Differential item functioning for items in Berger's HIV Stigma Scale: an analysis of cohorts from the Indian, Swedish, and US contexts.

PURPOSE: To examine whether items in Berger's HIV Stigma Scale function differently with persons of different age, gender, and cultural backgrounds. METHODS: Secondary data from cohorts, collected in South India (n = 250), Sweden (n = 193), and the US (n = 603) were reanalyzed to evaluate DIF within, between, and across these cohorts. All participants had answered the revised version of the HIV stigma scale consisting of 32 items forming the subscales Personalized stigma, Disclosure concerns, Concerns about public attitudes, and Negative self-image. Differential Item Functioning (DIF) for these items was assessed using hybrid ordinal regression-IRT technique. When DIF was detected, the cumulative impact of DIF on individual subscale scores was evaluated. RESULTS: DIF was detected for 9 items within, between, or across cohorts, but the DIF was negligible in general. Detected DIF between the Swedish and Indian cohorts had a cumulative salient impact on individual scores for the subscale Disclosure Concerns; Disclosure concerns were overestimated in the Swedish cohort and both over- and underestimated in the Indian cohort. CONCLUSIONS: The items in the 32-item version of the HIV stigma scale did not seem to be particularly prone to present DIF. The DIF between the Indian and Swedish cohort for items in the subscale Disclosure Concerns could, however, result in both type I and type II errors if scores should be compared between the Indian and Swedish cohort.

Sociocultural and structural perpetuators of domestic violence in pregnancy: A qualitative look at what South Indian women believe needs to change.

In India, reported rates of domestic violence rise as high as 31%. Abuse against pregnant women in India is associated with depressive and PTSD symptoms, and poor birth outcomes, yet no evidence-based interventions have been tested on this population. In this cross-sectional qualitative study, we sought perspective on South Indian women's concerns about abuse during pregnancy and what they believed would help. Participants cited economic dependence on husbands and sociocultural structures as factors perpetuating domestic violence. Women also described resilience factors that can protect against abuse. Our participants highlighted a requisite for interventions within health and social systems.

Spectacle Compliance among Adolescents: A Qualitative Study from Southern India.

PURPOSE: To understand the perceptions of adolescents and their parents about spectacle compliance of adolescents in Southern India. METHODS: Using a qualitative snapshot design, three focus group discussions were conducted each with parents and adolescents studying in schools located in and around Chennai, Tamil Nadu. Purposive sampling technique was used in the selection of participants. Separate focus group guides were developed for parents and adolescents. All focus group discussions were conducted in the school premises and audio recorded. These audio files were then transcribed verbatim and then translated into English. A framework analytical approach was used for data analysis that involved gaining familiarity with the data to identify a thematic framework. RESULTS: Two major themes that emerged were (1) perceptions on barriers to spectacle compliance that was further subdivided into physical, psychological, and societal barriers; and (2) solutions to improve spectacle use. Barriers identified included scars on the nose, unattractive frames contributing to poor appeal, adolescents feeling discriminated and set apart, fears of injury to eyes, lack of parental involvement, and negative attitudes of society toward those wearing spectacles. Solutions given by the stakeholders included provision of lightweight, well-fitting, trendy frames of adolescents' choice, importance and need for periodical eye examinations, including teachers in encouraging spectacle use and preventing bullying and teasing by other adolescents, provision of free spectacles along with periodic replacement, and inclusion of awareness sessions on spectacle use for both parents and adolescents. CONCLUSIONS: The study has identified both barriers and solutions for improving spectacle compliance among school adolescents from the viewpoint of the stakeholders involved. Implementing the solutions suggested by the stakeholders through planned intervention programs could possibly help in ensuring better compliance of spectacle use among school adolescents.

Caregiver perceptions on intensive care: A qualitative study from southern India.

BACKGROUND: Admission of a patient to an intensive care unit (ICU) can result in tremendous stress to family caregivers not only because of the need to provide physical and emotional support to the sick relative, but also due to the burden of decision-making on behalf of the critically ill person. We enquired about family caregivers' perspectives on intensive care, the challenges they faced with decision-making and their perceptions on the nature of their interactions with healthcare providers. METHODS: We used maximum variation sampling and enrolled 20 consenting caregivers for semi-structured interviews. Each interview, based on an interview guide, took 30-40 minutes and was conducted in a private place within the hospital premises. All interviews were recorded, transcribed verbatim and entered into a qualitative software (NVivo) for analysis. RESULTS: The three emergent themes of analysis were (i) understanding about ICU, (ii) decision-making concerning ongoing treatment; and (iii) relationship with healthcare-providers. Some respondents saw the intensive care as an expensive facility for seriously ill patients while others were not so clear. The family's relationship with the patient and their financial status were seen as important deciding factors in continuing treatment. Decision-making was a complex and emotional issue and doctors were held in awe and seen as the main deciding authority. The importance of doctors being compassionate and communicative was stressed. CONCLUSION: Our study highlights the problems faced by family caregivers and of the need to improve their satisfaction through clear and simple communication strategies.

The impact of domestic violence and depressive symptoms on preterm birth in South India.

PURPOSE: India has the highest absolute number of maternal deaths, preterm birth cases, and under-5 mortality in the world, as well as high domestic violence (DV) rates. We sought to examine the impact of DV and its psychosocial correlates on pregnancy and birth outcomes. METHODS: Women seeking antenatal care in Tamil Nadu, South India (N = 150) were assessed during pregnancy, and birth outcomes were abstracted from medical records after the babies were born. RESULTS: We found that psychological abuse (OR 3.9; 95% CI 1.19-12.82) and mild or greater depressive symptoms (OR 3.3; 95% CI 0.99-11.17) were significantly associated with increased risk of preterm birth. Physical abuse was also associated with increased risk of preterm birth, but this was not statistically significant (OR 1.9; 95% CI 0.59-6.19). In each of the above adjusted models, low maternal education was associated with increased risk of preterm birth, in the analysis with depressive symptoms OR 0.18, CI 0.04-0.86 and in the analyses with psychological abuse OR 0.19, CI 0.04-0.91. CONCLUSIONS: These findings suggest that future research should focus on understanding the psychosocial antecedents to preterm birth, to better target interventions and improve maternal child health in limited resource settings.

Cultural adaptation of the Brief COPE for persons living with HIV/AIDS in southern India.

Physical and psychological stressors of HIV infection demand adequate coping responses from persons living with HIV/AIDS (PLHA) and coping strategies may vary by cultural context. The Brief COPE is a well validated scale that has been used extensively to assess coping with cancer, depression, and HIV infection in other settings, but never in India. In this study we translated and validated the 28 item Brief COPE among 299 PLHA in South India, assessing reliability, validity, and cultural appropriateness. Although the original scale demonstrated acceptable internal consistency (alpha = 0.70) and good convergent validity with depression, the test-retest reliability was marginal (test-retest = 0.6) and the original factor structure demonstrated poor fit in a confirmatory factor analysis (CFA). An exploratory factor analysis yielded a 16 item scale with five factors (active planning, social support, avoidant emotions, substance use, religion). A second CFA demonstrated good model fit and acceptable reliability (alpha = 0.61) of the adapted scale.

Antiretroviral therapy adherence measurement in non-clinical settings in South India.

Optimal adherence to antiretroviral therapy (ART) is key to viral suppression, but may be impeded by psychosocial consequences of HIV-infection such as stigma and depression. Measures of adherence in India have been examined in clinic populations, but little is known about the performance of these measures outside clinical settings. We conducted a cross-sectional study of 151 Tamil-speaking people living with HIV/AIDS (PLHA) in India recruited through HIV support networks and compared single item measures from the Adult AIDS Clinical Trial Group (AACTG) scale, a visual analog scale (VAS), and a question on timing of last missed dose. Depression was measured using the Major Depression Inventory (MDI) and HIV-related stigma was measured using an adaptation of the Berger Stigma Scale. Mean age was 35.6 years (SD ± 5.9); 55.6% were male; mean MDI score was 11.9 (SD ± 9.1); and mean stigma score was 67.3 (SD ± 12.0). Self-reported perfect adherence (no missed doses) was 93.3% using the AACTG item, 87.1% using last missed dose, and 83.8% using the VAS. The measures had moderate agreement with each other (kappa 0.45-0.57). Depression was associated with lower adherence irrespective of adherence measure used, and remained significantly associated in multivariable analyses adjusting for age and marital status. Stigma was not associated with adherence irrespective of the measure used. The VAS captured the greatest number of potentially non-adherent individuals and may be useful for identifying PLHA in need of adherence support. Given the consistent and strong association between poorer adherence and depression, programs that jointly address adherence and mental health for PLHA in India may be more effective than programs targeting only one.

Customising informed consent procedures for people with schizophrenia in India.

BACKGROUND: There is little information on how the ethical and procedural challenges involved in the informed participation of people with schizophrenia in clinical trials are addressed in low- and middle-income countries (LMICs). The informed consent procedure used in the collaborative community care for people with schizophrenia in India (COPSI) RCT was developed keeping these challenges in mind. We describe the feasibility of conducting the procedure from the trial, researcher and participants perspectives and describe the reasons for people consenting to participate in the trial or refusing to do so. METHODS: Three sources of information were used to describe the feasibility of the COPSI consent procedure: key process indicators for the trial perspective, data from a specially designed post-interview form for participant's observations and focus group discussion (FGD) with the research interviewers. Categorical data were analysed by calculating frequencies and proportions, while the qualitative data from the FGD, and the reasons for participation or refusal were analysed using a thematic content analysis approach. FINDINGS: 434 people with schizophrenia and their primary caregiver(s) were approached for participation in the trial. Consent interviews were conducted with 332, of whom 303 (91%) agreed to participate in the trial. Expectation of improvement was the most common reason for agreeing to participate in the trial, while concerns related to the potential disclosure of the illness, especially for women, were an important reason for refusing consent. CONCLUSIONS: The COPSI consent procedure demonstrates preliminary, observational information about the feasibility of customising informed consent procedures for people with schizophrenia LMIC contexts. This and other similar innovations need to be refined and rigorously tested to develop evidence-based guidelines for informed consent procedures in such settings.

DOWRY DEMAND AND HARASSMENT: PREVALENCE AND RISK FACTORS IN INDIA.

The practice of dowry is widespread in India and refers to the payment of cash/gifts by the bride's family to the bridegroom's family before marriage. Though prohibited by law, dowry is widely practised, and often contributes to severe injuries and even death of young brides. This study examined the prevalence and risk factors for dowry demand and dowry harassment and its psychosocial correlates across different social strata in India, and also by husband and mother-in-law characteristics. In a cross-sectional survey of 9938 women in rural, urban and urban non-slum sites across India conducted in 1998-99, dowry demand was found to be significantly higher (p<0.001) in the urban non-slum and rural areas (26% and 23% respectively) than in urban slum areas (18%). Overall, 17% of groom's families were not satisfied with the dowry, this being higher in rural areas (21%) than in urban slum and non-slum areas (about 14% in both). The overall prevalence of dowry harassment among this group of women was 13.3%. Mothers-in-law who had themselves experienced dowry demand were 14 (95% CI 5.0-40.4) and 5 (95% CI 1.3-18.9) times more likely to demand and harass daughters-in-law over dowry, respectively. Another significant risk factor for dowry-related harassment was mother-in law's status in the family. Interventions related to modifiable risk factors, such as increased social support at the community level, should help reduce dowry harassment.

A public health initiative for reducing access to pesticides as a means to committing suicide: findings from a qualitative study.

Widespread use of pesticides among farmers in rural India, provides an easy means for suicide. A public health initiative involving storage of pesticides in a central storage facility could be a possible strategy for reducing mortality and morbidity related to pesticide poisoning. This qualitative study explored community perceptions towards a central pesticide storage facility in villages in rural South India. Sixteen focus group discussions held with consenting adults from intervention and control villages were followed by eight more a year after initiation of the storage facility. Analysis revealed four themes, namely, reasons for committing suicide and methods used, exposure to pesticides and first-aid practices, storage and disposal of pesticides, and perceptions towards the storage facility. The facility was appreciated as a means of preventing suicides and for providing a safe haven for pesticide storage. The participatory process that guided its design, construction and location ensured its acceptability. Use of qualitative methods helped provide deep insights into the phenomenon of pesticide suicide and aided the understanding of community perceptions towards the storage facility. The study suggests that communal storage of pesticides could be an important step towards reducing pesticide suicides in rural areas.

Needs and readiness to use tele-practice for identification and rehabilitation of children with hearing and speech-language disorders: perceptions of public sector care providers in South India.

The current study was a first step towards planning the implementation of tele-practice in a South Indian state's public-sector services for childhood hearing and speech, language disorders. The aim was to understand the perceptions of public-sector health care providers (HCPs) regarding their need and readiness to accept and implement tele-practice-based diagnostics and rehabilitation services. A cross-sectional study design was used, which included focus group discussions (FGDs), semi-structured interviews (SSIs) and geo-spatial analysis. Participants in the qualitative component included various cadres of health HCPs in public-sector services. Theoretical saturation and cross-case variance were used to assess the data's sufficiency. A hybrid deductive-inductive thematic analytical approach was used to analyse the data. Geo-tags and geo-locations of addresses of all children with disabilities and all the public-sector service providers were used to generate geospatial maps. The HCPs considered the currently available services for childhood hearing and speech-language disorders to be insufficient and reported shortage of professionals to meet current demands. There was inconsistent availability of suitable equipment and professionals in the existing district-level facilities. HCPs were comfortable using technology, and were willing to investigate tele-practice, but they required training in tele-practice [Q2].

A multi-centric, single-blinded, randomized, parallel-group study to evaluate the effectiveness of nasoalveolar moulding treatment in non-syndromic patients with complete unilateral cleft lip, alveolus and palate (NAMUC study): a study protocol for a randomized controlled trial.

BACKGROUND: Cleft lip and palate (CLP) are among the most common congenital anomaly that affects up to 33,000 newborns in India every year. Nasoalveolar moulding (NAM) is a non-surgical treatment performed between 0 and 6 months of age to reduce the cleft and improve nasal aesthetics prior to lip surgery. The NAM treatment has been a controversial treatment option with 51% of the cleft teams in Europe, 37% of teams in the USA and 25 of cleft teams in India adopting this methodology. This treatment adds to the already existing high burden of care for these patients. Furthermore, the supporting evidence for this technique is limited with no high-quality long-term clinical trials available on the effectiveness of this treatment. METHOD: The NAMUC study is an investigator-initiated, multi-centre, single-blinded randomized controlled trial with a parallel group design. The study will compare the effectiveness of NAM treatment provided prior to lip surgery against the no-treatment control group in 274 patients with non-syndromic unilateral complete cleft lip and palate. The primary endpoint of the trial is the nasolabial aesthetics measured using the Asher McDade index at 5 years of age. The secondary outcomes include dentofacial development, speech, hearing, cost-effectiveness, quality of life, patient perception, feeding and intangible benefits. Randomization will be carried out via central online system and stratified based on cleft width, birth weight and clinical trial site. DISCUSSION: We expect the results from this study on the effectiveness of treatment with NAM appliance in the long term along with the cost-effectiveness evaluation can eliminate the dilemma and differences in clinical care across the globe. TRIAL REGISTRATION: ClinicalTrials.gov CTRI/2022/11/047426 (Clinical Trials Registry India). Registered on 18 November 2022. The first patient was recruited on 11 December 2022. CTR India does not pick up on Google search with just the trial number. The following steps have to be carried out to pick up. How to search: ( https://ctri.nic.in/Clinicaltrials/advsearch.php -use the search boxes by entering the following details: Interventional trial > November 2022 > NAMUC).

Assessing HIV/AIDS stigma in south India: validation and abridgement of the Berger HIV Stigma scale.

HIV-related stigma has been associated with depression, poor adherence, and nondisclosure of HIV-positive status, all of which can lead to increased transmission of HIV and poorer health outcomes for HIV-infected individuals. The Berger HIV Stigma scale has been used in multiple settings but never adapted and validated in India, home to the world's second largest HIV-infected population. We assessed the reliability and validity of a Tamil translation of the original 40-item scale, and conducted confirmatory and exploratory factor analyses to assess cultural appropriateness and abbreviate the scale. Reliability and validity were high (alpha = 0.91; test-retest reliability ICC = 0.89). Exploratory and confirmatory factor analysis resulted in an abridged 25-item version of the scale that possessed better psychometric properties than the 40-item version. This culturally validated, abridged HIV-Stigma scale can be used in busy clinical settings to identify individuals in need of psychosocial support and assess post-intervention changes in stigma in Southern India.

A central storage facility to reduce pesticide suicides--a feasibility study from India.

BACKGROUND: Pesticide suicides are considered the single most important means of suicide worldwide. Centralized pesticide storage facilities have the possible advantage of delaying access to pesticides thereby reducing suicides. We undertook this study to examine the feasibility and acceptability of a centralized pesticide storage facility as a preventive intervention strategy in reducing pesticide suicides. METHODS: A community randomized controlled feasibility study using a mixed methods approach involving a household survey; focus group discussions (FGDs) and surveillance were undertaken. The study was carried out in a district in southern India. Eight villages that engaged in floriculture were identified. Using the lottery method two were randomized to be the intervention sites and two villages constituted the control site. Two centralized storage facilities were constructed with local involvement and lockable storage boxes were constructed. The household survey conducted at baseline and one and a half years later documented information on sociodemographic data, pesticide usage, storage and suicides. RESULTS: At baseline 4446 individuals (1097 households) in the intervention and 3307 individuals (782 households) in the control sites were recruited while at follow up there were 4308 individuals (1063 households) in the intervention and 2673 individuals (632 households) in the control sites. There were differences in baseline characteristics and imbalances in the prevalence of suicides between intervention and control sites as this was a small feasibility study.The results from the FGDs revealed that most participants found the storage facility to be both useful and acceptable. In addition to protecting against wastage, they felt that it had also helped prevent pesticide suicides as the pesticides stored here were not as easily and readily accessible. The primary analyses were done on an Intention to Treat basis. Following the intervention, the differences between sites in changes in combined, completed and attempted suicide rates per 100,000 person-years were 295 (95% CI: 154.7, 434.8; p < 0.001) for pesticide suicide and 339 (95% CI: 165.3, 513.2, p < 0.001) for suicide of all methods. CONCLUSIONS: Suicide by pesticides poisoning is a major public health problem and needs innovative interventions to address it. This study, the first of its kind in the world, examined the feasibility of a central storage facility as a means of limiting access to pesticides and, has provided preliminary results on its usefulness. These results need to be interpreted with caution in view of the imbalances between sites. The facility was found to be acceptable, thereby underscoring the need for larger studies for a longer duration. TRIAL REGISTRATION ISRCTN: ISRCTN04912407.

Implementation factors influencing the sustained provision of tele-audiology services: insights from a combined methodology of scoping review and qualitative semistructured interviews.

OBJECTIVES: The objectives of the current study were to (a) identify long-term tele-audiology services reported to be implemented beyond the research phase and determine whether they are sustained, (b) map the implementation process to Standards for Reporting Implementation Studies guidelines and (c) map the factors that influenced its sustainability to the Implementation Outcomes Framework (IOF) to understand the gaps from an implementation research perspective. STUDY DESIGN, SETTING AND PARTICIPANTS: This cross-sectional study included a scoping review of articles describing long-term tele-audiology services from around the world to determine the factors influencing the implementation. Six electronic databases (PubMed, Cochrane Library, Web of Science, Scopus, Google Scholar and ProQuest) were searched for literature published between 2010 and 2023. This was followed by semistructured interviews (SSIs), which were guided by the IOF. Six project implementers were interviewed to obtain an in-depth understanding of factors that influenced sustainability of these tele-audiology services. Thematic analysis of the interview transcripts was carried out using a hybrid inductive-deductive approach. RESULTS: Data were extracted from 32 tele-audiology studies included in the review, which were then mapped to 21 projects. The findings of the scoping review reveal that tele-audiology services were predominantly provided using synchronous telepractice methods. The 'professional-facilitator-patient' model was most commonly used. None of the studies reported the use of implementation research and/or outcome frameworks. Factors that influenced sustainability of tele-audiology services were identified from the combined results of the scoping review and the SSIs. These factors could be mapped to implementation outcomes of acceptability, adoption, feasibility, implementation cost and sustainability. CONCLUSION: Implementation research and/or outcome framework should be used to guide the implementation processes, its evaluation and measurement of outcomes systematically in tele-audiology service delivery. When such frameworks are used, gaps in information regarding the context influencing implementation, reporting of fidelity and adaptability measures can be addressed.

'I don`t need an eye check-up'. A qualitative study using a behavioural model to understand treatment-seeking behaviour of patients with sight threatening diabetic retinopathy (STDR) in India.

Diabetic Retinopathy (DR) affects about 27% of patients with diabetes globally. According to the World Health Organization (WHO), DR is responsible for37 million cases of blindness worldwide. The SMART India study (October 2020-August 2021) documented the prevalence of diabetes, and DR in people40 years and above across ten Indian states and one Union Territory by conducting community screening. About 90% of people with sight threatening diabetic retinopathy (STDR) were referred from this screening study to eye hospitals for management, but failed to attend. This qualitative study, a component of the SMART India study, explored perceptions of referred patients regarding their susceptibility to eye related problems in diabetes and the benefits/barriers to seeking care. Perceived barriers from the viewpoint of ophthalmologists were also explored. Guided by the Health Beliefs Model (HBM), 20 semi structured interviews were carried out with consenting patients diagnosed with STDR. They included nine patients who had sought care recruited from eight eye hospitals across different states in India and eleven patients who did not seek care. Eleven ophthalmologists also participated. Four themes of analysis based on the HBM were, understanding of DR and its treatment, perceptions about susceptibility and severity, perceived barriers, perceived benefits and cues to action. Findings revealed poor understanding of the effects of diabetes on the eye contributing to low risk perception. Prohibitive costs of treatment, difficulties in accessing care services and poor social support were major barriers to seeking care. Ophthalmologists acknowledged that the absence of symptoms and the slow progressive nature of the disease deluded patients into thinking that they were fine. The study attests to the need for greater health literacy around diabetes, DR and STDR; for making treatment more affordable and accessible and for the development of effective patient education and communication strategies towards increasing compliance.

Reduction in prevalence of spousal physical violence against women in India: evidence from three national surveys.

Spousal physical violence (PV) against women is considered to be major health issue in developing countries. Lifetime physical violence is a composite outcome consists of hit, kick, beat, slap and threatened with weapon, perpetrated by the husband. The study aims to examine changes in prevalence and specific risk factors for PV from 1998 to 2016 in India. This study analyzed data from a cross sectional epidemiological survey in 1998-1999, NFHS-3 (2005-2006) and NFHS-4 (2015-2016) data. There was a significant decline of about 10% (95% CI: 8.8%-11.1%) in PV. Major risk factors for change in PV were husband's use of alcohol, illiteracy and socio-economic status of the household. The Protection of Women from Domestic Violence Act may have played a role in reducing the PV. Even though there was a decline in PV, actions have to be implemented from the root level to ensure women empowerment.