Designing and Evaluating a Personalized, Human-Centered Dietary Decision Support System for Use Among People With Diabetes in an Indian Setting: Protocol for a Quasi-Experimental Study.

BACKGROUND: Human-centered dietary decision support systems are fundamental to diabetes management, and they address the limitations of existing diet management systems. OBJECTIVE: The objective of the proposed study is to evaluate the use of an interactive, telephone-linked, personalized, human-centered decision support system for facilitating the delivery of personalized nutrition care for patients with diabetes. METHODS: A quasi-experimental trial was conducted between the period of June and December 2018. Study participants were recruited from Community Health Center, Dharamshala, Kangra (urban population), and Model Rural Health Unit, Haroli Block, Una (rural population). Eligible participants included adults aged ≥30 years with controlled or uncontrolled diabetes, those who agreed to participate in the study, those who were available for follow-up interviews, and those with a telephone or computer at home. Diabetic status was determined via a physician's diagnosis. Individuals with mental or physical challenges that affected their ability to use an electronic diet record, those who were not available for a telephone follow-up, and those who were involved in other protocols related to dietary assessments were excluded. The study participants were randomized into the following two groups: the intervention group (telephone-linked dietary decision support system) and the control group (paper-based diet record). Study participants in the intervention group recorded their daily dietary intake by using a telephone-linked, personalized, human-centered dietary decision support system and received personalized feedback and diet education via SMS text messaging. Study participants in the control group were provided with only a paper-based diet record for documenting their daily dietary intake. Follow-up visits were conducted at 3 and 6 months from the baseline in both groups. Differences in diabetes knowledge, attitudes, and practices will be measured across groups. RESULTS: The collection of baseline data from 800 study participants in both the intervention (n=400) and control groups (n=400), which were stratified by urban (control group: n=200; intervention group: n=200) and rural settings (control group: n=200; intervention group: n=200), has been completed. Follow-up data collection for months 3 and 6 is ongoing and is expected to be completed by October 2019. CONCLUSIONS: We anticipate that the intervention group will show significant changes in nutrition knowledge, attitudes, and practices; satisfaction with care; and overall diabetes management. We also expect to see urban-rural differences across the groups. The uniqueness of our nutrient data capture process is demonstrated by its cultural and contextually relevant features-diet capture in both English and Hindi, diet conversion into caloric components, sustained diet data collection and participant adherence through telephone-linked care, and auto-generated reminders. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/13635.

Effect of emergency obstetric care and proximity to comprehensive facilities on facility-based delivery in Malawi and Haiti.

Proximity of households to comprehensive obstetric care is a key determinant for preventing maternal mortality due to obstetric emergencies. The relationship between proximity to comprehensive care and facility delivery is further complicated by the use of varied methods in measuring facility obstetric capacity-which may misrepresent the real scenario of obstetric care availability in a service environment. We investigated the joint effects of proximity and two emergency obstetric care assessment (EmOC) methods on women's place of delivery in Malawi and Haiti. Household level and health facility data were obtained from the 2013-2018 Demographic and Health Surveys and Service Provision Assessment surveys. Records of women aged 15 to 49 years who had a childbirth in the last 5 years were linked to obstetric facilities within 5km, 10km and 15km from their households using Kernel Density Estimation. Log-binomial models were fitted to estimate the joint effects of proximity to comprehensive facilities on place of delivery and two EmOC methods (1. the facility's recent performance of signal functions only, and 2. a composite index of obstetric care), and whether this varied by urban/rural setting. Proximity to comprehensive facilities was significantly associated with facility delivery in Malawi among women living 5km of a comprehensive facility (using EmOC method 2), in addition, living further (15km) from facilities with high capacity of EmOC was associated with reduced likelihood for facility delivery in urban settings in stratified analyses. In contrast, positive associations were present in Haiti in both urban and rural settings, with the likelihood of facility delivery being higher with greater proximity of women to comprehensive facilities, regardless of methods to define EmOC. Women living within 5km of a comprehensive facility in Haiti were the most likely to deliver in facilities based on EmOC method 1 (APR: 1.81, 95% CI 1.56, 2.09). Findings from Malawi elucidates the relevance of context and suggests the need for research in diverse settings.

Burden of household food insecurity in urban slum settings.

This study examined the burden of food insecurity in India's un-notified slums, using an SDG framework to identify correlates of food insecurity. A convenience sampling approach was employed in selecting 38 slums from 675 un-notified slums across four geographic zones. Ten percent of the households in each slum site were selected from each zone, and one household member was interviewed, based on their availability and fulfilment of the eligibility criteria. Eligible individuals included those aged 18 years and above, who were resident in the selected slums and provided consent. Individuals with mental or physical challenges were excluded. A total sample of 907 study participants were included. Results showed that 43% (n = 393) of the participants were food insecure. More than half were females (73%, n = 285), who had not completed any schooling (51%, n = 202). One-third (n = 128) resided in the Northern Region of Delhi. SDG-related predictors of food insecurity included: household educational level (SDG 4 Quality education) (p = 0.03), coverage of health service needs (SDG 3 Good health and well-being) (p = 0.0002), electricity needs (SDG 7 affordable and clean energy) (p<0.0001), and employment needs (SDG 8 Decent and economic growth) (p = 0.003). Having healthcare needs that were partially or fully met was equally associated with higher food insecurity: this could be attributed to high healthcare costs and the lack of federal subsidies in un-notified slums, collectively contributing to high out-of-pocket health costs. Failure to fully meet employment needs was also significantly associated with higher food insecurity. However, met needs for electricity, finance, women's safety and satisfactory family relationships, were associated with lower food insecurity. Household predictors of food insecurity included: number of household members, and the presence of physically disabled household members. Necessary interventions should include connecting food insecure households to existing social services such as India's Public Distribution System, and multi-sector partnerships to address the existing challenges.