How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India.

INTRODUCTION: Coping occurs when health system personnel must make additional, often undocumented efforts to compensate for existing system and management deficiencies. While such efforts may be done with good intentions, few studies evaluate the broader impact of coping. METHODS: We developed a computational simulation model of Bihar, India's routine immunisation supply chain where coping (ie, making additional vaccine shipments above stated policy) occurs. We simulated the impact of coping by allowing extra trips to occur as needed up to one time per day and then limiting coping to two times per week and three times per month before completely eliminating coping. RESULTS: Coping as needed resulted in 3754 extra vaccine shipments over stated policy resulting in 56% total vaccine availability and INR 2.52 logistics cost per dose administered. Limiting vaccine shipments to two times per week reduced shipments by 1224 trips, resulting in a 7% vaccine availability decrease to 49% and an 8% logistics cost per dose administered increase to INR 2.73. Limiting shipments to three times per month reduced vaccine shipments by 2635 trips, which decreased vaccine availability by 19% to 37% and increased logistics costs per dose administered by 34% to INR 3.38. Completely eliminating coping further reduced shipments by 1119 trips, decreasing total vaccine availability an additional 24% to 13% and increasing logistics cost per dose administered by 169% to INR 9.08. CONCLUSION: Our results show how coping can hide major system design deficiencies and how restricting coping can improve problem diagnosis and potentially lead to enhanced system design.

Frequent exposure to suboptimal temperatures in vaccine cold-chain system in India: results of temperature monitoring in 10 states.

OBJECTIVE: To estimate the proportion of time the vaccines in the cold-chain system in India are exposed to temperatures of < 0 or > 8 °C. METHODS: In each of 10 states, the largest district and the one most distant from the state capital were selected for study. Four boxes, each containing an electronic temperature recorder and two vials of diphtheria, pertussis and tetanus vaccine, were placed in the state or regional vaccine store for each study state. Two of these boxes were then shipped - one per facility - towards the two most peripheral health facilities where vaccine was stored in each study district. The boxes were shipped, handled and stored as if they were routine vaccine supplies. FINDINGS: In state, regional and district vaccine stores and peripheral health facilities, respectively, the temperatures in the boxes exceeded 8 °C for 14.3%, 13.2%, 8.3% and 14.7% of their combined storage times and fell below 0 °C for 1.5%, 0.2%, 0.6% and 10.5% of these times. The boxes also spent about 18% and 7% of their combined times in transit at < 0 and > 8 °C, respectively. In shake tests conducted at the end of the study, two thirds of the vaccine vials in the boxes showed evidence of freezing. CONCLUSION: While exposure to temperatures above 8 °C occurred at every level of vaccine storage, exposure to subzero temperatures was only frequent during vaccine storage at peripheral facilities and vaccine transportation. Systematic efforts are needed to improve temperature monitoring in the cold-chain system in India.

Prevalence and risk factors of psychiatric disorders in an industrial population in India.

BACKGROUND: Recent information on psychiatric morbidity in industrial employees is not available in India. Such information may help in building mental health care for this population. AIM: The aim was to study the prevalence of psychiatric morbidity and the risk factors associated with it in an industrial population. MATERIALS AND METHODS: Two hundred thirty-eight individuals were selected by a stratified randomisation technique and screened using the General Health Questionnaire-12 (GHQ-12), Johns Hopkins University Hospital Test for alcoholism and a semistructured questionnaire for other substance use, sleep problems and past psychiatric history. Following a detailed clinical interview, diagnoses were based on International Classification of Diseases (ICD)-10, Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research (DCR). RESULTS: The prevalence rate for psychiatric disorder of one month's duration in the study population was 51.7%. Substance use, depression, anxiety and sleep disorders were common. Comorbidities were found in 65% of the subjects. Both univariate analysis and stepwise multiple regression revealed that educational level, perceived stress, job satisfaction and stressful life events were the independent determinants of psychiatric morbidity. CONCLUSION: A significant proportion of industrial employees had psychiatric morbidity and many psychosocial factors were associated with caseness.

Risk factors associated with attempted suicide : a case control study.

This study was conducted to identify the risk factors associated with attempted suicide among people living in and around Pondicherry. Using a case control study design, 137 consecutive cases of attempted suicide admitted to Jawaharlal Institute of Postgraduate Medical Education and Research, a teaching hospital in Pondicherry and an equal number of controls, matched individually with cases for age and sex, from the relatives and friends of the other patients, were studied. Variables related to socio demographic characteristics, family background, recent stressful life events, physical and psychiatric morbidity were analysed. The strength of association with the risk of attempt was calculated using odds ratio with 95% confidence interval. Odds ratios for the factors identified to be significantly associated with increased risk of suicide attempt were 15.82(95% CI 6.55-40) for unemployment, 3.02 (95%CI 1.78-5.14) for lack of formal education, 3.95 (95% CI 2.02-7.79) for the presence of stressful life events in the last six months, 3.12 (95%CI 1.37-7.24) for suffering from physical disorders and 6.78 (95% CI 2.39-2070) for suffering from idiopathic pain. Significant association was not revealed in respect to marital status, type of family, early parental losses, family history of suicide and presence of psychiatric morbidity.