Evaluating a community based mental health programme in West Bengal, India: Description of the methodology and lessons learned

Mental disorders impose an enormous burden on society. In developing countries like India, there is a lack of adequate number of trained mental health professionals to provide specialized care and 75-85 % of affected individuals do not have access to appropriate mental health services. The National Mental Health Programme (NMHP) is being implemented by the Government of India to support state governments in providing mental health services in the country. The Urban Mental Health Programme (UMHP) is a pilot initiative that has attempted the integration of mental health services in primary health care settings in two municipal wards in Kolkata, West Bengal, India. The overarching aim of this paper is to describe the methodology used for the evaluation of the community based mental health programme and to understand the processes of the programme in terms of barriers and facilitators. The current evaluation is based on a concurrent nested design, where qualitative and quantitative data are both collected at the same time but analysed separately and priority was given to qualitative data. This experience will contribute in helping other researchers to make some evaluations more effective, useful and manageable. Ethics approval was obtained from an institutional ethics committee of an organization (Ekjut) based in Ranchi, Jharkhand, India. The evaluation was undertaken by the George Institute for Global Health, New Delhi from February- June 2016.

SMART Mental Health Project: process evaluation to understand the barriers and facilitators for implementation of multifaceted intervention in rural India

BACKGROUND

Globally, mental health problems are a growing public health concern. Resources and services for mental disorders are disproportionately low compared to disease burden. In order to bridge treatment gaps, The Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health Project was implemented across 12 villages in West Godavari district of the southern Indian state of Andhra Pradesh. This paper reports findings from a process evaluation of feasibility and acceptability of the intervention that focused on a mental health services delivery model to screen, diagnose and manage common mental disorders (CMDs).

METHODS

A mixed methods evaluation was undertaken using quantitative service usage analytics, and qualitative data from in-depth interviews and focus group discussions were conducted with stakeholders including primary care physicians, community health workers, field staff and community members. Barriers to and facilitators of intervention implementation were identified. Andersen's Behavioral Model for Health Services Use was the conceptual framework used to guide the process evaluation and interpretation of data.

RESULTS

In all, 41 Accredited Social Health Activists (ASHAs) and 6 primary health centre (PHC) doctors were trained in mental health symptoms and its management. ASHAs followed up 98.7% of screen positive cases, and 81.2% of these were clinically diagnosed and treated by the PHC doctors. The key facilitators of implementation were adequate training and supervision of field staff, ASHAs and doctors, use of electronic decision support, incorporation of a door-to-door campaign and use of culturally tailored dramas/videos to raise awareness about CMDs, and organising health camps at the village level facilitating delivery of intervention activities. Barriers to implementation included travel distance to receive care, limited knowledge about mental health, high level of stigma related to mental health issues, and poor mobile network signals and connectivity in the villages. Lack of familiarity with and access to mobile phones, especially among women, to accessing health related messages as part of the intervention.

CONCLUSIONS

The evaluation not only provides a context to the interventions delivered, but also allowed an understanding of possible factors that need to be addressed to make the programme scalable and of benefit to policy makers.

Feasibility of a Lifestyle Intervention Program for Prevention of Diabetes Among Women With Prior Gestational Diabetes Mellitus (LIVING Study) in South Asia: A Formative Research Study

Aim: To refine and contextually adapt a postpartum lifestyle intervention for prevention of type 2 diabetes mellitus (T2DM) in women with prior gestational diabetes mellitus (GDM) in Bangladesh, India, and Sri Lanka. Materials and Methods: In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted with women with current diagnosis of GDM, and health care professionals involved in their management, to understand relevant local contextual factors for intervention optimization and implementation. This paper describes facilitators and barriers as well as feedback from participants on how to improve the proposed intervention. These factors were grouped and interpreted along the axes of the three main determinants of behavior-capability, opportunity, and motivation. IDIs and FGDs were digitally recorded, transcribed, and translated. Data-driven inductive thematic analysis was undertaken to identify and analyze patterns and themes. Results: Two interrelated themes emerged from the IDIs and FGDs: (i) The lifestyle intervention was acceptable and considered to have the potential to improve the existing model of care for women with GDM; and (ii) Certain barriers such as reduced priority of self-care, and adverse societal influences postpartum need to be addressed for the improvement of GDM care. Based on the feedback, the intervention was optimized by including messages for family members in the content of the intervention, providing options for both text and voice messages as reminders, and finalizing the format of the intervention session delivery. Conclusion: This study highlights the importance of contextual factors in influencing postpartum care and support for women diagnosed with GDM in three South Asian countries. It indicates that although provision of postpartum care is complex, a group lifestyle intervention program is highly acceptable to women with GDM, as well as to health care professionals, at urban hospitals.

Access to CKD Care in Rural Communities of India: a qualitative study exploring the barriers and potential facilitators

Background

Despite the high and rising burden of chronic kidney disease (CKD) in South Asia, factors that influence access to CKD care at the community level have not been studied previously, especially in the rural areas. We conducted a mixed methods study and interviewed key stakeholders to explore the views and experiences of key stakeholders, and identify barriers and potential facilitators that influence access to CKD care at the primary care level in rural India.

Methods

A total of 21 stakeholders participated in the study. We conducted 15 in-depth interviews on a purposive sample of stakeholders (CKD patients, healthcare providers and health planners) and one focus group discussion with 6 community health workers. The interviews were audio-recorded and transcribed verbatim. We employed the Lévesque’s framework for access to care to base interview guides and structure the initial codes. By inductive and deductive approaches, thematic analysis was undertaken using QSR NVivo version 11.

Results

The major patient-level barriers to CKD care as reported by the most patients and healthcare providers was poor knowledge and awareness of CKD. Health system-level barriers included shortages of skilled healthcare professionals and medicines, fragmented referrals pathways to the specialists at the hospitals with inadequate follow up care. Many patients and healthcare providers, when asked about areas for improving access to CKD care, reported educational initiatives to increase awareness of CKD among healthcare providers and patients, provision of CKD related supplies, and a systems-level approach to care coordination including task shifting by engaging community health workers in CKD care, as potential facilitators.

Conclusions

We identified several barriers to access CKD care at the primary care level in rural India that need urgent attention. Targeted CKD screening programs and CKD specific educational initiatives may improve awareness of CKD. Additionally, primary care infrastructure needs to be strengthened for CKD care, ensuring trained staff, availability of essential diagnostics and medications, and creating efficient referral pathways for quality CKD care.

Dose and time effects of solar-simulated ultraviolet radiation on the in vivo human skin transcriptome

Background

Terrestrial ultraviolet (UV) radiation causes erythema, oxidative stress, DNA mutations and skin cancer. Skin can adapt to these adverse effects by DNA repair, apoptosis, keratinization and tanning.

Objectives

To investigate the transcriptional response to fluorescent solar‐simulated radiation (FSSR) in sun‐sensitive human skin in vivo.

Methods

Seven healthy male volunteers were exposed to 0, 3 and 6 standard erythemal doses (SED). Skin biopsies were taken at 6 h and 24 h after exposure. Gene and microRNA expression were quantified with next generation sequencing. A set of candidate genes was validated by quantitative polymerase chain reaction (qPCR); and wavelength dependence was examined in other volunteers through microarrays.

Results

The number of differentially expressed genes increased with FSSR dose and decreased between 6 and 24 h. Six hours after 6 SED, 4071 genes were differentially expressed, but only 16 genes were affected at 24 h after 3 SED. Genes for apoptosis and keratinization were prominent at 6 h, whereas inflammation and immunoregulation genes were predominant at 24 h. Validation by qPCR confirmed the altered expression of nine genes detected under all conditions; genes related to DNA repair and apoptosis; immunity and inflammation; pigmentation; and vitamin D synthesis. In general, candidate genes also responded to UVA1 (340–400 nm) and/or UVB (300 nm), but with variations in wavelength dependence and peak expression time. Only four microRNAs were differentially expressed by FSSR.

Conclusions

The UV radiation doses of this acute study are readily achieved daily during holidays in the sun, suggesting that the skin transcriptional profile of ‘typical’ holiday makers is markedly deregulated.

What's already known about this topic?

The skin's transcriptional profile underpins its adverse (i.e. inflammation) and adaptive molecular, cellular and clinical responses (i.e. tanning, hyperkeratosis) to solar ultraviolet radiation.

Few studies have assessed microRNA and gene expression in vivo in humans, and there is a lack of information on dose, time and waveband effects.

What does this study add?

Acute doses of fluorescent solar‐simulated radiation (FSSR), of similar magnitude to those received daily in holiday situations, markedly altered the skin's transcriptional profiles.

The number of differentially expressed genes was FSSR‐dose‐dependent, reached a peak at 6 h and returned to baseline at 24 h.

The initial transcriptional response involved apoptosis and keratinization, followed by inflammation and immune modulation. In these conditions, microRNA expression was less affected than gene expression.

Linked Comment:Hart. Br J Dermatol 2020; 182:1328–1329.

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Study to Test and Operationalize Preventive Approaches for CKD of Undetermined Etiology in Andhra Pradesh, India

INTRODUCTION

High prevalence of chronic kidney disease (CKD) not associated with known risk factors has been reported from coastal districts of Andhra Pradesh. The Study to Test and Operationalize Preventive Approaches for Chronic Kidney Disease of Undetermined Etiology in Andhra Pradesh (STOP CKDu AP) aims to ascertain the burden (prevalence and incidence) of CKD, the risk factor profile, and the community perceptions about the disease in the Uddanam area of Andhra Pradesh.

METHODS

Study participants will be sampled from the Uddanam area using multistage cluster random sampling. Information will be collected on the demographic profile, occupational history, and presence of conventional as well as nonconventional risk factors. Glomerular filtration rate (GFR) will be estimated using the Chronic Kidney Disease Epidemiology Collaboration equation, and proteinuria will be measured. All abnormal values will be confirmed by repeat testing after 3 months. Cases of CKD not associated with identified etiologies will be identified. Biospecimens will be stored to explore future hypotheses. The entire cohort will be followed up every 6 months to determine the incidence of CKD and to identify risk factors for decline in kidney function. Qualitative studies will be performed to understand the community perceptions and expectations with respect to the interventions.

IMPLICATIONS

CKD is an important public health challenge in low- and middle-income countries. This study will establish the prevalence and determine the incidence of CKD not associated with known risk factors in a reported high-burden region, and will provide insights to help design targeted health systems responses. The findings will contribute to the policy development to tackle CKD in the region and will permit international comparisons with other regions with similar high prevalence.

No stone unturned: Nodule Net, an intervention to reduce loss to follow-up of lung nodules

OBJECTIVE

Inadequate lung nodule surveillance leads to diagnostic delays. We implemented a retrospective intervention program, Nodule Net, to improve surveillance in our hospital.

METHODS

9,224 Chest computed tomography (CT) scans between January 1, 2015 and December 31, 2016 were manually reviewed for lung nodules. For patients without follow-up, charts were reviewed to assess follow-up. If follow-up appeared indicated, the clinician or patient was contacted, and follow-up was tracked.

RESULTS

Lung nodules were identified on 5,101 (55%) of 9,224 scans. Follow-up was potentially indicated and not completed in 1,385 (27%). 183 (13%) were excluded after imaging review. 1,202 received outreach. Of the 801 (66%) with a provider in our system, 225 (27%) returned for follow-up. Nodules were stable in 199 (88%), new or growing in 23 (11%), resolved in 3 (1%), and stage 1 lung cancer in 2 (1%). 90 (11%) had follow-up outside our system and 431 (51%) had no follow-up due to a clinical contraindication. 55 (7%) have imaging pending and 14 (2%) are awaiting pulmonary evaluation. Of the 302 (25%) patients with providers outside our system, 121 (40%) had followed-up elsewhere. 146 (48%) had no follow-up due to a clinical reason. 35 (12%) providers did not respond to outreach.

CONCLUSIONS

We identified 1,202 patients with lung nodules who needed follow-up over a two-year period. Compliance was more successful with providers within our hospital system. We recommend robust surveillance for patients to ensure follow-up is completed and clinical contraindications are well documented.

Barriers and Facilitators to the Use of Cardiovascular Fixed-Dose Combination Medication (Polypills) in Andhra Pradesh, India: A Mixed-Methods Study

BACKGROUND

Polypills, fixed-dose combinations of blood pressure-lowering drug(s), and statin, with or without aspirin, improve the use of these recommended drugs in patients with or at high risk of cardiovascular disease. However, in India, there has been poor uptake of polypills despite market availability.

OBJECTIVES

This study sought to assess availability and cost of polypills and explore barriers and facilitators to their use in the state of Andhra Pradesh in India.

METHODS

A mixed-methods study was conducted. Availability and cost of polypills as well as individual component drugs was assessed through a survey of pharmacies across urban, urban slum, and rural regions in state of Andhra Pradesh in India. In-depth interviews with stakeholders at each level of the health system explored barriers and facilitators to use of polypills.

RESULTS

Overall, 30 pharmacies were surveyed (10 in each of urban, urban slum, and rural region). In urban region, 2 pharmacies stocked polypills (without aspirin) costing 121 Indian rupees (INR) per 10 pills, and 1 other pharmacy stocked a polypill (with aspirin) costing 24 INR per 10 pills. All pharmacies stocked a wide range of component drugs as separate pills with combined cost of the cheapest angiotensin-converting enzyme inhibitor, statin, and aspirin INR 124 per 10 pills. Patients were willing to use polypills if prescribed by their doctor, and pharmacies were willing to stock polypills if there was market demand. For prescribers, key barriers included perceptions that current polypills contained outdated drugs and inadequate flexibility in prescribing.

CONCLUSIONS

In a market in which polypill use is licensed, their availability and use is very low. Lack of prescription of polypills was the predominant barrier to polypill use; therefore, making polypills with drugs that are more acceptable and at different available strengths, in conjunction with broader prescriber education and training, may improve their use.

New approaches for post-vaccination surveillance of foot-and-mouth disease

Foot-and-mouth disease (FMD) is a contagious and important transboundary disease of cloven-hoofed animals and ruminants. In ruminants, an animal is considered as a foot-and-mouth disease virus (FMDV) carrier if a live FMDV/FMDV RNA is obtained from the oro-pharyngeal fluid (OPF) beyond 28 days after infection. These carrier animals may pose a risk for causing outbreaks in healthy animals. Moreover, it is important to conduct serosurveillance to know the virus circulation. In the present study, an ELISA was developed using field samples to detect FMDV specific secretory IgA antibodies. These samples were also tested for the presence of FMDV RNA using quantitative real-time PCR (qRT-PCR). It was found that more carrier animals were detected by IgA ELISA in comparison to qRT-PCR. Thus, IgA ELISA is an important tool to detect FMD carriers. An ELISA based on detection of antibodies against FMDV 2B non-structural protein (NSP) was also used to confirm the results obtained from screening of 3AB3 NSP ELISA. These two new approaches (IgA ELISA and 2B ELISA) form important tools for detection of carriers and virus circulation, respectively, during FMD eradication program. Keywords: foot-and-mouth disease virus; carriers; IgA; 2B non-structural protein; 3AB3 non-structural protein.

A Psychosexual Rehabilitation Booklet Increases Vaginal Dilator Adherence and Knowledge in Women Undergoing Pelvic Radiation Therapy for Gynaecological or Anorectal Cancer: A Randomised Controlled Trial

AIMS

Women treated with pelvic radiation therapy (PRT) for gynaecological or anorectal cancer report a high number of sexual problems and unmet post-treatment psychosexual information needs. Currently, there is suboptimal adherence to recommended rehabilitation aids, such as vaginal dilators, and a paucity of resources to facilitate post-radiation rehabilitation and reduce distress in this population. This randomised controlled trial aimed to evaluate the effectiveness of a study-developed psychosexual rehabilitation booklet in this setting.

MATERIALS AND METHODS

Eighty-two women scheduled for PRT to treat gynaecological/anorectal cancer were randomised to receive the intervention booklet (n = 44) or standard information materials (n = 38). Self-report questionnaires administered at pre-treatment baseline and at 3, 6 and 12 months post-treatment assessed adherence with rehabilitation aids, booklet knowledge, anxiety, depression and sexual functioning/satisfaction.

RESULTS

Dilator adherence and booklet knowledge were significantly higher in the intervention group than in the control group (averaged over time points), with scores significantly increasing over time. Younger age and gynaecological cancer were significant predictors of greater dilator adherence. No significant group differences were found on psychological and sexual measures.

CONCLUSIONS

The psychosexual rehabilitation booklet was effective in educating women with gynaecological and anorectal cancers about PRT-related psychosexual side-effects and rehabilitation options, as well as promoting uptake of vaginal dilator use. Future research should elucidate the effectiveness of this booklet in women with greater psychological and sexual functioning needs.

Sunscreen applied at ≥ 2 mg cm-2 during a sunny holiday prevents erythema, a biomarker of ultraviolet radiation-induced DNA damage and suppression of acquired immunity

BACKGROUND

Sun protection factor (SPF) is assessed with sunscreen applied at 2 mg cm^-2 . People typically apply around 0·8 mg cm^-2 and use sunscreen daily for holidays. Such use results in erythema, which is a risk factor for skin cancer.

OBJECTIVES

To determine (i) whether typical sunscreen use resulted in erythema, epidermal DNA damage and photoimmunosuppression during a sunny holiday, (ii) whether optimal sunscreen use inhibited erythema and (iii) whether erythema is a biomarker for photoimmunosuppression in a laboratory study.

METHODS

Holidaymakers (n = 22) spent a week in Tenerife (very high ultraviolet index) using their own sunscreens without instruction (typical sunscreen use). Others (n = 40) were given SPF 15 sunscreens with instructions on how to achieve the labelled SPF (sunscreen intervention). Personal ultraviolet radiation (UVR) exposure was monitored electronically as the standard erythemal dose (SED) and erythema was quantified. Epidermal cyclobutane pyrimidine dimers (CPDs) were determined by immunostaining, and immunosuppression was assessed by contact hypersensitivity (CHS) response.

RESULTS

There was no difference between personal UVR exposure in the typical sunscreen use and sunscreen intervention groups (P = 0·08). The former had daily erythema on five UVR-exposed body sites, increased CPDs (P < 0·001) and complete CHS suppression (20 of 22). In comparison, erythema was virtually absent (P < 0·001) when sunscreens were used at ≥ 2 mg cm^-2 . A laboratory study showed that 3 SED from three very different spectra suppressed CHS by around ~50%.

CONCLUSIONS

Optimal sunscreen use prevents erythema during a sunny holiday. Erythema predicts suppression of CHS (implying a shared action spectrum). Given that erythema and CPDs share action spectra, the data strongly suggest that optimal sunscreen use will also reduce CPD formation and UVR-induced immunosuppression.

Process evaluation of the systematic medical appraisal, referral and treatment (SMART) mental health project in rural India

BACKGROUND

Availability of basic mental health services is limited in rural areas of India. Health system and individual level factors such as lack of mental health professionals and infrastructure, poor awareness about mental health, stigma related to help seeking, are responsible for poor awareness and use of mental health services. We implemented a mental health services delivery model that leveraged technology and task sharing to facilitate identification and treatment of common mental disorders (CMDs) such as stress, depression, anxiety and suicide risk in rural areas of the state of Andhra Pradesh, India. The intervention was delivered by lay village health workers (Accredited Social Health Activists - ASHAs) and primary care doctors. An anti-stigma campaign was implemented prior to this activity. This paper reports the process evaluation of the intervention using mixed methods.

METHODS

A mixed methods pre-post evaluation assessed the intervention using quantitative service usage analytics from the server, and qualitative interviews with different stakeholders. Barriers and facilitators in implementing the intervention were identified.

RESULTS

Health service use increased significantly at post-intervention, ASHAs could followup 78.6% of those who had screened positive, and 78.6% of the 1243 Interactive Voice Response System calls made, were successful. Most respondents were aware of the intervention. They indicated that knowledge received through the intervention empowered them to approach ASHAs and share their mental health symptoms. ASHAs and doctors opined that EDSS was useful and easy to use. Medical camps organized in villages to increase access to the doctor were received positively by all. However, some aspects or facilitators of the intervention need to be improved, including network connectivity, booster training, anti-stigma campaigns, quality of mental health services provided by doctors, provision of psychotropic medications at primary health centers and frequency of health camps.

CONCLUSION

The respondents' views helped to understand the barriers and facilitators for improving the likely effectiveness of the intervention using Andersen's Modified Behavioral Model of Health Services Use, and identify the mechanisms by which those factors affected mental health services uptake in the community.

TRIAL REGISTRATION

The study is registered with Clinical Trials Registry India (Applied - 16/07/14-Ref2014/07/007256; registration received - 04/10/17-CTRI/2017/10/009992 ).

Management of older adults with hip fractures in India: a mixed methods study of current practice, barriers and facilitators, with recommendations to improve care pathways

Evidence-based management can reduce deaths and suffering of older adults with hip fractures. This study investigates the evidence-practice gaps in hip fracture care in three major hospitals in Delhi, potential barriers and facilitators to improving care, and consequently, identifies contextually appropriate interventions for implementing best practice for management of older adults with hip fractures in India.

PURPOSE

Hip fracture in older adults is a significant public health issue in India. The current study sought to document current practices, identify barriers and facilitators to adopting best practice guidelines and recommend improvements in the management of older adults with hip fractures in Delhi, India.

METHODS

This mixed methods observational study collected data from healthcare providers, patients, carers and medical records from three major public tertiary care hospitals in Delhi, India. All patients aged ≥50 years with an X-ray confirmed hip fracture that were admitted to these hospitals over a 10-week period were recruited. Patients' data were collected at admission, discharge and 30 days post-injury. Eleven key informant interviews and four focus group discussions were conducted with healthcare providers. Descriptive data for key quantitative variables were computed. The qualitative data were analysed and interpreted using a behaviour change wheel framework.

RESULTS

A total of 136 patients, 74 (54%) men and 62 women, with hip fracture were identified in the three participating hospitals during the recruitment period and only 85 (63%) were admitted for treatment with a mean age of 66.5 years (SD 11.9). Of these, 30% received surgery within 48 h of hospital admission, 95% received surgery within 39 days of hospital admission and two (3%) had died by 30 days of injury. According to the healthcare providers, inadequate resources and overcrowding prevent adequate caring of the hip fracture patients. They unanimously felt the need for protocol-based management of hip fracture in India.

CONCLUSION

The development and implementation of national guidelines and standardized protocols of care for older people with hip fractures in India has the potential to improve both care and patient-related outcomes.

Testing the nicotine dependence measure mFTQ for adolescent smokers: A multinational investigation

BACKGROUND AND OBJECTIVES

As a measure of nicotine dependence among adolescent smokers, the modified Fagerström Tolerance Questionnaire (mFTQ; seven items), has been successfully used in the United States (USA). Nonetheless, the validity and reliability of mFTQ at the international level is still needed. The current study is the first to test the validity and reliability of mFTQ in four countries: Thailand, Spain, the USA, and Russia.

METHODS

In a cross-sectional survey, mFTQ, risk factors of nicotine dependence, and sociodemographic characteristics were assessed. Risk factors included age of first cigarette, frequency of alcohol use, frequency of marijuana use, and number of cigarettes smoked yesterday. Salivary cotinine was also obtained in Thailand and Spain.

RESULTS

For all four countries, mFTQ exhibited a single factor structure, as supported by previous work in the USA. For all studied countries except Thailand, mFTQ presented acceptable internal reliability. Overall, risk factors of nicotine dependence have predicted mFTQ scores across countries. Frequency of alcohol use in the USA and frequency of marijuana use in Thailand and Spain were not associated with mFTQ scores.

DISCUSSION AND CONCLUSIONS

mFTQ is a single-factor measure of nicotine dependence that shows acceptable internal consistency and validity across countries. Further work can advance the scale and tailor it to different cultures.

SCIENTIFIC SIGNIFICANCE

mFTQ can be a clinically practical international measure of nicotine dependence. This study provides initial support for the utility of the mFTQ among Thai, Spanish, American, and Russian adolescents. Further research is needed to test and advance mFTQ across cultures. (Am J Addict 2017;26:689-696).

Concomitant effect of low dose of lindane and intranasal lipopolysaccharide on respiratory system of mice

Lindane is very commonly used organochlorine pesticide and has been reported to cause several toxic effects including respiratory insufficiency. However, effects of low concentration of lindane alone or in combination with microbial molecules on lungs are not fully understood. To understand the effects a preliminary study was designed on Swiss albino mouse. Male mice were divided into treatment and control group (20; each). Treatment mice were given lindane in ground nut oil orally at 0.25 mg kg^-1 day^-1 for 60 days. After treatment, 10 mice were challenged with intranasal Escherichia coli lipopolysaccharide (LPS; 80 μg per mice) and remaining 10 with normal saline. The mice were euthanized 16 h post-LPS exposure. Control mice (10 each) were given normal saline or the LPS alone. Mice exposed with lindane and in combination with LPS had increase in total cell counts and leukocyte counts in broncho-alveolar lavage. Histological examination showed lung injury in the lindane-treated mice. The histopathological changes were more pronounced in lindane along with LPS-exposed mice. Lindane alone and in combination with LPS showed expression of immunopositive Toll-like receptor (TLR)-4 and tumour necrosis factor-alpha (TNF-α) positive reaction in various cells of lungs. While LPS induced acute inflammation in the lungs, combination of lindane and LPS exacerbated histological signs of the inflammation. The data indicate that lindane alone or in combination with LPS caused changes in lung morphology and altered TLR-4 and TNF-α expression which may have led to altered response to LPS challenge.

Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach

BACKGROUND

Stigma related to mental health is a major barrier to help-seeking resulting in a large treatment gap in low- and middle-income countries (LMIC). This study assessed changes in knowledge, attitude and behaviour, and stigma related to help-seeking among participants exposed to an anti-stigma campaign.

METHOD

The campaign, using multi-media interventions, was part of the SMART Mental Health Project, conducted for 3 months, across 42 villages in rural Andhra Pradesh, in South India. Mixed-methods evaluation was conducted in two villages using a pre-post design.

RESULTS

A total of 1576 and 2100 participants were interviewed, at pre- and post-intervention phases of the campaign. Knowledge was not increased. Attitudes and behaviours improved significantly (p < 0.01). Stigma related to help-seeking reduced significantly (p < 0.05). Social contact and drama were the most beneficial interventions identified during qualitative interviews.

CONCLUSION

The results showed that the campaign was beneficial and led to improvement of attitude and behaviours related to mental health and reduction in stigma related to help-seeking. Social contact was the most effective intervention. The study had implications for future research in LMIC.

The Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health Project: Development and Testing of Electronic Decision Support System and Formative Research to Understand Perceptions about Mental Health in Rural India

INTRODUCTION

Common mental disorders (CMD) such as depression, suicidal risk and emotional/medically unexplained complaints affect a large number of people in India, but few receive appropriate care. Key reasons for this include few trained mental health professionals and stigma associated with mental health. A potential approach to address poor access to care is by training village healthcare workers in providing basic mental health care, and harnessing India's vast mobile network to support such workers using mobile-based applications. We propose an intervention to implement such an approach that incorporates the use of mobile-based electronic decision support systems (EDSS) to provide mental health services for CMD, combined with a community-based anti-stigma campaign. This will be implemented and evaluated across 42 villages in Andhra Pradesh, a south Indian state. This paper discusses the development and testing of the EDSS, and the formative research that informed the anti-stigma campaign.

MATERIALS AND METHODS

The development of the EDSS used an iterative process that was validated against clinical diagnosis. A mixed methods approach tested the user acceptability of the EDSS. Focus group discussions and in-depth interviews provided community-level perceptions about mental health. This study involved 3 villages and one primary health centre.

RESULTS

The EDSS application was found to be acceptable, but some modifications were needed. The community lacked adequate knowledge about CMD and its treatment and there was stigma associated with mental illness. Faith and traditional healers were considered to be important mental health service providers.

DISCUSSION

A number of barriers and facilitators were identified in implementing the intervention analysed in a framework using Andersen's behavioural model of health services use.

CONCLUSION

The findings assisted with refining the intervention prior to large-scale implementation and evaluation.

Protocol-based management of older adults with hip fractures in Delhi, India: a feasibility study

Background

Worldwide hip fractures are projected to increase from 1.7 million in 1990 to 6.3 million in 2050. In India, conservative estimates suggest an annual incidence of 600,000 osteoporotic hip fractures and this is expected to increase significantly due to ageing and increase life expectancy. Protocol-based ‘care pathways’ for the management of adults, over 60 years of age, with hip fractures in high-income countries has resulted in decreased mortality rates, early hospital discharge, improved quality of life and reduction in healthcare costs. The study objectives are to determine appropriateness, acceptability and feasibility of adopting best-practice guideline or protocol-based care for the management of hip fractures among older adults in India. The study will also identify barriers and facilitators in recruiting patients and retention till the agreed follow-up period.

Methods

This will be a mixed-methods prospective cohort study. The quantitative data collection will involve recruitment of consecutive patients aged >50 years with an X-ray-confirmed hip fracture admitted in four tertiary care hospitals in Delhi, India, over a 2-month period. The quantitative data will be collected at three points: from patients at admission to hospital, from medical records at discharge and by telephone interviews with patients at 30 days post hip fracture. Qualitative data collection will involve key informant interviews, conducted with clinical leads and focus group discussions, conducted with groups of healthcare providers and patients and/or their carers. COM-B theoretical framework (capability, opportunity, motivation and behaviour) will be used to explore healthcare providers’ behaviour in order to facilitate development and implementation of appropriate integrated care pathway for management of older adults with hip fractures in India.

Discussion

The proposed study will identify gaps in best practice in the management of older people with hip fractures in tertiary care hospitals in Delhi and document barriers and facilitators to the implementation of protocol-based care through recording the contextual realities of the health systems and care-seeking behaviours. Insights into these factors will be used to facilitate the development of protocol-based management of older people with hip fractures that is appropriate, context specific and acceptable by stakeholders in a low- and middle-income country setting, such as India.

Electronic supplementary material

The online version of this article (doi:10.1186/s40814-016-0056-0) contains supplementary material, which is available to authorized users.

Care seeking pathways of older adults with hip fracture in India: exploratory study protocol

BACKGROUND

The incidence of hip fractures in older adults in India is likely to increase dramatically in the coming decades as a result of an aging population and increasing life expectancy. Currently, more than 600,000 adults over 60 years of age suffer a hip fracture annually in India. This paper outlines a protocol for a qualitative study investigating the care seeking behavior of older adults with hip fractures: to determine the processes in decision making, identify causes for delay in obtaining care, and identify potential barriers and facilitators to seeking appropriate care in time.

METHODS AND DESIGN

The planned study will consider Odisha, an eastern state in India with limited health care facility, as a suitable case study. It is proposed to conduct 30 in-depth interviews in two administrative districts of Odisha. The participants will be patient and their carers in seven health facilities- four public hospitals, two private hospitals and one traditional bone-setting facility. The study relies on a purposive sampling strategy. Ethics permission will be sought from each participating institution and participants. The participants will be adults aged 50 years or older of both sexes arriving at the recruiting centers with a history of fall or injury, pain in the hip region and inability to walk and X-ray confirmed diagnosis of proximal femoral fracture and their primary carer. Trained qualitative research team will conduct these interviews. A thematic framework approach will be used to analyze the data using NVivo 9 software. The data collected from the interviews will be analysed to explore the cause of the hip fracture, events following the injury, the experiences of patients from the time of sustaining the injury, pain relief measures, decision to seek care, understanding of the urgency for treatment, causes for delay in receiving treatment, funding sources, cost liabilities for the family, financing mechanisms for out of pocket expenditure and the burden for caring.

DISCUSSION

The findings of this study will provide an increased understanding of the care seeking behaviors of older adults with hip fracture, and inform contextually appropriate changes in healthcare program and policy aimed at improving health outcomes.

Insulin and the Brain: A Sweet Relationship With Intensive Care

BACKGROUND

Insulin receptors (IRs) in the brain have unique molecular features and a characteristic pattern of distribution. Their possible functions extend beyond glucose utilization. In this systematic review, we explore the interactions between insulin and the brain and its implications for anesthesiologists, critical care physicians, and other medical disciplines.

METHODS

A literature search of published preclinical and clinical studies between 1978 and 2014 was conducted, yielding 5996 articles. After applying inclusion and exclusion criteria, 92 studies were selected for this systematic review.

RESULTS

The IRs have unique molecular features, pattern of distribution, and mechanism of action. It has effects on neuronal function, metabolism, and neurotransmission. The IRs are involved in neuronal apoptosis and neurodegenerative processes.

CONCLUSION

In this systematic review, we present a close relationship between insulin and the brain, with discernible effects on memory, learning abilities, and motor functions. The potential therapeutic effects extend from acute brain insults such as traumatic brain injury, brain ischemia, and hemorrhage, to chronic neurodegenerative diseases such as Alzheimer and Parkinson disease. An understanding of the wider effects of insulin conveyed in this review will prompt anaesthesiologists and critical care physicians to consider its therapeutic potential and guide future studies.

Correlation between mutans Streptococci counts of parents and their children residing in Chandigarh, India

Objectives: To determine the prevalence of Mutans Streptococci (MS) in children and to evaluate the relationship between the salivary levels of MS in children and their parents. Material and Methods: 100 children aged 3-6 years along with their parents (100 mothers and fathers each) were included in the study. The children were segregated depending upon their age and level of caries experience. The children were examined clinically on an ordinary chair in natural daylight using the Møller’s index criteria. Assays for Mutans Streptococci (MS) were done for both the children and their parents using the Dentocult SM strip mutans test. Collected data was assessed using SPSS software. Results: The overall prevalence of MS in the children was 83%. A statistically significant correlation (p<0.05) was observed between salivary MS counts of children and their mothers. No significant correlation was seen with the fathers. Conclusions: The findings conclude that if primary caregivers harbour high levels of MS in their saliva, it is likely that their children will have the same.

Key words:Mutans streptococci, parents, children, dentocult SM kits.

Indian Students’ Perspectives on Obesity and School-Based Obesity Prevention

Childhood obesity has recently been reported as a growing problem in low- and middle-income countries. One potential prevention strategy is to apply effective obesity prevention approaches from the United States and/or other Western countries into programs that can be implemented in developing countries such as India. The purpose of this study was to explore Indian students’ perceptions of social–contextual factors related to obesity and whether they perceived a role for school-based obesity prevention. This study was conducted as a first step in a model to translate interventions from one culture to another. A total of 183 fourth- and fifth-grade students of middle socioeconomic status participated in focus group discussions. Analyses were guided by the essential principles of qualitative research and informed by social cognitive and social ecological theories. Results yielded five relevant themes: (a) student health behavior knowledge, (b) parental influence on health behavior, (c) school influence on health behavior, (d) media influence on health behavior, and (e) contexts for health promotion intervention. We found that students had moderate knowledge related to health behaviors (i.e., food intake and physical activity); that parents, schools, and the media are all important contributors to healthy and unhealthy behavior; and that schools can play an important role in the prevention of obesity. Results suggest that Indian middle socioeconomic status students are already moderately aware of the health benefits to nutritious food intake and physical activity, but parents, schools, and the media can influence unhealthy behaviors.

Robot assisted laparoscopic prostatectomy in 2013

Robot assisted laparoscopic prostatectomy has surpassed open radical prostatectomy as the most common surgical approach for radical prostatectomy in the United States. In this article we briefly describe the evolution of this minimally invasive technique. The current diagnostic approaches of multiparametric magnetic resonance imaging and fusion biopsy used in preoperative workup of the patients are discussed, followed by a description of risk stratified a thermal nerve sparing approach with total anatomical reconstruction. Finally we present a critical appraisal of the published oncological, continence and potency outcomes.

Exploring Perception of Indians about Plain Packaging of Tobacco Products: A Mixed Method Research

This study assessed perceptions and support among the Indian populace about plain packaging for all tobacco products. Twelve focus group discussions (n = 124), stakeholder analysis with 24 officials and an opinion poll with 346 participants were conducted between December 2011 and May 2012, Delhi. Plain packages for tobacco products were favored by majority of participants (69%) and key stakeholders (92%). The majority of participants perceived that plain packaging would reduce the appeal and promotional value of the tobacco pack (>80%), prevent initiation of tobacco use among children and youth (>60%), motivate tobacco users to quit (>80%), increase notice ability, and effectiveness of pictorial health warnings on tobacco packs (>90%), reduce tobacco usage (75% of key stakeholders). Majority of participants favored light gray color for plain packaging. This study provides key evidence to advocate with Indian Government and other countries in South Asia region to introduce plain packaging legislation for all tobacco products.

Detection of rotavirus from hospitalized diarrheic children in uttar pradesh, India

In the present study 220 stool samples collected from diarrheic children admitted to different hospitals and nursing homes of Uttar Pradesh and Uttarakhand were screened for rotavirus. Of 220 diarrheic samples screened 46 samples were found to be positive for rotavirus by RNA PAGE. All the isolates exhibited 4-2-3-2 migration pattern suggesting group A rotavirus. Both long and short electropherotypes were prevalent in these regions. Six different electropherotypes were detected in this study period. Male diarrheic children were found to be more susceptible to rotavirus infection (22.96 %) than that of the female ones (17.64 %). Viral RNA isolated from stool samples again subjected to VP4 gene amplification by RT-PCR using con2 and con3 primer which resulted 876 bp product suggesting group A rotavirus. Besides virus isolation was successfully done using MA104 cell line.

Renal transplantation across ABO barrier

In India, patients without a compatible blood group donor are usually excluded from renal transplantation. For young patients, it is a difficult therapeutic choice to stay on long-term dialysis. We describe the case of a 19-year-old male patient who had blood group O +ve and had no compatible donor in the family. His mother was B +ve and was willing to donate. The patient had an initial anti-B antibody titer of 1:512 and underwent antibody depletion with plasmapheresis (11 sessions) and intravenous immunoglobulin (IVIG) 100 mg/kg after every plasmapheresis. He also received rituximab 500 mg for 3 days prior to transplant and was induced with basiliximab. At the time of transplant, his anti-B titers were <1:8. Post-operatively, he required four sessions of plasmapheresis and IVIG as his titers rebounded to 1:64. The titers then spontaneously subsided to <1:16 and have stayed at the same level for 6 months post-transplant. The patient continues to have normal renal function with a creatinine of 1.4 mg/dl% and has had no episodes of rejection.