Implementation of Pediatric Allergic Rhinitis Module as a Part of AETCOM among First-Year Medical Undergraduates: Mixed Methods Evaluation.

Background: Children suffering from allergic rhinitis (AR) in their earlier days of life, not receiving proper treatment, subsequently develop asthma. To sensitize the first-year medical undergraduates about AR by implementing pediatric allergic rhinitis (PAR) module as a part of their attitude, ethics, and communication (AETCOM) curriculum. Materials and Methods: Triangulation type of mixed method study was conducted from January 2021 to June 2021 among 125 first-year medical undergraduate students. The PAR module communication checklist was developed and validated by an interprofessional (IP) team. Twenty multiple-choice questions (MCQs) were framed for both pretest and posttest cognitive assessment of the students. The pretest assessment was done (first 15 min) followed by the teaching of the PAR module (30 min), and lastly the posttest assessment along with open-ended feedback (last 15 min). Objective Structured Clinical Examination (OSCE) communication checklist along with the guidelines was given to the observer during the student-patient encounter to score the learner and to assess the communication skill. Apart from descriptive analysis, paired t-test and content analysis were done. Results: A statistically significant difference in the mean scores before and after the PAR module and communication checklist (P < 0.001). Majority (78/81, 96%) of the students favored this module, while (28/81) 34.6% suggested modifications. Most of the parent's feedback was good about the student's communication skill in terms of empathy (118), behavior (107), and greet (125); however, 33 parents were about the opinion of difficulties in closing the session, 17 parents commented about student's language problem and 27 about feedback. Conclusion: The PAR module should be taught in the current medical curriculum as a part of AETCOM in the foundation course as early clinical exposure with some modifications in the existing module.

Quality, Equity and Partnerships in Mixed Methods and Qualitative Research during Seven Years of Implementing the Structured Operational Research and Training Initiative in 18 Countries.

Introduction: Qualitative studies are often inadequately reported, making it difficult to judge their appropriateness for decision making in public health. We assessed the publication characteristics and quality of reporting of qualitative and mixed-method studies from the Structured Operational Research and Training Initiative (SORT IT), a global partnership for operational research capacity building. Methods: A cross-sectional analysis of publications to assess the qualitative component using an adapted version of the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Results: In 67 publications involving 18 countries, 32 journals and 13 public health themes, 55 were mixed-methods studies and 12 were qualitative studies. First authorship from low-and-middle-income (LMIC) countries was present in 64 (96%), LMIC last authorship in 55 (82%), and female first authorship in 30 (45%). The mean LMIC institutions represented per publication was five (range 1-11). Sixty-three (94%) publications were open access. Reporting quality was graded as 'good' to 'excellent' in 60 (89%) publications, 'fair' in five (8%) and 'poor' in two (3%). Conclusion: Most SORT IT publications adhered to COREQ standards, while supporting gender equity in authorship and the promotion of LMIC research leadership. SORT IT plays an important role in ensuring quality of evidence for decision making to improve public health.

Evaluation of e-learning in a department of Community Medicine as a response to COVID-19 pandemic.

BACKGROUND: COVID-19 pandemic pushed all educational institutions to rely exclusively on technology-based learning. As this was done for the first time, it is ideal to evaluate the e-learning program to refine and consolidate the learned experience. Hence, the current study was undertaken to evaluate the online learning and teaching experiences of students and teachers. MATERIALS AND METHODS: This program evaluation on e-learning was carried out in the department of Community Medicine (DCM) in a private medical college using context/input/process/product framework among IV, VI, and VII semester undergraduate students and faculties in DCM who were exposed to e-learning for the period of 2 months since April 2020. Google Forms was used to design a survey questionnaire that was conceptualized as per the needs of the evaluation framework. Ethics Committee approval was obtained. Descriptive analysis was done for quantitative variables and manual content analysis using Lewin's force field framework was performed for the qualitative data. RESULTS: Out of 301 undergraduates contacted, 196 (65.1%) responded to online survey. Their mean age was 19.9 years and 128 (65.3%) were females. Mobile phone was used by 93.4% to access e-learning. Combined modality of learning was preferred by 58.2% of them in future. Six "for" and "against" factors on e-learning emerged out of content analysis pertaining to three main stakeholders, namely administrator, faculty, and student. CONCLUSION: Our evaluation conveys that for effective e-learning in any subject, the students, educators, and institutional factors that were identified need to be considered throughout all phases of program development with careful assumptions about its acceptance by the millennial.

Effect of a community-based intervention on self-care among diabetes patients in rural Tamil Nadu: A mixed-method study.

INTRODUCTION: Peer support models for the management of diabetes self-care have been hailed as a promising solution to strengthen a formal health system to support diabetes patients. Diabetes self-care in patients can truncate the risk factors and reduce the complications. OBJECTIVE: To identify self-care level (adherence to the diet, exercise, treatment) and depression among known diabetes patients and to find the effect of the support group intervention on diabetes self-care. METHODS AND MATERIAL: A Sequential type Embedded Mixed-Method study (qual→QUAN(qual)→qual) was conducted in three phases in 168 known diabetes adults aged ≥ 30 years in a rural setting. After obtaining IEC clearance, the intervention was carried out over eight months, forming peer support groups in four villages. Each group comprises between six to 12 participants. Assessment of self-care, treatment adherence and depression with standardized scales. DATA ANALYSIS: A manual content analysis was performed on the qualitative data. The Wilcoxon rank test was used to compare the quantitative data before and after intervention and analyzed using SPSS (Version_24) software package. RESULTS: In this study, we found improved self-care practices and treatment adherence among study participants (p < 0.001). About 88.7% of participants said that the support group was useful and provided moral support for diabetes. CONCLUSION: We found an improvement in treatment adherence, self-care among diabetes patients' and marginal improvement in depression status through support group intervention. Also the peer support group was well accepted, and it provided the low-cost, feasible intervention respect to the chronic conditions like diabetes, by addressing their behavioral changes and support from community. By sustaining the support group, might able to achieve the efficient health care in high quality even at resource-poor settings. KEY MESSAGES: A Community-Based intervention for the diabetes self-care using peer support group among the diabetes patients will improve the self-care practices in the area with limited access to healthcare and financial resources, it provides a low-cost, flexible, culturally sensitive approach to support self-care management and reduce the further complications among It also imporve the problem-solving capacity and social support from families and peers patients.

Breastfeeding Positioning and Attachment among Postnatal Mothers: A Mixed Methods Study in a Tertiary Care Hospital in Puducherry, South India.

Introduction: Proper positioning and attachment play a key role in exclusive breastfeeding. Whereas incorrect breastfeeding techniques lead to poor milk transfer and early discontinuation of breastfeeding. Objectives: 1. To assess the breastfeeding techniques among postnatal mothers and to identify the factors associated with improper positioning and poor attachment. 2. To prioritize the action points to improve the poor breastfeeding practices according to the viewpoint of the staff nurses. Materials and Methods: A hospital-based mixed-methods study was carried out in Puducherry for 6 months. In quantitative phase, 99 postnatal mothers were interviewed consecutively and breastfeeding techniques were observed based on Baby Friendly Hospital Initiative and Integrated Management of Neonatal and Childhood Illness guidelines. In qualitative phase, 45 staff nurses ranked the action points to improve the poor breastfeeding practices. Bivariate and multivariate analyses were employed. Mean rank and Kendalls' Concordance Coefficient were calculated for the ranked data. Results: About 28.3% and 27.3% of mothers demonstrated improper positioning and poor attachment, respectively. Young mothers, housewives, <10 days old infants, and failure to receive breastfeeding counseling were associated with poor breastfeeding techniques. Poster displays, healthcare workers' training, targeted counseling, and assistance were the priority action points suggested by the staff nurses. Conclusion: Maternal age, maternal occupation, infants' age, and breastfeeding counseling influenced breastfeeding techniques. The prioritized action points need to be implemented to achieve the level of Baby Friendly Hospital.

Promotion of toilet construction and usage in rural Tamil Nadu: A mixed-methods evaluation study.

Background: Open defecation is the leading cause for malnutrition and diarrhoeal deaths in low- and middle-income countries. The negative public health impacts of open defecation could be neutralized by toilet usage. However, the usage of improved sanitation facilities is unsatisfactory in rural India. Objectives: The study was carried out to find the psycho-social barriers among households for not having toilets and for not using the owned toilets and to develop and find out the effect of Behaviour Change Communication (BCC) strategy on toilet construction and usage. Methods: A community-based Embedded Experimental Mixed Methods study was undertaken in the four field practice villages of Urban Health Training Centre, Villupuram. For baseline and end-line surveys, 422 independent sample households who were not having or not using the toilets were selected by Simple Random Sampling. After IEC clearance, interviews and direct observation of the toilets were undertaken. Context-specific multi-faceted BCC strategy was employed through community participation. The data were analyzed in SPSS software. Chi-square test was used to determine the significance of difference and effect size was calculated to estimate the size of the difference between the baseline and end-line data. Results: Toilet ownership and utilization improved by 21.3% and 23.3% points, respectively. There was a significant reduction in households' perceived psychosocial barriers in toilet adoption. Conclusion: Our intervention demonstrated considerable improvements in both toilet construction and usage surpassing the psycho-social barriers. Future sanitation promotion interventions should focus more on community participation and the key messages should be reinforced multiple times using different channels.

Early initiation of breastfeeding and factors associated with its delay among mothers at discharge from a single hospital.

BACKGROUND: According to the National Family Health Survey- 4, in India, 78.9% of deliveries occur in institutions, although only 42.6% of new mothers initiate breastfeeding within 1 hour of delivery. PURPOSE: To estimate the proportion of early initiation of breastfeeding (EIBF) among new mothers at discharge from a tertiary care hospital and identify the determinants of delayed initiation of breastfeeding among them. METHODS: This was a hospital-based analytical cross-sectional study of 108 new mothers. After obtaining Institutional Review Board approval and informed consent, we interviewed the new mothers on the day of discharge. Multivariate logistic regression was performed using IBM SPSS Statistics ver. 24. RESULTS: The median breastfeeding initiation time was 90 minutes (interquartile range, 30-180 minutes). Overall, 43.5% of the mothers practiced EIBF, 77.4% practiced exclusive breastfeeding, and 43.5% were rooming in at discharge. Reasons for breastfeeding delays included extended recovery time from spinal anesthesia, maternal lassitude, and uncomfortable breastfeeding position due to post-cesarean pain. In the multivariate analysis, a birth weight less than 2,500 g (adjusted odds ratio [aOR], 4.33; 95% confidence interval [CI], 1.12-16.82; P=0.03), cesarean section delivery (aOR, 4.68; 95% CI, 1.57- 13.92; P=0.005), and mother's poor knowledge of breastfeeding (aOR, 4.61; 95% CI, 1.44-14.72; P=0.010) were more likely to delay the initiation of breastfeeding. CONCLUSION: EIBF was practiced by less than half of the new mothers as determined by the cesarean section, baby's birth weight, and mothers' awareness of breastfeeding. Thus, it is vital to improve breastfeeding and nutritional counseling among mothers during the antenatal period and improve healthcare professionals' training to facilitate EIBF, even in circumstances such as cesarean section.

How to reduce Domestic Violence against married women? a mixed methods study from rural Tamil Nadu.

BACKGROUND: Despite government legislations for protection of women, domestic violence (DV) continues to remain as a public health problem in India. Objectives 1. To find out the prevalence of various types of self-reported DV among married women of 18-45 years of age and to identify its social determinants and their help-seeking behavior. 2. To understand the solutions from key informants' point of view. METHODS: It was a sequential explanatory mixed methods study design, which consisted of quantitative (Survey) followed by qualitative (Interviews) phase. A representative sample of 360 married women was chosen by two-stage cluster sampling from villages in Tamil Nadu, South India. The female investigator conducted the survey by house to house visit. Post-survey, six key informant interviews were conducted to explore the solutions and suggestions from experts' point of view. Bivariate and multivariate regression analysis was carried out to identify the significant predictors of DV. Manual content analysis of qualitative data was done. RESULTS: The overall prevalence of spousal DV was 49.5% [95% CI: 44.3-54.6] in the last one year. In multivariate analysis, two factors namely 'current alcoholism in husband' and 'controlling behavior of husband' were found to be the significant predictors of DV. In order to prevent alcoholism in husband, the key informants suggested deaddiction services and measures to limit access to alcohol. Furthermore, to prevent controlling behavior of husband, the key informants suggested women's empowerment, employment, helplines, responsible parenting, social change in dowry practice and gender equality. CONCLUSIONS: The prevalence of spousal DV was found to be high. Current alcohol consumption and controlling behavior of the husband were the important determinants of domestic violence. Key informants suggested interprofessional approach consisting of deaddiction services, women empowerment and strengthening of family life to address the problem of DV.

Pregaming on Alcohol Products among Male College Students in Puducherry-Mixed-Methods Study.

BACKGROUND: There are some risky practices such as preloading or pregaming which exist among college students. When students pregame, compared with drinking episodes when they do not, they consume a greater number of drinks and have higher blood alcohol concentrations. OBJECTIVES: (1) To explore the perceptions about pregaming among male college students in Puducherry. (2) To study the prevalence of pregaming among current alcohol users. MATERIALS AND METHODS: A sequential exploratory mixed-method study (Qualitative-Focus Group Discussion [FGD] to explore pregaming followed by Quantitative-self-administered questionnaire [survey]) was conducted among 450 male engineering college students by simple random sampling. RESULTS: The prevalence of pregaming among current alcohol users was 66.7%. Among all occasions, the students were involved in pregaming mostly on birthdays 92.5% and marriages 92.5% followed by college cultural events 90%. All of the students 100% wanted to pregame for anticipated alcohol cost problems, 100% pregamed for fun and 87.5% easy conversations with the opposite sex and majority 66.6% had the intention to quit pregaming among current users. CONCLUSION: The prevalence of pregaming is high among current users however, the majority of them had the intention to quit this behavior. Counselors and health care professionals working in alcohol de-addiction centers should specifically question pregaming and its associated symptoms. Tailor-made interventions should be promoted to target the concept of pregaming-related consequences of alcohol addiction.

Strengths, Weaknesses, and Suggestions for Improvement in Postgraduate Assessment in Community Medicine in India: A Delphi Study.

OBJECTIVES: It was to understand the strengths and weaknesses of the current postgraduate assessment system in community medicine in India, to identify recommendations for change, and to build a consensus around them. MATERIALS AND METHODS: A conventional Delphi technique was preferred for consensus building among experts. We completed three Delphi rounds over a period of 4 weeks, and 16 experts participated in the study. Content analysis was done for open-ended responses, and consensus analysis was done for Likert-type scale questionnaire. In round three, we obtained their top five preferences for change in assessment. RESULTS: The experts agreed to have an assessment system based on ongoing formative and one end-of-year summative assessment. Apart from this, they agreed on the various occasions for carrying out the formative assessment. Furthermore, they clearly agreed on measures such as blueprinting, improving test formats, and adequate briefing of test-taking students. CONCLUSION AND RECOMMENDATIONS: Most of the consensus items were found to be in alignment with the modern assessment theory. Regulating body and policymakers should revise the current postgraduate assessment system in community medicine to enhance its validity and reliability.

Constructing Practical and Realistic Asset-Based Socioeconomic Status Assessment Scale Using Principal Component Analysis for Urban Population of Puducherry, India.

BACKGROUND: Socioeconomic status (SES) is a key determinant of health. However, ascertaining the SES in developing countries is really challenging. Hence, we decided to develop an asset-based simple and rational SES tool for urban population of Puducherry and compare it with Modified Kuppuswamy's (MK) scale. MATERIALS AND METHODS: Sequential mixed methods design was used. The list of local household assets to determine SES was created based on group interviews with stakeholders and review of literature. Then, survey was carried out among 500 urban households by trained medical interns after obtaining informed consent. EpiCollect-5, mobile-based software, was used to capture data. Principal component analysis (PCA) was carried out to construct a wealth index using SPSS version 24. The assets included in the final PCA were ranked based on their contribution to the index by linear regression. RESULTS: The eigenvalue for the first principal component was 6.7 accounting for 33.6% of the variance in the original data. Finally, reduced 10-item-based SES scale was created and scoring system was formulated based on regression coefficient. The weighted kappa statistics and correlation coefficient measure of reliability between household quintiles on 20-item and 10-item reduced SES tool were 0.77 and 0.95, respectively. There was a moderate correlation between SES obtained from MK scale and newly constructed scale. CONCLUSIONS: The newly devised SES scale is context specific, reliable, easy to administer, and quick to ascertain the SES and thus can be used for a similar context in future health research.

Health insurance coverage and its determinants among middle-income households in Urban Puducherry: A mixed methods study.

BACKGROUND: In India, there exists public health insurance for government employees and poor people. However, the middle-income households (MIHs) remain neglected. OBJECTIVES: The study was conducted to find out the coverage of health insurance and its determinants among MIH. METHODS: It was a community-based sequential exploratory mixed methods study. Group interview and key informant interview were conducted among various stakeholders related to insurance coverage. The quantitative survey was done among 400 randomly selected head of households (HoHs) in an urban area of Puducherry. Manual content analysis was done for qualitative data. Generalized linear model with Poisson distribution was used to calculate the adjusted prevalence ratio (aPR) using Stata software. RESULTS: The coverage of health insurance among the MIH was 41% (95% confidence interval [CI]: 36.1-50). The major reasons reported for not having insurance were poor financial status (63.7%) and lack of felt needs (59.4%). The significant determinants for the lack of health insurance among MIH were unskilled occupation (aPR: 1.62, 95% CI: 1.13-2.34) and lower education status (aPR: 1.79, 95% CI: 1.22-2.64) of HoH and less monthly family income (aPR: 2.19, 95% CI: 1.18-4.08). CONCLUSION: The health insurance coverage of 41% among MIH is better despite the fact that there was no public insurance scheme available for them in Puducherry. The MIH with the identified determinants might be considered in future for including them under publicly sponsored health insurance scheme.

Process of Developing Palliative Care Curriculum for Training Medical Interns in a Tertiary Care Teaching Hospital in Puducherry, India.

OBJECTIVES: The department of community medicine (DCM) has been training medical interns for palliative care in the hospital and community setting. There was no specific curriculum or course material available for training them. This study aims to develop, implement and evaluate the palliative care curriculum for training medical interns. MATERIALS AND METHODS: The present program development and evaluation of palliative care curriculum was done in the DCM, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India. We followed the Kern's six steps for curriculum development. It was done during July 2016 and May 2017. We framed expected outcomes from literature review and interviews with experts. The curriculum was delivered through small group sessions followed by hands-on exposure to hospital- and community-based palliative care programs guided by a workbook. Medical interns were given feedback on their field assignments on history taking, followed by reflection using structured template incorporated in the workbook. The reaction to the curriculum was collected from various stakeholders. RESULTS: Medical interns found the curriculum useful for them to acquire basic skills of pain management, communication skills and teamwork. Patients and family felt satisfied with the quality of care provided. CONCLUSION: The new palliative care curriculum was well received by all the stakeholders involved. This can be adopted in similar context for training medical interns in palliative care.

Behavior Change Communication: Past, Present, and Future.

Behavior change communication (BCC) aids in the prevention of both communicable and noncommunicable diseases in clinical settings and public health. Emerging and re-emerging infectious diseases in the future need to be tackled by developing behavioral immunity through effective BCC strategies. Health education and Information Education and Communication gradually evolved to BCC primarily focusing on creating a conducive environment for promoting behavior change. Various theories/models operating at the individual, inter-personal, and community levels were put forward to explain the core constructs of behavior change. Each theory/model has its own strengths and weaknesses in its applicability. In practice, no theory is perfect and each has certain limitations. Hence, a battery of theories may be needed to develop a BCC strategy. This review article critically appraises the evolution of BCC, the strengths and weaknesses of BCC theories/models and it's applicability from the past to the future. This review will benefit postgraduates and public health workers in understanding the concepts of BCC and applying the same in their practice.

What Do Women in Rural Tamil Nadu Think about Postmenopausal Bleeding? A Mixed-Method Study.

INTRODUCTION: Perception of women about postmenopausal bleeding (PMB) may have a greater influence on their treatment-seeking behavior. OBJECTIVES: The objective was to explore the perceptions of causes and treatment of PMB among menopausal women and to quantify its perceived reasons. MATERIALS AND METHODS: It was a sequential exploratory mixed-method study design, with two group interviews (qualitative phase), followed by a survey among 1530 postmenopausal women (quantitative phase). The qualitative data were analyzed by thematic analysis and quantitative data using descriptive statistics. RESULTS: Lack of seriousness about PMB and stigma were stated as barriers for the treatment of PMB. Among 1530 women, 40.8% of them did not know the cause for PMB. The problem in the uterus, cancer, and improved nutrition were stated as reasons by 17.6%, 16.8%, and 15.8% of women, respectively. CONCLUSION: Most of the women did not know the reason for PMB and its awareness is crucial for better uptake of screening and detection of pathology at an early stage.

Understanding barriers in implementation and scaling up WIFS from providers perspective: A mixed-method study, Rishikesh, India.

CONTEXT: Since the implementation of Weekly Iron and Folic acid Supplementation (WIFS) program in India in 2013, little effort has been made to comprehensively evaluate the program. AIMS: This study was carried out to assess the coverage of WIFS among adolescent girls, explore implementation barriers, and suggest solutions to improve WIFS through public schools in Rishikesh, India (2018-19). METHODS AND MATERIALS: This was a sequential explanatory mixed-methods study. Quantitative component was a community-based cross-sectional survey to determine the prevalence of anemia and coverage of WIFS. Qualitative component added an explanation to understand WIFS implementation through document review and nonparticipant observation of WIFS session. We invited stakeholders for nominal group discussion on barriers and solutions. STATISTICAL ANALYSIS USED: Variables were described as proportion and mean. Group discussion transcript was analyzed using content analysis. RESULTS: Of 400 adolescent girls, 16% (95% CI: 12.4, 19.6) received weekly and 45% ever received iron tablets over the last 3 months and 79% were anemic. From ten schools, one school never implemented WIFS. There was iron-folic acid (IFA) stock out for 10 months last year. Major barriers identified were nonavailability of IFA, and irregularity in submitting IFA consumption report. Suggested solutions were ensuring IFA stock, strengthening supervision, ownership, training, and regular meetings of stakeholders. CONCLUSIONS: To conclude, in a setting with high anemia prevalence, WIFS was poorly implemented. Ownership and strengthening supervision is essential for the success of the program.

Effect of Interactive Lectures and Formative Assessment on Learning of Epidemiology by Medical Undergraduates - A Mixed-Methods Evaluation.

BACKGROUND: Previously, we had a course in epidemiology for medical undergraduates that was based on traditional lecture methods with no formal formative assessment (FA). We found poor uptake of our course in terms of learning and attendance by students. OBJECTIVE: The objective was to assess the effect of improved course (interactive lectures and formal FA) in epidemiology on student learning and attendance. MATERIALS AND METHODS: It was a triangulation type of mixed-methods program evaluation, where both quantitative (quasi-experimental design) and qualitative (open-ended responses) analysis was done. This study was carried out in the department of community medicine in a tertiary care teaching hospital, Puducherry. We improved the quality of the course material, interaction in lectures and included formal structured FA in the last course. Kirkpatrick's framework was used for the course evaluation. We compared the performance of three batches to check the effect of our revisions on students' learning and their attendance. RESULTS: Student's learning outcome was measured using end-of-course assessment scores (Level-2). The percentage of students successfully completing the course improved from 39% to 81% and attendance status of ≥90% improved from 50% to 57%. Learner's immediate reactions (Level-1) were captured using open-ended questions, and content analysis was done. Students appreciated the course material, FAs, and in-class activity. CONCLUSIONS: Little improvement in a traditional epidemiology course for undergraduates in the form of interactive lectures and formative feedback and providing the student with course material led to significant gains in students' knowledge and attendance.