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Background: Diabetes mellitus (DM) is a chronic disease, which requires optimal glycemic control to prevent its ensuing vascular complications. Pathway to optimal glycemic control in T2DM has a complex socio-behavioral construct, especially in vulnerable populations, like slum dwellers, who have reduced health-care access and lower prioritization of health needs. Objective: The study aimed to map trajectories of glycemic control amongst individuals with T2DM living in urban slums and identify key determinants associated with unfavourable glycaemic trajectory. Methods: This study was a community-based longitudinal study conducted in an urban slum of Bhopal in Central India. Adult patients diagnosed with T2DM and on treatment for more than one year were included. All 326 eligible participants underwent a baseline interview, which captured sociodemographic, personal behavior, medication adherence, morbidity profile, treatment modality, anthropometric and biochemical measurements (HbA1c). Another 6-month follow-up interview was conducted to record anthropometric measurements, HbA1c and treatment modality. Four mixed effect logistic regression models (through theory-driven variable selections) were created with glycemic status as dependent variable and usage of insulin was considered as random effect. Results: A total of 231 (70.9%) individuals had unfavorable glycemic control trajectory (UGCT), and only 95 (29.1%) had a favorable trajectory. Individuals with UGCT were more likely to be women, with lower educational status, non-vegetarian food preference, consumed tobacco, had poor drug adherence, and were on insulin. The most parsimonious model identified female gender (2.44,1.33-4.37), tobacco use (3.80,1.92 to 7.54), and non-vegetarian food preference (2.29,1.27 to 4.13) to be associated with UGCT. Individuals with good medication adherence (0.35,0.13 to 0.95) and higher education status (0.37,0.16 to 0.86) were found to be protective in nature. Conclusion: Unfavorable glycemic control trajectory seems to be an inescapable consequence in vulnerable settings. The identified predictors through this longitudinal study may offer a cue for recognizing a rational response at societal level and adopting strategy formulation thereof.

ObjectiveCOVID-19 pandemic has had significant impacts on healthcare systems across the world. However, its impact on healthcare systems in Low- and Middle-Income Countries (LMICs) has been especially devastating, resulting in restricted access to healthcare. The present study was conducted to assess healthcare access for non-communicable diseases (NCDs) in Central India.DesignInductive and deductive thematic analysis of in-depth semi-structured interviews.SettingStudy was conducted in communities of two urban and rural districts of central India.ParticipantsInterviewed participants included PLNCDs, their caregivers, community dwellers, CHWs such as, Accredited Social Health Activists (ASHAs) and Anganwadi Workers (AWWs), Medical Officers, and Community Leaders. Recruitment of the participants was done via purposive and convenience sampling.ResultA total of fifty Key Informant Interviews were (KIIs) conducted. All participants reported facing considerable difficulties while trying to access care from both public as well as private healthcare facilities. Absence of staff, equipment and medicines, restricted commute, misconceptions regarding the spread of COVID-19, and the stigma attached to COVID-19 infection acted as major barriers to accessing care, while door-to-door visits by community health workers, community support, and presence of privately owned healthcare facilities in the vicinity acted as facilitators.ConclusionIn our study, we found that continued functioning of primary healthcare centres, ensuring uninterrupted supply of medicine and effective dissemination of information regarding COVID-19 could have acted to ease access to healthcare. Going ahead, capacity building to offset the impact of future emergencies and pandemics should be a crucial consideration while developing resilient healthcare systems.Strengths and limitations of this studyOur study is the first study to explore the barriers faced by PLNCDs of low socio-economic status during the pandemic.We explored the perspectives of both patients and healthcare workers before triangulating the data findings.The study was conducted in the PLNCDs of lower socio-economic group and hence the perspectives and experiences of other socio-economic groups are yet to be explored.

Background. Mental illness affects over one-third of the Indian population, and only a little is known about the exact situation of health systems in Madhya Pradesh, India. Therefore, the present research work provides an assessment of state mental health systems in Madhya Pradesh. Methods. The present cross-sectional study was conducted as a part of National Mental Health Survey 2015-16 in 48 districts of Madhya Pradesh, to provide an overview of the status of mental health systems. Secondary data was also retrieved from the state office so as to present the situational analysis in a more comprehensive and inferential way. The proforma for the study was developed based on the experience gained from studies conducted earlier with World Health Organization’s Assessment Instrument for Mental Health Systems (WHO-AIMS) and with WHO’s Mental Health Atlas as the base for thematic analysis. Results. Out of 51 districts, 13.7% of the districts of the state have been covered under District Mental Health Program (DMHP) in 2015-16. Around 11.8% of district/general hospitals were involved in providing mental health services. The availability of psychiatrist was 0.05 per Lakh population. Around 0.2% of the total health budget was allocated by the state for the last financial year for mental health. The overall average score of Madhya Pradesh in the assessment of qualitative indicators was 31 out of 100 in the year 2015-16. Conclusion. There is huge scope and an urgent need to increase mental healthcare facilities (with upgradation of existing one) along the availability of mental healthcare staff.

Background The success of the Community Based Management of Severe Malnutrition (CSAM) programme largely depends on the knowledge and skills of Front-Line Workers (FLWs). A robust supportive supervision system in CSAM should be tailored to individualistic learning needs by distinguishing the FLWs as per their ability and simultaneously identifying the task domains to be emphasized more in supervisory visits. This paper details the ability assessment strategy developed and employed in the selected geographical locations in Madhya Pradesh (Central India) among the 197 Anganwadi workers (FLWs involved in CSAM implementation). Methodology A 25 items tool was developed based on an analytical construct for ability estimation through Rasch Analysis (RA). RA models the probability of right/wrong answers as a function of a person (participants) and item (questions) parameters and calculates the item difficulty in relation to personability on the same unidimensional linear scale. Suitable visualization like item characteristic curve (ICC), person item map (PIM) and quadratic allocation were plotted in RA. The data fitting to the Rasch model (Rasch diagnostic) was tested by numeric (Anderson LR and Wald test) and graphical methods. Results The item easiness parameter (β) value related to Diarrhoeal assessment was lowest (-2.32, -2.91 to -1.73) and related to peer assessment meaningful action (2.009, 1.669- 2.348)) was highest (most difficult). Anderson LR test (LR=31.32, df=24, p=0.079) showed the absence of global outliers. Quadrant analysis using the permutations of ability score and adjusted burden of malnutrition further mapped 41/197 (20.8%) FLWs to low ability -high burden quadrant and 44/197(25%) as low ability low burden quadrant. Conclusion Rasch assessment may address the innate challenges to maintain homogeneity, discrimination capacity and linearity in a raw score-based measurement construct. The monitoring strategy developed on this thus may offer a judicious, pragmatic and thematic approach to supportive supervision in the CSAM program.

India accounts for 18% of the global population and 26·6% of global suicide deaths. However, robust population-based, nationally representative data on suicidality are not readily available to plan and implement suicide prevention programmes in India. We aimed to investigate the prevalence and sociodemographic differentials of suicidality using data from the National Mental Health Survey (NMHS) of India, 2015-16.Trained field data collectors from the NMHS obtained information on suicidality (during the past month) from a community sample of adults aged 18 years and older using the suicidality module of the Mini-International Neuropsychiatric Interview (version 6.0). Suicidality was categorised as low, moderate, high, and overall (representing any suicidality), and examined for sociodemographic differentials using normalised sampling weights. For each of the 12 surveyed states, we calculated the age-standardised suicidality prevalence for men and women, men-to-women ratio of weighted suicidality prevalence, ratio of suicidality to suicide deaths, and ratio of suicide attempts to suicide deaths. We used logistic regression analysis to examine the association between sociodemographic factors and overall suicidality and severity.Among 34 748 participants with complete interviews, 5·1% (95% CI 4·7-5·6) had some level of suicidality, and 0·3% (0·2-0·4) had at least one suicide attempt in the past month. The prevalence of overall suicidality was higher in women (6·0% [5·4-6·6]) than in men (4·1% [3·7-4·6]). The prevalence of overall suicidality was highest in those aged 40-49 years among women and in those aged 60 years or older among men. Compared with their counterparts, individuals with lower educational attainment, individuals residing in urban metropolitan cities, individuals who were widowed, separated, or divorced, and unemployed individuals had a higher prevalence of overall suicidality. The men-to-women ratio of overall suicidality prevalence for India was 0·68 (range 0·55-0·85). For every death by suicide in India, there were more than 200 people with suicidality and more than 15 suicide attempts. We found variations for various severities of suicidality. We found an increased risk for overall suicidality in women versus men (odds ratio [OR] 1·54 [95% CI 1·31-1·81]; p0·0001) and in individuals residing in urban metropolitan cities versus those residing in rural areas (1·75 [1·30-2·35]; p=0·0002). Individuals belonging to the lowest income quintile (reference group with OR1·00 and p0·05 for other income quintiles), those with depressive disorders (28·78 [20·04-41·33]; p0.0001) and those with alcohol use disorders (6·52 [3·83-11·10]; p0.0001) had an increased risk for high suicidality, compared with their corresponding counterparts.A national suicide prevention strategy that is comprehensive, using multisectoral approaches, is required to address the prevailing sociodemographic and other risk factors for reducing suicidality and suicide deaths in India. This study also has implications for other low-income and middle-income countries in south Asia, where sociodemographic factors play a crucial role for suicide prevention.Ministry of Health and Family Welfare, Government of India.

BackgroundThe success of the Community Based Management of Severe Malnutrition (CSAM)programme, largely depends on the knowledge and skills of Front-Line Workers (FLWs).A robust supportive supervision system in CSAM should be tailored to individualistic learning needs by distinguishing the FLWs as per their ability and simultaneously identifying the task domains to be emphasized more in supervisory visits.This paper details the ability assessment strategy developed and employed in the selected geographical locations in state of Madhya Pradesh (Central India) among the 197 Anganwadi workers (FLWs involved in CSAM implementation)MethodologyA 25 items tool was developed based on an analytical construct for ability estimation through Rasch Analysis (RA). RA models the probability of right/wrong answer as a function of person(participants) and item (questions) parameters and calculates the item difficulty in relation with person ability on same unidimensional linear scale. The fitting of the data to Rasch model (Rasch diagnostic) was tested by both numeric (Anderson LR and Wald test) and graphical method. Suitable visualization like Item Characteristic Curve (ICC) and Person Item Map (PIM) were plotted in RA.Further a quadratic allocation of all AWWs into 4 quadrants were done as per the ability estimation (Rasch score) and adjusted numbers of SAM/MAM children in her center.ResultsThe item easiness parameter (β) value related to Diarrhoeal assessment was lowest (−2.32, -2.91 to -1.73) and related to peer assessment consequential action (2.009, 1.669-2.348)) was highest (most difficult). Anderson LR test (LR=31.32, df=24, p=0.079) showed the absence of global outliers. Quadrant analysis using the permutations of ability score and adjusted burden of malnutrition further mapped 41/197 (20.8%) FLWs to low ability -high burden quadrant and 44/197(25%) as low ability low burden quadrant.ConclusionRASCH assessment may address the innate challenges to maintain homogeneity, discrimination capacity and linearity in a raw score-based measurement construct. The monitoring strategy developed on this thus may offer a judicious, pragmatic and thematic approach to supportive supervision in CSAM program.

In the wake of rising number of SARS-CoV-2 cases, the Government of India had placed mass-quarantine measures, termed as “lockdown” measures from end-March 2020. The subsequent phase-wise relaxation from July 2020 led to a surge in the number of cases. This necessitated an understanding of the true burden of SARS-CoV-2 in the community. Consequently, a sero-epidemiological survey was carried out in the central Indian city of Ujjain, Madhya Pradesh. This article details the processes of data acquisition, compilation, handling, and information derivation from the survey. Information on socio-demographic and serological variables were collected from 4,883 participants using a multi-stage stratified random sampling method. Appropriate weightage was calculated for each participant as sampling fraction derived from Primary Sampling Unit (PSU), Secondary Sampling Unit (SSU) and Tertiary Sampling Unit (TSU). The weightage was then applied to the data to adjust the findings at population level. The comprehensive and robust methodology employed here may act as a model for similar future endeavours. At the same time, the dataset can also be relevant for researchers in fields such as data science, epidemiology, virology and earth modelling.

Tobacco use can lead to tobacco/nicotine dependence and serious health problems. Quitting smoking significantly reduces the risk of developing smoking-related diseases. In a low resource setting like India, the role of primary healthcare providers in tobacco cessation is immense. The current study was conducted with the objective of evaluating the preparedness, knowledge and attitude of the primary healthcare providers in tobacco cessation.A cross-sectional study involving 289 trainees taking part in a non-communicable disease training in the calendar year 2015, held at All India Institute of Medical Sciences, Bhopal were interviewed with a close-ended questionnaire on the demographic profile of participants, their preparedness, and current knowledge and attitude related with tobacco cessation activities.Among the 289 trainees, majority of the study participants were staff nurses (54.7%) and medical officers (41.2%) with a mean (± Standard Deviation, range) age of 35 (±10, 22-63) years predominantly from district and sub-district hospitals (52.9%). In total, 86.9% counsel their patients regarding tobacco cessation and 13.1% use nicotine replacement therapy in aiding tobacco cessation. 174 (60.2%) participants received on-job training of various duration on tobacco control, and 96 (33.2%) did not receive any training. Preparedness toward tobacco cessation was present in 15.01% (41) of the study participants.The study reveals that the majority of the healthcare providers were not prepared, and only half of the participants had favorable attitudes and practices of delivering tobacco cessation activities.

Background Periodic information on risk factor distribution is critical for public health response for reduction in non-communicable disease (NCDs). For this purpose, the WHO has developed STEPs wise approach. State representative population-based STEPS survey was last conducted in 2007–08 in seven states of In India. Since then no such work has been reported from low ETL states. This survey was carried out to assess the prevalence of risk factors associated with NCDs and the prevalence of NCDs in the low ETL state of Madhya Pradesh using the WHO STEPs approach. Methods A total of 5680 persons aged 18–69 years were selected from the state of Madhya Pradesh using multi-stage cluster random sampling. Using the WHO STEPs approach, details were collected on demographics, STEP 1 variables (tobacco consumption, alcohol consumption, physical activity, diet), STEP 2 variables (weight, height, waist circumference, blood pressure) and STEP 3 variables (fasting blood glucose, blood cholesterol). Results We found that 9.4% individuals smoked tobacco, 15.3% were overweight/obese, 22.3% had hypertension, and 6.8% have diabetes mellitus. As compared to women, men were less likely to be overweight or obese, but more likely to smoke tobacco, and have diabetes mellitus. Hypertension was also more common in men. Overall, about a fourth of all adults had three or more risk factors for cardiovascular disease. Conclusion The survey shows that a large section of the population from Madhya Pradesh is either suffering from NCDs or have risk factors which predispose them to acquire NCDs. This state representative survey provides benchmarking information for behavioural and biological risk factor distribution for recently scaled up National Programme for the Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS).

Background National and statewide assessment of cardiovascular risk factors needs to be conducted periodically in order to inform public health policy and prioritise allocation of funds, especially in LMICs. Although there have been studies from India which have explored the determinants of cardiovascular risk factors, they have mostly been from high epidemiological transition states. The present study assessed the determinants of cardiovascular (CVD) risk factors in a low epidemiological transition state (Madhya Pradesh) using the WHO STEPwise approach to surveillance (STEPS). Methods A total of 5,680 persons aged 18–69 years were selected from the state of Madhya Pradesh through multi-stage cluster random sampling. Key CVD risk factors we sought to evaluate were from behavioural (tobacco, alcohol, physical activity, diet) and biological domains (overweight or obese, Hypertension, Diabetes, and Raised serum cholesterol). Key socio-demographic factors of interest were the caste and tribe groups, and rural vs urban location, in addition to known influencers of CVD risk such as age, gender and education level Results Those belonging to the scheduled tribes were more at risk of consuming tobacco (OR 2.13 (95% CI [1.52–2.98]), and a diet with less than five servings of fruits and vegetables (OR 2.78 (95% CI [1.06–7.24]), but had had the least risk of physical inactivity (OR 0.31 (95% CI [0.02–0.54]). Residence in a rural area also reduced the odds of physical inactivity (OR 0.65 (95% CI [0.46–0.92])). Lack of formal education was a risk factor for both tobacco consumption and alcohol intake (OR 1.40 (95% CI [1.08–1.82]) for tobacco use; 1.68 (95% CI [1.14–2.49]) for alcohol intake). Those belonging to schedules tribes had much lower risk of being obese (OR 0.25; 95% CI [0.17–0.37]), but were at similar risk of all other clinical CVD risk factors as compared to other caste groups. Conclusion In the current study we explored socio-demographic determinants of behavioural and biological CVD risks, and found that in Madhya Pradesh, belonging to a scheduled tribe or living in a rural location, protects against being physically inactive or being overweight or obese. Increasing age confers a greater CVD-risk in all domains. Being a male, and lack of formal education confers a greater risk for behavioural domains, but not for most clinical risk domains. Future efforts at curbing CVDs should be therefore two pronged –a population-based strategy targeting biological risk factors, and a more focussed approach directed at those displaying risky behaviour.

Background: About 14% of the global mental health burden is contributed by India. However, there exists a disparity in mental health patterns, utilization, and prioritization among various Indian states. The state of Madhya Pradesh is a low performer among Indian states, ranking lower than the national average on the Human Development Index, Hunger Index, and Gross Domestic Product (GDP). The state also performes poorly on other health-related indicators. Objectives of Study: To estimate the prevalence and patterns of mental illnesses in the state of Madhya Pradesh, India. Material and Methods: This study used the multistage, stratified, random cluster sampling technique, with selection probability proportionate to size at each stage. A total of 3240 individuals 18 years and older were interviewed. The mixed-method study that was employed had both quantitative and qualitative components. The Mini International Neuropsychiatric Interview along with 10 other instruments were used. Results: The overall weighted prevalence for any mental illness was 13.9%, with 16.7% over the lifetime. The treatment gap for all of the mental health problems is very high (91%), along with high suicidal risk and substance use in the state. Conclusions: This study provides evidence of the huge burden of mental, behavioral, and substance use disorders as well as the treatment gap in Madhya Pradesh. This information is crucial for developing an effective prevention and control strategy. The high treatment gap in the state calls for coordinated efforts from all stakeholders, including policy makers, political leaders, health care professionals, and the society at large to give mental health care its due priority. These findings also highlight the need for multi-pronged interventions rooted in health policy directed at reducing the treatment gap in the short term and disease burden in the long run.

Understanding the burden and pattern of mental disorders as well as mapping the existing resources for delivery of mental health services in India, has been a felt need over decades. Recognizing this necessity, the Ministry of Health and Family Welfare, Government of India, commissioned the National Mental Health Survey (NMHS) in the year 2014-15. The NMHS aimed to estimate the prevalence and burden of mental health disorders in India and identify current treatment gaps, existing patterns of health-care seeking, service utilization patterns, along with an understanding of the impact and disability due to these disorders. This paper describes the design, steps and the methodology adopted for phase 1 of the NMHS conducted in India. The NMHS phase 1 covered a representative population of 39,532 from 12 states across 6 regions of India, namely, the states of Punjab and Uttar Pradesh (North); Tamil Nadu and Kerala (South); Jharkhand and West Bengal (East); Rajasthan and Gujarat (West); Madhya Pradesh and Chhattisgarh (Central) and Assam and Manipur (North East). The NMHS of India (2015-16) is a unique representative survey which adopted a uniform and standardized methodology which sought to overcome limitations of previous surveys. It employed a multi-stage, stratified, random cluster sampling technique, with random selection of clusters based on Probability Proportionate to Size. It was expected that the findings from the NMHS 2015-16 would reveal the burden of mental disorders, the magnitude of the treatment gap, existing challenges and prevailing barriers in the mental-health delivery systems in the country at a single point in time. It is hoped that the results of NMHS will provide the evidence to strengthen and implement mental health policies and programs in the near future and provide the rationale to enhance investment in mental health care in India. It is also hoped that the NMHS will provide a framework for conducting similar population based surveys on mental health and other public health problems in low and middle-income countries.

Introduction: Altered pharmacokinetics of antituberculosis (anti-TB) drugs due to interaction with non-TB medications or concomitant diseases may lead to suboptimal plasma levels of the affected drugs and hence contribute to the emergence of drug resistance in mycobacteria. Yet, few studies have investigated the prevalence of concomitant drug intake or concurrent diseases in patients on anti-TB therapy (ATT). The objective of this study is to study the prevalence of concomitant diseases and intake of non-TB drugs in patients on ATT. Methods: Adult patients who were undergoing treatment for TB at a directly observed treatment short-course (DOTS) center were interviewed to find out any concomitant drug intake and ailments they were suffering from. Data were also collected from the patients' treatment cards. Results: A total of 105 patients were interviewed for the study over a period of 1 month. Among these, 66 (62.9%) patients reported having taken a non-ATT drug in the last 3 months, 61 (58.1%) of which were drugs that may affect the ATT. A comparable number of patients (61 [58.1%]) reported suffering from one or the other concurrent illnesses or symptoms while on DOTS, including one patient with AIDS and eight with diabetes mellitus. Fluoroquinolones had been prescribed to four patients while on DOTS. Conclusion: A large proportion of the patients with TB were found to be on non-TB concomitant medications including drugs with potential for interactions that are capable of affecting ATT outcomes. It is, therefore, important that the patients and prescribing physicians be aware of any possible drug interactions.

The All India Institute of Medical Sciences, Bhopal is one of the pioneer institutes of health care in India. As we aim at achieving Health for all, we have to shift from medical care to health care. For achieving, it was crucial to have good rapport with the community. Therefore, we organized different awareness, generating activities among the local community. We faced various challenges and learned from them for the future activities in the community. We learned the importance of being a care manager rather than physician only to achieve health in all aspects. Our real time experiences in community and family health can help the new emerging health professional to provide more efficient health care.

Objective We assessed uptake of isoniazid preventive therapy (IPT) among child contacts of smear-positive tuberculosis (TB) patients and its implementation challenges from healthcare providers’ and parents’ perspectives in Bhopal, India. Methods A mixed-method study design: quantitative phase (review of programme records and house-to-house survey of smear-positive TB patients) followed by qualitative phase (interviews of healthcare providers and parents). Results Of 59 child contacts (

Introduction Community-based direct observed treatment (DOT) providers are an important bridge for the national tuberculosis programme in India to reach the unreached. The present study has explored the knowledge, attitude, practice and barriers perceived by the community-based DOT providers. Methods Mixed–methods study design was used among 41 community-based DOT providers (Accredited Social Health Activist (ASHAs)) working in 67 villages from a primary health center in Raisen district of Madhya Pradesh, India. The cross-sectional quantitative component assessed the knowledge and practices and three focus-group discussions explored the attitude and perceived barriers related to DOT provision. Result ‘Adequate knowledge’ and ‘satisfactory practice’ related to DOT provision was seen in 14 (34%) and 13 (32%) ASHAs respectively. Only two (5%) received any amount of honorarium for completion of DOT in last 3 years. The focus-group discussions revealed unfavourable attitude; inadequate training and supervision, non-payment of honorarium, issues related to assured services after referral and patient related factors as the barriers to satisfactory practice of DOT. Conclusion Study revealed inadequate knowledge and unsatisfactory practice related to DOT provision among ASHAs. Innovations addressing the perceived barriers to improve practice of DOT provision by ASHAs are urgently required.

Introduction: Although diarrheal diseases with known etiologies are under regular surveillance by the integrated disease surveillance project in India, only limited food-borne outbreaks were subjected to systematic epidemiological investigation. We examined one incidence of a food-borne outbreak among medical students in Bhopal, India, to identifying the source and mode of transmission, and to implement appropriate preventive measures. Materials and Methods: We constituted two teams. We did the line listing, filled the structured questionnaire and collected the biological samples. We did in-depth interviews of the case patients. We interviewed food handlers in mess. We randomly collected food and water samples. Results: The study results identified 30 hosteller case patients for a total of 239 students (overall attack rate [AR]: 12.6%). In female students, the AR was 18.1% and in the male students it was 6.7%. The AR was highest in female hostel no. One compared to other female and male hostel (19.8% vs. 14.3%, 6.7%). We identified four different risk factors for the illness. Discussion : As AR s are high compared to the general population. As the AR was high among the girls, the probable source of infection resides in the female hostel.