Assistive technology usage, unmet needs and barriers to access: a sub-population-based study in India.

Background: Assistive technology (AT) is essential to minimize functional limitations. The current study aimed to estimate the prevalence of needs, met and unmet needs for AT, and barriers to accessing AT among a subnational population in India. Methods: This cross-sectional study was conducted in eight districts, representing four zones of India, using the WHO Rapid Assistive Technology Assessment (rATA) tool. The tool was administered by trained staff using read aloud technique. Multi-stage cluster random sampling was used, as well as the probability proportional to size, to select smaller administrative units from the larger ones. Findings: In total, 8486 participants were surveyed out of 8964 individuals enumerated with a response rate of 94.6%. The sample prevalence of at least one difficulty was 31.8% (2700), with 6.3% (532) having severe or total difficulties. The sample prevalence for AT need was 27.8% (2357) with an estimated population prevalence of 24.5% (95% CI: 23.5-25.4). Similarly, the sample prevalence of unmet needs was 9.7% (823) with an estimated population unmet needs of 8.0% (95% CI: 7.43-8.60). The unmet needs among persons with severe or total difficulties was 52.3% (278/532), and was higher among females, rural residents, and older persons. Spectacles were the most used products, followed by canes/sticks, tripods, and quadripods. Nearly two-thirds of AT users purchased assistive products at their own expense, particularly from the private sector. The inability to afford AT (36.9%) was the most common barrier. Interpretation: The results show that the need for AT was substantial in the study population, the highest being for seeing difficulties. The unmet needs are higher in females, older population, rural residents, and persons having serious difficulties. While the majority of users have to make out-of-pocket payments to obtain AT, inability to afford and limited availability were the common barriers among those with unmet needs. Funding: This research is non-commercial, and was conducted in the interest of public health. The authors have not declared any specific grant for this research.

Agreement between Noninvasive Hemoglobin and Laboratory Hemoglobin Measurements in Neonates: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVE: The noninvasive hemoglobin (NHb) devices are recently evaluated as an alternative to laboratory hemoglobin (LHb) in neonates. This systematic review explores the diagnostic accuracy of NHb devices for neonatal hemoglobin measurement. METHODS: Literature related to the comparison of NHb device with LHb in neonates was searched from Medline, PubMed Central, PubMed, Web of Science, Google Scholar, and Scopus databases after PROSPERO registration. The quality of included publications was assessed by QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies). The pooled correlation coefficient and bias (precision) in Bland-Altman difference plots were used for summary statistics using MetaXL 5.0 software. RESULTS: A total of 1,477 paired NHb-LHb observations were analyzed from 1,047 neonates in 10 studies. Massimo radical-pulse co-oximetry (8 studies) and Mediscan-2000 (2 studies) were used for NHb estimation. The pooled correlation coefficient between NHb and LHb was r = 0.94 (95% CI: 0.83-0.98, p < 0.001), and the pooled bias (precision) was -0.013 (1.4) gm/dL between NHb and LHb measurements in Bland-Altman analysis. NHb device had better precision in stable neonates (0.91gm/dL) over sick neonates (1.66 gm/dL). CONCLUSIONS: Hemoglobin measurement by NHb is excellently correlated with LHb measurement with a minimal average difference. It may be used as a screening tool for hemoglobin measurement in neonates to avoid frequent phlebotomy.

Gender dimensions of youth vulnerability toward access to cigarettes in South-East Asia: Evidence from global youth tobacco survey.

Background: Youths are lured to smoking to make them tobacco customers. Limiting access to tobacco products by youths is a proven strategy to reduce youth tobacco use. This study aimed to examine the burden of cigarette smoking and access to tobacco by youth in South-East Asia (SEA). Methods: The burden along with the physical (methods of obtaining cigarettes), financial (cigarette affordability by pocket money), and illegal (sale to minors) access to cigarettes among school-going boys and girls were examined by analyzing the Global Youth Tobacco Survey (GYTS) data (2013-2016) from seven SEA member countries. Descriptive statistics using country-specific GYTS sample weight was used to estimate parameters with 95% confidence intervals. Results: The proportion of youths reporting cigarette smoking was highest in East Timor [boys: 55.57 % (51.93-59.21) and girls: 11.35% (9.12-13.59)] and lowest in Sri Lanka [boys: 2.96% (2.91-3.0) and girls: 0%]. Smoking prevalence was higher among boys than girls. Smoking among boys and girls was positively correlated (r = 0.849, p = 0.032). The most common method of obtaining cigarettes was "buying it from a store/kiosk/street hawker" and "other sources." Except in Indonesia, financial access was limited for most youths. Financial access had a positive but negligible influence on cigarette smoking. Despite legal restrictions on sales to minors, students could obtain cigarettes from vendors. Conclusion: Contextual cigarette smoking and access to cigarettes by youths despite the legal ban and unaffordability is a concern. Country-specific socio-cultural-economic and legal dimensions need to be examined to limit cigarette use among youths.

Effectiveness and Implementation Outcome Measures of Mental Health Curriculum Intervention Using Social Media to Improve the Mental Health Literacy of Adolescents.

Purpose: Globally, adolescent mental health problems reportedly manifest more severely in individuals with lower mental health literacy. Mental health curriculum interventions using social media have been associated with positive implementation outcomes. This study aimed to investigate whether such an intervention significantly improves adolescent mental health literacy and is associated with positive implementation outcome measures. Methods: This study employed a quasi-experimental design, comparing the before-and-after difference between the intervention group (n1=77) and the control group (n1=76). A mental health literacy module was delivered using social media. Data were collected using validated questionnaires. Effect size and difference-in-differences model calculations (and associated 95% confidence intervals, CI) were conducted alongside other descriptive analyses. Results: The estimated intervention effect size and difference-in-differences estimates were greater than zero. The effect was greater in the intervention than in the control group (p<0.05) despite sex and age differences. The effect size estimate provided by Cohen's d and Hedges' g values was medium-to-large (d/g=0.429-0.767, p<0.05). The difference-in-differences reflected a significant effect (DID=0.348, CI: 0.154-0.542, p<0.001) in increasing mental health literacy despite differences associated with sex, age, and school grade. The intervention program was acceptable, appropriate, feasible, and satisfactory, and more than 80% of participants said they agree to completely agree with these implementation outcomes. Resources and personal and family-related factors were among the perceived influencing factors determining the effectiveness and implementation outcome measures. Conclusion: The intervention program effectively improved the mental health literacy of adolescents. It has been highlighted that social media interventions for mental health promotion could be practical and scalable; however, there is a need to take into account socio-demographic differences and barriers to inclusion/compliance.

Is Lower Vitamin D Level Associated with Increased Risk of Neonatal Sepsis? A Prospective Cohort Study.

OBJECTIVE: To evaluate the effect of maternal/ neonatal vitamin D levels on culture positive neonatal sepsis. METHODS: This prospective cohort study was conducted in the NICU of a tertiary care teaching hospital in Odisha, Eastern India from January 2015 through December 2016. Forty (40) neonates with culture positive sepsis were included in the study group. Forty (40) healthy neonates admitted for evaluation of neonatal jaundice who are similar in gender, gestational age, postnatal age and without any clinical signs of sepsis were recruited as control group after informed consent. Vitamin D level (25 OH D) was assessed in the neonates and their mothers in both the groups. RESULTS: Neonatal 25 OH vitamin D level in the study group (12.71 ± 2.82 ng/ml) was significantly lower than in the control group (25.46 ± 7.02 ng/ml). The Odds ratio was 273 (95% CI 30.39-2451.6) for culture positive sepsis in neonates with vitamin D deficiency/insufficiency. Mothers of septic neonates had significantly lower 25 OH vitamin D level (20.92 ± 3.92 ng/ml) than the mothers of healthy neonates in control group (27.31 ± 6.83 ng/ml). The Odds ratio was 4.71 (95% CI 1.69-13.1) for culture positive sepsis in babies born to mothers with vitamin D deficiency/insufficiency. CONCLUSIONS: Neonates with vitamin D deficiency/insufficiency are at higher risk for developing sepsis than those with sufficient vitamin D levels. Lower vitamin D levels in mothers is also associated with increased risk of sepsis in the neonates.

Tobacco use and quit behaviour assessment in the Global Adult Tobacco Survey (GATS): invalid responses and implications.

BACKGROUND: Tobacco use and quit attempts are two key indicators of the Global Adult Tobacco Survey (GATS) that assess quit attempts among current as well as former tobacco users. The relevant data have inherent policy implications for tobacco cessation programme evaluation. This study aimed to review the concepts of quit attempt assessment and quantifying invalid responses considering GATS-India data. MATERIALS AND METHODS: GATS assessment of tobacco use and quit attempts were examined in the current literature. Two categories of invalid responses were identified by stratified analysis of the duration of last quit attempt among current users and duration of abstinence among former users. Category A included absolute invalid responses when time- frame of assessment of current tobacco use and less than former tobacco use were violated. Category B included responses that violated the unit of measurement of time. RESULTS: Current daily use, current less than daily use and former use in GATS were imprecisely defined with overlapping of time-frame of assessment. Overall responses of 3,102 current smokers, 4,036 current smokeless users, 1,904 former smokers and 1,343 former smokeless users were analyzed to quantify invalid responses. Analysis indicated overall 21.2% (category A: 7.32%; category B: 17.7%) and 22.7% (category A: 8.05%; category B: 18.1%) invalid responses among current smokers and smokeless users respectively regarding their duration of last quit attempt. Similarly overall 6.62% (category A: 4.7%; category B: 2.3%) and 10.6% (category A: 8.6%; category B: 3.5%) invalid responses were identified among former smokers and smokeless users respectively regarding their duration of abstinence. CONCLUSIONS: High invalid responses for a single assessment are due to the imprecise definition of current use, former use and quit attempt; and failure to utilize opportunity of direct data entry interface use during the survey to validate responses instantly. Redefining tobacco use and quit attempts considering an appropriate timeframe would reduce invalid responses.

Correlates of digit bias in self-reporting of cigarette per day (CPD) frequency: results from Global Adult Tobacco Survey (GATS), India and its implications.

BACKGROUND: Cigarette per day (CPD) use is a key smoking behaviour indicator. It reflects smoking intensity which is directly proportional to the occurrence of tobacco induced cancers. Self reported CPD assessment in surveys may suffer from digit bias and under reporting. Estimates from such surveys could influence the policy decision for tobacco control efforts. In this context, this study aimed at identifying underlying factors of digit bias and its implications for Global Adult Tobacco Surveillance. MATERIALS OR METHODS: Daily manufactured cigarette users CPD frequencies from Global Adult Tobacco Survey (GATS)--India data were analyzed. Adapted Whipple Index was estimated to assess digit bias and data quality of reported CPD frequency. Digit bias was quantified by considering reporting of '0' or '5' as the terminal digits in the CPD frequency. The factors influencing it were identified by bivariate and logistic regression analysis. RESULTS: The mean and mode of CPD frequency was 6.7 and 10 respectively. Around 14.5%, 15.1% and 15.2% of daily smokers had reported their CPD frequency as 2, 5 and 10 respectively. Modified Whipple index was estimated to be 226.3 indicating poor data quality. Digit bias was observed in 38% of the daily smokers. Heavy smoking, urban residence, North, South, North- East region of India, less than primary, secondary or higher educated and fourth asset index quintile group were significantly associated with digit bias. DISCUSSION: The present study highlighted poor quality of CPD frequency data in the GATS-India survey and need for its improvement. Modeling of digit preference and smoothing of the CPD frequency data is required to improve quality of data. Marketing of 10 cigarette sticks per pack may influence CPD frequency reporting, but this needs further examination. Exploring alternative methods to reduce digit bias in cross sectional surveys should be given priority.

Global Adult Tobacco Survey (GATS): a case for change in definition, analysis and interpretation of "cigarettes" and "cigarettes per day" in completed and future surveys.

BACKGROUND: The Global Adult Tobacco Survey has 15 key indicators, cigarettes smoked per day (CPD) among daily smokers being one of them. The first wave of GATS in 14 countries indicated that mean CPD use is higher in women than men in India only, which is contrary to the current understanding of tobacco use globally. This study was undertaken to understand the unusual findings for mean CPD use in the GATS-India survey. MATERIALS AND METHODS: Items B06a and B06b of the GATS India survey questionnaire that collected information on daily consumption of manufactured and rolled cigarettes were analyzed using SPSS software. Exclusive users were identified from these items after excluding the concurrent users of other tobacco products. Cigarette type, exclusive use and gender stratified analyses were made. Consumption of different types of cigarettes among the mixed users of manufactured and rolled cigarettes were correlated. RESULTS: Higher mean number of CPD use among male daily-smokers was observed than their female counterparts in product specific analysis. Mean CPD as per GATS cigarette definition was higher in males than females for exclusive users but a reverse trend was observed in case of non-exclusive users. Use of manufactured cigarettes increased with increase in use of rolled cigarette among the mixed users and around half of these users reported equal CPD frequency for the both types of cigarettes. CONCLUSIONS: The anomaly in mean CPD estimate in GATS-India data was due to inclusion of two heterogeneous products to define cigarettes, variation in cigarette product specific user proportions contributing to the average and non-exclusive concurrent use of other tobacco products. The consumption pattern of cigarettes among the mixed users highlights bias in CPD reporting. Definition, analysis and interpretation of 'cigarettes per day' in the GATS India survey need to be improved by redefining cigarettes and making product specific analyses.

Examining physicians' preparedness for tobacco cessation services in India: Findings from primary care public health facilities in two Indian states.

BACKGROUND: A total of 275 million tobacco users live throughout India and are in need of tobacco cessation services. However, the preparation of physicians to deliver this service at primary care health facilities remains unknown. AIMS: The study aimed to examine the primary care physicians' preparedness to deliver tobacco cessation services in two Indian states. METHOD: Researchers surveyed physicians working in primary care public health facilities, primarily in rural areas using a semistructured interview schedule. Physicians' preparedness was defined in the study as those possessing knowledge of tobacco cessation methods and exhibiting a positive attitude towards the benefits of tobacco cessation counselling as well as being willing to be part of tobacco prevention or cessation program. RESULTS: Overall only 17% of physicians demonstrated adequate preparation to provide tobacco cessation services at primary care health facilities in both the States. The findings revealed minimal tobacco cessation training during formal medical education (21.3%) and on-the-job training (18.9%). Factors, like sex and age of service provider, type of health facility, location of health facility and number of patients attended by the service provider, failed to show significance during bivariate and regression analysis. Preparedness was significantly predicted by state health system. CONCLUSION: The study highlights a lack of preparedness of primary care physicians to deliver tobacco cessation services. Both the curriculum in medical school and on-the-job training require an addition of a learning component on tobacco cessation. The addition of this component will enable existing primary care facilities to deliver tobacco cessation services.

Hardcore smoking in three South-East asian countries: results from the global adult tobacco survey.

BACKGROUND: Hardcore smoking is represented by a subset of daily smokers with high nicotine dependence, inability to quit and unwillingness to quit. Estimating the related burden could help us in identifying a high risk population prone to tobacco induced diseases and improve cessation planning for them. This study assessed the prevalence and associated factors of hardcore smoking in three South-East Asian countries and discussed its implication for smoking cessation intervention in this region. MATERIALS AND METHODS: Global Adult Tobacco Survey (GATS) data of India, Bangladesh and Thailand were analyzed to quantify the hardcore smoking prevalence in the region. On the basis of review, an operational definition of hardcore smoking was adopted that includes (1) current daily smoker, (2) no quit attempt in the past 12 months of survey or last quit attempt of less than 24 hours duration, (3) no intention to quit in next 12 months or not interested in quitting, (4) time to first smoke within 30 minutes of waking up, and (5) knowledge of smoking hazards. Logistic regression analysis was carried out using hardcore smoking status as response variable and gender, type of residence, occupation, education, wealth index and age-group as possible predictors. RESULTS: There were 31.3 million hardcore smokers in the three Asian countries. The adult prevalence of hardcore smoking in these countries ranges between 3.1% in India to 6% in Thailand. These hardcore smokers constitute 18.3-29.7% of daily smokers. The logistic regression model indicated that age, gender, occupation and wealth index are the major predictors of hardcore smoking with varied influence across countries. CONCLUSIONS: Presence of a higher number of hardcore smoking populations in Asia is a major public health challenge for tobacco control and cancer prevention. There is need of intensive cessation interventions with due consideration of contextual predictors.

Extending application of the 'hardcore' definition to smokeless tobacco use: estimates from a nationally representative population in India and its implications.

BACKGROUND: The term 'hardcore' has been applied to use of smoking tobacco and generally referred to as the inability or unwillingness of regular smokers to quit. The component constructs of hardcore except nicotine dependence are product neutral. With the use of 'time to first chew' as a measure of nicotine dependence, hardcore definition can be extended to characterize smokeless tobacco users. Hardcore users respond less to tobacco cessation interventions, and are prone to tobacco induced diseases including cancer. Thus identifying hardcore users would help in estimate the burden of high risk population for tobacco induced diseases. Smokeless tobacco use is predominant and accounts for more than 50% of oral cancer in India. Hence, hardcore chewing information could be used for planning of tobacco and cancer control interventions. The objective of this study was to assess the prevalence and associated factors of hardcore smokeless tobacco use in India. MATERIALS AND METHODS: Global Adult Tobacco Survey (GATS)-India 2010 data were analyzed to quantify hardcore smokeless tobacco use in India with following five criteria: (1) current daily smokeless tobacco use; (2) no quit attempt in the past 12 months of survey or last quit attempt of less than 24 hours duration; (3) no intention to quit in next 12 months or not interested in quitting; (4) time to first use of smokeless tobacco product within 30 minutes of waking up; and (5) knowledge of smokeless tobacco hazards. RESULTS: The number of hardcore smokeless tobacco users among adult Indians is estimated to be 5% (39.5 million). This group comprises 23.2% of daily smokeless tobacco users. The population prevalence varied from 1.4-9.1% across different national regions of India. Logistic regression modeling indicated age, education and employment status to be the major predictors of hardcore smokeless tobacco use in India. CONCLUSIONS: The presence of a huge number (39.5 million) of hardcore smokeless tobacco users is a challenge to tobacco control and cancer prevention in India. There is an unmet need for a universal tobacco cessation programme and intensification of anti-tobacco education in communities.