Task shifting of frontline community health workers for cardiovascular risk reduction: design and rationale of a cluster randomised controlled trial (DISHA study) in India

Training of Community Health Workers in Diabetes Lead to Improved Outcomes for Diabetes Screening and Management in Low- and Middle-Income Countries: Protocol for a Systematic Review

BACKGROUND

Diabetes is a growing concern worldwide, particularly in low- and middle-income countries (LMICs). Type 2 diabetes mellitus constitutes a significant proportion of cases and is associated with debilitating microvascular complications. Type 2 diabetes mellitus is steadily increasing among the LMICs where many barriers to health care exist. Thus, task shifting to community health workers (CHWs) has been proposed as a solution to improve diabetes management in these settings. However, CHWs often lack the necessary training to manage diabetes effectively. Thus, a systematic review is required to present evidence of the highest degree for this intervention.

OBJECTIVE

This study aims to establish the protocols for a systemic review.

METHODS

Using the Participants Intervention Comparator Outcome Time Study Design (PICOTS) framework, this study outlines a systematic review aiming to evaluate the impact of training programs for CHWs in diabetes management in LMICs. Quantitative studies focusing on CHWs, diabetes training, focusing on diabetes management outcomes like hemoglobin A1c levels and fasting blood glucose levels, between January 2000 and December 2023 and found on databases such as PubMed, Ovid MEDLINE, Evidence Based Medicine Reviews, BASE, Google Scholar, and Web of Science will be included. We will include randomized controlled trials but will also include observational studies if we find less than 5 randomized controlled trials. An author committee consisting of 3 reviewers will be formed, where 2 reviewers will conduct the review independently while the third will resolve all disputes. The Cochrane Methods Risk of Bias Tool 2 will be used for assessing the risk of bias and the Grading of Recommendations, Assessment, Development and Evaluation approach for the meta-analysis and narrative synthesis analysis will be used. The results will be presented in a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram.

RESULTS

The review will begin in May 2024 and conclude in 3 months.

CONCLUSIONS

The review will synthesize existing evidence and provide insights into the effectiveness of such programs, informing future research and practice in diabetes care in LMICs.

TRIAL REGISTRATION

PROSPERO CRD42022341717; https://tinyurl.com/jva2hpdr.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/57313.

Improving medication adherence among persons with cardiovascular disease through m-health and community health worker-led interventions in Kerala; protocol for a type II effectiveness-implementation research-(SHRADDHA-ENDIRA)

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, and at present, India has the highest burden of acute coronary syndrome and ST-elevation myocardial infarction (MI). A key reason for poor outcomes is non-adherence to medication.

METHODS

The intervention is a 2 × 2 factorial design trial applying two interventions individually and in combination with 1:1 allocation ratio: (i) ASHA-led medication adherence initiative comprising of home visits and (ii) m-health intervention using reminders and self-reporting of medication use. This design will lead to four potential experimental conditions: (i) ASHA-led intervention, (ii) m-health intervention, (iii) ASHA and m-health intervention combination, (iv) standard of care. The cluster randomized trial has been chosen as it randomizes communities instead of individuals, avoiding contamination between participants. Subcenters are a natural subset of the health system, and they will be considered as the cluster/unit. The factorial cluster randomized controlled trial (cRCT) will also incorporate a nested health economic evaluation to assess the cost-effectiveness and return on investment (ROI) of the interventions on medication adherence among patients with CVDs. The sample size has been calculated to be 393 individuals per arm with 4-5 subcenters in each arm. A process evaluation to understand the effect of the intervention in terms of acceptability, adoption (uptake), appropriateness, costs, feasibility, fidelity, penetration (integration of a practice within a specific setting), and sustainability will be done.

DISCUSSION

The effect of different types of intervention alone and in combination will be assessed using a cluster randomized design involving 18 subcenter areas. The trial will explore local knowledge and perceptions and empower people by shifting the onus onto themselves for their medication adherence. The proposal is aligned to the WHO-NCD aims of improving the availability of the affordable basic technologies and essential medicines, training the health workforce and strengthening the capacity of at the primary care level, to address the control of NCDs. The proposal also helps expand the use of digital technologies to increase health service access and efficacy for NCD treatment and may help reduce cost of treatment.

TRIAL REGISTRATION

The trial has been registered with the Clinical Trial Registry of India (CTRI), reference number CTRI/2023/10/059095.

Socioeconomic and Ethnic Disparities in the Process of Care and Outcomes Among Cancer Patients With Acute Coronary Syndrome

Cancer and acute coronary syndrome (ACS) are the leading causes of morbidity and mortality globally, with many shared risk factors. There are several challenges to the management of patients with cancer presenting with ACS, owing to their higher baseline risk profile, the complexities of their cancer-related therapies and prognosis, and their higher risk of adverse outcomes after ACS. Although previous studies have demonstrated disparities in the care of both cancer and ACS among patients from ethnic minorities and socioeconomic deprivation, there is limited evidence around the magnitude of such disparities specifically in cancer patients presenting with ACS. This review summarises the current literature on differences in prevalence and management of ACS among patients with cancer from ethnic minorities and socioeconomically deprived backgrounds, as well as the gaps in evidence around the care of this high-risk population and potential solutions.

Undesirable Levels of Practice Behaviours and Associated Knowledge amongst Community Health Workers in Rural South India Responsible for Type 2 Diabetes Screening and Management

BACKGROUND

Type 2 diabetes (T2DM) poses an enormous global health care challenge, especially among rural communities. Healthcare in these areas can be inadequate and inaccessible due to socio-demographic barriers. To overcome this situation, many low- and middle-income countries are resorting to task shifting, using community health workers (CHWs) for diabetes management. However, its successful implementation depends on the practice behaviours and knowledge of these workers.

OBJECTIVE

This cross-sectional study aimed to evaluate the proficiency of CHWs involved in diabetes screening and management in rural South India by identifying the existing practice behaviours and knowledge gaps.

METHODS

Employing a customised questionnaire, developed through inputs from experts and government officials, we assessed practice behaviours and the corresponding knowledge base of 275 CHWs. Analytical methodologies consisted of descriptive statistics, logistic regression, and mosaic plots for comprehensive data interpretation.

RESULTS

The study showcased significant deficiencies in both practice behaviours (97%) and knowledge (95%) with current mean levels ranging from 48 to 50%, respectively, among the participants. The identified areas of insufficiency were broadly representative of the core competencies required for effective diabetes management, encompassing diabetes diagnosis and referral, HbA1c testing, diabetes diet, diabetes type and self-management, microvascular complications and their screening, peripheral neuropathy management, and diabetes risk assessment. In several areas, correct practice behaviour was reported by a relatively large number of CHWs despite incorrect answers to the related knowledge questions such as referral to the health centres, self-management, and calculation of diabetes risk assessment.

CONCLUSION

This study highlights widespread deficiencies (97% CHWs) in diabetes management practices and knowledge (95% CHWs). To overcome these deficiencies, a thorough needs assessments is vital for effective CHW training. Training of CHWs should not only identify prior knowledge and/or behaviour but also their interrelationship to help create a robust and flexible set of practice behaviours.

Doctor Clerk Implementation in Rural Community Hospitals for Effective Task Shifting of Doctors: A Grounded Theory Approach

With the diversification of medical care and work reform, doctor clerks play a major role today and are recruited to mitigate the burden of doctors worldwide. Their recruitment can improve the working conditions of physicians, facilitate task shifting in rural community hospitals, improve patient care, and help address the lack of healthcare resources. This study used a qualitative method to investigate difficulties in the implementation of doctor clerks and ascertain the features of effective implementation by collecting ethnographic data through field notes and semi-structured interviews with workers. We observed and interviewed 4 doctor clerks, 10 physicians, 14 nurses, 2 pharmacists, 1 nutritionist, and 2 therapists for our study. We clarified the doctor clerk process in rural hospitals through four themes: initial challenge, balance between education and expansion, vision for work progression, and drive for quality of care. We further clarified effectiveness, difficulties, and enhancing factors in implementation. Doctor clerk recruitment and bridging of discrepancies among medical professionals can mitigate professional workloads and improve staff motivation, leading to better interprofessional collaboration and patient care.

Approaches and outcomes of community health worker's interventions for hypertension management and control in low-income and middle-income countries: systematic review

OBJECTIVES

To critically appraise the scope, content and outcomes of community health worker (CHW) interventions designed to reduce blood pressure (BP) in low-income and middle-income countries (LMICs).

METHOD

We performed a database search (PUBMED, EMBASE, CINAHL, PsycINFO, OpenGrey, Cochrane Central Trials Register and Cochrane Database of Systematic Reviews) to identify studies in LMICs from 2000 to 2020. Eligible studies were interventional studies published in English and reporting CHW interventions for management of BP in LMICs. Two independent reviewers screened the titles, abstracts and full texts of publications for eligibility and inclusion. Relevant information was extracted from these studies using a tailored template. Risk of bias was assessed using the Cochrane collaboration risk of bias tool. Qualitative synthesis of results was done through general summary of the characteristics and findings of each study. We also analysed the patterns of interventions and their outcomes across the studies. Results were presented in form of narrative and tables.

RESULTS

Of the 1557 articles identified, 14 met the predefined criteria. Of these, 12 were cluster randomised trials whereas two were pretest/post-test studies. The CHW interventions were mainly community-based and focused on behaviour change for promoting BP control among hypertensive patients as well as healthy individuals. The interventions had positive effects in the BP reduction, linkage to care, treatment adherence and in reducing cardivascular-disease risk level.

DISCUSSION AND CONCLUSION

The current review is limited in that, a meta-analysis to show the overall effect of CHW interventions in the management of hypertension was not possible due to the diversity of the interventions, and outcomes of the studies included in the review. Summarised outcomes of individual studies showed CHW enhanced the control and management of hypertension. Further studies are needed to indicate the impact and cost-effectiveness of CHW-led interventions in the control and management of hypertension in LMICs.

Structured Lifestyle Modification Interventions Involving Frontline Health Workers for Population-Level Blood Pressure Reduction: Results of a Cluster Randomized Controlled Trial in India (DISHA Study)

Background Population-wide reduction in mean blood pressure is proposed as a key strategy for primary prevention of cardiovascular disease. We evaluated the effectiveness of a task-sharing strategy involving frontline health workers in the primary prevention of elevated blood pressure. Methods and Results We conducted DISHA (Diet and lifestyle Interventions for Hypertension Risk reduction through Anganwadi Workers and Accredited Social Health Activists) study, a cluster randomized controlled trial involving 12 villages each from 4 states in India. Frontline health workers delivered a custom-made and structured lifestyle modification intervention in the selected villages. A baseline survey was conducted in 23 and 24 clusters in the control (n=6663) and intervention (n=7150) groups, respectively. The baseline characteristics were similar between control and intervention clusters. In total 5616 participants from 23 clusters in the control area and 5699 participants from 24 clusters in the intervention area participated in a repeat cross-sectional survey conducted immediately after the intervention phase of 18-months. The mean (SD) systolic blood pressure increased from 125.7 (18.1) mm Hg to 126.1 (16.8) mm Hg in the control clusters, and it increased from 124.4 (17.8) mm Hg to 126.7 (17.5) mm Hg in the intervention clusters. The population average adjusted mean difference in difference in systolic blood pressure was 1.75 mm Hg (95% CI, -0.21 to 3.70). Conclusions Task-sharing interventions involving minimally trained nonphysician health workers are not effective in reducing population average blood pressure in India. Expanding the scope of task sharing and intensive training of health workers such as nurses, nutritionists, or health counselors in management of cardiovascular risk at the population level may be more effective in primary prevention of cardiovascular disease. Registration URL: https://www.ctri.nic.in; Unique identifier: CTRI/2013/10/004049.

Primer of Epidemiology IV. Study designs II: Interventional or experimental designs

In this article, we describe experimental study designs and focus on randomized controlled trials. Experimental studies are intervention studies in which the investigator tests a new treatment on a selected group of patients. In a controlled design, the effects of an intervention (new treatment) are measured by comparing the outcome in the experimental group with that in a control group. Experimental studies are similar to cohort studies except that the exposure is a deliberate change (intervention) made by the researcher in one group of participants and it overcomes confounding because the treatment is assigned randomly. Further, we discuss various types of randomization (random sequence allocation) and importance of allocation concealment and blinding for proper assessment of outcomes in randomized trials.

Leveraging role of non-physician health workers in prevention and control of non-communicable diseases in India: Enablers and challenges

Due to upsurge of non-communicable disease (NCD) burden, there is accentuated emphasis on task sharing and shifting NCDs-related health care delivery to non-physician healthcare workers especially nursing personnel and grass root level health professionals. This narrative review summates role of non-physician health workers, highlights various enablers and challenges while engaging them in delivery of NCD services so as to prevent and control various NCDs in India. Pubmed, Google scholar databases were searched using various keywords and Mesh terminologies. In addition, reference lists of selected articles were also screened. It is concluded that with regular update of knowledge, training, and supervision, these workers can efficiently deliver promotive, preventive, curative, and rehabilitative NCD-related healthcare services to needy. While engagement of this workforce in NCDs mitigation is a transforming concept, it also has its own challenges and issues which need to be explored and addressed in order to utilize this human resource to their maximum potential.

The Integrated Tracking, Referral, and Electronic Decision Support, and Care Coordination (I-TREC) program: scalable strategies for the management of hypertension and diabetes within the government healthcare system of India

Background

Hypertension and diabetes are among the most common and deadly chronic conditions globally. In India, most adults with these conditions remain undiagnosed, untreated, or poorly treated and uncontrolled. Innovative and scalable approaches to deliver proven-effective strategies for medical and lifestyle management of these conditions are needed.

Methods

The overall goal of this implementation science study is to evaluate the Integrated Tracking, Referral, Electronic decision support, and Care coordination (I-TREC) program. I-TREC leverages information technology (IT) to manage hypertension and diabetes in adults aged ≥30 years across the hierarchy of Indian public healthcare facilities. The I-TREC program combines multiple evidence-based interventions: an electronic case record form (eCRF) to consolidate and track patient information and referrals across the publicly-funded healthcare system; an electronic clinical decision support system (CDSS) to assist clinicians to provide tailored guideline-based care to patients; a revised workflow to ensure coordinated care within and across facilities; and enhanced training for physicians and nurses regarding non-communicable disease (NCD) medical content and lifestyle management. The program will be implemented and evaluated in a predominantly rural district of Punjab, India. The evaluation will employ a quasi-experimental design with mixed methods data collection. Evaluation indicators assess changes in the continuum of care for hypertension and diabetes and are grounded in the Reach, Effectiveness, Adoption Implementation, and Maintenance (RE-AIM) framework. Data will be triangulated from multiple sources, including community surveys, health facility assessments, stakeholder interviews, and patient-level data from the I-TREC program’s electronic database.

Discussion

I-TREC consolidates previously proven strategies for improved management of hypertension and diabetes at single-levels of the healthcare system into a scalable model for coordinated care delivery across all levels of the healthcare system hierarchy. Findings have the potential to inform best practices to ultimately deliver quality public-sector hypertension and diabetes care across India.

Trial registration

The study is registered with Clinical Trials Registry of India (registration number CTRI/2020/01/022723). The study was registered prior to the launch of the intervention on 13 January 2020. The current version of protocol is version 2 dated 6 June 2018.

Social factors associated with chronic non-communicable disease and comorbidity with mental health problems in India: a scoping review

OBJECTIVES

The purpose of this study is to examine the existing literature of the major social risk factors which are associated with diabetes, hypertension and the comorbid conditions of depression and anxiety in India.

DESIGN

Scoping review.

DATA SOURCES

Scopus, Embase, CINAHL Plus, PsycINFO, Web of Science and MEDLINE were searched for through September 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies reporting data on social risk factors for diabetes or hypertension and depression or anxiety in community-based samples of adults from India, published in English in the 10 years to 2019, were included. Studies that did not disaggregate pooled data from other countries were excluded.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted study aims; methods; sample size and description; demographic, social and behavioural risk factors and a summary of findings from each paper. Risk factors were synthesised into six emergent themes.

RESULTS

Ten studies were considered eligible and included in this review. Nine presented cross-sectional data and one was a qualitative case study. Six themes emerged, that is, demographic factors, economic aspects, social networks, life events, health barriers and health risk behaviours.

CONCLUSIONS

Literature relating to the major social risk factors associated with diabetes, hypertension and comorbid depression and anxiety in India is sparse. More research is required to better understand the interactions of social context and social risk factors with non-communicable diseases and comorbid mental health problems so as to better inform management of these in the Indian subcontinent.

Multicomponent Short-Term Training of ASHAs for Stroke Risk Factor Management in Rural India

Background Stroke is one of the leading causes of disability-adjusted life years and may be the leading cause of death in rural regions in India. We aim to train the ASHAs (Accredited Social Health activist) for nonpharmacological management of risk factors for secondary stroke prevention in rural India. We tested the hypothesis that focused, multicomponent, short-term training on secondary prevention of stroke enhances the knowledge of ASHAs about risk factor management. Objectives To test the hypothesis that focused, multicomponent, short-term training on secondary prevention of stroke enhances the knowledge of ASHAs about risk factor management. Materials and Methods This study is part of the ASSIST trial (Training ASHA to Assist in Secondary Stroke Prevention in Rural Population). The study design is quasi-experimental (pretest and posttest). Culturally appropriate and pragmatic training material was developed by the study team. Three focused group training sessions were conducted in Sidhwan Bet and Pakhowal blocks of Ludhiana district, Punjab. Results A total of 274 ASHAs from 164 villages with mean ± SD age of 39.5 ± 7.6 years participated in the three training sessions. The perceived knowledge of stroke risk factors and blood pressure assessment was 67.5 ± 18.3% and 84.4 ± 16.7%, respectively. The objective baseline knowledge about stroke prevention and management among ASHAs was lower 58.7 ± 19.7% compared with perceived knowledge ( p = 0.04). This increased to 82.5 ± 16.36% ( p < 0.001) after the mop-up training after a mean of 191 days. More than 30% increment was seen in knowledge about the stroke symptoms (35.9%, p < 0.001), avoiding opium after stroke for treatment (39.5%, p < 0.001), causes of stroke (53.3%, p < 0.001), modifiable risk factors for stroke (45.4%, p < 0.001), and lifestyle modifications for stroke prevention (42.1%, p < 0.001). Conclusions Focused group training can help enhance the knowledge of ASHAs about stroke prevention and management. ASHAs are also able to retain this complex multicomponent knowledge over a 6-month period. ASHA may be able to partake in reducing the secondary stroke burden in rural India.

Effect of a Community Health Worker-Based Approach to Integrated Cardiovascular Risk Factor Control in India: A Cluster Randomized Controlled Trial

BACKGROUND

Eighty percent of premature mortality from cardiovascular disease occurs in low- and middle-income countries. Hypertension, diabetes, and smoking are the top risk factors causing this disease burden.

OBJECTIVES

The study aimed to test the hypothesis that utilizing community health workers (CHWs) to manage hypertension, diabetes and smoking in an integrated manner would lead to improved control of these conditions.

METHODS

This was a 2-year cluster (n = 12) randomized controlled trial of 3,556 adults (35 to 70 years of age) in a single town in India, who were screened at home for hypertension, diabetes, and smoking. Of these adults, 1,242 (35%) had at least 1 risk factor (hypertension = 650, diabetes = 317, smoking = 500) and were enrolled in the study. The intervention group had behavioral change communication through regular home visits from community health workers. The control group received usual care in the community. The primary outcomes were changes in systolic blood pressure, fasting blood glucose, and average number of cigarettes/bidis smoked daily among individuals with respective risk factors.

RESULTS

The mean ± SD change in systolic blood pressure at 2 years was -12.2 ± 19.5 mm Hg in the intervention group as compared with -6.4 ± 26.1 mm Hg in the control group, resulting in an adjusted difference of -8.9 mm Hg (95% confidence interval [CI]: -3.5 to -14.4 mm Hg; p = 0.001). The change in fasting blood glucose was -43.0 ± 83.5 mg/dl in the intervention group and -16.3 ± 77.2 mg/dl in the control group, leading to an adjusted difference of -21.3 mg/dl (95% CI: 18.4 to -61 mg/dl; p = 0.29). The change in mean number of cigarettes/bidis smoked was nonsignificant at +0.2 cigarettes/bidis (95% CI: 5.6 to -5.2 cigarettes/bidis; p = 0.93).

CONCLUSIONS

A population-based strategy of integrated risk factor management through community health workers led to improved systolic blood pressure in hypertension, an inconclusive effect on fasting blood glucose in diabetes, and no demonstrable effect on smoking. (Study of a Community-Based Approach to Control Cardiovascular Risk Factors in India [SEHAT]; NCT02115711).

Cardiovascular Diseases in India Compared With the United States

This review describes trends in the burden of cardiovascular diseases (CVDs) and risk factors in India compared with the United States; provides potential explanations for these differences; and describes strategies to improve cardiovascular health behaviors, systems, and policies in India. The prevalence of CVD in India has risen over the past 2 decades due to population growth, aging, and a stable age-adjusted CVD mortality rate. Over the same time period, the United States has experienced an overall decline in age-adjusted CVD mortality, although the trend has begun to plateau. These improvements in CVD mortality in the United States are largely due to favorable population-level risk factor trends, specifically with regard to tobacco use, cholesterol, and blood pressure, although improvements in secondary prevention and acute care have also contributed. To realize similar gains in reducing premature death and disability from CVD, India needs to implement population-level policies while strengthening and integrating its local, regional, and national health systems. Achieving universal health coverage that includes financial risk protection should remain a goal to help all Indians realize their right to health.

Strategic Opportunities for Leveraging Low-cost, High-impact Technological Innovations to Promote Cardiovascular Health in India

Accelerated epidemiological transition in India over the last 40 years has resulted in a dramatic increase in the burden of cardiovascular diseases and the related risk factors of diabetes and hypertension. This increase in disease burden has been accompanied by pervasive health disparities associated with low disease detection rates, inadequate awareness, poor use of evidence-based interventions, and low adherence rates among patients in rural regions in India and those with low socioeconomic status. Several research groups in India have developed innovative technologies and care-delivery models for screening, diagnosis, clinical management, remote-monitoring, self-management, and rehabilitation for a range of chronic conditions. These innovations can leverage advances in sensor technology, genomic tools, artificial intelligence, big-data analytics, and so on, for improving access to and delivering quality and affordable personalized medicine in primary care. In addition, several health technology start-ups are entering this booming market that is set to grow rapidly. Innovations outside biomedical space (eg, protection of traditional wisdom in diet, lifestyle, yoga) are equally important and are part of a comprehensive solution. Such low-cost, culturally tailored, robust innovations to promote health and reduce disparities require partnership among multi-sectors including academia, industry, civil society, and health systems operating in a conducive policy environment that fosters adequate public and private investments. In this article, we present the unique opportunity for India to use culturally tailored, low-cost, high-impact technological innovations and strategies to ameliorate the perennial challenges of social, policy, and environmental challenges including poverty, low educational attainment, culture, and other socioeconomic factors to promote cardiovascular health and advance health equity.

Low quality cardiovascular care is important coronary risk factor in India

Global Burden of Disease study has reported that cardiovascular and ischemic heart disease (IHD) mortality has increased by 34% in last 25 years in India. It has also been reported that despite having lower coronary risk factors compared to developed countries, incident cardiovascular mortality, cardiovascular events and case-fatality are greater in India. Reasons for the increasing trends and high mortality have not been studied. There is evidence that social determinants of IHD risk factors are widely prevalent and increasing. Epidemiological studies have reported low control rates of hypertension, hypercholesterolemia, diabetes and smoking/tobacco. Registries have reported greater mortality of acute coronary syndrome in India compared to developed countries. Secondary prevention therapies have significant gaps. Low quality cardiovascular care is an important risk factor in India. Package of interventions focusing on fiscal, intersectoral and public health measures, improvement of health services at community, primary and secondary healthcare levels and appropriate referral systems to specialized hospitals is urgently required.

Caregiver oral rehydration solution fluid monitoring charts versus standard care for the management of some dehydration among Kenyan children: a randomized controlled trial

Background

Diarrhoea is a major cause of child mortality. Although oral rehydration solution (ORS) is an efficacious intervention for correcting dehydration, inadequate monitoring may limit its effectiveness in routine settings. We evaluated the effect of using a caregiver-administered chart to monitor oral fluid therapy on hydration status among children with some dehydration.

Methods

An open-label randomized controlled trial was conducted among children 2-59 months of age. ORS fluid monitoring charts were given to caregivers in the intervention arm to record the hourly intake of ORS. ORS was administered without charting in the control arm. The primary outcome was dehydration defined by the presence of clinical signs of some dehydration, severe dehydration or shock assessed 4 h after initiation of treatment. We also assessed the acceptability of the charts among caregivers.

Results

We evaluated 252 patients for the primary endpoint. Among those who received the intervention, 7/122 (5.7%) were still dehydrated following 4 h of ORS administration vs 20/130 (15.4%) in the control group (risk ratio 0.37 [95% confidence interval 0.16-0.85]). Caregivers in the intervention arm reported positive experiences using the fluid charts.

Conclusions

The use of fluid monitoring charts reduced the frequency of dehydration and was well accepted by caregivers, representing a promising innovation for the management of diarrhoea and dehydration in resource-limited settings.

Hypertension: The most important non communicable disease risk factor in India

Non-communicable diseases are important causes of mortality and morbidity in India. Data from the Registrar General of India, World Health Organization and Global Burden of Disease (GBD) Study have reported that cardiovascular diseases (CVD) are the most important causes of death and disability. Age-adjusted mortality from these conditions has increased by 31% in last 25 years. Case-control studies have reported that hypertension is most important risk factor for CVD in India. GBD Study has estimated that hypertension led to 1.6 million deaths and 33.9 million disability-adjusted life years in 2015 and is most important cause of disease burden in India. Intensive public health effort is required to increase its awareness, treatment and control. UN Sustainable Development Goals highlight the importance of high rates of hypertension control for achieving target of 1/3 reduction in non-communicable disease mortality by 2030. It is estimated that better hypertension control can prevent 400-500,000 premature deaths in India.

Socioeconomic Status and Cardiovascular Outcomes: Challenges and Interventions

Socioeconomic status (SES) has a measurable and significant effect on cardiovascular health. Biological, behavioral, and psychosocial risk factors prevalent in disadvantaged individuals accentuate the link between SES and cardiovascular disease (CVD). Four measures have been consistently associated with CVD in high-income countries: income level, educational attainment, employment status, and neighborhood socioeconomic factors. In addition, disparities based on sex have been shown in several studies. Interventions targeting patients with low SES have predominantly focused on modification of traditional CVD risk factors. Promising approaches are emerging that can be implemented on an individual, community, or population basis to reduce disparities in outcomes. Structured physical activity has demonstrated effectiveness in low-SES populations, and geomapping may be used to identify targets for large-scale programs. Task shifting, the redistribution of healthcare management from physician to nonphysician providers in an effort to improve access to health care, may have a role in select areas. Integration of SES into the traditional CVD risk prediction models may allow improved management of individuals with high risk, but cultural and regional differences in SES make generalized implementation challenging. Future research is required to better understand the underlying mechanisms of CVD risk that affect individuals of low SES and to determine effective interventions for patients with high risk. We review the current state of knowledge on the impact of SES on the incidence, treatment, and outcomes of CVD in high-income societies and suggest future research directions aimed at the elimination of these adverse factors, and the integration of measures of SES into the customization of cardiovascular treatment.

Chronic disease concordance within Indian households: A cross-sectional study

BACKGROUND

The household is a potentially important but understudied unit of analysis and intervention in chronic disease research. We sought to estimate the association between living with someone with a chronic condition and one's own chronic condition status.

METHODS AND FINDINGS

We conducted a cross-sectional analysis of population-based household- and individual-level data collected in 4 socioculturally and geographically diverse settings across rural and urban India in 2013 and 2014. Of 10,703 adults ages 18 years and older with coresiding household members surveyed, data from 7,522 adults (mean age 39 years) in 2,574 households with complete covariate information were analyzed. The main outcome measures were diabetes (fasting plasma glucose ≥ 126 mg/dL or taking medication), common mental disorder (General Health Questionnaire score ≥ 12), hypertension (blood pressure ≥ 140/90 mmHg or taking medication), obesity (body mass index ≥ 30 kg/m2), and high cholesterol (total blood cholesterol ≥ 240 mg/dL or taking medication). Logistic regression with generalized estimating equations was used to model associations with adjustment for a participant's age, sex, education, marital status, religion, and study site. Inverse probability weighting was applied to account for missing data. We found that 44% of adults had 1 or more of the chronic conditions examined. Irrespective of familial relationship, adults who resided with another adult with any chronic condition had 29% higher adjusted relative odds of having 1 or more chronic conditions themselves (adjusted odds ratio [aOR] = 1.29; 95% confidence interval [95% CI] 1.10-1.50). We also observed positive statistically significant associations of diabetes, common mental disorder, and hypertension with any chronic condition (aORs ranging from 1.19 to 1.61) in the analysis of all coresiding household members. Associations, however, were stronger for concordance of certain chronic conditions among coresiding household members. Specifically, we observed positive statistically significant associations between living with another adult with diabetes (aOR = 1.60; 95% CI 1.23-2.07), common mental disorder (aOR = 2.69; 95% CI 2.12-3.42), or obesity (aOR = 1.82; 95% CI 1.33-2.50) and having the same condition. Among separate analyses of dyads of parents and their adult children and dyads of spouses, the concordance between the chronic disease status was striking. The associations between common mental disorder, hypertension, obesity, and high cholesterol in parents and those same conditions in their adult children were aOR = 2.20 (95% CI 1.28-3.77), 1.58 (95% CI 1.15-2.16), 4.99 (95% CI 2.71-9.20), and 2.57 (95% CI 1.15-5.73), respectively. The associations between diabetes and common mental disorder in husbands and those same conditions in their wives were aORs = 2.28 (95% CI 1.52-3.42) and 3.01 (95% CI 2.01-4.52), respectively. Relative odds were raised even across different chronic condition phenotypes; specifically, we observed positive statistically significant associations between hypertension and obesity in the total sample of all coresiding adults (aOR = 1.24; 95% CI 1.02-1.52), high cholesterol and diabetes in the adult-parent sample (aOR = 2.02; 95% CI 1.08-3.78), and hypertension and diabetes in the spousal sample (aOR = 1.51; 95% CI 1.05-2.17). Of all associations examined, only the relationship between hypertension and diabetes in the adult-parent dyads was statistically significantly negative (aOR = 0.62; 95% CI 0.40-0.94). Relatively small samples in the dyadic analysis and site-specific analysis call for caution in interpreting qualitative differences between associations among different dyad types and geographical locations. Because of the cross-sectional nature of the analysis, the findings do not provide information on the etiology of incident chronic conditions among household members.

CONCLUSIONS

We observed strong concordance of chronic conditions within coresiding adults across diverse settings in India. These data provide early evidence that a household-based approach to chronic disease research may advance public health strategies to prevent and control chronic conditions.

TRIAL REGISTRATION

Clinical Trials Registry India CTRI/2013/10/004049; http://ctri.nic.in/Clinicaltrials/login.php.

Cardiovascular Diseases in India: Current Epidemiology and Future Directions

Cardiovascular diseases (CVDs) have now become the leading cause of mortality in India. A quarter of all mortality is attributable to CVD. Ischemic heart disease and stroke are the predominant causes and are responsible for >80% of CVD deaths. The Global Burden of Disease study estimate of age-standardized CVD death rate of 272 per 100 000 population in India is higher than the global average of 235 per 100 000 population. Some aspects of the CVD epidemic in India are particular causes of concern, including its accelerated buildup, the early age of disease onset in the population, and the high case fatality rate. In India, the epidemiological transition from predominantly infectious disease conditions to noncommunicable diseases has occurred over a rather brief period of time. Premature mortality in terms of years of life lost because of CVD in India increased by 59%, from 23.2 million (1990) to 37 million (2010). Despite wide heterogeneity in the prevalence of cardiovascular risk factors across different regions, CVD has emerged as the leading cause of death in all parts of India, including poorer states and rural areas. The progression of the epidemic is characterized by the reversal of socioeconomic gradients; tobacco use and low fruit and vegetable intake have become more prevalent among those from lower socioeconomic backgrounds. In addition, individuals from lower socioeconomic backgrounds frequently do not receive optimal therapy, leading to poorer outcomes. Countering the epidemic requires the development of strategies such as the formulation and effective implementation of evidence-based policy, reinforcement of health systems, and emphasis on prevention, early detection, and treatment with the use of both conventional and innovative techniques. Several ongoing community-based studies are testing these strategies.

A PROgramme of Lifestyle Intervention in Families for Cardiovascular risk reduction (PROLIFIC Study): design and rationale of a family based randomized controlled trial in individuals with family history of premature coronary heart disease

BACKGROUND

Recognizing patterns of coronary heart disease (CHD) risk in families helps to identify and target individuals who may have the most to gain from preventive interventions. The overall goal of the study is to test the effectiveness and sustainability of an integrated care model for managing cardiovascular risk in high risk families. The proposed care model targets the structural and environmental conditions that predispose high risk families to development of CHD through the following interventions: 1) screening for cardiovascular risk factors, 2) providing lifestyle interventions 3) providing a framework for linkage to appropriate primary health care facility, and 4) active follow-up of intervention adherence.

METHODS

Initially, a formative qualitative research component will gather information on understanding of diseases, barriers to care, specific components of the intervention package and feedback on the intervention. Then a cluster randomized controlled trial involving 740 families comprising 1480 participants will be conducted to determine whether the package of interventions (integrated care model) is effective in reducing or preventing the progression of CHD risk factors and risk factor clustering in families. The sustainability and scalability of this intervention will be assessed through economic (cost-effectiveness analyses) and qualitative evaluation (process outcomes) to estimate value and acceptability. Scalability is informed by cost-effectiveness and acceptability of the integrated cardiovascular risk reduction approach.

DISCUSSION

Knowledge generated from this trial has the potential to significantly affect new programmatic policy and clinical guidelines that will lead to improvements in cardiovascular health in India.

TRIAL REGISTRATION NUMBER

NCT02771873, registered in May 2016 ( https://clinicaltrials.gov/ct2/show/results/NCT02771873 ).