No Child's Play: Under-five Child Feces Management in a Rural Area of Bengaluru Urban District, India.

Background: Inappropriate feces disposal leads to environmental contamination, and increases the risk of exposure to children. We aimed to estimate the proportion of rural households with knowledge and practice of safe management of feces (SMoF) among under-five children and to identify associated factors. Materials and Methods: A cross-sectional study was conducted in eight villages in Bengaluru Urban district over 2 months, using a face-validated semi-structured interview schedule. SMoF was defined based on five criteria - defecation site, transport tool, feces disposal, cleaning of transport tool, and hand washing. Results: Out of 320 under-five children surveyed, 15.7% were pre-ambulatory and 84.3% were ambulatory. The majority of the caregivers (92.5%) felt that children should defecate in the latrine and only 23.7% were aware that child feces were more infectious than adult feces. SMoF was only practiced by caregivers of ambulatory children (52.6%). Households with older caregivers (P = 0.01) and those living in a pucca house (P = 0.02) with a latrine inside (P = 0.04) were found to practice SMoF. Children of households that practiced unsafe disposal of child feces experienced more diarrheal episodes (P = 0.04). Caregivers >20 years were found to have better odds of SMoF [20-25 years (adjusted odds ratio, aOR: 9.02), 26-30 years (aOR: 12.17), >30 years (aOR: 8.93)] compared to those <20 years. Conclusion: The proportion of households with knowledge and practice of SMoF was low. Awareness of SMoF is essential to reduce the incidence of diarrheal diseases and improve sanitation. Our findings also call for awareness building at schools and colleges.

Knowledge, attitude, and practice of patients, visiting a private primary level health care facility towards family physicians.

Aim and Objective: To study the knowledge, perception, attitude, and practice of patients visiting a private primary health centre towards family physicians. Methodology: A cross-sectional questionnaire-based study was planned. Results: A total of 272 patients visiting the health centre were included in the study. Knowledge: Above 90% of the patients felt confident in the capabilities of family physicians in managing all kinds of health problems and the time/cost-effectiveness of this speciality. Timely referral and holistic care were other areas that boosted their confidence on family physicians. 96.7% knew that family physicians are trained specialists. Attitude: Although only 50% of the study participants were already seeking the services of a family physician, 88% of them felt that a family physician would be their primary point of contact in their health care needs. Practice: The positive attitude, knowledge, and perception towards family medicine were not reflected on their treatment seeking practice in areas of care, such as childcare (66.2%) and pregnancy (81.6%), where they preferred the services of a specialist. Also, for diabetes (52%) and chest pain (66%) related issues, the patients favoured a specialist's care over that of a family physician. Conclusion: Patients visiting our primary health centre had good knowledge and positive perception about the family physicians. Preference for specialists over family physicians was seen for conditions such as chest pain, diabetes care, child care, and obstetrics issues.

Community perceptions and individual experiences of breast cancer in communities in and around Bangalore, India: a qualitative study.

Breast cancer is the most common cause of cancer mortality in India, yet breast cancer literacy remains poor. This study aimed to assess community perceptions and experiences with breast cancer in order to identify and address the gaps in our understanding of the socio-cultural barriers to awareness and care-seeking for breast cancer.Qualitative focus group discussions and in-depth interviews were conducted among breast cancer survivors and caretakers, health workers, and general population individuals in a tertiary care facility, urban underprivileged community, and rural setting around Bangalore city. Data was thematically analyzed using inductive approach.Breast cancer awareness was commonly gained through interpersonal relationships or self-experiencing breast cancer, mass media, and medical personnel. The most significant barriers to seeking care for breast cancer were cost of care, lack of female doctors, fears of diagnosis, and death. Stigma of breast cancer was attributed to possible isolation by the community members and misconception that cancer is infectious thereby delaying care-seeking.This study provides an understanding of what individuals perceive about breast cancer and highlights some important anecdotes from breast cancer survivors who have experienced the full extent of a breast cancer diagnosis in India. The institutional and social barriers brought out by this study may be taken into consideration when planning targeted interventions for breast cancer in India.

Fear of Childbirth among Pregnant Women Availing Antenatal Services in a Maternity Hospital in Rural Karnataka.

BACKGROUND: Pregnancy, though joyful, may be a time of fear and anxiety. Twenty percent of pregnant women in developed nations report a fear of childbirth, and 6%-10% describe a severe fear that is crippling. This could lead to adverse maternal and fetal outcomes. Data on fear of childbirth among pregnant women are lacking in India and would help in incorporating measures to enhance routine antenatal care. METHODOLOGY: With the objective of documenting fear of childbirth and associated factors, a cross-sectional study was conducted in rural Karnataka among women availing antenatal care services, using a face-validated 30 item questionnaire developed by the authors which was then scored to determine fear of childbirth. RESULTS: Of 388 women studied, 45.4% (176) had a fear of childbirth. The commonest fears documented were: not feeling confident about childbirth, being afraid or tense about the process of childbirth, fear of labor pains, and fear of cesarean section. Teenage pregnancy, nulliparity, primigravida status, and having no living child were significantly associated with fear of childbirth. CONCLUSION: Overall, 45.4% (176) of women had a fear of childbirth. It is important to identify and address the various fears of childbirth that women may have, as revealed by this study, with a view to providing information and reassurance to the mother, with the aim of improved maternal and fetal outcomes.

Cardiovascular risk factor reduction by community health workers in rural India: A cluster randomized trial.

BACKGROUND: There is a need to identify and test low-cost approaches for cardiovascular disease (CVD) risk reduction that can enable health systems to achieve such a strategy. OBJECTIVE: Community health workers (CHWs) are an integral part of health-care delivery system in lower income countries. Our aim was to assess impact of CHW based interventions in reducing CVD risk factors in rural households in India. METHODS: We performed an open-label cluster-randomized trial in 28 villages in 3 states of India with the household as a unit of randomization. Households with individuals at intermediate to high CVD risk were randomized to intervention and control groups. In the intervention group, trained CHWs delivered risk-reduction advice and monitored risk factors during 6 household visits over 12 months. Households in the non-intervention group received usual care. Primary outcomes were a reduction in systolic BP (SBP) and adherence to prescribed BP lowering drugs. RESULTS: We randomized 2312 households (3261 participants at intermediate or high risk) to intervention (1172 households) and control (1140 households). At baseline prevalence of tobacco use (48.5%) and hypertension (34.7%) were high. At 12 months, there was significant decline in SBP (mmHg) from baseline in both groups- controls 130.3 ±â€¯21 to 128.3 ±â€¯15; intervention 130.3 ±â€¯21 to 127.6 ±â€¯15 (P < .01 for before and after comparison) but there was no difference between the 2 groups at 12 months (P = .18). Adherence to antihypertensive drugs was greater in intervention vs control households (74.9% vs 61.4%, P = .001). CONCLUSION: A 12-month CHW-led intervention at household level improved adherence to prescribed drugs, but did not impact SBP. To be more impactful, a more comprehensive solution that addresses escalation and access to useful therapies is needed.

"DIABETIC TAX" - Cost of Care among Persons with Type 2 Diabetes Mellitus in an Urban Underprivileged Area of Bengaluru.

BACKGROUND: Diabetes mellitus drains a significant percent of the health budget by cost toward direct diabetes care and diabetes-related disabilities. OBJECTIVES: The aim of the study is to assess the annual costs incurred by patients with type 2 diabetes mellitus. METHODOLOGY: This cross-sectional study was undertaken among 153 diabetic people in an urban underprivileged area of Bengaluru from January 2013 to January 2014. This was a cost of illness study done from the patient's perspective using a structured interview schedule. RESULTS: A diabetic person in an urban underprivileged community in Bengaluru spends 11,489.38 ± 28,341.77 annually for diabetic care. Direct and indirect costs accounted for 95% and 5% of costs. Majority were spent on admission (45.1%), followed by drugs (21.8%), investigations (5.6%), and consultations (4.5%). Nonmedical costs such as food and transport accounted for 18% of the costs. About 50% of them had delayed treatment due to financial constraints. Nearly 25% of patient's income and 10.7% of the family income were spent for diabetic care. Higher education, income, duration of disease, hospital admission, type of treatment, and place of treatment were found to be associated with costs. CONCLUSION: Estimates of cost will help conceptualize strategies to deal with the situation at local, regional, and national level.

Nutritional Status, Hygiene Level, Morbidity Profile, and Their Effect on Scholastic Performance among School Children in Two Subcenter Areas of a PHC in Anekal Taluk, Karnataka, India.

BACKGROUND: Various factors such as age, sex, nutrition, hygiene, and morbidity impact the scholastic performance of schoolchildren. OBJECTIVES: (1) The objective of the study is to assess the hygiene level, nutritional status, morbidity profile, and scholastic performance of children attending government schools in two select subcenter areas of Karnataka and (2) to study the association of hygiene level, nutritional status, and morbidity profile with scholastic performance. METHODOLOGY: A cross-sectional study was done from July to August 2017 among children studying in the government schools of Mugalur and Kuthganahalli subcenters under Sarjapur PHC, Anekal Taluk, Bengaluru urban district. After obtaining permissions, general checkup of the students was done for morbidity pattern, and their anthropometric measurements were documented. Hygiene levels of the students were observed with a checklist to obtain scores that were grouped into good and poor. Attendance and grades were obtained from the class teacher to assess the scholastic performance. RESULTS: Of a total 403 students studied, the mean age was 10.2 years (standard deviation: 2.87) with 51.1% girls. Nutrition status was good in 236 (58.6%) students and 262 (65%) had good hygiene. At the time of examination, 211 (53%) had at least one morbidity, with most common being dental caries (16.3%). Logistic regression showed that odds of girls having better grades is 2.4 times more when compared to boys and 2.1 times more likely in students with good hygiene. Students with good hygiene are 2.1 times more likely to have good attendance. CONCLUSION: Hygiene status impacts the attendance and grades of the students. Girl students had significantly better grades than the boys.

Effectiveness of Color Coded Diabetic Control Monitoring Charts among Elderly Diabetics Attending Outreach Primary Care Geriatric Clinics in Rural Karnataka: An Open Label Randomized Control Trial.

INTRODUCTION: Type 2 diabetes mellitus problem is progressively rising every day. The adherence to the treatment approaches and health-seeking make major difference in case of diabetics particularly elderly. Visual tools improve the involvement of patients in their care, especially among populations with low health literacy. OBJECTIVE: To evaluate the effectiveness of color-coded diabetic control monitoring charts on glycemic control among elderly diabetics. METHODOLOGY: 144 elderly diabetic patients attending rural primary care geriatric clinics were randomized into two groups. Those randomized to the intervention group received the color-coded diabetic monitoring chart and a health education package in addition to the usual consultation services. Baseline and 1-year follow-up glycated hemoglobin (HbA1C) values were used to assess the effectiveness of the intervention. RESULTS: The results of multivariate linear regression analysis showed that there was an average reduction of 0.265% in HbA1C value in the intervention group when compared to the nonintervention group when adjusted for baseline HbA1C and number of visits during the intervention period (ß coefficient = 0.265, P < 0.05). CONCLUSION: Color-coded diabetes charts are effective in achieving glycemic control among elderly diabetics, and steps should be made to inculcate visually appealing management approaches in case of elderly diabetic patients.

Adherence to prescribed medications for chronic illnesses among older adults in a rural community, Karnataka, India.

AIM: To assess adherence to prescribed medications for chronic illnesses and to identify factors associated with it among rural older adults. METHODS: A cross-sectional study was carried out from September to November 2011 in three subcenters in Lakkur PHC, Kolar District, India. All older adults were listed, and those suffering from chronic non-communicable diseases were included in the study. A structured interview schedule comprising of 48 items was used to measure adherence, and to identify factors associated with adherence in the domains of socioeconomic status, therapy, health systems, patient behavior and physical factors. RESULTS: Of the 184 older adults included in the study, 63.6% were fully adherent to their medication. Non-adherence to medication showed a statistically significant relationship with the absence of a medical store within their village, non-availability of drugs at the nearest medical store, inability to understand the doctor's language, failure to explain the consequences of not taking medicines by the healthcare provider, self-alteration of medicine dosage, fear that medicines will lead to the development of dependence to medicines and difficulty in swallowing. Those who led busy lives, those who had been prescribed three or more types of medicines prescribed per day, those who required special skills to take medicines (injections, inhalers), those who had made adjustments to their usual lifestyle to take medicines and those who had knowledge that medicines need to be taken lifelong were more likely to be adherent to their medications. Four factors, namely, the doctor explaining the consequences of not taking medicines, altering the dosage of the medicines by the patients themselves, the number of medicines prescribed per day and having the knowledge that medicines need to be taken lifelong, were critical determinants of adherence to medications. Geriatr Gerontol Int 2016; 16: 1339-1345.

Prevalence of Malnutrition and Relationship with Scholastic Performance among Primary and Secondary School Children in Two Select Private Schools in Bangalore Rural District (India).

BACKGROUND: Malnutrition is a serious problem among children in developing countries. In India; a school meal program is in place to combat malnutrition, but only in government schools. This study is an attempt to assess the prevalence of malnutrition in primary and secondary school children in private schools and to also assess the relationship between malnutrition and academic performance. MATERIALS AND METHODS: All 582 students from class 1-7 from two select schools in rural Bangalore, India were included in the study. Information on age of study subjects were collected from school records. Height and weight measurements were taken. BMI was calculated. Children were clinically examined for pallor. Data on height, weight and BMI was transformed into WHO 2007 Z scores and then was categorized as < -3 SD, -2 to -3 SD, > -2 SD, > 2 SD. Mathematics and English scores of the previous two class tests were taken, average scores were calculated. Statistical tests used were Chi square test, Odd's ratio, Chi square for trend. RESULTS: A total of 582 students participated in this study. Males were 54% (315) and females were 46% (267). One hundred and fifty-nine (27%) of the children had pallor, 81 (20%) had under nutrition, 38 (7%) had stunting, 197 (34%) had thinness and 5 (1%) were found to be obese. Positive relationship was found between weight for ageZscores and English as well as Maths; Height for age Z scores with English. CONCLUSION: Hence we conclude that the prevalence of malnutrition is high among children in private schools also; and the nutritional status of the children is strongly associated with their academic performance.

Challenges in conducting community-based trials of primary prevention of cardiovascular diseases in resource-constrained rural settings.

Cardiovascular diseases account for almost half of all deaths from noncommunicable diseases, and almost 80% of these deaths occur in low- and middle-income countries such as India. The PrePAre (Primary pREvention strategies at the community level to Promote treatment Adherence to pREvent cardiovascular disease) trial was a primary prevention trial of community health workers aimed at improving adherence to prescribed pharmacological and nonpharmacological therapies in cardiovascular diseases. It was conducted at three geographically, culturally and linguistically diverse sites across India, comprising 28 villages and 5699 households. Planning and implementing large-scale community-based trials is filled with numerous challenges that must be tackled, while keeping in mind the local community dynamics. Some of the challenges are especially pronounced when the focus of the activities is on promoting health in communities where treating disease is considered a priority rather than maintaining health. This report examines the challenges that were encountered while performing the different phases of the trial, along with the solutions and strategies used to tackle those difficulties. We must strive to find feasible and cost-effective solutions to these challenges and thereby develop targeted strategies for primary prevention of cardiovascular diseases in resource-constrained rural settings.

Rationale and design of the Primary pREvention strategies at the community level to Promote Adherence of treatments to pREvent cardiovascular diseases trial number (CTRI/2012/09/002981).

INTRODUCTION: Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality in low-income countries including India. There is a need for effective, low-cost methods to prevent CVDs in rural India. One strategy is to identify and implement interventions at high-risk individuals using community health workers (CHWs). There is a paucity of CHW-based CVD intervention trials from low-income countries. METHODS: We designed a multicenter, household-level, cluster-randomized trial with 1:1 allocation to intervention and control arms. The CHWs undertook a door-to-door survey and screened 5,699 households in 28 villages from 3 rural regions in India to identify at-risk households. The households were defined as those with ≥1 individual aged ≥35 years and at moderate or high risk for CVD based on the non-laboratory-based National Health and Nutrition Examination Survey score. All at-risk individuals were invited to attend a physician-led village clinic that provided a CVD risk reduction prescription and education about target risk factor levels for CVD control. All households in which at least 1 member at moderate to high risk for CVD had received a risk reduction prescription were eligible for randomization. Households randomized to the CHW-based intervention will receive 1 household visit by a CHW every 2 months, for 12 months. During these visits, CHWs will measure blood pressure, ascertain and reinforce adherence to prescribed therapies, and modify therapy to meet targets. Households randomized to the control arm do not receive CHW visits. At 12 months after randomization, we will evaluate 2 primary outcomes of systolic blood pressure and adherence to antihypertensive drugs and secondary outcomes of INTERHEART risk score, body mass index, and waist-to-hip ratios. At 18 to 24 months after randomization and 6 to 12 months after the last intervention, we will record these outcomes to evaluate sustainability of intervention. RESULTS: Community health workers screened a total of 5,033 households that included 9,248 individuals and identified 2,571 households with 3,784 at-risk individuals. We randomized 2,438 households (1,219 to intervention and 1,219 to control groups). CONCLUSION: Our large trial of CHWs in rural India will provide important information regarding a promising approach to primary prevention of CVDs.