Structured Counselling and Regular Telephonic follow up to improve Referral flow and compliance in Nepal for Diabetic Retinopathy(SCREEN-D Study): a randomised controlled trial

BACKGROUND

Diabetic Retinopathy (DR) is an emerging public health issue, leading to severe visual impairment or blindness. Early identification and prompt treatment play a key role in achieving good visual outcomes. The objective of the study was to estimate the effectiveness of SCREEN package on improving referral compliance from peripheral centres to a tertiary eye centre in Nepal.

METHODS

In this facility-based cluster-randomized trial, ten out of 19 referring centres of the tertiary eye care centre in Lumbini zone, Nepal were randomized into intervention and control groups. A SCREEN packagewereprovided as intervention for DR patients who require advanced treatment in the tertiary centres and was compared with the current practice of the control arm, where structured counselling and follow-up mechanism are absent. Compliance was estimated by a weekly follow-up between the referring centre and the referred hospital.

RESULTS

We recruited 302 participantsof whom 153 were in the intervention arm. The mean age of the participants was 57.8 years (Standard deviation [SD]±11.7 years). With implementation of SCREEN package71.2% (n=109) in the intervention group and 42.9% (n=64) in the control group were compliant till three months of follow-up (Difference 28.3%, 95% CI: 17.6- 39.0, p<0.05). Compliance was 43% (n=66) with counselling alone, and 66% (n=103) with first telephonic follow-up in the intervention arm. The mean duration to reach the referral centre was 14.7 days (SD± 9.4 days) and 18.2 days (SD± 9.1 days) in the intervention and the control arm, respectively (Difference 3.5 days, 95% CI: 0.7 to 6.4 days).

CONCLUSIONS

Counselling& follow-up to patients is the key factor to improve the utilization of the health services by patients with DR. Health systems must be strengthened by optimizing the existing referral structure in Nepal.

TRIAL REGISTRATION

ClinicalTrials.gov Protocol Registration and Results System, ClinicalTrials.gov Identifier: NCT04834648 , 08/04/2021.

Prospective cohort study of surgical site infections following single dose antibiotic prophylaxis in caesarean section at a tertiary care teaching hospital in Medchal, India

BACKGROUND

Caesarean section (CS) is considered to be a life-saving operative intervention for women and new-borns in certain antepartum and intrapartum conditions. Caesarean delivery may be accompanied by several complications including surgical site infections (SSI). However, there is a significant lack of uniformity in the administration of antibiotics for preventing surgical site infections (SSI) following caesarean deliveries. The present study was conducted to determine the incidence of post CS SSI following the adoption of single-dose antibiotic prophylaxis as recommended by WHO at a tertiary care teaching hospital in Medchal, India. Also, to identify the risk factors of SSI and reported the bacteriological profiles and the antimicrobial susceptibility pattern of the culture positive isolates.

MAIN OBJECTIVES

To estimate the incidence of surgical site infections (SSI's) according to CDC criteria following WHO-recommended single-dose antibiotic prophylaxis for caesarean section at a tertiary care teaching hospital in Medchal, India.

METHODS

A prospective hospital-based study was conducted between June 2017 and December 2019, in which women who underwent caesarean delivery were followed up for 30 days post-delivery. Clinical details were collected using a structured questionnaire, and participants were followed up weekly after discharge to document any signs and symptoms of SSI. Symptomatic patients were requested to come to the hospital for further investigation and treatment. Standard microbiological tests were conducted to detect microorganisms and their antibiotic sensitivity.

RESULTS

The study included 2,015 participants with a mean age of 24.1 years. The majority were multigravida (n = 1,274, 63.2%) and underwent emergency caesarean delivery (n = 1,232, 61.1%). Ninety two participants (4.6%, 95% CI: 3.7% to 5.6%) developed surgical site infections, with 91 (98.9%) having superficial and 1 (1.1%) having a deep infection. Among those who developed an SSI, 84 (91.3%) did so during their hospital stay, while 8 (8.7%) developed an SSI at home. The adjusted relative risk (a RR) for developing an SSI was 2.5 (95% CI: 1.4 to 4.6; power 99.9%) among obese women and 2.3 (95% CI: 1.1 to 4.7; power 100%) among women aged 25 years or younger. Microbial growth in culture was observed from 55 (75.8%) out of total 66 samples. The most common organisms identified were Staphylococcus aureus (n = 7(12.3%)23, 46.0%), Klebsiella sp. (n = 13, 26.0%), and Escherichia coli (n = 12, 24.0%).

CONCLUSION

The rate of SSI following caesarean deliveries subjected to single dose antibiotic prophylaxis was low. Young women and obese women were at high risk of developing SSI.

Infertility Burden Across Indian States: Insights from a Nationally Representative Survey Conducted During 2019-21

Background

Infertility is an escalating global concern, impacting approximately one-sixth of the reproductive age population worldwide. Employing data from the National Family Health Survey-5 (NFHS-5, 2019-21), this study assessed the prevalence of primary infertility at both national and state levels in India.

Methods

The data of the study was extracted from the National Family Health Survey and Individual file (women file) of the fifth round of NFHS encompassing a sample of 491,484 currently married women in the age group of 15-49 years.

Results

The findings showed that the prevalence of infertility is 18.7 per 1,000 women among those married for at least five years and currently in union. This prevalence increases as the duration of marriage decreases. On a state-level analysis, regions such as Goa, Lakshadweep, and Chhattisgarh exhibit the highest burdens.

Conclusion

These findings underscore the growing challenge posed by primary infertility in India, calling for targeted interventions and policy measures. The establishment of a national infertility surveillance system is of pivotal importance in addressing this pressing public health issue.

Evaluating the Effectiveness of Interventions to Improve the Follow-up Rate for Children With Visual Disabilities in an Eye Hospital in Nepal: Nonrandomized Study

BACKGROUND

Monitoring ocular morbidity among pediatric patients requires regular follow-up visits. We found that the follow-up rate was poor among children in our setting. Therefore, we intended to assess the effectiveness of 2 interventions-(1) counseling and (2) SMS text messaging and phone calls-to improve the follow-up rates.

OBJECTIVE

This study aimed to evaluate the effectiveness of 2 interventions, counseling and SMS and phone calls group, as well as a routine standard care for improving the follow-up rate of pediatric patients.

METHODS

A Nonrandomized, quasiexperimental design was used. Children (aged 0-16 years) with ocular conditions requiring at least 3 follow-up visits during the study period were included. A total of 264 participants were equally allocated to the 3 intervention groups of (1) counseling, (2) SMS and phone calls, and (3) routine standard care group. A 20-minute counseling session by a trained counselor with the provision of disease-specific leaflets were given to those in the counseling group. For the second intervention group, parents of children received an SMS text 3 days before and a phone call 1 day before their scheduled follow-up visits. Participants allocated for the routine standard care group were provided with the existing services with no additional counseling and reminders. Participants attending 3 follow-ups within 2 days of the scheduled visit date were considered compliant. The difference in and among the proportion of participants completing all 3 follow-up visits in each group was assessed.

RESULTS

The demographic characteristics of the participants were similar across the study groups. Only 3% (8/264) of participants completed all 3 follow-up visits, but overall compliance with the follow-up, as defined by the investigators, was found to be only 0.76% (2/264). There was no statistically significant difference in the proportion of follow-up between the intervention groups. However, the proportion of participants attending the first and second follow-ups, as well as the overall total number of follow-ups, was more in the SMS and phone-call group followed by the counseling group.

CONCLUSIONS

We did not find any evidence on the effectiveness of our interventions to improve the follow-up rate. The primary reason could be that this study was conducted during the COVID-19 pandemic. It could also be possible that the intensity of the interventions may have influenced the outcomes. A rigorously designed study during the absence of any lockdown restrictions is warranted to evaluate intervention effectiveness. The study also provides useful insights and highlights the importance of designing and systematically developing interventions for improving the follow-up rate and ensuring a continuum of care to children with visual disabilities in Nepal and similar contexts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04837534; https://clinicaltrials.gov/ct2/show/NCT04837534.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/31578.

"Augmenting the referral pathway for retinal services among diabetic patients at Reiyukai Eiko Masunaga Eye Hospital, Nepal: a non-randomized, pre-post intervention study"

BACKGROUND

Diabetic Retinopathy (DR) is an important public health issue in Nepal. Despite the availability of retinal services, people may not access them because of the lack of knowledge about DR and poor referral systems. DR screening uptake was low at Reiyukai Eiko Masunaga Eye Hospital(REMEH) since retina services were started. Scheer Memorial Hospital is a multispeciality hospital near to REMEH. It has no eye department but has been running a regular diabetic clinic. This was a site for referring diabetic patients for DR screening. Improving DR awareness among general physicians has the potential to address these challenges.

METHODS

The aim of our study was to investigate the effectiveness of providing health education to selected health personnel and establish a referral pathway on the attendance of diabetic patients for retinal screening at REMEH. This was a non-randomized, pre-post intervention study design. Total of three health education sessions were provided to the health care professionals of Scheer on diabetic retinopathy using Power Point presentations, posters, pamphlets and videos. The study period was 16 months (2020 June -2021 September) and divided into 8 months pre-intervention(baseline data collection) and 8 months post intervention period. The proportional increase in number of diabetes attendance pre and post intervention was calculated by Z test. The change in knowledge of health care personnels pre and post intervention was scored and evaluated through a questionnaire and calculated by paired- t test. Data was analyzed using Excel and Epi Info 7.The Protocol was published on August 21, 2021, in JMIR Publications.

RESULTS

The proportional increase in number of referrals of diabetes attendance post intervention increased from 50 to 95% and was statistically significant (p < 0.001, 95% CI: 0.214-0.688). The mean score of knowledge gained by physicians on DR awareness was more at post intervention (8.8 ± 1.32) than pre intervention (6.4 ± 1.51). It was statistically significant (p < 0.001).

CONCLUSION

This study shows that a well-planned health education intervention changes the knowledge in physicians about DR. There is an increase in the number of referrals and attendance of patients for DR screening with the change in knowledge and referral mechanism.

TRIAL REGISTRATION

Clinical Trials.gov NCT04829084; https://clinicaltrials.gov/ct2/show/NCT04829084 :02/04/2021.

Forecasting the Anti-Rabies Vaccine Demand at Jawaharlal Medical College and Hospital, Ajmer, Rajasthan: A Comparative Analysis based on Time Series Model

Background: In India, high mortality and morbidity rates of human rabies is observed. Hence, a structured surveillance system is yet to be put in place for public health discussion. At the tertiary care hospital and all public health centres, requirement of anti-rabies vaccine is needed in advance to predict the upcoming months coverage so that wastage of vaccine is minimum. Objective: To find a suitable model for forecasting the appropriate stock of anti-rabies vaccines to avoid shortage and over-supply at anti rabies clinic. Methods and Material: This was a record based cross sectional study, conducted at anti rabies clinic of Jawaharlal Nehru Medical College and Hospital, Ajmer. Data of used anti rabies vaccine was taken from immunization inventory during the period from 2017 to 2020. Time series analysis based on Holt-Winter and Box-Jenkins methods were carried out to predict the need of vaccine. Results: Study series was not stationary and stationarity was observed by taken difference in the observation between two consequent months. Residuals of the series were normally distributed and independent to each other. ARIMA(0, 1, 1) was the best model in comparison to Holt-Winter model for prediction because of low value of model selection criterion.  The forecasted value for anti-rabies vaccine was done for the year 2021. Conclusions: The following study concluded that time series can be used as a tool to forecast anti-rabies vaccine coverage and will help the policy makers to formulate appropriate plans and strategies and improve the management of vaccination resources and inventory.

Study of the trend pattern of COVID-19 using spline-based time series model: a Bayesian paradigm

A vast majority of the countries are under economic and health crises due to the current epidemic of coronavirus disease 2019 (COVID-19). The present study analyzes the COVID-19 using time series, an essential gizmo for knowing the enlargement of infection and its changing behavior, especially the trending model. We consider an autoregressive model with a non-linear time trend component that approximately converts into the linear trend using the spline function. The spline function splits the series of COVID-19 into different piecewise segments between respective knots in the form of various growth stages and fits the linear time trend. First, we obtain the number of knots with their locations in the COVID-19 series to identify the transmission stages of COVID-19 infection. Then, the estimation of the model parameters is obtained under the Bayesian setup for the best-fitted model. The results advocate that the proposed model appropriately determines the location of knots based on different transmission stages and know the current transmission situation of the COVID-19 pandemic in a country.