A Cross-Sectional Study to Assess Reproductive and Child Health Profile of Working Women Residing in Urban Slums of Rajkot City.

CONTEXT: In India, people residing in slum are not able to get safe food, drinking water, and shelter. Special vulnerable group such as women and children are at higher risk for infectious- and nutritional-related problems. Because of the dual responsibility of working women for her family and job, chances are always higher that the reproductive and child health (RCH) of such families are compromised. AIMS: The aim of this study is to assess RCH profile of working women residing in slums. SUBJECTS AND METHODS: A community-based cross-sectional observational study was carried out among slums of Rajkot city. With the usage of simple random sampling technique and informed verbal consent for the study, a total of 480 working and nonworking women were enrolled in this study. Semi-closed prestandardized questionnaire was used to capture their sociodemographic, reproductive health, and child health parameters. The World Health Organization growth standard was used to categorize the nutritional status of their children. RESULTS: Age of marriage and first conception were significantly delayed among working women. Only 37.8%working women had adequate birth spacing between two children. About 33.3% had received adequate antenatal care (ANC) services during pregnancy. Higher prevalence of malnutrition (65.2%) and lower prevalence of full immunization (39.4%) were found among children of working women. CONCLUSIONS: Low birth spacing, lower utilization of ANC care services, higher malnutrition, and poor immunization coverage among working women had indicated underutilization of RCH services by working women of slum.

Analysis of Out-of-Pocket Expenditure in Utilization of Maternity Care Services in Urban Slums of Rajkot City, Gujarat.

BACKGROUND: India contributes 20% global maternal deaths every year. An important reason of such maternal mortality is due to cost of maternity services which makes it in accessible to the poor. Knowledge of maternity-related expense and its determinants is useful for health authorities to focus public resources and target financial assistance or exemption guidelines toward the "neediest." METHODOLOGY: It was a cross-sectional descriptive study conducted amongst 180 women living in urban slums and who had delivered a baby within 1 year of the interview date. RESULTS: The mean cost of delivery was around Rs. 8880. The average delivery cost of private institutions was significantly higher than that of government hospitals or home delivery. Around 75% of women delivered in private institution had health expenditure of more than 10% of total annual family income - catastrophic expenditure. CONCLUSION: In spite of significantly higher maternity care-related costs in private institutes than government hospitals, majority of mothers had utilized services from private clinics and had suffered catastrophic expenditures during utilization of maternity care services. This study highlights the need for birth preparedness counseling as well as effective implementation of maternity benefit schemes to prevent families from pushing downward to the poverty line.

'M-TRACK' (mobile phone reminders and electronic tracking tool) cuts the risk of pre-treatment loss to follow-up by 80% among people living with HIV under programme settings: a mixed-methods study from Gujarat, India.

BACKGROUND: In 2016, the National AIDS Control Programme (NACP) in Gujarat, India implemented an innovative intervention called 'M-TRACK' (mobile phone reminders once every week for four weeks after diagnosis and electronic patient tracking tool) to reduce pre-treatment loss to follow-up (LFU) among people living with HIV (PLHIV) in Vadodara district while other districts received standard of care. OBJECTIVES: To assess the effectiveness of M-TRACK in reducing pre-treatment LFU (proportion of diagnosed PLHIV not registering for HIV care by four weeks after diagnosis) and to explore the implementation enablers and challenges from health care providers' and PLHIV perspective. METHODS: An explanatory mixed-methods study design was used wherein the quantitative phase (cohort study with two groups: Vadodara district exposed to M-TRACK and Rajkot district as unexposed) was followed by a qualitative phase (descriptive study involving group interview with 16 health care providers, personal interviews with two programme managers and telephonic interviews with 16 PLHIV). Data were collected during October 2016 to February 2017. RESULTS: During the pre-M-TRACK period (July-September 2016), the LFU proportion was similar [13% (25/191) in Vadodara; 15% (21/141) in Rajkot (p = 0.8)]. During the M-TRACK period (October-December 2016), LFU decreased to 4% (9/209) in Vadodara (exposed), whereas it remained similar at 16% (18/113) in Rajkot (unexposed) district (p = 0.02). PLHIV exposed to M-TRACK had an 80% lower risk of LFU (aRR 0.2; 95% CI: 0.1-0.5) compared with standard care, after adjusting for socio-demographics, time and clustering at district level. During interviews, M-TRACK was welcomed by both PLHIV and the counsellors. The latter felt it saved time by obviating the need for home visits and helped in documentation. Inconvenience of using landline phone available at the health facility, lack of budgets for reimbursement of mobile call expenses and internet connectivity problems were the key implementation challenges. CONCLUSION: M-TRACK was highly effective in reducing the gap between diagnosis and treatment. It may be considered for scale-up after addressing the challenges noted.

Scorecard - An Innovative Simplified Tool to Supplement the Existing Monitoring Mechanism to Assess and Improve Performance of Antiretroviral Treatment Centers.

INTRODUCTION: All 26 antiretroviral treatment (ART) centers of Gujarat were monitored by Gujarat State AIDS Control Society under the National AIDS Control Program. A comprehensive tool is needed to identify gap in service delivery and to prioritize monitoring visits. OBJECTIVES: To supplement the existing monitoring system, identify strengths/weakness of ART centers, and give recommendations. METHODOLOGY: Scorecard was developed in spreadsheet format with 17 scoring indicators on monthly base from March 2014 onward. The centers were classified in three color zones: green (score ≥80%), yellow (score <80% and ≥50%), and red (score <50%). Visits were prioritized at centers with more indicators in yellow/red zone. The performance of centers was compared for March 2014 and March 2015. RESULTS: The statistically significant improvement was observed in indicator "ART initiation within 2 months of eligibility," while after removing red zone from analysis, four more indicators named "eligible patients transferred out before ART initiation, general clients started on ART, antenatal women started on ART, and pre-ART follow-up CD4 done" reflect statistically significant improvement. Quadrant analysis was done for some indicators, which provide insight that less number of eligible patients may be a reason for low initiation of ART at one center, and at four other centers, the possible reasons for low retention are high death rate and high lost to follow-up rate. Based on these findings, the recommendations were made to regular mentoring centers, improve coordination between ART center and care and support centers (CSCs), and conduct verbal autopsy. CONCLUSION: Scorecard is a simple and cost-effective tool for monitoring, and by highlighting low-performing indicators, it helps in improving quality of services provided at ART centers.

Evaluation of Integrated Child Development Services program in Gujarat, India.

OBJECTIVE: To evaluate Integrated Child Development Services (ICDS) program in terms of infrastructure of Anganwadi centers, inputs, process, coverage and utilization of services, and issues related to program operation in twelve districts of Gujarat, India. DESIGN: Facility (Anganwadi) based study. SETTING: Twelve districts of Gujarat, India (April 1, 2012 to March 31, 2013). PARTICIPANTS: ICDS service providers (60 Anganwadi workers from 46 rural and 14 urban Anganwadi centers) and their beneficiaries. MAIN OUTCOME MEASURES: Coverage of supplementary nutrition, pre-school education, immunization and referral services. RESULTS: Supplementary nutrition coverage was reported in 48.3% in children. Interruption in supply of supplementary nutrition during last six months was reported in 61.7% Anganwadi centers. Only 20% centers reported 100% pre-school education coverage among children. Immunization of all children was recorded in only 10% Anganwadi centers, while in 76.7% centers, no such records were available. Regular health checkup of beneficiaries was done in 30% centers. Referral slips were available in 18.3% Anganwadi centers and referral of sick children was done from only 8.3% centers. CONCLUSIONS: There are program gaps in coverage of supplementary nutrition in children, its regular supply to the beneficiaries, in pre-school activities coverage, recording of immunization, and regular health check-up of beneficiaries and referral of sick children.

Characteristics of Hospitalized Patients with Severe and Non-Severe Pandemic Influenza A (H1N1) in Saurashtra Region, India (Two Waves Analysis).

BACKGROUND: In India, the first case of 2009 pandemic influenza A (H1N1) virus infection was reported in May 2009 and the same in Saurashtra region in August 2009. We describe the epidemiology and factors associated with severe and non-severe cases of 2009 influenza A (H1N1) infection reported in the Saurashtra region. MATERIALS AND METHODS: From September 2009 to January 2011, we reported 511 patients who were infected with 2009 influenza A (H1N1) virus and admitted in different hospitals of Rajkot city. Real-time reverse transcriptase polymerase chain reaction (RT-PCR) testing was used to confirm infection. Factors associated with severe cases were determined by comparing with non-severe cases. RESULTS: Out of 511 patients, 140 had severe disease (requiring intensive care or died) and 371 non-severe diseases (admitted in wards and survived). Median age of 30 years; median time of 5 days from onset of illness to diagnosis, and 4 days median time was reported for hospital stay among severe disease patients. More than half (60.7%) were females. Out of the patients with severe disease, 52.1% patients residing in urban area (OR = 1.68, CI = 1.13-2.49). Significant association was reported among severe disease patients for delayed referral from general practitioner/physician after initial treatment. All patients received antiviral drug, however, only 27.1% received within 2 days of illness. Presence of coexisting condition (pregnancy (OR = 0.19, CI = 0.08-0.48) was strongly associated with severe disease. CONCLUSION: Delayed referral from general practitioner/physician, duration of antiviral treatment, presence of coexisting condition (i.e., pregnancy) were responsible for intensive care or mortality among severe influenza A (H1N1) illness.

Clinical and epidemiological characteristics of 2009 pandemic influenza A in hospitalized pediatric patients of the Saurashtra region, India.

BACKGROUND: The first case of 2009 pandemic influenza A or H1N1 virus infection in India was reported in May 2009 and in the Saurashtra region in August 2009. We describe the two waves clinicoepidemiological characteristics of children who were hospitalized with 2009 influenza A infection in the Saurashtra region. METHODS: From September 2009 to February 2011, we treated 117 children infected with 2009 influenza A virus who were admitted in different hospitals in Rajkot city. Real-time reverse transcriptase polymerase chain reaction (RT-PCR) test was used to confirm infection, and the clinico-epidemiological features of the disease were closely monitored. RESULTS: In the 117 patients, with a median age of 2 years, 59.8% were male. The median time from onset of the disease to influenza A diagnosis was 5 days, and that from onset of the disease to hospitalization was 7 days. The admitted patients took oseltamivir, but only 11.1% of them took it within 2 days after onset of the disease. More than one fourth (29.1%) of the admitted patients died. The most common symptoms of the patients were cough (98.3%), fever (94.0%), sore throat and shortness of breathing. Pneumonia was detected by chest radiography in 80.2% of the patients. CONCLUSIONS: In children with infection-related illness, the survival rate was about 71% after oseltamivir treatment. The median time for virus detection with real-time RT-PCR is 5 days. Early diagnosis and treatment may reduce the severity of the disease.

Clinico-epidemiological features of the hospitalized patients with 2009 pandemic influenza A (H1N1) virus infection in Saurashtra region, India (September, 2009 to February, 2010).

BACKGROUND: The first case of 2009 pandemic influenza A (H1N1) virus infection in India was reported in May, 2009 and in Saurashtra region in August, 2009. We describe the clinico-epidemiological characteristics of patients who were hospitalized with 2009 influenza A (H1N1) infection in Saurashtra region. MATERIALS AND METHODS: From September, 2009 to February, 2010, we observed 274 persons infected with 2009 influenza A (H1N1) virus who were admitted in different hospitals in Rajkot city. Real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) testing was used to confirm infection; the clinico-epidemiological features of the disease were closely monitored. RESULTS: Of 274 patients, median age was 29.5 years, and 51.5% were males. Only 1.1% patients had recent travel history to infected region. Median time of five days was observed from onset of illness to influenza A (H1N1) diagnosis, while median time of six days reported for hospital stay. All admitted patients received oseltamivir drug, but only 16.1% received it within two days of onset of illness. One fourth of admitted patients were expired. The most common symptoms were cough (96.7%), fever (92%), sore throat and shortness of breathing, and coexisting conditions including diabetes mellitus (9.9%), hypertension (8.8%), chronic pulmonary diseases (5.5%) and pregnancy (5.5%) (P<0.05). Pneumonia was reported in 93% patients with chest radiography. CONCLUSION: We have demonstrated that infection-related illness affects both children and adults with survival of 74% patients. The median time from onset of illness to virus detection with use of real-time RT-PCR is five days. Pregnancy is found as a significant (P<0.05) risk factor for severe disease.

Iodine nutritional status and goiter prevalence in 6-12 years primary school children of Saurashtra region, India.

BACKGROUND: Iodine deficiency disorder (IDD) or goiter is the cause of preventable brain damage, mental retardation, and stunted growth and development in children. This study aimed to detect the prevalence of IDD in Rajkot district, India by testing urinary iodine excretion levels and iodine salt intake of school children. METHODS: A cross-sectional study was conducted in 2940 school children of both sexes aged 6-12 years from 14 talukas subdivisions of the district. Thirty clusters were selected by using cluster sampling technique. Goiter was assessed in all the studied children along with biochemical analysis of iodine in 420 urine samples and iodine content in 840 edible salt samples in the studied area. RESULTS: Goiter was reported from all talukas subdivisions of the studied area. Goiter prevalence ranged from 1% to 35%, and the overall prevalence was 8.8% (grade 1: 7.6%; grade 2: 1.2%), indicating a mild public health problem. In the study areas, 18.1% of the population showed a level of urinary iodine excretion <50 microg/L. The median level of urinary iodine in the studied areas was 110 microg/L (range 10-415 microg/L). The iodine level of more than 15 ppm was found in 81% of salt samples tested at the household level. CONCLUSION: There is mild goiter prevalence in primary school children of Rajkot district, which is due to the inadequate iodine intake or content from salt at the household level.

Hospitalizations associated with 2009 influenza A (H1N1) and seasonal influenza in Saurashtra region, India.

INTRODUCTION: This study investigated the clinico-epidemiological characteristics of patients who were hospitalized with 2009 pandemic H1N1 influenza virus infection and seasonal influenza in the Saurashtra region of India. METHODOLOGY: From September 2009 to February 2010, a total of 773 patients with influenza virus attending different hospitals in Rajkot city were studied. Real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) testing was used to confirm infection; the clinico-epidemiological features of the disease were closely monitored. RESULTS: Of the 733 patients, 35.4% (274/773) were cases of 2009 pandemic H1N1 influenza and 64.6% (499/773) were cases of seasonal influenza. Of the 274 patients with 2009 pandemic H1N1 influenza, the median age was 29.5 years, and 51.5% were males. Only 1.1% positive patients had recent travel history to an infected region. A median time of five days was observed from onset of illness to influenza A (H1N1) diagnosis, and a median time of six days was reported for hospital stay. All admitted influenza A (H1N1) patients received Oseltamivir drug, but only 16.1% received it within two days of onset of illness. One fourth of the admitted positive patients died. The most common symptoms were cough, fever, sore throat, and shortness of breath. The coexisting conditions were diabetes mellitus, hypertension, chronic pulmonary diseases, and pregnancy (p = 0.001). Chest radiography revealed 93% of the positive patients had pneumonia. CONCLUSION: The clinical course and outcomes of the 2009 pandemic (H1N1) influenza virus are comparable to those of the currently circulating seasonal influenza, with high mortality in influenza A (H1N1) patients.

Correlates of severe disease in patients admitted with 2009 pandemic influenza A (H1N1) infection in Saurashtra region, India.

BACKGROUND: India reported its first case of 2009 pandemic influenza A (H1N1) virus infection in May 2009 and in Saurashtra region in August 2009. We describe the epidemiology and factors associated with severe and non-severe cases of 2009 influenza A (H1N1) infection reported in Saurashtra region. MATERIALS AND METHODS: From September 2009 to February 2010, we observed 274 patients who were infected with 2009 influenza A (H1N1) virus and admitted in different hospitals in Rajkot city. Real-time reverse transcriptase-polymerase chain reaction (RT-PCR) testing was used to confirm infection. Factors associated with severe disease were determined by comparing with non-severe cases. RESULTS: Out of 274 patients, 87 had severe disease (requiring intensive care or died) and 187 had non-severe diseases (admitted in wards and survived). The median age of severe disease patients was 30 years; the median time was 5 days from the onset of illness to diagnosis, and 4 days median time was reported for hospital stay. More than half of the patients (56.3%) were females, and 58.6% patients were residing in urban area (OR = 1.65, CI = 0.97-2.8), among severe disease patients. Significant association (P < 0.01) was reported among severe disease patients for delayed referral from general practitioner/physician after initial treatment. All patients received antiviral drug, but only 19.5% received the same within 2 days of illness. Presence of coexisting condition [odds ratio (OR) = 0.53, confidence interval (CI) = 0.31-0.90], mainly pregnancy (OR = 0.22, CI = 0.06-0.76), was strongly associated with severe disease. CONCLUSION: Delayed referral from general practitioner/physician, duration of antiviral treatment, and presence of coexisting condition (especially pregnancy) were responsible for intensive care or mortality in patients of severe influenza A (H1N1) illness.