminth eggs were recorded in 44% of household soil (n = 43/97) and separately in 88% of soil near a water source (n = 28/32). Animal contact was associated with 4.05 higher odds of having helminth eggs in the household soil (P = 0.01), and also having a water source at the household was associated with a 0.33 lower odds of having helminth eggs in the household soil (P = 0.04). Soil moisture was a mediator of this association with a significant indirect effect (P < 0.001). The proportion mediated was 0.50. While our work does not examine transmission, these results support consideration of animal-associated exposure to STH and potentially zoonotic helminths in future interventions to reduce helminth burden. Our study provides support for further investigation of the effects of animals and animal fecal matter on human health.

Epidemiology of soil transmitted helminths and risk analysis of hookworm infections in the community: Results from the DeWorm3 Trial in southern India.

Since 2015, India has coordinated the largest school-based deworming program globally, targeting soil-transmitted helminths (STH) in ~250 million children aged 1 to 19 years twice yearly. Despite substantial progress in reduction of morbidity associated with STH, reinfection rates in endemic communities remain high. We conducted a community based parasitological survey in Tamil Nadu as part of the DeWorm3 Project-a cluster-randomised trial evaluating the feasibility of interrupting STH transmission at three geographically distinct sites in Africa and Asia-allowing the estimation of STH prevalence and analysis of associated factors. In India, following a comprehensive census, enumerating 140,932 individuals in 36,536 households along with geospatial mapping of households, an age-stratified sample of individuals was recruited into a longitudinal monitoring cohort (December 2017-February 2018) to be followed for five years. At enrolment, a total of 6089 consenting individuals across 40 study clusters provided a single adequate stool sample for analysis using the Kato-Katz method, as well as answering a questionnaire covering individual and household level factors. The unweighted STH prevalence was 17.0% (95% confidence interval [95%CI]: 16.0-17.9%), increasing to 21.4% when weighted by age and cluster size. Hookworm was the predominant species, with a weighted infection prevalence of 21.0%, the majority of which (92.9%) were light intensity infections. Factors associated with hookworm infection were modelled using mixed-effects multilevel logistic regression for presence of infection and mixed-effects negative binomial regression for intensity. The prevalence of both Ascaris lumbricoides and Trichuris trichiura infections were rare (<1%) and risk factors were therefore not assessed. Increasing age (multivariable odds ratio [mOR] 21.4, 95%CI: 12.3-37.2, p<0.001 for adult age-groups versus pre-school children) and higher vegetation were associated with an increased odds of hookworm infection, whereas recent deworming (mOR 0.3, 95%CI: 0.2-0.5, p<0.001) and belonging to households with higher socioeconomic status (mOR 0.3, 95%CI: 0.2-0.5, p<0.001) and higher education level of the household head (mOR 0.4, 95%CI: 0.3-0.6, p<0.001) were associated with lower odds of hookworm infection in the multilevel model. The same factors were associated with intensity of infection, with the use of improved sanitation facilities also correlated to lower infection intensities (multivariable infection intensity ratio [mIIR] 0.6, 95%CI: 0.4-0.9, p<0.016). Our findings suggest that a community-based approach is required to address the high hookworm burden in adults in this setting. Socioeconomic, education and sanitation improvements alongside mass drug administration would likely accelerate the drive to elimination in these communities. Trial Registration: NCT03014167.

Prevalence and Risk Factors of Vitamin A Deficiency in Children and Women of Childbearing Age in a Southern Indian Tribal Population: A Cross-Sectional Study.

BACKGROUND: Night blindness and keratomalacia continue to be a problem among the tribal children and pregnant women residing in Jawadhi hills. OBJECTIVES: The objective of the study is to determine the prevalence and risk factors of Vitamin A deficiency (VAD) among children aged 1-8 years and women of reproductive age in a southern Indian tribal population. MATERIALS AND METHODS: A cross-sectional study was done among children aged 1-8 years and women aged 15-45 years residing in Jawadhi hills. Participants were randomly selected by cluster sampling. Their sociodemographic characteristics and frequency of consumption of Vitamin A rich food were collected through a structured questionnaire. Anthropometric measures and serum retinol levels, using high-performance liquid chromatography, were estimated for all participants. RESULTS: A total of 166 children and 211 women participated in this study. The prevalence of VAD among the children (1-8 years) was 10.2% (95% confidence interval [CI] 5.5%-14.9%) and among women of the reproductive age group was 3.8% (95% CI: 1.2%-6.4%). Dietary intake was not associated with serum retinol levels. Low educational status of the head of the household (adjusted odds ratio [aOR] = 8.9) and pregnancy (aOR = 11.6) was significantly associated with an increased risk of VAD among children and women, respectively. CONCLUSIONS: The prevalence of VAD among children is a moderate public health problem. Strategies must focus on pregnant women and children from families with more than four children.

Consultation on the feasibility and ethics of specific, probable Controlled Human Infection Model study scenarios in India: A report.

On March 6, 2019, a workshop was held as part of a larger public consultation exercise to evaluate the perceptions of participants from diverse backgrounds of studies involving Controlled Human Infection Models (CHIMs) (1,2) in India, through three specific case scenarios. This workshop was organised by the Health and Humanities Division of the St. John's Research Institute, Bangalore with funding from the Translational Health Science and Technology Institute (TSHTI), Faridabad (www.thsti.res.in), an autonomous institute of the Department of Biotechnology, Government of India This was an on-going effort of the Division to bring public discourse centre stage in the discussion on the use, ethics and regulations related to CHIM studies, and the introduction of such studies in India. Participants included epidemiologists, community/public health experts, microbiologists, infectious disease specialists, basic and translational scientists, ethicists, journalists and lawyers.

Prevalence of ocular morbidity among tribal children in Jawadhi hills, southern India: A cross-sectional study.

PURPOSE: Childhood blindness is second to cataract in terms of blind person years; population-based prevalence of ocular morbidity among tribal children has not been studied. We conducted this study to determine the prevalence of ocular morbidity in tribal children age 15 years or younger in Jawadhi hills, southern India. METHODS: A population-based cross-sectional study was conducted in four tribal villages where all children below 15 years of age were invited to participate in the study. After appropriate consent/assent, an optometrist assessed uncorrected vision refraction and best-corrected visual acuity using suitable techniques. A comprehensive ophthalmic examination was also done by an ophthalmologist to determine the presence of ocular morbidity. Children requiring cycloplegic refraction or further treatment were referred to the base hospital. RESULTS: Among 260 children examined, the prevalence of ocular morbidity was 10.8% [95% confidence interval (CI): 6.3-13.7]. Vitamin A deficiency (VAD) was the foremost morbidity: 4.6% (95% CI 1.6-6.3) followed by refractive error (2.7%). Three (10.7%) children had more than one ocular morbidity. Nearly 1 in 10 tribal children suffer from ocular morbidity and 1 in 57 had low vision. CONCLUSION: VAD is a public health problem in this tribal region which requires immediate intervention with prophylaxis and treatment. Uncorrected refractive errors in school-age children also need to be attended.

Bioethics of establishing a CHIM model for dengue vaccine development.

INTRODUCTION: Controlled human infection models (CHIM) have been used in vaccine development to up-select and down-select potential vaccine candidates and to provide proof of vaccine efficacy, and have also been used as a basis for licensure of vaccines for cholera and typhoid by regulatory agencies. CHIM IN DENGUE VACCINES DEVELOPMENT: Dengue fever results in ∼400 million infections a year and is of significant health concern especially in India. There are currently no antivirals for the disease and the only licensed vaccine for dengue is not widely used owing to safety concerns. Controlled dengue human challenge models (DHCM) are currently being used to assess the efficacy of vaccines in development for dengue. DENGUE CHIM IN INDIA: Conducting CHIM studies in India especially for evaluation of dengue vaccine candidates will be hugely beneficial as the disease is endemic to India and hence the effect of pre-exposure to the virus on vaccine safety and efficacy can be established. However, to date no CHIM studies have been conducted in India and there is a need to educate ethics committee members, policy makers and the public on the importance of such studies and what they entail.

Unintentional injuries among children aged 1-5 years: understanding the burden, risk factors and severity in urban slums of southern India.

BACKGROUND: Globally, 5.82 million deaths occurred among children under the age of five years in 2015 and injury specific mortality rate was 73 per 100,000 population. In India, injury specific mortality rate is around 2.1 per 1000 live births contributing to 4% of the total under 5 mortality rate. This study aims to estimate the burden and understand factors associated with unintentional injuries among children aged 1-5 years residing in urban slums of Vellore, southern India. We also attempted to assess the hazards posed by the living environment of these children and study their association with unintentional injury patterns. METHODS: This cross-sectional study was conducted in eight urban slums of Vellore, southern India and primary caregivers of children aged 1-5 years were interviewed with a questionnaire to obtain the details of injuries sustained in the past three months. Environmental hazard risk assessment was conducted at places frequented by these children and their scores calculated. Baseline prevalence and incidence rates of unintentional injuries were estimated. Multivariate logistic regression and poisson regression analysis were performed to examine factors associated with unintentional injuries and repeated injuries respectively. Association between environmental hazard risk and unintentional injuries was estimated. RESULTS: Prevalence of unintentional injuries was 39.1% (95% CI 35.4-42.9%) and incidence rate was 16.5 (95% CI 14.7-18.3) per 100 child months (N = 662). Bivariate analysis revealed that children of working mothers (OR 1.48; 1.01-2.18) and children from overcrowded families (OR 1.78; 1.22-2.60) had increased odds of sustaining unintentional injuries. Multivariate regression analysis revealed that children from overcrowded families had increased odds of sustaining unintentional injuries (AOR 1.66, 95% CI 1.14-2.41). Boys (IRR 1.33, 95% CI 1.07-1.66) and children from overcrowded families (IRR 1.50; 1.14-1.98) were at increased risk of having repeated injuries. There is an increase in incidence rate of injuries with an increased environmental hazard risk, although not statistically significant. CONCLUSIONS: The burden of unintentional injuries was very high among study children when compared to studies in other urban slums in India. Environment plays an important role in the epidemiology of unintentional injuries; providing safe play environment and adequate supervision of children is important to reduce its burden.

The ethics of volunteer selection and compensation in Controlled Human Infection Models in India.

Controlled human infection model studies, or challenge studies, involve the intentional infection of a consenting healthy human volunteer with a virulent organism under controlled conditions Such studies differ from clinical trials in that though both involve healthy volunteers, in challenge studies the potential harm experienced by participants is intended, not merely potentially foreseen, as in clinical trials. Given the special nature of CHIM studies, careful consideration of participant selection and compensation is essential. This paper explores the ethical criteria for recruiting participants in such studies, their own possible motivation such as monetary payment or access to treatment and how that should not be an inducement. It also distinguishes between compensation as inducement and fair compensation for the possible contracting of an illness, isolation and adverse effects, and indicates that more research on the subject needs to be done.

Perception of unintentional childhood injuries among mothers in rural South India.

Parental perception of safe and risk-free environment is critical in the prevention of unintentional childhood injury. In this cross-sectional study, hundred mothers from 13 clusters were interviewed to assess the perception of mothers regarding the risks and hazards leading to unintentional childhood injuries from March to April 2013. A tool developed by Glik et al. was used. Mothers' perception of likelihood of injury from hazards such as household door and drawers, small toys, plastic bags, and cribs was poor. Mothers had a poor perception of injury by entrapment in refrigerators, choking, and strangulation by a rope. Age, education, and literacy (P < 0.05) were found to be significant predictors of perception of risk and hazard. Very few mothers (9%) believed injuries can be completely prevented and illiteracy (P < 0.05) was associated with poor perception on prevention. Health education should focus on improving maternal perception which may bring positive impact on prevention.

Study design and baseline results of an open-label cluster randomized community-intervention trial to assess the effectiveness of a modified mass deworming program in reducing hookworm infection in a tribal population in southern India.

INTRODUCTION: Hookworm infection is a leading cause of iron deficiency anemia and malnutrition in resource-poor settings. Periodic mass deworming with anthelminthic drugs remains the cornerstone of hookworm control efforts worldwide. Reinfection following treatment occurs, reflecting the human host's inability to acquire immunity following exposure to an untreated reservoir of infection. This cluster randomized trial will evaluate the effectiveness of a modified, population-based, mass deworming strategy in reducing hookworm infection in an endemic southern Indian population. METHODS: Forty five tribal villages were randomized into three groups: one received annual treatment; the second received two rounds of treatment at 1-month intervals; and the third received four rounds of treatment - two rounds 1 month apart at the beginning, followed by another two after 6 months. Stool samples collected through cross-sectional parasitological surveys pre- and post-intervention, and at 3-monthly intervals for a period of 1 year were tested for presence of hookworm ova. Long-term effectiveness of treatment will be assessed through another survey conducted 2 years after the last treatment cycle. RESULTS: From a population of 11,857 individuals, 8681 (73.2%) were found to be eligible and consented to participate, out-migration being the primary reason for non-participation. Baseline stool samples were obtained from 2082 participants, with 18.5% having hookworm infection, although majority were low intensity infections (<2000 eggs per gram of feces). DISCUSSION: This study will help identify the optimal mass deworming strategy that can achieve the greatest impact in the shortest period of time, particularly in settings where long-term program sustainability is a challenge.

Incidence and Impact of Unintentional Childhood Injuries: A Community Based Study in Rural South India.

OBJECTIVE: To estimate the incidence of unintentional childhood injuries and to assess the impact of injury during childhood. METHODS: This is a cross sectional study, conducted in 13 clusters of a rural block in Vellore. Children were screened by two-stage cluster sampling method by two weeks and three months recall method. The primary caregivers of injured children were administered a questionnaire to assess the impact of the injury. RESULTS: Childhood injury related morbidity was 292.5 per 1000 y. Children between 10 and 14 y (4.6%) and boys (4.5%) had a higher rate of injury. Fall (43.1 %) was the most common cause of injury followed by RTIs (Road Traffic Incidents- 27.6%). Work absenteeism for primary caregivers ranged from 1 to 60 (IQR 2-7) days. Sickness absenteeism ranged from 1 to 45 d with a mean of 7.64 (IQR 2-7) days. Half of the children missed school after an injury. The days spent with temporary disability ranged from 1 to 60 d with a mean of 11.79 (IQR 2-7) d and 7.73% had permanent disability. CONCLUSIONS: Unintentional childhood injury is a neglected public health problem which leads to sickness absenteeism and disability. Boys and older children are the most common victims of injury. There is a need for establishing state or nationwide injury registries to help understand accurate estimates of disability-adjusted life year (DALY) and loss of productivity.

Community perspectives on alcohol use among a tribal population in rural southern India.

BACKGROUND: Alcohol use is common in many cultures. Excessive use of alcohol adversely impacts individuals, families and communities. Medicine, which uses biomedical models and perspectives, views alcohol dependence as a disease. Alcohol use and dependence are complex societal problems, which need to be viewed through multidisciplinary approaches and corrected by adopting intersectoral efforts involving local communities. METHODS: We used qualitative methods such as focus group discussions and in-depth interviews to document perspectives on alcohol use among a tribal community in southern India. We recorded traditional norms, changing patterns of use of alcohol and its consequences for individuals, families and the community. RESULTS: Eight focus group discussions and eleven in-depth interviews were conducted. Though consumption of alcohol is part of the local culture, changes in occupation and availability of alcohol has made its consumption a problem. The introduction and easy availability of Indian-made foreign liquor, which is stronger than the locally brewed variety, in government-run outlets has changed the culture of drinking at festivals to drinking more often. This leads to public fights, domestic violence and increasing mortality and morbidity due to road traffic incidents and ill health. The age of initiation into drinking has decreased. CONCLUSION: The introduction of non-traditional and commercial alcohol use has put a heavy price on tribal and rural people. Community-based interventions targeting young children and adolescents may pay more dividends than pursuing purely medical treatments for problem drinkers.