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Background: Cardiovascular diseases (CVDs) are the leading cause of mortality in India. Guidelines recommend using tools, such as the Framingham Risk Score (FRS), to predict the 10-year CVD risk of adults for primary prevention of CVDs. However, FRS was developed based on data from a predominantly White population in the United States, limiting its applicability to other regions. Objectives: This study aimed to recalibrate the FRS equations among adults in Kerala, India. Materials and Methods: Baseline survey data from the Kerala Diabetes Prevention Program were analyzed: 921 males and 567 females for lipid-based FRS scores and 1042 males and 646 females for body mass index (BMI)-based FRS scores. Recalibration of the original FRS scores was performed using local data on CVD risk factors and CVD mortality. Results: Among males, the median 10-year CVD risk with the recalibrated lipid-based FRS score was 7.34 (interquartile ranges [IQR] 4.33–12.42), compared with the original score of 8.88 (5.23–14.87) (P < 0.001). For BMI-based FRS scores, the median 10-year CVD risk was 7.40 (4.27–11.83) for the recalibrated score, compared with 9.32 (5.40–14.80) for the original score (P < 0.001). In females, the median 10-year CVD risk was 4.83 (2.90–8.36) for the recalibrated score, compared with 2.85 (IQR 1.71–4.98) for the original score (P < 0.001). Similarly, the median 10-year CVD risk was 4.66 (2.74–8.81) for the recalibrated BMI-based FRS score, compared for 2.95 (1.72–5.61) with the original score (P < 0.001). Conclusion: Recalibrated FRS scores estimated a significantly lower 10-year CVD risk in males and a higher risk in females than the original FRS scores.

Abstract Background In view of the WHO’s call for the elimination of cervical cancer as a public health problem, and current low screening coverage, Indian policy makers need evidence on how to effectively implement cervical screening programmes, ensuring equity in access. Our study will follow the INSPIRE implementation framework to co-design and test HPV-based screening approaches in two states of India with different health system organisation, based on understanding the status of screening as currently implemented, readiness and challenges to transition to HPV-based screening, and preferences of key stakeholders. Here, we describe our protocol for the formative phase of the study (SHE-CAN). Methods The study population includes women from vulnerable populations, defined as residents of tribal areas, rural villages, and urban slums, in the states of Mizoram and Tamil Nadu. The baseline assessment will use mixed methods research, with desktop reviews, qualitative studies, and surveys. A capacity assessment survey of screening and treatment facilities will be done, followed by interviews with healthcare providers, programme managers, and community health workers. Interviews will be conducted with previously screened women and focus group discussions with under and never-screened women and community members. Stakeholder workshops will be held in each state to co-design the approaches to delivering HPV-based screening among 30–49-year-old women. Discussion The quality and outcomes of existing screening services, readiness to transition to HPV-based screening, challenges in providing and participating in the cervical cancer care continuum, and acceptability of screening and treatment approaches will be examined. The knowledge gained about the current system, as well as recognition of actions to be taken, will inform a stakeholder workshop to co-design and evaluate implementation approaches for HPV-based screening through a cluster randomised implementation trial.

Background and objectivesPatient-reported measures of encounters in healthcare settings and consideration of their preferences could provide valuable inputs to improve healthcare quality. Although there are increasing reports of user experiences regarding health care in India in recent times, there is a lack of evidence from Indian healthcare settings on the care provided for patients with chronic diseases.MethodsWe selected diabetes mellitus and cancer as representatives of two common conditions requiring different care pathways. We conducted a scoping review of studies reporting experiences or preferences of patients/caregivers for these conditions, in PubMed, Global Index Medicus and grey literature, from the year 2000 onwards. Both published and emergent themes were derived from the data and summarised as a narrative synthesis.ResultsOf 95 included studies (49 diabetes, 46 cancer), 73% (65) were exclusively quantitative surveys, 79% included only patients (75), and 59.5% (44) were conducted in government centres. Studies were concentrated in a few states in India, with the underrepresentation of vulnerable population groups and representative studies. There was a lack of standardised tools and comprehensive approaches for assessing experiences and preferences of patients and caregivers, concerning diabetes and cancers in India. The commonest type of care assessed was therapeutic (74), with 14 cancer studies on diagnosis and nine on palliative care. Repeated visits to crowded centres, drug refill issues, unavailability of specific services in government facilities, and expensive private care characterised diabetes care, while cancer care involved delayed diagnosis and treatment, communication, and pain management issues.ConclusionsThere is a need for robust approaches and standardised tools to measure responsiveness of the healthcare system to patient needs, across geographical and population subgroups in India. Health system reforms are needed to improve access to high-quality care for treatment and palliation of cancer and management of chronic diseases such as diabetes.

BackgroundIn order for low and middle income countries (LMIC) to transition to Human Papilloma Virus (HPV) test based cervical cancer screening, a greater understanding of how to implement these evidence based interventions (EBI) among vulnerable populations is needed. This paper documents outcomes of an implementation research on HPV screening among women from tribal, rural, urban slum settings in India.MethodsA mixed-method, pragmatic, quasi-experimental trial design was used. HPV screening on self-collected cervical samples was offered to women aged 30-60 years. Implementation strategies were 1) Assessment of contextual factors using both qualitative and quantitative methods like key informant interviews (KII), focus group discussions (FGDs), pre-post population sample surveys, capacity assessment of participating departments 2) enhancing provider capacity through training workshops, access to HPV testing facility, colposcopy, thermal ablation/cryotherapy at the primary health care centers 3) community engagement, counselling for self-sampling and triage process by frontline health care workers (HCWs). Outcomes were assessed using the RE-AIM (Reach, Effectiveness, adoption, implementation, maintenance) framework.ResultsScreening rate in 8 months' of study was 31.0%, 26.7%, 32.9%, prevalence of oncogenic HPV was 12.1%, 3.1%, 5.5%, compliance to triage was 53.6%, 45.5%, 84.6% in tribal, urban slum, rural sites respectively. Pre-cancer among triage compliant HPV positive women was 13.6% in tribal, 4% in rural and 0% among urban slum women. Unique challenges faced in the tribal setting led to programme adaptations like increasing honoraria of community health workers for late-evening work and recalling HPV positive women for colposcopy by nurses, thermal ablation by gynaecologist at the outreach camp site.ConclusionsSelf-collection of samples combined with HCW led community engagement activities, flexible triage processes and strengthening of health system showed an acceptable screening rate and better compliance to triage, highlighting the importance of identifying the barriers and developing strategies suitable for the setting.Trial registrationCTRI/2021/09/036130.

Objective: To recalibrate the Framingham Risk Score-cardiovascular diseases (FRS-CVD) using 10-year mortality data and baseline risk factor data for a rural cohort and assess the effect of recalibration on proportion categorised as high risk. Methods: Participants of a cardiovascular risk factor survey aged 30–64 years in 2011–12, from 9 villages of a rural block in Vellore, Tamil Nadu, were followed up for mortality till 2021, as part of an established demographic surveillance system. We calculated both lipid-based and Body Mass Index-based FRS-CVD risk scores, as well as recalibrated scores using risk factor data from the baseline survey and CVD mortality observed over 10 years. Results: Based on original lipid-based FRS-CVD scores, 8.48% (109) of 1285 males had a 10-year CVD risk ≥30%, compared to 11.60% (149) with recalibrated scores. Among 1737 females, 1.50% (26) had a 10-year CVD risk of ≥30%, using original FRS-CVD scores, and 3.22% (56) using recalibrated scores. Similarly, for BMI based FRS-CVD scores, overall, 3.63% (110/3028) had a 10-year risk of ≥30%, compared to 6.64% (201) using recalibrated scores.The median 10-year FRS-CVD original score in males was 7.57 (IQR: 3.67–15.83), and 2.53 (IQR: 1.28–5.32) in females, compared to 8.95 (IQR: 4.35–18.52) and 3.79 (IQR: 1.92–7.93) respectively, for the recalibrated FRS-CVD risk scores. Conclusion: The recalibrated Framingham models showed a greater proportion of the population at risk of CVDs compared to the original FRS scores, with males having 2–3 times greater CVD risk scores compared to females.

PURPOSEAlthough cervical cancer is a disease of inequity, it can be eliminated as a public health problem through vaccination, screening, and treatment. Human papillomavirus vaginal self-collection cervical screening is a high-performance test that can increase reach of screening. This review describes the different contexts and models of care used to pilot or implement self-collection within the Asia-Pacific, measures the extent that implementation outcome measures are reported and, where available, summarizes key implementation findings.METHODSA scoping review was conducted by searching five databases of the peer-reviewed literature on June 20, 2022. Two researchers assessed eligibility and extracted data independently to the model of care used and the Conceptual Framework for Implementation Outcomes. A mixed-method consolidation of findings (quantitative: count and frequencies; qualitative: content analysis) was undertaken to narratively report findings.RESULTSFifty-seven articles, comprising 50 unique studies from 11 countries and two special autonomous regions, were included; 82% were conducted in trials. The implementation of self-collection was conducted in low- (2%), lower-middle– (32%), upper-middle– (32%), and high-income (35%) settings, with 10 different delivery models used; 80% delivered through practitioner-supported models with diversity in how samples were processed, and treatment was offered. Acceptability (73%) and appropriateness (64%) measures were most reported, followed by adoption (57%), feasibility (48%), and fidelity (38%). Only 7% of articles reported implementation cost or penetration measures. No articles reported sustainability measures.CONCLUSIONThe literature confirms that self-collection cervical screening has been implemented within the Asia-Pacific region, with evidence demonstrating that it is acceptable and appropriate from the user's perspective. Well-designed, high-quality implementation trials and real-world evaluations of self-collection that report the breadth of implementation outcomes can support the progression toward the elimination of cervical cancer.

COVID-19, an infectious respiratory illness caused by the severe acute respiratory syndrome–corona virus 2 (SARS-CoV2), has now spread to multiple countries including India. The pace at which the disease spread in the last 4 months, since it was first recognized from China, is unprecedented. This review of the epidemiology of COVID-19 summarizes the burden of infection, transmission dynamics, and other related epidemiological features. While countries such as China, Italy, and the United States have particularly high-rates of infection, the disease is gradually spreading in India as well, threatening the health and economy of the country. Transmission in asymptomatic cases, early symptomatic phase, as well as limited access to testing in different settings are factors that have led to the rapid spread of infection. A large case series from China revealed that 81% of cases had mild symptoms, 14% had severe disease, and 5% were afflicted with critical illness. While the mortality in China was reported as 2.3%, Italy, with a high-proportion of elderly, reported a case fatality report of 7.2% due to higher infection and mortality rates among the elderly. Being a highly infectious disease, with a basic reproduction number between 2 to 3, COVID-19 is affecting a large number of healthcare workers, as evidenced by the fact that a sizeable portion of reported infections in the US included healthcare workers. Delivering health care for both COVID-19 affected individuals, as well those with other acute and chronic conditions, with limited access to healthcare facilities and services, are challenges for the health systems in low- and middle-income countries, which require immediate measures for health system strengthening across sectors.

Background and Objectives: Physical inactivity is an important cardiovascular risk factor. This study assessed the prevalence and factors associated with insufficient physical activity (PA) in urban and rural Vellore, Tamil Nadu, India, among adults aged 30–64 years. Methodology: A cross-sectional World Health Organization STEPS survey was carried out in 48 wards of Vellore Municipality and nine rural villages of Tamil Nadu in 2010–2012. Adults (n = 6164, men 43.9%) aged 30–64 years were interviewed using the Global PA Questionnaire (2390 urban and 3774 rural). Insufficient PA was defined as not meeting the recommendation of 150 min of moderate aerobic PA, or 75 min of vigorous aerobic PA, or an equivalent combination, achieving at least 600 metabolic equivalent-minutes per day. Results: The prevalence of insufficient PA was 63.3% (95% confidence interval [CI]: 61.3%–65.3%) in the urban area and 40.6% (95% CI: 39.0%–42.2%) in the rural area. Women had a higher prevalence of insufficient PA compared to men, in both urban (70.8% vs. 53.8%) and rural (44.5% vs. 35.6%) areas. Those with higher education (odds ratio [OR]: 1.36, 95% CI: 1.20–1.53) and who were unemployed (OR: 2.97, 95% CI: 2.59–3.39) reported insufficient PA which was significantly higher than their counterparts. While urban participants had higher leisure time PA, rural participants had higher work- and travel-related PA. Conclusions: The high prevalence of insufficient PA found in this study shows that targeted interventions are needed to reduce insufficient PA, especially for women and urban populations.

BackgroundThe Achutha Menon Centre Diabetes Risk Score (AMCDRS), which was developed in rural Kerala State, South India, had not previously been externally validated. We examined the performance of the AMCDRS in urban and rural areas in the district of Vellore in the South Indian state of Tamil Nadu, and compared it with other diabetes risk scores developed from India.MethodsWe used the data from 4,896 participants (30 to 64 years) of a cross-sectional study conducted in Vellore (2010 to 2012), to calculate the AMCDRS scores using age, family history, and waist circumference. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV), and the area under the receiver operating characteristic curve (AROC) were calculated for undiagnosed and total diabetes.ResultsOf the 4,896 individuals surveyed, 274 (5.6%) had undiagnosed diabetes and 759 (15.5%) had total diabetes. The AMCDRS, with an optimum cut-point of ≥4, identified 45.0% for further testing with 59.5% sensitivity, 60.5% specificity, 9.1% PPV, 95.8% NPV, and an AROC of 0.639 (95% confidence interval [CI], 0.608 to 0.670) for undiagnosed diabetes. The corresponding figures for total diabetes were 75.1%, 60.5%, 25.9%, 93.0%, and 0.731 (95% CI, 0.713 to 0.750), respectively. The AROC for the AMCDRS was not significantly different from that of the Indian Diabetes Risk Score, the Ramachandran or the Chaturvedi risk scores for total diabetes, but was significantly lower than the AROC of the Chaturvedi score for undiagnosed diabetes.ConclusionThe AMCDRS is a simple diabetes risk score that can be used to screen for undiagnosed and total diabetes in low-resource primary care settings in India. However, it probably requires recalibration to improve its performance for undiagnosed diabetes.

Background: Chronic periodontitis is a common cause of poor oral health globally. Those at higher risk of this preventable and easily treatable condition need to be identified so that efforts can be taken to decrease disease burden and subsequent consequences. Aims: The aims of the study were (1) To compare the prevalence of chronic periodontitis among individuals with and without type 2 diabetes, aged 35–65 years from a rural block in Vellore, Tamil Nadu and (2) to assess risk factors for chronic periodontitis among individuals with diabetes. Settings and Design: A cross-sectional study was done in nine villages of Kaniyambadi block, Vellore, between October 2015 and July 2016 among participants aged 35–65 years of a previous cross-sectional survey which had identified individuals with and without type 2 diabetes. Materials and Methods: Chronic periodontitis was assessed using the Community Periodontal Index and Treatment Needs index. Oral hygiene was assessed clinically using the Simplified Oral Hygiene Index. Diabetes was defined as on medication for type 2 diabetes or detected to have fasting blood glucose ≥126 mg/dl (in a previous survey). Statistical Analysis: Chi-square test and odds ratios (adjusted using logistic regression) were used to study risk factors for periodontitis among those with diabetes. Results: Prevalence of chronic periodontitis was 45.9% (95% confidence interval [CI]: 40.88%–50.9%) among 98 individuals with diabetes and 35.6% (95% CI: 30.91–40.29%) among 104 individuals without diabetes. Poor oral hygiene (odds ratio: 8.33, 95% CI: 3.33–25.00), low socioeconomic status (odds ratio: 3.19, 95% CI: 1.00–10.12), and smoking (odds ratio: 3.51, 95% CI: 1.17–10.51) were associated with periodontitis among diabetics. Conclusions: Individuals with type 2 diabetes have a higher prevalence of periodontitis. As poor oral hygiene is a strong risk factor for periodontitis, there is a need for targeted education regarding dental hygiene to reduce this preventable condition.

Background: With the increase of cardiovascular risk factors in India, the prevalence of coronary heart disease (CHD) is also expected to rise. A cross-sectional study in 2010–2012 assessed the prevalence and risk factors for CHD in urban and rural Vellore, Tamil Nadu. The secondary objectives were to compare the current prevalence with the prevalence of CHD in the same areas in 1991–1994. Methods: A cross-sectional survey was carried out among adults aged 30–64 years to determine the prevalence of CHD (previously diagnosed disease, symptoms detected using Rose angina questionnaire, or ischemic changes on electrocardiography). The study used the WHO STEPS method in addition to the Rose angina questionnaire and resting electrocardiography and was conducted in nine clusters of a rural block in Vellore district and 48 wards of Vellore town. The results were compared with a similar study in the same area in 1991–1994. Results: The prevalence of CHD was 3.4% (95% CI: 1.6–5.2%) among rural men, 7.4% (95% CI: 4.7–10.1%) among rural women, 7.3% (95% CI: 5.7–8.9%) among urban men, and 13.4% (95% CI: 11.2–15.6%) among urban women in 2010–2012. The age-adjusted prevalence in rural women tripled and in urban women doubled, with only a slight increase among males, between 1991–1994 and 2010–2012. Conclusions: The large increase in prevalence of CHD, among both pre- and post-menopausal females, suggests the need for further confirmatory studies and interventions for prevention in both rural and urban areas.

Background: Repeat cross sectional surveys document the trend of prevalence rates for non-communicable diseases and their risk factors. In this study, we compare the prevalence rates for risk factors for cardiovascular disease in urban and rural Vellore between 1991–1994 and 2010–2012. Methods: Cross sectional survey was carried out in 1991–1994 in a rural block in Vellore district and in Vellore town, to study the prevalence of cardiovascular risk factors among adults aged 30–60 years. A repeat survey was done in 2010–2012 using the WHO STEPS method. In both surveys, socio-demographic and behavioral history, physical measurements, biochemical measurements, and medical history were obtained. Age adjusted rates were used to compare the rates in the two surveys. Results: In the rural areas, there was a three times increase in diabetes and body mass index (BMI) ≥25 kg/m2 (overweight/obese) with a doubling of the prevalence of hypertension. In urban areas there was a tripling of diabetes, doubling of proportion with BMI ≥ 25 kg/m2 and 50% increase in prevalence of hypertension. While the proportion of male current smokers reduced by 50% in both rural and urban Vellore, lifetime abstainers to alcohol decreased in the rural area from 46.8% to 37.5% (p

BackgroundMalnutrition among children is one of the most pressing health concerns middle- and low-income countries face today, particularly those in Sub-Saharan Africa and South Asia. Early-life malnutrition has been shown to affect long-term health and income. One hypothesized channel linking early-life malnutrition and long-term outcomes is cognitive development. However, there is limited empirical evidence on the relationship between nutritional status and cognitive achievement in middle childhood.Study designAs part of the South India Community Health Study (SICHS), we collected educational attainment and anthropometric data from 1,194 children in rural Vellore district of Tamil Nadu, India, and assessed their math and reading skills. We analyzed the relationship between continuous and binary anthropometric measures of nutritional status and three measures of cognitive achievement (reading, math, and grade level), adjusting for potential confounders, using a regression framework.ResultsLower height-for-age and weight-for-age and their corresponding binary measures (stunting, underweight) were associated with lower reading scores, lower math scores, and lower grade level, with the exception of the association between weight-for-age and reading, which was marginally significant. A stunted child had one-third of a grade disadvantage compared to a non-stunted counterpart, whereas an underweight child had one-fourth of a grade disadvantage compared to a non-underweight counterpart. Lower BMI-for-age was associated with grade level and marginally associated with lower math scores, and its binary measure (thinness) was marginally associated with lower math scores.ConclusionsAcute and chronic malnutrition in middle childhood were negatively associated with math scores, reading scores, and educational attainment. Our study provides new evidence that cognitive achievement during middle childhood could be an important mechanism underlying the association between early-life malnutrition and long-term wellbeing.

Context: There is a shortage of voluntary blood donors in developing countries which are, therefore, more dependent on replacement donors. Aim: To study the knowledge, attitude, and practices regarding voluntary blood donation in a rural block in Vellore, South India. Settings and Designs: A cross-sectional survey in randomly selected villages of a rural block in Vellore, South India. Materials and Methods: Knowledge, attitude, and practices were assessed using a pilot-tested, semi-structured, interviewer-administered questionnaire on randomly chosen rural adults aged between 18 and 60 years. Results: Of the 104 individuals interviewed, 90% were aware of voluntary blood donation, the main source of this awareness being television. Nearly, two-thirds of the participants felt they would fall sick by donating blood and that women and manual laborers were not capable of blood donation. Among the interviewed, 70.3% were of the opinion that blood can purchased with money. Only 44% were willing to donate blood on a voluntary basis. Perceived weakness and a misconception on the apparent lack of blood were the major reasons for unwillingness to donate blood. There was a significant association between willingness to donate blood and educational status as well as occupation, with the less educated and manual laborers unwilling to donate blood on a voluntary basis (odds ratio [OR] = 3.758, confidence interval [CI] = 1.54–9.156; OR = 5.333, CI = 1.429–19.90, respectively). Conclusions: The study found that although awareness on voluntary blood donation among individuals in the rural community was widespread, hesitancy to donate blood in real life situation was high. Since voluntary unpaid donors are the best candidates for blood donation, community being the best available source, education, and motivation of the community should play a greater role in increasing voluntary blood donation.

Introduction: Calcium is the most abundant mineral in our body with varied functions and its dietary deficiency leads to osteoporosis, besides playing a significant role in the pathogenesis of other diseases. The data regarding dietary calcium intake (DCI) among postmenopausal women in urban areas of South India is limited. Objectives: This study was aimed to assess DCI and physical activity among postmenopausal women. The risk factors for a low intake of dietary calcium were also assessed. Materials and Methods: A cross-sectional study was done among 106 postmenopausal women selected by systematic random sampling from the city of Erode, Tamil Nadu, India. DCI and physical activity were measured using validated questionnaires. Results: The mean DCI was 632.72 ± 28.23 mg/day. The proportion of women consuming less than 800 mg/day of dietary calcium was 74.5%. Only 10.4% of the women studied (11 out of 106) were on calcium supplements while 55% had low physical activity. A low knowledge score [adjusted odds ratio (OR): 5.17; 95% confidence interval (CI): 1.31-20.42] and a low socioeconomic status (SES) score of the family (adjusted OR: 4.00; 95% CI: 1.32-12.11) were significantly associated with low DCI after adjusting the age, dietary preferences, and educational and occupational statuses. Conclusions: DCI was below the Recommended Dietary Allowance (RDA) and the majority of postmenopausal women were physically inactive, indicating the need for better education regarding DCI and the need for calcium supplements and physical activity, all of which can contribute to the prevention of the consequences of osteoporosis.