Depression and its role in adherence to anti-retroviral treatment in people living with HIV and AIDS in Chennai.

Context: The AIDS epidemic has drastically reduced in India since it was first identified in 1986, largely due to the widespread availability of anti-retroviral treatment (ART). Management of HIV is currently more focussed on long term morbidities, including mental health. Depression is the most common co-morbidity seen in people living with HIV. Depression is found to negatively affect patient adherence to ART. Poor adherence to ART leads to drug resistance and susceptibility to opportunistic infections. Aims: The purpose of this study is to find the prevalence of depression among people living with HIV and to study the correlation between depression and adherence to ART. Setting and Design: The study was conducted in the ART centre at Rajiv Gandhi Government General Hospital in Chennai, between August and October 2022. Methods and Materials: Patient health questionnaire-9 (PHQ-9) was used to identify depression, and the Adult AIDS clinical trials group (AACTG) questionnaire was used to identify adherence. Statistical Analysis Used: Data were entered in MS Excel and were analysed using Statistical Package for Social Science (SPSS) Version 16. The association between categorical data were analysed using Chi-square and Fisher exact test. The correlation between adherence and depression was done using the Spearman correlation. Results: The prevalence of depression was found to be 20.2%. A mild negative correlation was found between depression and adherence. Depression was found to have a significant correlation with women, unemployed, widowed, divorced individuals, and those with diabetes mellitus and tuberculosis. Conclusion: Depression is an important risk factor for adherence to ART. Though severe depression was not found in this study, mild and moderate depression was associated with reduced adherence to ART. Treating depression is likely to improve adherence and the overall wellbeing of patients with HIV and AIDS.

Prevalence of Noncommunicable Disease (NCDs) risk factors in Tamil Nadu: Tamil Nadu STEPS Survey (TN STEPS), 2020.

BACKGROUND: Noncommunicable diseases (NCDs) account for nearly 75% of all deaths in Tamil Nadu. The government of Tamil Nadu has initiated several strategies to control NCDs under the Tamil Nadu Health Systems Reform Program (TNHSRP). We aimed to estimate the prevalence of NCD risk factors and determine the predictors of diabetes and hypertension, which will be helpful for planning and serve as a baseline for evaluating the impact of interventions. METHODS: A state-wide representative cross-sectional study was conducted among 18-69-year-old adults in Tamil Nadu in 2020. The study used a multi-stage sampling method to select the calculated sample size of 5780. We adapted the study tools based on WHO's STEPS surveillance methodology. We collected information about sociodemographic factors, NCD risk factors and measured blood pressure and fasting capillary blood glucose. The predictors of diabetes and hypertension were calculated using generalised linear models with 95% confidence intervals (95% CI). RESULTS: Due to the COVID-19 pandemic lockdown, we could cover 68% (n = 3800) of the intended sample size. Among the eligible individuals surveyed (n = 4128), we had a response rate of 92%. The mean age of the study participants was 42.8 years, and 51% were women. Current tobacco use was prevalent in 40% (95% CI: 33.7-40.0) of men and 7.9% (95% CI: 6.4-9.8) of women. Current consumption of alcohol was prevalent among 39.1% (95% CI: 36.4-42.0) of men. Nearly 28.5% (95% CI: 26.7-30.4) of the study participants were overweight, and 11.4% (95% CI: 10.1-12.7) were obese. The prevalence of hypertension was 33.9% (95% CI: 32.0-35.8), and that of diabetes was 17.6% (95% CI: 16.1-19.2). Older age, men, and obesity were independently associated with diabetes and hypertension. CONCLUSION: The burden of NCD risk factors like tobacco use, and alcohol use were high among men in the state of Tamil Nadu. The prevalence of other risk factors like physical inactivity, raised blood pressure and raised blood glucose were also high in the state. The state should further emphasise measures that reduce the burden of NCD risk factors. Policy-based and health system-based interventions to control NCDs must be a high priority for the state.

Contribution of infection and vaccination to population-level seroprevalence through two COVID waves in Tamil Nadu, India.

This study employs repeated, large panels of serological surveys to document rapid and substantial waning of SARS-CoV-2 antibodies at the population level and to calculate the extent to which infection and vaccination separately contribute to seroprevalence estimates. Four rounds of serological surveys were conducted, spanning two COVID waves (October 2020 and April-May 2021), in Tamil Nadu (population 72 million) state in India. Each round included representative populations in each district of the state, totaling ≥ 20,000 persons per round. State-level seroprevalence was 31.5% in round 1 (October-November 2020), after India's first COVID wave. Seroprevalence fell to 22.9% in round 2 (April 2021), a roughly one-third decline in 6 months, consistent with dramatic waning of SARS-Cov-2 antibodies from natural infection. Seroprevalence rose to 67.1% by round 3 (June-July 2021), with infections from the Delta-variant induced second COVID wave accounting for 74% of the increase. Seroprevalence rose to 93.1% by round 4 (December 2021-January 2022), with vaccinations accounting for 63% of the increase. Antibodies also appear to wane after vaccination. Seroprevalence in urban areas was higher than in rural areas, but the gap shrunk over time (35.7 v. 25.7% in round 1, 89.8% v. 91.4% in round 4) as the epidemic spread even in low-density rural areas.

Ethics and professionalism among community health workers in Tamil Nadu, India: A qualitative study.

Community health workers (CHW) are the backbone of the public health system in developing countries. Little is known about the practice of ethics and professionalism in their work. This study was conducted to explore the experiential wisdom of ethics and professionalism among CHWs in Tamil Nadu. We conducted a qualitative study among 125 CHWs in six districts of Tamil Nadu. We found that the CHWs went beyond the call of their duty to do good to the community. Their conceptualization of autonomy ranged from shared to full paternalistic decision making. The CHWs were sensitive to issues of privacy and confidentiality, but the discussion on these topics were limited. They reflected the societal norms of gender, class, and caste hierarchies in their work. They had to work amidst difficult power struggles and had their own innovative strategies to subvert power. In conclusion, there is a need for framing a code of ethics and professionalism for CHWs and training in ethics and professionalism for them to help them effectively deliberate on ethical issues.

Ethical issues in m-Health applications in community health work in India - a scoping review.

BACKGROUND: Mobile phone-based interventions are being increasingly used in community health work in India. The extensive use of mobile phones in community health work is associated with several ethical issues. This review was conducted to identify the ethical issues related to mHealth applications in community health work in India. METHODS: We performed a scoping review of literature in PubMed and Google Scholar using a search strategy that we developed. We included studies that mentioned ethical issues in mHealth applications that involved community health work and community health workers in India, published in peer reviewed English language journals between 2011 and 2021. All three authors screened the articles, shortlisted them, read them, and extracted the data. We then synthesised the data into a conceptual framework. RESULTS: Our search yielded 1125 papers, from which we screened and shortlisted 121, after reading which we included 58 in the final scoping review. The main ethical issues identified from review of these papers included benefits of mHealth applications such as improved quality of care, increased awareness about health and illness, increased accountability of the health system, accurate data capture and timely data driven decision making. The risks of mHealth applications identified were impersonal communication of community health worker, increased workload, potential breach in privacy, confidentiality, and stigmatisation. The inherent inequities in access to mobile phones in the community due to gender and class led to exclusion of women and the poor from the benefits of mHealth interventions. Though mHealth interventions increased access to healthcare by taking healthcare to remote areas through tele-health, unless we contextualise mHealth to local rural settings through community engagement, it is likely to remain inequitable. CONCLUSION: This scoping review revealed that there is a lack of well conducted empirical studies which explore the ethical issues related to mHealth applications in community health work.

COMMENT: Ethics and professionalism of a community health worker: A virtue ethics approach.

Community health workers are the link between the community and the health system, delivering primary care services at the frontline. Every profession has its own ethics and professional values, and there is a need to formulate the ethics of community health work which should be informed by their rich experiential wisdom. In one such effort, we interviewed a senior community health worker in the Tamil Nadu health system and present it here as a virtue ethics case study. Several situations of ethical conflict arising in her work, and her process for resolving these conflicts were discussed during the interview. The worker discussed some ethical principles: doing good, not doing any harm, maintaining justice, being honest, providing respectful care, maintaining self-respect, being accessible, earning the community's trust, and building solidarity. This interview confirms the assumption that ethics and professionalism are inherent in this community health worker, and emphasises the need for systematic research to document the experiences of such frontline workers, and to frame relevant standards of ethics and professionalism in the local context.

Clinical profile of patients infected with suspected SARS-CoV-2 Omicron variant of concern, Tamil Nadu, India, December 2021-January 2022.

Background & objectives: COVID-19 cases have been rising rapidly in countries where the SARS-CoV-2 variant of concern (VOC), Omicron (B.1.1.529) has been reported. We conducted a study to describe the epidemiological and clinical characteristics and outcomes of COVID-19 patients with 'S' gene target failure (SGTF, suspected Omicron). Furthermore, their clinical outcomes with COVID-19 patients with non-SGTF (non-Omicron) were also compared. Methods: This study was conducted in Tamil Nadu, India, between December 14, 2021 and January 7, 2022 among patients who underwent reverse transcription-PCR testing for SARS-CoV-2 in four laboratories with facilities for S gene screening. Consecutively selected COVID-19 patients with SGTF were telephonically contacted, seven and 14 days respectively after their date of positive result to collect information on the socio-demographic characteristics, previous history of COVID-19, vaccination status and clinical course of illness along with treatment details. To compare their outcomes with non-SGTF patients, one randomly suspected non-Omicron case for every two suspected Omicron cases from the line-list were selected, matching for the date of sample collection and the testing laboratory. Results: A total of 1175 SGTF COVID-19 patients were enrolled for this study. Almost 6 per cent (n=72) reported a history of previous infection. 141 (13.5%) suspected Omicron cases were non-vaccinated, while 148 (14.2%) and 703 (67.4%) had received valid one and two doses of COVID-19 vaccines, respectively. Predominant symptoms reported included fever (n=508, 43.2%), body pain (n=275, 23.4%), running nose (n=261, 22.2%) and cough (n=249, 21.2%). Five (0.4%) of the 1175 suspected Omicron cases required oxygen supplementation as compared to ten (1.6%) of the 634 suspected non-Omicron cases. No deaths were reported among omicron suspects, whereas there were four deaths among suspected non-Omicron cases. Interpretation & conclusions: Majority of the suspected Omicron cases had a mild course of illness. The overall severity of these cases was less compared to the suspected non-Omicron cases.

A qualitative inquiry into stigma among patients with Covid-19 in Chennai, India.

INTRODUCTION: The Covid-19 pandemic has left a serious impact on the lives of people globally. One key social consequence of the infection has been the stigma associated with it. OBJECTIVES: This study was conducted to explore the lived experiences of stigma among persons who have recovered from Covid-19 in Chennai, India. METHODS: In depth telephonic interviews were conducted among 12 persons who had recovered from Covid-19 in Chennai. The participants were encouraged to narrate their experiences of stigma. The telephonic interviews were transcribed and coded by both the researchers. The codes were then grouped into meaningful themes and the lived experiences of stigma described with the help of rich narrative quotes. RESULTS: The common manifestations of stigma were exclusion from public spaces and essential services, loss of livelihood, loss of social support and, in an extreme case, physical violence. The stigma was also manifested in health facilities in the form of neglect, and rude and insensitive treatment of patients. The factors that aggravated the stigma included fear of infection, lack of information, legitimisation of segregation by forced public health interventions, involvement of police in contact tracing, and isolation. Stigma was associated with psychosocial consequences such as loneliness, uncertainty, anxiety, anger, and humiliation. Demonstration of empathy, advances in communication technology, solidarity in communities and protecting confidentiality could potentially mitigate stigma. The intersectionality of age, gender, poverty, and disability worsened the experience of stigma. CONCLUSIONS: People who had recovered from Covid-19 experienced various degrees of social stigma. The future impact of the pandemic will depend strongly on the ability of health systems to address stigma.

COVID-19 Pandemic: a Litmus Test of Trust in the Health System.

The pandemic caused by the SARS-CoV2 novel coronavirus is creating a global crisis. There is a global ambience of uncertainty and anxiety. In addition, nations have imposed strict and restrictive public health measures including lockdowns. In this heightened time of vulnerability, public cooperation to preventive measures depends on trust and confidence in the health system. Trust is the optimistic acceptance of the vulnerability in the belief that the health system has best intentions. On the other hand, confidence is assessed based on previous experiences with the health system. Trust and confidence in the health system motivate people to accept the public health interventions and cooperate with them. Building trust and confidence therefore becomes an ethical imperative. This article analyses the COVID-19 pandemic in the south Indian state of Tamil Nadu and the state's response to this pandemic. Further, it applies the Trust-Confidence-Cooperation framework of risk management to analyse the influence of public trust and confidence on the Tamil Nadu health system in the context of the preventive strategies adopted by the state. Finally, the article proposes a six-pronged strategy to build trust and confidence in health system functions to improve cooperation to pandemic containment measures.

Does the Distribution of Empanelled Hospitals have an Impact on the Utilization of Services under State Insurance Scheme?

CONTEXT: Tamil Nadu's Chief Minister's Comprehensive Health Insurance Scheme (CMCHIS) aims at reducing inequity by making the health service affordable and available by roping in both the public and private providers. AIMS: This study aims to find if there exist any inter-district disparity in the distribution of hospitals empaneled and utilization of services under the CMCHIS scheme. SETTINGS AND DESIGN: A secondary data analysis was done using the CMCHIS data on hospitals empanelled and number of claims made in the scheme for the year 2018. SUBJECTS AND METHODS: The districts were classified into high-developed district (HDD), middle-developed district (MDD), and low-developed district (LDD) based on the Human Development Index. Availability of hospital services was calculated as the number of empanelled hospitals/100,000 families enrolled. Utilization was calculated as the number of claims made by people living in the district per one lakh families enrolled and number of claims made by hospitals under CMCHIS/100,000 enrolled. STATISTICAL ANALYSIS USED: The relationship between enrolment ratio, hospital availability, number of claims made, and Human Development Index across districts was examined using the Pearson's Correlation analysis. RESULTS: Enrolment was highest in the LDDs (22.8%), followed by MDDs (21.9%) and HDDs (18.7%). The number of hospitals per 100,000 families enrolled was the highest in HDDs (8.0) and lowest in LDDs (4.6). The utilization was the highest in HDD followed by MDD and lowest in LDD. CONCLUSIONS: The disparity in the hospitals availability and utilization between districts should be addressed by adopting a targeting approach giving priorities to empanelling hospitals in the less-developed districts.

Psycho-social impact of stillbirths on women and their families in Tamil Nadu, India - a qualitative study.

BACKGROUND: Stillbirth has serious psycho-social consequences on the parents and on the family. The psychological impact of stillbirth is strongly influenced by the social and cultural context. There is very scarce information on this from the Indian context. This qualitative study was conducted to understand the psycho-social impact, aggravating factors, coping styles and health system response to stillbirths. METHODS: A qualitative study was conducted using in-depth interviews with mothers who experienced stillbirth in the past 1 year and their families. A total of 8 women and two health care providers were interviewed by trained interviewers. The interviews were transcribed into the local language and thematic analysis was performed by the researchers retaining the transcripts in the local language. Themes were identified, and a conceptual framework was developed. RESULTS: Women who experienced stillbirths suffered from serious forms of grief and guilt. These emotions were aggravated by the insensitive health system, health care providers, friends, and neighbours, as well as strained marital relationship and financial burdens. The women and their families were disturbed by the 'suddenness' of the stillbirth and frantically searched for the cause. They were frustrated when they couldn't find the cause and blamed various people in their lives. The women and their families perceived poor quality of services provided in the health system and reported that the health care providers were inconsiderate and insensitive. On the other hand, the health care providers reported that they were over-worked, and the health facilities were under-staffed. The community health workers reported that they felt caught in the crossfire between the health facility staff and the family who suffered the stillbirth. The women reported several coping mechanisms including isolation, immersion in work, placing maternal love on other children, the anticipation of next pregnancy and religiosity. CONCLUSION: Stillbirth is a major cause of psycho-social morbidity. Health systems should be responsive to the psycho-social needs of women who suffer stillbirths and their families.

A picture speaks a thousand words: Using participant photography in environmental pedagogy for medical students.

Imparting a positive attitude toward social determinants of health among medical students has remained a challenge in medical education. This pedagogical exercise attempted to use a toxic tour with participant photography technique to impart environmental health education as part of the community medicine curriculum for medical students. In collaboration with a local environmental health nongovernmental organization, faculty from two medical colleges took a set of 13 medical students to Ennore thermal power plants as a part of a toxic tour to view the air and water pollution caused due to the operation of the power plants. The students were instructed to capture photographs of the environmental hazards using their mobile phone cameras and share them on a social media platform. Immediately after the tour, the students discussed their experiences with the faculty. Two weeks after the toxic tour, the students engaged in a focus group discussion in which they discussed their experiences, advantages, and disadvantages of the toxic tour and participant photography method and their attitudes toward environmental health. This pedagogical exercise led to the active engagement of the students with the environmental hazards in the area. They shared 70 photographs on the social media platform. In reflection, students described that they found the method very useful to actively engage with the environment, look for and find the hazards, revisit, and reflect on the photos, and use the photos to share the knowledge and experience. They also demonstrated a positive social determinants and public health attitude during the discussions. Participant photography technique during a toxic tour can impart affective domain of learning related to environmental health among medical students.

Ocular morbidity patterns among children in schools for the blind in Chennai.

PURPOSE: To identify the morbidity patterns causing blindness in children attending schools for the blind in Chennai and comparing our data with similar studies done previously. METHODS: A cross-sectional prevalence study was carried out in two schools for the blind in Chennai. Blind schools were visited by a team of ophthalmologists and optometrists. Students with best-corrected visual acuity (BCVA) worse than 3/60 in the better eye were included and relevant history was noted. Every student underwent anterior segment evaluation and detailed fundus examination. Morbidity of the better eye was taken as cause of blindness. Health records maintained by the school were referred to wherever available. RESULTS: The anatomical causes of blindness include optic nerve disorders in 75 (24.8%) cases, retinal disorders in 55 (18.2%), corneal disorders in 47 (15.6%), lens-related disorders in 39 (12.9%), congenital anomalies in 11 (3.6%), and congenital glaucoma in 20 (6.6%) cases. The whole globe was involved in six cases (1.99%). Among conditions causing blindness, optic atrophy seen in 73 (24.17%) cases was the most common, followed by retinal dystrophy in 44 (14.56%), corneal scarring in 35 (11.59%), cataract in 22 (7.28%), and congenital glaucoma in 20 (6.6%) cases. CONCLUSION: It was found that avoidable causes of blindness were seen in 31% of cases and incurable causes in 45%. Optic nerve atrophy and retinal dystrophy are the emerging causes of blindness, underlining the need for genetic counseling and low vision rehabilitation centers, along with a targeted approach for avoidable causes of blindness.