Impact of community-based health insurance and economic status on utilization of healthcare services: A household-level cross-sectional survey from rural central India.

Background: . Community-based health insurance (CBHI) is a health-financing mechanism based on voluntary membership, risk pooling, with a non-profit objective and relies on social capital as a driving force. It aims to improve equity in healthcare utilization in the community. We did this study to understand if CBHI schemes reach the poor, improve healthcare utilization and protect them from catastrophic health events. Methods: . Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sevagram, located in Wardha district of Maharashtra, India, runs a variety of CBHI schemes in surrounding villages. Many households (HHs) have opted for these schemes. We conducted a cross-sectional survey of all HHs of 35 villages and collected information about sociodemographics, inpatient healthcare utilization (in previous 5 years), outpatient healthcare utilization (in previous 1 year) and insurance status of the HHs. We derived wealth index based on 33 sociodemographic variables and classified HHs in quintiles of wealth index. We compared the distribution of healthcare utilization variables by insurance status and wealth index and used logistic regression to evaluate if health insurance independently improves healthcare utilization, after adjusting for confounders. Results: . Of a total of 7261 HHs surveyed, 2210 (30.4%) were uninsured, 4153 (57.2%) were insured under MGIMS CBHI schemes, and 898 (12.4%) had family insurance either from MGIMS or other providers. Insured HHs had a higher wealth index compared to uninsured. Mean (SD) hospitalization episodes in an HH were 0.82 (1.75) among uninsured, 1.13 (1.56) in CBHI insured and 1.21 (1.55) in those with family insurance. Within each category, healthcare utilization was lower for poor HHs (lowest quintile of wealth index) and higher for affluent HHs (higher quintiles of wealth index). Among those who were hospitalized, catastrophic health events were less in CBHI insured (7.9%) compared to uninsured (12.3%). After adjusting for socioeconomic status and other confounders, our data suggest that participating in a CBHI scheme increased odds of utilization of inpatient services (OR 1.18; 95% CI 1.04-1.33) and protected from catastrophic health events (OR 0.52; 95% CI 0.43-0.64). Conclusion: . CBHI schemes improve healthcare utilization and protect against catastrophic health expenditure among those who get hospitalized. However, there also exists a socioeconomic gradient both in membership and in utilization of healthcare services favouring those who are more affluent.

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.

Changing landscape of acute encephalitis syndrome in India: a systematic review.

BACKGROUND: Seasonal outbreaks of acute encephalitis syndrome (AES) occur with striking regularity in India and lead to substantial mortality. Several viruses, endemic in many parts of India, account for AES. Although Japanese encephalitis virus (JEV) is a key aetiological agent for AES in India, and has attracted countrywide attention, many recent studies suggest that enteroviruses and rhabdoviruses might account for outbreaks of AES. We did a systematic review of published studies to understand the changing landscape of AES in India. DATA SOURCES: Electronic databases (PubMed, Web of Science and BIOSIS) from the start of the database to 2010. We also hand-searched journals and screened reference lists of original articles, reviews and book chapters to identify additional studies. STUDY SELECTION: We included studies only on humans and from three time-periods: pre-1975, 1975-1999 and 2000-2010. DATA EXTRACTION: Independent, duplicate data extraction and quality assessment were conducted. Data extracted included study characteristics, type of study and aetiological agent identified. DATA SYNTHESIS: Of the 749 unique published articles screened, 57 studies met the inclusion criteria (35 outbreak investigations and 22 surveillance studies). RESULTS: While most studies from 1975 to 1999 identified JEV as the main cause of AES, many studies published after 2000 identified Chandipura and enteroviruses as the most common agents, in both outbreaks and surveillance studies. Overall, a positive yield with respect to identification of aetiological agents was higher in outbreak investigations as compared to surveillance studies. CONCLUSION: The landscape of AES in India has changed in the previous decade, and both outbreak investigations and surveillance studies have increasingly reported non-JEV aetiologies. Because of these findings, there is a need to explore additional strategies to prevent AES beyond vector control and JEV vaccination.

Ethics of clinical research and practice in India during the Covid-19 pandemic.

Covid-19 has been one of the worst public health calamities faced by humankind in over a century. As of July 23, 2020, there have been 15,633,159 confirmed cases and 635,422 deaths reported, worldwide (1). We are six months into the pandemic, and yet we know little about the disease. The role of medicines is far from optimal, and vaccines are still under trials. Therefore, we have little to defend ourselves against this novel virus.

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Profile of adults seeking voluntary HIV testing and counseling in rural Central India: results from a hospital-based study.

Rural India has an undetected load of HIV-positive individuals. Few rural adults present for HIV testing and counseling due to stigma, discrimination, and fear of social ostracization. In this rural hospital clinic-based study, we document profiles of rural adults seeking voluntary testing and counseling, and analyze correlates of HIV seropositivity. This cross-sectional study was conducted in 450 participants presenting to the outpatient clinics of Mahatma Gandhi Institute of Medical Sciences, Sevagram, Central India. After informed consent, pre- and post-test counseling, HIV testing, and face-to-face interviews were conducted. Data were collected using a structured questionnaire. The median age of the 450 study participants was 34 years (range 18-88 years); the majority (74%) was married. The overall proportion of HIV seropositivity was 32% [95% CI 28%, 37%]. The proportions of HIV seropositivity in married women, married men, and single men were 41%, 37%, 18%, respectively. No single woman was found seropositive in the study. Very few married women were aware of their husbands' HIV status. In a multivariate analysis, correlates of HIV seropositivity in men were: age 30-39 years, being married, having sex with multiple partners, use of alcohol before sex, and testing positive for HIV in the past. In married women, the only predictor of seropositivity was being married. Although limited by the non-random nature of the sampling method, this pilot study is unique in that it is the first from this rural region of Central India. It provides baseline data on marginalized, largely unstudied populations that may aid in designing probabilistic community-based surveys in this neglected population.

Chikungunya epidemic: an Indian perspective.

Chikungunya, caused by the chikungunya virus, recently emerged as an important public health problem in the Indian Ocean Islands and India. In 2006, an estimated 1.38 million people across southern and central India developed symptomatic disease. The incidence of the disease may have been higher but may have been underreported due to lack of accurate reporting. First isolated in Tanzania in 1953, the chikungunya virus belongs to the family Togaviridae (single-stranded RNA alphaviruses) and has 3 distinct genotypes: East African, West African and Asian. Previous outbreaks in India (1963 and 1973) were caused by the Asian genotypes, but the 2005 epidemic in the Indian Ocean islands and the 2006 epidemic in India have been attributed to the East African genotype. The virus is transmitted to humans by the bites of mosquitoes of the species Aedes aegypti and A. albopictus. Researchers speculate that mutation of the virus, absence of herd immunity, lack of vector control, and globalization of trade and travel might have contributed to the resurgence of the infection. Chikungunya is characterized by high fever, severe arthralgia and rash. Although viral diagnostics (culture, serological tests and polymerase chain reaction tests) can be used to confirm the infection, these tests are not accessible during outbreaks to the majority of the population. The disease is a self-limiting febrile illness and treatment is symptomatic. As no effective vaccine or antiviral drugs are available, mosquito control by evidence-based interventions is the most appropriate strategy to contain the epidemic and pre-empt future outbreaks.

Simple clinical predictors of brain lesions in patients with impaired consciousness: a cross sectional study from a rural, tertiary hospital in central India.

OBJECTIVE: To evaluate the diagnostic accuracy of vital signs for detecting brain lesions in patients with impaired consciousness in a rural setting. METHODS: We enrolled patients older than 12 years who presented with impaired consciousness of non-traumatic origin to the intensive care unit of a rural teaching hospital. The design was a cross sectional analysis of a hospital-based case series, independently comparing vital signs on admission (temperature, pulse, systolic and diastolic blood pressure) against a reference standard (final diagnosis). Diagnostic accuracy was measured by computing multi-level likelihood ratios, and area under the receiver operating characteristic (ROC) curve. RESULTS: We studied 386 patients of whom 242 (62.7%) were men. A total of 178 patients (46%) had a brain lesion. None of the clinical predictors could accurately distinguish between those with and without a brain lesion. The area under the ROC curve for pulse was 0.61 (S.E. 0.02); that for the systolic and diastolic blood pressure 0.70 (S.E. 0.02) each. Systolic BP provided informative test results in 29.7%, diastolic BP in 37.2% and pulse rate in 19.9% patients. CONCLUSION: Our findings suggest that the vital signs lack accuracy for ruling in or ruling out brain lesion in patients with impaired consciousness.

A simple bedside manoeuvre to detect ascites.

BACKGROUND: Shifting dullness and fluid wave are two techniques commonly used to detect ascites. However, these may fail to detect moderate or minimal ascites. Ultrasonography is a good non-invasive method to detect ascites but may not be available in distant rural areas of India. We assessed the utility of the puddle sign and auscultatory percussion for detecting ascites. METHODS: Sixty-six patients with suspected ascites were included in the study. Those with a previous history of ascites, or therapeutic paracentesis and in whom ascites was detected by shifting dullness or fluid wave were excluded. The puddle sign and auscultatory percussion were elicited in all the patients. Ultrasonography was used as the gold standard. To eliminate any observer bias the investigators were blinded to each others' findings. RESULTS: Auscultatory percussion had a greater sensitivity (65.7% v. 45%, p < 0.05) but a lower specificity than the puddle sign (48.4% v. 67.7%, p < 0.05). There were no significant differences between positive and negative predictive values and the positive and negative likelihood ratios. CONCLUSION: Auscultatory percussion is a better method than puddle sign for detecting ascites as it has a greater sensitivity.

Poor accuracy of the Siriraj and Guy's hospital stroke scores in distinguishing haemorrhagic from ischaemic stroke in a rural, tertiary care hospital.

BACKGROUND: In India stroke is associated with a high morbidity and mortality. Bedside clinical examination does not always help in distinguishing cerebral infarction from intracranial haemorrhage. We evaluated the accuracy of the Guy's hospital and Siriraj stroke scores in distinguishing haemorrhagic from ischaemic stroke in a rural setting. METHODS: Patients with suspected stroke admitted to a rural teaching hospital were prospectively enrolled. Two investigators collected data for computing the Guy's hospital and Siriraj scores. Cut-off points, as described by the authors of the original scores, were used to predict haemorrhage and infarction. The scores were compared in a blind and independent manner with the computed tomography (CT) scan. The sensitivity, specificity, positive and negative likelihood ratios and agreement between the two scores were calculated. RESULTS: Of the 259 patients admitted for suspected stroke, 134 patients (73 men) underwent both clinical evaluation and a CT scan. The Siriraj score discriminated haemorrhage from infarction with a sensitivity of 78.5% (95% CI: 66.5, 87.7) and specificity of 71% (95% CI: 52, 85.8). The likelihood ratio of a positive test was 2.7 (95% CI: 1.54, 4.75) and that of a negative test was 0.3 (95% CI: 0.17, 0.53). For the Guy's hospital score the sensitivity was 81% (95% CI: 68.6, 90.1), specificity 76.2% (95% CI: 52.8, 91.8), likelihood ratio of a positive test 3.4 (95% CI: 1.57, 7.39) and that of a negative test 0.25 (95% CI: 0.11, 0.54). Both scores, when combined, were 80% sensitive (95% CI: 66.3, 90) and 80% specific (95% CI: 51.9, 95.7). The agreement between the two scores was modest (kappa = 0.51), but very good (kappa = 0.93) after exclusion of equivocal score results. CONCLUSION: Our study suggests that neither of the stroke scores is sufficiently accurate for distinguishing the type of stroke. CT scan, and not history and clinical signs, can accurately identify haemorrhage from infarction in acute stroke.

Risk factors for acute myocardial infarction in a rural population of central India: a hospital-based case-control study.

BACKGROUND: There is a paucity of data on the relative importance of various traditional risk factors for coronary artery disease among rural Indians. We conducted a prospective case-control study to determine the risk factors for acute myocardial infarction in a rural population of central India. METHODS: We recruited 111 consecutive patients admitted to our hospital with a first episode of acute myocardial infarction and 222 age- and sex-matched controls. Demographics, anthropometric measures, lipids, blood glucose, smoking and other lifestyle factors were compared among cases and controls. Multivariate analyses were used to identify the risk factors independently associated with acute myocardial infarction. RESULTS: Elevated fasting blood glucose (odds ratio [OR] 8.9; 95% confidence interval [CI] 4.5, 17.9), abnormal waist-hip ratio (OR 3.0; 95% CI 1.7, 5.4) and income (OR 4.0 and 5.9 for the high- and middle-income categories, compared to the lowest category) were independently associated with the first episode of acute myocardial infarction. Abnormal triglycerides (OR 1.7; 95% CI 0.9, 3.1) and current smoking (OR 1.9; 95% CI 0.9, 4.0) were risk factors but were not statistically significant. CONCLUSION: Reduction in blood glucose levels and truncal obesity may be important in controlling the burden of coronary artery disease in rural Indians.

Accuracy and reliability of palpation and percussion for detecting hepatomegaly: a rural hospital-based study.

BACKGROUND: Palpation and percussion are standard bedside techniques used to diagnose hepatomegaly. Ultrasonography is a noninvasive and accurate method for measurement of liver size, but many patients in developing countries have limited access to it. We compared the accuracy of palpation and percussion in a rural population in central India, using ultrasonography as a reference standard. METHODS: The study design was a blinded, cross-sectional analysis of a hospital-based case series. Three physicians, blind to clinical data and to each other's results, independently used palpation and percussion to detect hepatomegaly. Diagnostic accuracy was measured by computing sensitivity, specificity, and likelihood ratio values. Inter-physician agreement was assessed using the kappa statistic. RESULTS: Of the 180 study patients, 36 (20%) had enlarged liver on ultrasonography. The likelihood ratios for findings at both palpation (2.2, 3.0, and 2.5 for the three physicians, respectively) and percussion (1.1 for all three physicians) as predictors of true hepatomegaly were low. The kappa values for inter-observer agreement between three physicians for the presence of hepatomegaly at palpation (=0.44-0.53) and percussion (=0.17-0.33) were low, indicating poor reliability of these techniques. CONCLUSION: Clinical assessment of hepatomegaly by palpation and percussion lacks both accuracy and reliability.

Attitude of teachers towards teaching.

INTRODUCTION: Teaching is an art and the quality of teaching depends on the love, dedication and devotion of the teacher towards the subject of the knowledge. The quality of any teaching programme cannot rise above the quality of its teachers. In medical colleges it is the teacher who is responsible for influencing a student's learning of the subject. METHODS: We assessed the attitude of 31 teachers working at MGIMS. Twenty one of them were of the rank of Reader and above and had more than five years teaching experience. Ten were of the rank of lecturers with three years of teaching experience. The assessment was done by a likert type scale containing 20 items on various aspects of teaching. All the participants were given the scale and requested to mark the agreement or otherwise on a scale i.e. strongly disagree, disagree, cannot say, disagree, strongly agree. OBSERVATION AND CONCLUSION: The mean score was 3.808, which indicates a positive attitude. There was not much difference in attitude of teachers in different group. Thus indicating that our study group has predominantly positive attitude for most of the items. This positive attitude helps the teachers to be role model for the future generation of students.

Left ventricular muscle mass by echocardiography: methodology.

The limitations of electrocardiography for diagnosing left ventricular hypertrophy (LVH), due to unacceptable accuracy and lack of serial quantifications, are well known. The use of angiocardiography for LVH assessment is invasive, hazardous and costly. Echocardiography provides an excellent method of estimation of left ventricular muscle mass, which is simple, non-hazardous, accurate and reproducible.

The prevalence of hypertension in rural population around Sevagram.

To detect the prevalence of hypertension in an asymptomatic rural community from Central India, we screened 4045 subjects (2247 men and 1798 women) aged 20 and beyond. The prevalence of hypertension was 34.12 per thousand population, being higher in women (40.60 per thousand) than in men (28.92 per thousand). Level of physical activity, economic status, smoking and body mass index showed real association with hypertension.

False positive ECG and coronary heart disease.

In 1983, we carried out a cross-sectional, rural community based study and highlighted an abysmally low prevalence of probable coronary heart disease in resting electrocardiogram. A seven year follow-up (1983-1990) of 179 suspects showed no morbidity or mortality from coronary heart disease. Eighty one out of 98 suspects tested negative on a symptom limited maximal exercise test. Though seventeen suspects had an asymptomatic exercise-induced ST depression (> 1.0 mm) their haemodynamic response to exercise and effort tolerance was excellent. Of the twelve subjects who took a repeat exercise test six months later, eleven failed to show ST depression on exercise. We attribute the false positivity of exercise test and its poor reproducibility to labile electrocardiographic changes unmasked by exercise.

Left ventricular mass by M-mode echocardiography.

A comparison of various M-mode echocardiographic methods for assessment of left ventricular mass (LVM) was done in 21 subjects. The anatomical LVM was taken as Standard; it varied from 64.55 to 341.82 g. Of the six different M-mode echo methods compared, the method of Devereux and Reichek (1977) was found to correlate best with anatomical LVM (r = 0.99; SD = 49.54). By this method LVM = 1.4 [(LVIDd + LVPWTd + IVSTd)3 - (LVIDd)3] - 14 g.

Role of oxygen free radicals in causing endothelial damage in acute myocardial infarction.

OBJECTIVES: This work was done in order to study the oxidant and anti-oxidant status in a disease resulting from endothelial injury. The disease selected for study was acute myocardial infarction. METHODS: Sixty patients of acute myocardial infarction were selected after being diagnosed in accordance to the guidelines laid down by the WHO. Thirty subjects were included as controls. Plasma levels of certain markers of oxidative stress and anti oxidant activity were measured in all the subjects. Malonaldehyde (MDA) and nitrite (NO2) were measured as markers of free radical mediated endothelial injury, and superoxide dismutase (SOD) enzyme as an indicator of antioxidant activity. RESULTS: It was found that the plasma levels of MDA and nitrite were significantly elevated in the patients of acute myocardial infarction compared to the control group (7.29 +/- 3.28 v/s 4.57 +/- 0.63 nmol/ml and 12.85 +/- 8.71 v/s 0.97 +/- 0.25 microM respectively), thereby indicating that oxygen free radicals cause endothelial damage in them. The superoxide dismutase levels were also found to be elevated in these patients (5.57 +/- 1.47 v/s 3.91 +/- 0.66 U/ml). CONCLUSION: These results indicate that acute myocardial infarction is a state of enhanced free radical activity, which causes endothelial damage. The elevated SOD levels may imply that the body attempts to combat this oxidative stress by raising it's level of anti-oxidants.