SPARSH electronic sub-health centers (e-SHCs) - A model of nurse-run SHCs supported by general practitioners through telemedicine.

Background: The primary health care services in India suffer from inconsistent availability of providers, lack of quality, poor availability of medicines and diagnostics, and a poorly functioning referral linkage. A multi-pronged approach is required to address these issues. Methods: We describe here a model of electronic sub-health centers (e-SHCs) managed by trained nurses supported by a general practitioner over telemedicine. The e-SHCs are expected to meet two objectives - 1) to create a point of comprehensive primary health care delivery at an affordable cost and 2) to create a referral support system backed by information technology and physical movement. Results: The model is described in nine sections - service delivery framework, human resources, diagnostics, infrastructure, quality improvement, health management information system, materials management, financing, and branding. It is a video-based real-time (synchronous) health worker to the registered medical practitioner telemedicine facility. The model has been compared with five other telemedicine and five other tele-rehabilitation models. Conclusion: Although there are inherent challenges to operationalize this model, it also presents a unique opportunity of testing an innovative approach of providing quality primary health care at an affordable cost. The process will generate learnings for addressing the primary care health care delivery gaps in the country.

Epidemiology of Parkinson's Disease in Rural Gujarat, India.

INTRODUCTION: In India, there have been only few published studies of Parkinson's disease (PD) showing a wide range of prevalence. We conducted this study to determine the prevalence of PD in the rural population of Gujarat, in the western region of India. METHODS: This cross-sectional descriptive study was conducted in the villages of Anand, a district of Gujarat, India, between September 2019 and February 2020. This study used a multistep approach including a screening questionnaire and video recording followed by clinical examination by a neurologist, laboratory evaluation, and brain imaging to evaluate patients with PD. RESULTS: A total population of 18,896 was screened. The overall crude prevalence of PD was 42.3 per 100,000, and the prevalence over the age of 60 was 308.9 per 100,000 which showed the trend of increasing disease prevalence with age. Their mean duration of illness was 39.3 ± 27.3 months, and more than half of patients with PD had multiple associated nonmotor symptoms and nearly one-third had comorbid anxiety or depression. Environmental factors are important in the pathogenesis of PD, but there was no clear association between patients with PD and certain variables including consumption of well water, exposure to pesticides or other toxins, smoking cigarettes, and drinking alcohol or coffee in our study. CONCLUSIONS: The present study showed the current epidemiological data of PD from Gujarat, in western India. Further studies across different regions in India need to be encouraged for better understanding of PD prevalence in the Indian population.

Can urban Accredited Social Health Activist (ASHA) be change agent for breast cancer awareness in urban area: Experience from Ahmedabad India.

BACKGROUND AND AIMS: Globally, breast cancer is one of the major public health problem. In Indian women, breast cancer is now the most common cancer, having recently overtaken cervical cancer in this respect. Breast Cancer though on the rise among Indian women, they still do not perceive themselves at risk. Poor awareness about the disease, its risk factors and the absence of population-based screening contribute to delayed diagnosis. The aim of this study is to assess knowledge and practice of breast cancer in general and breast self-examination (BSE) amongst urban accredited social health activist in Ahmedabad, Gujarat. METHODS: The study was conducted in three phases: pre-intervention phase, intervention phase, and post-intervention phase during 2018. A total of 104 ASHA participants were included and awareness about breast cancer and practices of breast self-examination was assessed through interviewing two different groups at two points of time: Control and Intervention group at the base line and end line. Interventional breast health education was administrated through lectures, charts and silicon breast model for the basic knowledge of the breast cancer. The data had been analyzed by using software Epi info. RESULTS: There was a significant improvement in knowledge regarding breast cancer and breast self-examination among the intervention group from pre- to post-test. An overall increase in the awareness of breast cancer 33%, Method of doing BSE of 54% and 42% of BSE practice was observed in the study group after intervention. CONCLUSION: A significant changes were observed in the knowledge. However, the behavior change requires reinforced training in regular interval.

Automated versus physician assignment of cause of death for verbal autopsies: randomized trial of 9374 deaths in 117 villages in India.

BACKGROUND: Verbal autopsies with physician assignment of cause of death (COD) are commonly used in settings where medical certification of deaths is uncommon. It remains unanswered if automated algorithms can replace physician assignment. METHODS: We randomized verbal autopsy interviews for deaths in 117 villages in rural India to either physician or automated COD assignment. Twenty-four trained lay (non-medical) surveyors applied the allocated method using a laptop-based electronic system. Two of 25 physicians were allocated randomly to independently code the deaths in the physician assignment arm. Six algorithms (Naïve Bayes Classifier (NBC), King-Lu, InSilicoVA, InSilicoVA-NT, InterVA-4, and SmartVA) coded each death in the automated arm. The primary outcome was concordance with the COD distribution in the standard physician-assigned arm. Four thousand six hundred fifty-one (4651) deaths were allocated to physician (standard), and 4723 to automated arms. RESULTS: The two arms were nearly identical in demographics and key symptom patterns. The average concordances of automated algorithms with the standard were 62%, 56%, and 59% for adult, child, and neonatal deaths, respectively. Automated algorithms showed inconsistent results, even for causes that are relatively easy to identify such as road traffic injuries. Automated algorithms underestimated the number of cancer and suicide deaths in adults and overestimated other injuries in adults and children. Across all ages, average weighted concordance with the standard was 62% (range 79-45%) with the best to worst ranking automated algorithms being InterVA-4, InSilicoVA-NT, InSilicoVA, SmartVA, NBC, and King-Lu. Individual-level sensitivity for causes of adult deaths in the automated arm was low between the algorithms but high between two independent physicians in the physician arm. CONCLUSIONS: While desirable, automated algorithms require further development and rigorous evaluation. Lay reporting of deaths paired with physician COD assignment of verbal autopsies, despite some limitations, remains a practicable method to document the patterns of mortality reliably for unattended deaths. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02810366. Submitted on 11 April 2016.

Standardizing hypertension management in a primary care setting in India through a protocol based model.

Hypertension is a leading cause of death in India. Control rates of hypertension are abysmal, even for people on treatment. There are a number of barriers to adequate control of hypertension in India, including therapeutic inertia and the lack of a systematic, simplified approach. Standardizing hypertension management through an evidence based model that sets thresholds for diagnosis, treatment goals, follow up intervals and choice of drugs can lead to improved management of hypertension in an individual hospital or health system. In this paper, we summarize the evidence for such a model, and adapt it to the Indian context, focusing on maximizing effectiveness, safety and ease of use by a non-expert. This model can be utilized by individual practitioners, hospitals, primary health centers (PHCs) and the Health and Wellness Centers (HWCs) under the Ayushman Bharat initiative.

Age-and-sex stratified prevalence of atrial fibrillation in rural Western India: Results of SMART-India, a population-based screening study.

BACKGROUND: Early detection of Atrial Fibrillation (AF) is a public health priority across the globe because AF-related strokes are preventable. Despite an ongoing stroke epidemic in India, a public health strategy for AF screening and treatment is missing because the epidemiology of AF in India remains poorly defined. METHODS: This population-based study used mobile technology to derive age and sex-stratified AF prevalence by screening 7 participants in each of six age and sex strata (age 40-55, 56-65, 65+, and male and female) from 50 villages (2100 participants). A health worker from each village used a handheld digital electrocardiogram (iECG) device (Kardia) to screen for AF on 3 separate days, and administered a questionnaire. All abnormal (AF or unclassified) iECGs were reviewed by the Indian cardiologist and AF determination confirmed by a US-based cardiac electrophysiologist. RESULTS: Of the 2100 individuals enrolled, iECGs were collected from 2074 participants (98.8%) and 1947 (92.7%) participants responded to the questionnaire. AF was identified in 33 participants (1.6%), two-thirds on the first iECG. AF prevalence was higher among males (2.3% vs 1.0%, p = 0.03) and in older people (0.6%, 0.9%, 2.1%, 5.6%; p < 0.01). CONCLUSIONS: The prevalence of AF observed in our population-based sample is comparable to rates found in studies from North America and Western Europe and increases similarly with age. AF screening using village health workers in rural India is feasible and presents an opportunity for a strategy to address the stroke epidemic in India through primary prevention.

Study protocol for Smartphone Monitoring for Atrial fibrillation in Real-Time in India (SMART-India): a community-based screening and referral programme.

INTRODUCTION: Atrial fibrillation (AF), the world's most common arrhythmia, often goes undetected and untreated in low-resource communities, including India, where AF epidemiology is undefined. AF is an important risk factor for stroke, which plagues an estimated 1.6 million Indians annually. As such, early detection of AF and management of high-risk patients is critically important to decrease stroke burden in individuals with AF. This study aims to describe the epidemiology of AF in Anand District, Gujarat, India, characterise the clinical profile of individuals who are diagnosed with AF and determine the performance of two mobile technologies for community-based AF screening. METHODS: This observational study builds on findings from a previous feasibility study and leverages two novel technologies as well as an existing community health programme to perform door-to-door AF screening for 2000 people from 60 villages of Anand District, Gujarat, India using local health workers. A single-lead ECG and a pulse-based application is used to screen each individual for AF three times over a period of 5 days. Participants with suspected arrhythmias are followed up by study cardiologist who makes final diagnoses. Participants diagnosed with AF are initiated on treatment based on current anticoagulation guidelines and clinical reasoning. ANALYTICAL PLAN: Age-stratified and sex-stratified prevalence of AF in the Anand District will be calculated for sample and estimated for Anand distribution using survey design weights. Sociodemographic and clinical factors associated with AF will be evaluated using multivariable regression methods. Performance of each mobile technology in detecting AF will be evaluated using a 12-lead ECG interpretation as the gold standard. ETHICS AND DISSEMINATION: This protocol was approved separately by the Institutional Review Board of University of Massachusetts Medical School and the Human Research Ethics Committee at Charutar Arogya Mandal. The findings of this study will be disseminated through peer-reviewed journals and scientific conferences.

Training Village Health Workers in Detection and Monitoring of Noncommunicable Diseases: A Low Cost Option for Rural Areas Facing the Emerging Health Epidemic.

Noncommunicable diseases account for 53% of deaths and 44% of disability-adjusted life years lost in India. Village health workers (VHWs) were trained in blood pressure (BP) and blood sugar (BS) measurement and assessed using a checklist. A total of 38 VHWs with a mean age of 44.8 years, schooling of 9.9 years, scored 10.0 (76.9%) for BP and 9.74 (69.6%) for BS. There was no difference in scores for education and age. It is possible to train VHWs in BP and BS measurement and utilize them for screening and monitoring of hypertension and diabetes in a noncommunicable disease care program.

RAHI-SATHI Indo-U.S. Collaboration: The Evolution of a Trainee-Led Twinning Model in Global Health Into a Multidisciplinary Collaborative Program.

BACKGROUND: In recent years there has been a surge in the number of global health programs operated by academic institutions. However, most of the existing programs describe partnerships that are primarily faculty-driven and supported by extramural funding. PROGRAM DESCRIPTION: Research and Advocacy for Health in India (RAHI, or "pathfinder" in Hindi) and Support and Action Towards Health-Equity in India (SATHI, or "partnership" in Hindi) are 2 interconnected, collaborative efforts between the University of Massachusetts Medical School (UMMS) and Charutar Arogya Mandal (CAM), a medical college and a tertiary care center in rural western India. The RAHI-SATHI program is the culmination of a series of student/trainee-led research and capacity strengthening initiatives that received institutional support in the form of faculty mentorship and seed funding. RAHI-SATHI's trainee-led twinning approach overcomes traditional barriers faced by global health programs. Trainees help mitigate geographical barriers by acting as a bridge between members from different institutions, garner cultural insight through their ability to immerse themselves in a community, and overcome expertise limitations through pre-planned structured mentorship from faculty of both institutions. Trainees play a central role in cultivating trust among the team members and, in the process, they acquire personal leadership skills that may benefit them in their future careers. CONCLUSION: This paradigm of trainee-led twinning partnership promotes sustainability in an uncertain funding climate and provides a roadmap for conducting foundational work that is essential for the development of a broad, university-wide global health program.

High Burden of Unrecognized Atrial Fibrillation in Rural India: An Innovative Community-Based Cross-Sectional Screening Program.

BACKGROUND: Atrial fibrillation, the world's most common arrhythmia, is a leading risk factor for stroke, a disease striking nearly 1.6 million Indians annually. Early detection and management of atrial fibrillation is a promising opportunity to prevent stroke but widespread screening programs in limited resource settings using conventional methods is difficult and costly. OBJECTIVE: The objective of this study is to screen people for atrial fibrillation in rural western India using a US Food and Drug Administration-approved single-lead electrocardiography device, Alivecor. METHODS: Residents from 6 villages in Anand District, Gujarat, India, comprised the base population. After obtaining informed consent, a team of trained research coordinators and community health workers enrolled a total of 354 participants aged 50 years and older and screened them at their residences using Alivecor for 2 minutes on 5 consecutive days over a period of 6 weeks beginning June, 2015. RESULTS: Almost two-thirds of study participants were 55 years or older, nearly half were female, one-third did not receive any formal education, and more than one-half were from households earning less than US $2 per day. Twelve participants screened positive for atrial fibrillation yielding a sample prevalence of 5.1% (95% CI 2.7-8.7). Only one participant had persistent atrial fibrillation throughout all of the screenings, and 9 screened positive only once. CONCLUSIONS: Our study suggests a prevalence of atrial fibrillation in this Indian region (5.1%) that is markedly higher than has been previously reported in India and similar to the prevalence estimates reported in studies of persons from North America and Europe. Historically low reported burden of atrial fibrillation among individuals from low and middle-income countries may be due to a lack of routine screening. Mobile technologies may help overcome resource limitations for atrial fibrillation screening in underserved and low-resource settings.

Burden of Self-Reported Noncommunicable Diseases in 26 Villages of Anand District of Gujarat, India.

Introduction. Noncommunicable diseases (NCDs) account for 53% of deaths and 44% of disability adjusted life years lost in India. A survey was undertaken to measure the prevalence of tobacco and alcohol use and self-reported NCDs in a rural community in western part of India. Methodology. Trained Village Health Workers did the survey in the years 2012-13 under supervision. The data was collected for five NCDs, namely, hypertension, diabetes mellitus, cancer, heart disease, and mental illnesses. Results. 18,269 households with a population of 89755 were covered. Prevalence of any form of tobacco use in the age group of >20 years was 34.5 and 52.7% and 15.2% in males and females, respectively. Prevalence of any NCD was 5.3% with a slightly higher prevalence in females (5.4%) than males (5.2%) in the age group of 20-69 years. Prevalence of NCD multimorbidity (≥2 NCDs) was 0.7% in the age group of 20-69 years. 80.7% of hypertensives and 94.9% of diabetics were taking treatment. More females than males were taking antihypertensive treatment. Conclusion. Tobacco use was high. Prevalence of NCDs was less than that reported in other studies. Data generated from this study can be useful in planning a community based NCD programme.

Self-Care Practices among Diabetic Patients in Anand District of Gujarat.

Background. Diabetes care requires a multipronged approach, wherein the patient has an important role to play. This study was undertaken to explore self-care practices of diabetic patients residing in Anand district of Gujarat. Methods. A cross-sectional study, involving 100 diabetic patients, was conducted in 2009-2010. Self-care practices in seven domains of physical activity, dietary practices, medication taking, monitoring of glucose, problem solving, foot care, and psychosocial adjustment were assessed using scores assigned to participants' responses. Results. The mean age was 60.9 (SD = 12.2) years and 57% were males. Majority (92%) were Hindus and were consulting private medical practitioners (71%). "Medication taking" was the domain with the best performance score (88.1%) and "problem solving" the worst (11.0%). The "psychosocial adjustment" of the participants was satisfactory (82.5%). Overall mean performance percentage score was 54.41%. Males had better performance scores as compared to females in areas of "physical activity," "dietary practices," and "problem solving." Housewives had poorer performance scores. Total mean performance score was similar for patients on treatment from specialists and general practitioners. Conclusion. A self-care education program designed for this region should address the lacunae identified in various domains with a special emphasis on females.

A Qualitative Study of Psychosocial Problems among Parents of Children with Cerebral Palsy Attending Two Tertiary Care Hospitals in Western India.

Objective. To explore the psychosocial problems faced by the parents of children with cerebral palsy (CP) in rural and urban settings. Design. Qualitative research design using focus group discussions (FGDs) was used for the study. Setting. Two FGDs comprising one at a rural tertiary level care hospital and the other at an urban tertiary level care hospital were conducted. Participants. A total of thirteen parents participated in the two FGDs. Main Outcome Measured. Psychosocial problems experienced by the parents of children suffering from CP were measured. Results. The problems experienced by the mothers were associated with common themes such as disturbed social relationships, health problems, financial problems, moments of happiness, worries about future of the child, need for more support services, and lack of adequate number of trained physiotherapists. All the parents had children with problems since birth and most had approached various health care providers for a cure for their child. Conclusions. A wide range of psychosocial problems are experienced by the parents of children with CP. Studies like this can provide valuable information for designing a family centered care programme for children with CP.