The role of local governments in the implementation of evidence-based nutrition interventions in Kerala.

OBJECTIVE: To study the involvement and influence of local participatory governments consisting of Panchayat Raj institutions (PRIs) in implementing evidence-based interventions for eliminating maternal and child undernutrition in the state of Kerala, India. METHODS: In-depth interviews were carried out among stakeholders in six selected local governments using a semi-structured questionnaire. Transcribed interviews were coded and thematically analysed. RESULTS: PRIs facilitated nutrition interventions through additional resource mobilisation, nutrition monitoring and surveillance, acting as a more approachable point of governance, utilising general acceptance to mobilise volunteers to tackle local challenges, enabling formal and informal platforms for community participation and spaces of co-creation. Changes in the attitude of different stakeholders, timely policy backing and support, and interconnections at the local level aided the process. Gaps exist in awareness creation, dietary diversification, feeding behaviours, maternal mental health, infrastructure development, monitoring of anthropometric indicators and planning for nutrition interventions during emergencies. CONCLUSION: Results illustrate complex linkages PRIs have within the health system and how these linkages help in the implementation of interventions. The study explored previously identified pathways from the literature and identified additional pathways through which local participatory governance contributes to the successful implementation of nutrition interventions.

OBJECTIF: Étudier l'implication et l'influence du système de gouvernement participatif local, composé des institutions du Panchâyat Raj (PRI), dans la mise en place d'interventions fondées sur des données scientifiques en vue d'éliminer la sous-nutrition maternelle et infantile dans l'État du Kérala, Inde. MÉTHODES: Des entretiens approfondis, avec questionnaire semi-structuré, ont été réalisés avec les parties prenantes de six gouvernements locaux préalablement sélectionnés. La transcription des entretiens a été codée et analysée de manière thématique. RÉSULTATS: Les PRI ont facilité les interventions nutritionnelles en mobilisant des ressources supplémentaires, en organisant une surveillance et un suivi nutritionnels, en agissant en tant que point de contact gouvernemental plus accessible, en misant sur l'acceptation générale afin de mobiliser les volontaires pour s'attaquer aux problèmes locaux, en mettant en place des plateformes de participation communautaire formelles et informelles et en laissant la place à la co-création. Les changements d'attitude de différentes parties prenantes, un soutien politique opportun et les liens tissés au niveau local ont contribué au processus. Certaines lacunes ont été observées, en matière d'actions de sensibilisation, de diversification alimentaire, de comportements alimentaires, de santé mentale des mères, de développement des infrastructures, de suivi des indicateurs anthropométriques et de planification des interventions nutritionnelles en période d'urgence. CONCLUSION: Les résultats mettent en évidence les liens complexes entre les PRI et le système de santé, et comment ces liens contribuent à la mise en place des interventions. Cette étude a analysé certains moyens, précédemment décrits dans la littérature, et en a identifié de nouveaux par lesquels les gouvernements participatifs locaux contribuent à la bonne mise en place des interventions nutritionnelles.

Role of decentralised governance in implementing the National AIDS Control Programme in Kerala.

SETTING: In alignment with the UN Sustainable Development Goals (SDGs), Kerala State in India aims to end the HIV/AIDS epidemic, using its strong background in local governance to implement the National AIDS Control Programme (NACP). OBJECTIVE: To examine the role of local governments in the implementation of NACP in tune with SDGs. DESIGN: We conducted a state-wide exploratory study using document reviews, key informant and in-depth interviews, which were analysed thematically. RESULTS: Four overarching themes that emerged were 1) preparation for programme implementation, 2) positive impact of local government involvement, 3) convergence with other organisations, and 4) barriers to implementation. Local government commitment to implementing the programme was evidenced by their adoption of the HIV/AIDS policy, facilitative interdepartmental coordination and local innovations. Interventions focused on improving awareness about the disease and treatment, and social, financial and rehabilitative support, which were extended even during the COVID-19 pandemic. Fund shortages and poor visibility of the beneficiaries due to preference for anonymity were challenges to achieving the expected outcomes. CONCLUSION: The NACP is ably supported by local governments in its designated domains of interventions, prevention, treatment, and care and support. The programme can achieve its target to end the AIDS epidemic by overcoming the stigma factor, which still prevents potential beneficiaries from accessing care.

CONTEXTE: En accord avec les Objectifs de développement durable (SDG) des Nations unies, l'État du Kérala en Inde a pour objectif de mettre fin à l'épidémie de VIH/SIDA en s'appuyant sur sa forte expérience de gouvernance locale en matière de mise en œuvre du Programme national de lutte contre le SIDA (NACP). OBJECTIF: Examiner le rôle des gouvernements locaux dans la mise en œuvre du NACP, en accord avec les SDG. MÉTHODES: Nous avons réalisé une étude exploratoire à l'échelle de l'État, par le biais d'analyses documentaires, d'entretiens avec des informateurs clés et d'entretiens approfondis, qui ont ensuite été analysés de manière thématique. RÉSULTATS: Quatre thèmes centraux ont été identifiés : 1) préparation de la mise en place du programme, 2) impact positif de l'implication des gouvernements locaux, 3) convergence avec d'autres organisations, et 4) obstacles à la mise en œuvre. L'engagement des gouvernements locaux à mettre en œuvre le programme se manifestait par l'adoption de la politique de lutte contre le VIH/SIDA, par une coordination interdépartementale facilitée et par des innovations locales. Les interventions portaient sur l'amélioration de la sensibilisation au VIH/SIDA et à son traitement, ainsi qu'aux systèmes de soutien social, financier et de réadaptation disponibles ; ces interventions ont même été maintenues pendant la pandémie de COVID-19. Le manque de financements et la mauvaise visibilité des bénéficiaires en raison d'une volonté d'anonymat représentaient autant d'obstacles empêchant d'atteindre les résultats escomptés. CONCLUSION: Les gouvernements locaux apportent leur soutien efficace au NACP dans les domaines d'intervention qui lui ont été assignés (prévention, traitement, soins et soutien). Le programme peut atteindre son objectif d'éradication de l'épidémie de SIDA s'il parvient à lutter contre la stigmatisation associée à la maladie, qui empêche encore d'éventuels bénéficiaires d'accéder aux soins.

Palliative care management committees: a model of collaborative governance for primary health care.

SETTING: The community-based primary palliative care programme in Kerala, India, has received international acclaim. Programme functioning is supported through Palliative Care Management Committees (PMCs) at the local government (LG) level. OBJECTIVE: To study the functioning of the PMCs within the decentralised governance space to identify achievements, gaps and notable innovations. DESIGN: This qualitative study included seven key informant interviews (KIIs), 28 in-depth interviews and a review of relevant publicly available policies and documents. Major themes were recognised from the KII transcripts. Codes emerging from the document review and in-depth interview transcripts were mapped into the identified thematic areas. RESULTS: Successful PMCs raised resources like money, human resource, equipment, had good skilled care options for symptom relief and facilitated reduced out-of-pocket expenditure by providing home care and free medicines, and improved access to interventions that addressed the social determinants of suffering like poverty. PMCs had varying managerial and technical capacities. In some LGs, the programme was weak and mostly limited to the supply of medicines, basic aids and appliances to patients' homes. CONCLUSION: Despite varied implementation patterns, PMCs in Kerala are examples of state-supported, community-owned care initiatives, that can potentially address medical and social determinants of suffering.

CONTEXTE: Le programme communautaire de soins palliatifs primaires du Kérala, Inde, a été applaudi sur la scène internationale. Le fonctionnement du programme est soutenu par des Comités de gestion des soins palliatifs (PMC) au niveau des gouvernements locaux (LG). OBJECTIF: Évaluer le fonctionnement des PMC au sein de l'espace de gouvernance décentralisée, afin d'identifier les réussites, les lacunes et les principales innovations. MÉTHODES: Dans le cadre de cette étude qualitative, sept entretiens avec des informateurs clés (KIIs), 28 entretiens approfondis et une analyse des politiques et documents accessibles au public ont été réalisés. Les transcriptions des KII ont permis de faire émerger les thèmes principaux. Les codes émergeant de l'analyse documentaire et des transcriptions des entretiens approfondis ont été associés aux domaines thématiques identifiés. RÉSULTATS: Les PMC les plus performants ont pu mobiliser des ressources, telles que de l'argent, des ressources humaines ou des équipements. Ils proposaient également des options de soins de qualité pour soulager les symptômes, facilitaient la réduction des frais à la charge du patient en fournissant des soins à domicile et des médicaments gratuits, et ont permis d'améliorer l'accès aux interventions qui s'attaquaient aux déterminants sociaux de la souffrance, tels que la pauvreté. Les capacités techniques et de gestion variaient d'un PMC à l'autre. Le programme de certains LG était faible, principalement limité à la fourniture de médicaments et d'aides et de matériels de base pour le domicile des patients. CONCLUSION: Malgré des schémas de mise en œuvre variés, les PMC du Kérala sont des exemples d'initiatives communautaires de santé soutenues par l'état qui peuvent potentiellement s'attaquer aux déterminants sociaux et médicaux de la souffrance.

Head to head comparison between neurology residents and a mobile medical application for diagnostic accuracy in cognitive neurology.

BACKGROUND: A novel Mobile Medical Application (App) App was created on iOS platform (Neurology Dx®) to deduce Differential Diagnoses (DDx) from a set of user selected Symptoms, Signs, Imaging data and Lab findings. The DDx generated by the App was compared for diagnostic accuracy with differentials reasoned by participating neurology residents when presented with same clinical vignettes. METHODS: Hundred neurology residents in seven leading Neurology centers across India participated in this study. A panel of experts created 60 clinical vignettes of varying levels of difficulty related to Cognitive neurology. Each neurology resident was instructed to formulate DDx from a set of 15 cognitive neurology vignettes. Experts in Cognitive Neurology made the gold standard DDx answers to all 60 clinical vignettes. The differentials generated by the App and neurology residents were then compared with the Gold standard. RESULTS: Sixty clinical vignettes were tested on 100 neurology residents (15 vignettes each) and also on the App (60 vignettes). The frequency of gold standard high likely answers accurately documented by the residents was 25% compared with 65% by the App (95% CI 33.1-46.3), P < 0.0001. Residents correctly identified the first high likely gold standard answer as their first high likely answer in 35% (95% CI 30.7-36.6) compared with 62% (95% CI 14.1-38.5), P < 0.0001. CONCLUSION: An App with adequate knowledge-base and appropriate algorithm can augment and complement human diagnostic reasoning in drawing a comprehensive list of DDx in the field of Cognitive Neurology (CTRI/2017/06/008838).

Usefulness of the Rowland Universal Dementia Assessment scale in South India.

BACKGROUND: The number of older people with cognitive impairment being seen in out patient settings is increasing. A brief screening test, which is culturally and educationally fair, would be very useful for clinicians for identifying dementia in these settings. OBJECTIVES: To examine the new cognitive screening test, the Rowland Universal Dementia Assessment Scale (RUDAS), and to compare it with the Mini-Mental State Examination (MMSE). METHOD: We administered MMSE and RUDAS to 116 subjects, consisting of 58 patients with mild to moderate dementia and 58 age and sex matched controls. The two screening tests were compared with regard to sensitivity and specificity. We looked at the correlation of both tests with years of formal education among the controls. RESULT: RUDAS had a similar sensitivity but better specificity than MMSE, but did have an educational bias. CONCLUSIONS: RUDAS is a useful brief screening test in clinical settings.

Modulation of alpha2beta1 integrin changes during mammary gland development by beta-oestradiol.

In order to study the role of cell-matrix interactions in mammary gland function, temporal changes in alpha2beta1 integrin, the major receptor for collagen and the influence of beta-oestradiol on its level and distribution in rat mammary gland at different stages of development were studied. The level of alpha2beta1 integrin determined by ELISA, was found to be high during different days of pregnancy, while in the lactating stage, it was significantly reduced. By immunocytochemical analysis, alpha2beta1 integrin was found to be localized towards the luminal side of acinar cells, both in the virgin and midpregnant stage, while it was not detected in the lactating stage. The possible role of hormones in modulating the level of integrin was examined in both in vitro and in vivo experiments using beta-oestradiol. Supplementing beta-oestradiol to isolated mammary epithelial cells from both virgin and lactating glands caused a concentration dependent increase in the incorporation of [35S]methionine into alpha2beta1 integrin associated with the cells. Administration of beta-oestradiol to virgin and lactating glands caused about 1.4-4-fold increase in the level of alpha2 integrin, indicating that upregulation of integrin during pregnancy may be due to oestrogen and as the oestrogen level falls during lactating phase, downregulation of alpha2beta1 integrin occurs. Treatment with beta-oestradiol also resulted in the appearance of alpha2beta1 integrin in the acinar region of the lactating tissue, while in the untreated controls no staining for integrin was seen. These results indicate that oestrogen, apart from directly affecting the cellular activity, can influence mammary tissue function by affecting cell-ECM interactions through the modulation of integrin receptors for matrix proteins.

Malnutrition and childhood epilepsy in developing countries.

A high prevalence of epilepsy in children is frequently found in developing countries. Though high rates of acquired brain injury may contribute, the possibility that malnutrition may lower seizure threshold has rarely been examined. This review suggests potential biochemical mechanisms that could adversely affect seizure threshold, particularly the effect of malnutrition on inhibitory neurotransmitters and electrolytes. Supporting evidence from animal research and epidemiological findings in children are discussed.