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PURPOSE: Caregivers of people with disability experience difficulties in a variety of care domains. Understanding the predictive factors of caregiver strain is important in developing and implementing evidence-based intervention to reduce the difficulties experienced by the carers. METHODS: The current study is a cross sectional comprehensive one-phase survey conducted in randomly selected sub-districts (taluks) of the Ernakulam district in Kerala. Primary caregivers (n = 851) for persons with different kinds of disability were identified with the help of ASHAs (Accredited Social Health Activities) from the selected geographical locations and were interviewed in a house-to-house survey after obtaining written informed consent. Validated tools measuring caregiver strain, financial burden, access to services and wellbeing were used to study the population. RESULTS: Majority of the caregivers were females (77.3%) and spouses (35.2%). Of the caregivers 27% reported high levels of caregiver strain. The major factors associated with caregiver strain were female gender (B = 1.379, p = 0.000), financial issues (B = 0.105, p = 0.000), the general health of caregivers (B = 0.467, p = 0.000) and issues relating to employment (B = 0.956, p = 0.000) and the availability of government welfare services (B = 1.138, p = 0.000). CONCLUSION: High caregiver burden and strain is experienced by almost a third of people caring for a person with a disability. Comprehensive interventions to reduce caregiver strain should be developed.Implications for rehabilitationThe rehabilitation sector needs to be made aware of the high levels of caregiver strain (especially in carers who were female, unemployed, have health issues and lack formal support).To improve wellbeing for people with disability we firstly need to promote social inclusion and support schemes for caregiver.Co-designed systems are needed to assist carers to access formal and informal support resources, and increase social connectedness.

Whereas some medical missionaries may already have moved away from “traditional” models of medical mission, in the experience of the authors from the Asia-Pacific region, many potential medical missionaries in the region still imagine a stereotypical generalist medical missionary who runs a mission hospital. The authors argue that with the economic and socio-political development of low- and middle-income countries (LMICs) in recent decades, the landscape for medical missions has changed. Hence, contemporary medical missionaries should be well-advised to have specialist qualifications and be more likely to teach, mentor, and do research rather than only doing hands-on clinical work. Professionalism and quality, rather than “make-do,” should be the norm. There are more opportunities to partner with and strengthen existing local institutions rather than setting up a Christian health service. Furthermore, mission opportunities may be available in academia, government, or secular organisations, including places where Christianity has a hostile reception. Multi-disciplinary expertise and collaboration within health services are increasingly important and provide another opportunity for missions. Medical missionaries may also come from other LMICs, or from within the same country. Job-sharing, self-funding, or fly-in-fly-out, may be a viable and legitimate means of sending more medical missionaries. These non-traditional models of medical mission that incorporate a diversity of approaches, but without sacrificing the “traditional” missional values and practices, should allow even more people to serve in medical missions. The purpose of this paper is to survey this topic in hope of stimulating discussions on non-traditional medical mission opportunities in the Asia-Pacific region and beyond.

PURPOSE: Family members are preferred providers of care for people with disability in India. Despite this, research which evaluates the impact of caregiving is limited. This qualitative study provides a comprehensive, in-depth exploration of the lived experience of carers who provide assistance to persons with a disability in Southwest India. METHODS: In this qualitative study, 20 carers who assist persons with disability were purposively selected to undertake semi-structured interviews across a variety of domains. Data analysis was informed by Attride-Stirling's thematic network analysis. RESULTS: Five global themes were identified which included; carers commitment to caring; concurrent demands of caregiving; mental and physical health of carers; networks and sources of non-financial support; and finances - strains and supports. CONCLUSIONS: This study provides an in-depth exploration of the lived experience of carers in Kerala, India which will inform the future development of interventions to assist primary carers.Implications for rehabilitationFamily members are preferred providers of care for people with disability in India.By understanding the issues that affect carers who assist people with disability, it is possible to develop more effective, targeted, and sustainable interventions, that meet the needs of carers and alleviate some of their burden.Improving the health and wellbeing of carers needs to be urgently addressed in order to improve outcomes for those with disability - whom they care for.

Could ongoing COVID-19 'lockdowns' in India risk more harm than the pandemic itself given a population already facing major poverty and health challenges? © 2020 Center for Health in Mission All rights reserved

Background and Aims: Non-communicable diseases (NCDs) account for 61% of deaths in India. This review focuses on Community Health Workers’ (CHW) effectiveness in preventing and managing NCDs in India which could help direct future research and government policy. Methods: A search of PubMed, Ovid, Embase and CINAHL using terms related to “community health workers” and “India” was used to find articles that quantitatively measured the effect of CHW delivered interventions on NCD risk and health outcomes. Results: CHW interventions are associated with improved health outcomes, metabolic parameters, and lifestyle risk factors in diabetes, cardiovascular disease, and oral cancer. Current literature on CHW interventions for NCDs in India is limited in number of studies and the scope of NCDs covered. Conclusion: There is weak to moderate evidence that CHWs can improve NCD health outcomes in India.

India has 600 million young people, more than any other country in the world. Mental illness is the leading burden of disease for young people, and those affected experience restrictions in social participation that compromise recovery. The aim of this study was to assess the impact of a peer-led, community-based, participatory group intervention on social inclusion and mental health among 142 young people affected by psycho-social disability (PSD) in Dehradun district, Uttarakhand. Qualitative data were obtained via in-depth interviews and focus-group discussions. A realist evaluation identified contextual factors, mechanisms and outcomes to develop the programme theory. Group participants described intermediate outcomes including establishment of new peer friendship networks, increased community participation, greater self-efficacy (for young women particularly), and improved public image (for young men) that are likely to have contributed to the primary outcomes of greater (self-perceived) social inclusion and improved mental health (as assessed quantitatively). Mechanisms were identified that explain the link between intervention and outcomes. These findings demonstrate the effectiveness of a brief intervention to improve mental health and social inclusion for young people with PSD and are potentially relevant to programme implementers and policy-makers working with young people and promoting social inclusion, in other low- and middle-income settings.

PURPOSE: To identify the competencies required by Community-Based Rehabilitation (CBR) practitioners in India and determine typical pathways of competency development, including minimum practice standards. METHODS: Following a literature review of existing frameworks and guidelines for CBR delivery, Delphi methods were used with Indian CBR experts to identify the main competency requirements of CBR personnel. Rubric writing workshops with CBR experts then expressed the performance of these competencies developmentally as learning progressions. The rubrics were converted into an observation form and field tested with 100 CBR personnel of varying expertise levels, through third party assessments by workplace supervisors. Finally, a second Delphi panel determined major competency stages and minimum standards for practice. RESULTS: Three broad job functions pertaining to five focus areas and 37 developmentally described competencies were found important for delivery of quality CBR. Through a standard setting process, for each job function experts reached agreement on major competency stages, including a minimum practice standard. CONCLUSIONS: The study suggests India's CBR expertise proceeds in four stages within three broad job functions - Assessment and Intervention, Inclusive Community Development, and Professional and Ethical Behaviour and Practice. The findings have direct implications for designing curricula to facilitate the competency development of CBR personnel.Implications for rehabilitationMeeting the rehabilitation and inclusion needs of people with disability in low and middle-income countries requires adequately trained local personnel.Currently, lack of knowledge and understanding of the competencies required of CBR personnel is affecting training and workforce quality.Consensus amongst Indian experts about a CBR learning pathway indicates possibilities for effective competency-based course design.

KEY MESSAGESThere has been concern, and much heated debate, on the possible negative effects of restrictions, stay-at-home orders and lockdowns during the COVID-19 pandemic.Most published studies on health impacts of restrictions and lockdowns are low quality and often severely biased.Focusing on the few studies that approximate a change in restrictions alone (i.e. not the impact of the pandemic per se), we see clear adverse impacts of lockdowns on intimate partner violence and physical activity. Regarding diseases, road traffic crashes decrease, and anxiety increases.A discussion driven by science (not politics) is urgently needed on what lockdowns can deliver, their limitations and how to optimally deploy them – along other public health strategies – in the fight against COVID-19.

ObjectiveThis study aims to quantify the extent to which people’s use of tobacco products varies by local areas (city ward and village) across India and the variation in this clustering by tobacco products.DesignCross-sectional study.Setting and participantsData on 73 954 adults across 2547 city wards and villages were available for analysis from 30 states and 2 union territories in India.Primary and secondary outcome measuresWe included as primary outcomes self-reported any tobacco use, current cigarette smoking, current bidi smoking, current smokeless tobacco use and a derived variable for dual use describing respondents who engaged in both smoking and smokeless tobacco use.ResultsThe median risk of an individual using tobacco was 1.64 times greater if a person hypothetically moved from an area of low to high risk of tobacco use (95% CI: 1.60 to 1.69). Area-level partitioning of variation differed by tobacco product used. Median ORs ranged from 1.77 for smokeless tobacco use to 2.53 for dual use.ConclusionsTobacco use is highly clustered geographically in India. To be effective in India, policy interventions should be directed to influence specific local contextual factors on adult tobacco use. Where people live in India influences their use of tobacco, and this association may be greater than has been observed in other settings. Tailoring tobacco control policies for local areas in India may, therefore, provide substantial public health benefits.

Purpose: This study aimed to investigate the experiences of people living with a psychosocial disability in rural India and Nepal, and to highlight key barriers and enablers for inclusion.Method: Participatory action research approaches and Photovoice methodology were employed to investigate the lived experience of 32 participants in rural India and Nepal. There were 12 participants and 4 caregivers of people with psychosocial disability from each of the two countries. Semi-structured interviews with study participants were transcribed and analysed thematically to answer the study question.Results: The findings revealed themes related to various supports, meaningful engagement in activity, and community awareness. Among these categories were both enabling and impeding factors to inclusion, the presence or absence of which was typically associated with improvements or worsening of symptoms respectively.Conclusions and Implications: This study underscores the need for integrated community-based approaches that are multisectoral, inclusive of family, and strengthen community responses. Photovoice was also shown to be a feasible research methodology for providing insights into the lived experience of people with psychosocial disability and for fostering their empowerment.

Background Children with Intellectual and Developmental Disabilities (IDD) face considerable challenges in participating in dental services. These challenges include resource constraints and inadequate skills of health service providers to work with this population. Aim The aim was to scope published studies that addressed access to dental services for children with IDD in order to determine the extent to which various barriers have been researched, using an access framework derived from the literature. Access was defined to include the six dimensions of accessibility, availability, affordability, accommodation, acceptability, and appropriateness. Method Arksey and O'Malley's scoping review framework was used. Relevant databases (e.g., Medline) were searched for all empirical studies conducted from January 2000 to February 2017 that met inclusion criteria. Data were extracted along the six dimensions of the access framework. Results Sixteen international studies were identified which indicated common key barriers to dental service use: the difficulties of physical inaccessibility, lack of access to information among carers, lack of knowledge of disability issues, and low experience and skills in caring for children with IDD among dental practitioners. Conclusions Key recommendations made were exploring dental practitioners' understanding of disability legislation and developing training for practitioners to expand on issues specific to IDD.

Editorial introducing the special issue on pandemic response, with these key resource links: CCIH resources & forum: https://www.ccih.org/cpt_resources/covid-19/ CCIH survey: https://www.ccih.org/covid-19-response-survey-of-fbos/ Leadership consultations (HFAN): https://www.healthforallnations.com/ Book & mission blogs: https://www.medicalmissions.com/coronavirus ICMDA Resource Links: https://mailchi.mp/a46dcc104406/covid01? Joint Learning Initiative for Faith and Local Communities: https://jliflc.com/covid/ CUGH resources for educators and researchers: https://myemail.constantcontact.com/COVID-19-Newsletter-Vol--5.html?soid=1112846108446&aid=AUbGAK-oI_U FBO resources from CDC: https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/index.htm Community health fact sheet (in 25 languages):https://protect-au.mimecast.com/s/8jexCP7yBlsK0MxPpUzK3Iv?domain=r20.rs6.net

Young people experiencing mental ill-health are often excluded from peer networks, family events, education, marriage and employment. We evaluated a community-based, peer-led intervention guided by the Nae Disha (new pathways) program, targeting young people affected by mental ill-health in Uttarakhand, India. A total of 11 groups involving 142 young people (30 male, 112 female) and 8 peer facilitators participated, most of whom were enrolled in a community mental health program. The impact of the intervention on participation, mental health, and social strengths and difficulties was measured at baseline and endline using validated instruments. The proportion experiencing significant social isolation reduced from 20.6 to 5.9% (p

Background There are few available data regarding the prevalence of diabetes in the sub-Himalayan region of India. The aim of this study was to determine the prevalence of pre-diabetes and diabetes in rural Garhwal based on glycosylated hemoglobin. Methods In a cross-sectional survey of 500 adults from five randomly selected villages in Chamba, a mountainous Tehri Garhwal district in Uttarakhand in north-west India, we determined the prevalence of diabetes (hemoglobin (Hb) A1c ≥ 6.5%) and pre-diabetes (5.7% ≤ HbA1c ≤ 6.4%). In a sub-sample of those diagnosed with diabetes or pre-diabetes (n = 140), fasting blood glucose (FBG, n = 117) or postprandial blood glucose (PBG, n = 23), and blood hemoglobin concentration, was measured at follow-up. Results Based on HbA1c, 10.0% had diabetes and 56.4% pre-diabetes. Of those diagnosed as diabetic by HbA1c, 10 of 16 (62.5%) were diagnosed as diabetic by FBG (> 125 mg/dL) or PBG (≥200 mg/dL). In those diagnosed as pre-diabetic by HbA1c, only 55 of 124 (44.4%) were diagnosed as pre-diabetic by FBG (100–125 mg/dL) or PBG (140–199 mg/dL). A large proportion of these 140 individuals (67.1%) were moderately to severely anemic (Hb

This chapter explains the causes, types, and importance of disability, and ways in which needs of those with disability can be met through community-based rehabilitation (CBR). It explains how any CBR programme should be based on the principles in the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). It introduces the World Health Organization (WHO) CBR framework that shows the essential components of a programme. The chapter describes ways to identify people with disability in the community, how to assess their needs, and the importance of linking with community stakeholders and local CBR workers. The chapter goes into detail about the six steps of implementing a CBR programme: screening and assessment, maximizing function, setting up support groups, advocacy, mainstream inclusion, and programme monitoring and evaluation.

This chapter on non-communicable diseases (NCDs) explains how they are now the leading cause of death worldwide, and how their prevention, control, and treatment need to be built into our community health programme. It gives information about physical activity, alcohol moderation, tobacco cessation, and healthy eating, and for each topic uses WHO guidelines as the basis for the advice. The chapter suggests how to raise awareness in the community and ways to integrate the community response with existing services and government health programmes. It details five components for an effective NCD response at the community level—screening, promoting healthy behaviours, advocacy, disease-specific treatments, and interventions. It finishes with ways to monitor and evaluate the programme.

This article reports on an historic collaboration between Australian church-based development agencies and their partners in the Pacific – the largest in scale to date. It is now incontrovertible that climate change is damaging health and wellbeing in Pacific communities – especially in terms of climate-related disasters. Churches in the Pacific have a unique role and responsibility within the civil society in the region. This article traces some of the historical factors that have contributed to their social resonance. The article looks at how a network approach can be well suited to tackling difficult social challenges, and makes the case for the involvement of the Pacific churches in building community resilience through disaster risk reduction activities. A shared faith identity and trust are identified as two vital factors that help church-based consortia to coalesce. The article concludes that a focus on orthopraxy in its broader sense by Christian faith-based actors is a helpful perspective in achieving collaboration.

Background There are different estimates of disability prevalence reported in India due to the differences in definitions and methodologies. Reliable data is needed to plan effective disability inclusive strategies. Objective The objective of this study was to determine the prevalence and risk factors associated with disability among adults ≥18 years of age in Prakasam district of Andhra Pradesh using the Rapid Assessment of Disability (RAD) tool. Methods The RAD survey was conducted in 50 villages (clusters) of Ongole division of Prakasam district. A two-stage cluster random sampling was used. Within each village 80 participants were surveyed. Compact segment sampling was used to determine the houses included. A person was reported as disabled based on their responses to the functioning section of the RAD tool. Results A total of 4134 adults were included. The overall prevalence of disability was 10.4% (431 adults). The highest prevalence of functional impairment was related to mobility (4.7%) followed by vision (2.1%) and fine motor (1.8%). The prevalence of psychological distress was 2.3%. Disability was significantly more prevalent in the poor socio economic group (OR 2.8; 95% CI: 1.5; 5.0) and among unemployed (OR 3.6; 95% CI: 2.3, 5.5). The prevalence of disability was strongly associated with age where, participants aged 70 years and over were eleven times more likely to report disability than younger age groups. Conclusion The high prevalence of disability in the region points to disability being of public health concern and as a health condition needing urgent attention and specific interventions.

Background Disabled People’s Organisations (DPOs) are the mainstay of disability responses worldwide. Yet there is no quantitative data assessing their effectiveness in low-and middle-income countries (LMICs). The aim of this study was to measure the effectiveness of DPOs as a low-cost intervention to improve well-being and access to services and facilities for people with disabilities. Methods We undertook a cluster randomised intervention control trial across 39 distinct rural villages in Uttarakhand State, North India. A total of 527 participants were included from 39 villages: 302 people from 20 villages were assigned to the intervention arm and 225 from 19 villages were assigned to the control group. Over a 2-year period, people with disabilities were facilitated to form DPOs with regular home visits. Participants were also given financial support for public events and exposure visits to other DPOs. Seven domains were used to measure access and participation. Results DPO formation had improved participation in community consultations (OR 2.57, 95% CI 1.4 to 4.72), social activities (OR 2.46, 95% CI 1.38 to 4.38), DPOs (OR 14.78, 95% CI 1.43 to 152.43), access to toilet facilities (OR 3.89, 95% CI 1.31 to 11.57), rehabilitation (OR 6.83, 95% CI 2.4 to 19.42) and Government social welfare services (OR 4.82, 95% CI 2.35 to 9.91) in intervention when compared to the control. People who were part of a DPO had an improvement in having their opinion heard (OR 1.94, 95% CI 1.16 to 3.24) and being able to make friends (OR 1.63, 95% CI 1 to 2.65) compared to those who were not part of a DPO. All other well-being variables had little evidence despite greater improvement in the DPO intervention group. Conclusions This is the first randomised control trial to demonstrate that DPOs in LMICs are effective at improving participation, access and well-being. This study supports the ongoing role of DPOs in activities related to disability inclusion and disability services. This study also suggests that supporting the establishment, facilitation and strengthening of DPOs is a cost-effective intervention and role that non-governmental organisations (NGOs) can play. Trial registration ISRCTN36867362, 9th Oct 2019 (retrospectively registered).

India implemented larger 85% pictorial health warnings on all tobacco products from 1 April 2016. However, to remove the last bit of glamour and attraction from the tobacco packs, it must now embrace plain packaging. Plain packaging prevents tobacco packs from carrying the tobacco industry brand imagery as mobile billboards. Postimplementation of larger 85% pictorial health warnings on all tobacco products, this analysis was undertaken to assess the feasibility of plain packaging as the next logical tobacco control policy measure in India. As part of this analysis, the research team reviewed the available literature on legal and policy challenges to plain packaging as a tobacco control policy initiative for India. Literature from 2010 to 2016 in English language was reviewed, which reveals that, India has taken several preparatory steps implemented by other countries like Australia and the UK that have introduced plain packaging, for example, stronger smoke-free laws, ban on tobacco advertising, promotion and sponsorship, increase in taxes and a report from civil society task force on plain packaging. The trade and investment agreements signed by India are also within the international trade norms relating to public health. A Private Member’s Bill on plain packaging is also pending in the Parliament of India. Other potential challenges against such policy decision, for example, freedom of trade, right to property, violation of competition law and other laws including consumer protection laws, were found unsubstantiated by the research team. Plain packaging is the next logical step for tobacco control policy in India.

Background Plain packaging has been demonstrated to be effective in Australia, where it led to increased quit attempts among adult smokers. Graphic Health Warnings (GHWs) on tobacco packs in India have increased from 40% to 85%. This qualitative study assesses perceptions of Indian adults and children about impact of larger GHWs and plain packaging of tobacco products. Methods Focus Group Discussions (FGDs), conducted with children aged 13-17 years and adults aged 17+ years in the community settings. Separate FGDs were conducted with adults (male and female) and children (boys and girls) in selected urban and rural communities in Delhi and Telangana in 2016. Four dummy tobacco packs categories [A-40% old GHWs, B-40% new GHWs, C-85% new GHWs; D-85% new GHWs with plain pack] were shown. Data was coded and thematic analysis undertaken with using Atlas.ti 6.2. Results In total, fourteen (six in Delhi and eight in Telangana) FGDs were conducted. Participants highlighted the importance of larger GHWs on tobacco products in demonstrating the consequences of tobacco use and limit the pack's appeal. Participants opined, category C and D warnings were most effective to curb tobacco use. Category D was considered the most unattractive pack due to larger GHW, dull color and brand name not being prominent. Conclusions Larger GHWs and PP were perceived to be effective in reducing tobacco use. Plain packaging was further perceived to reduce the attractiveness of pack, enhance noticeability of the GHW, deter new users, and improve quitting among users.

With the achievements, failures and passing of the Millennium Development Goals (MDG), the world has turned its eyes to the Sustainable Development Goals (SDG), designed to foster sustainable social, economic and environmental development over the next 15 years.(1) Community-led initiatives are increasingly being recognised as playing a key role in realising sustainable community development and in the aspirations of universal healthcare.(2) In many parts of the world, faith-based organisations are some of the main players in community-led development and health care.(3) Community Health Global Network (CHGN) creates links between organisations, with the purpose being to encourage communities to recognise their assets and abilities, identify shared concerns and discover solutions together, in order to define and lead their futures in sustainable ways.(4) CHGN has facilitated the development of collaborative groups of health and development initiatives called ‘Clusters’ in several countries including India, Bangladesh, Kenya, Tanzania, Zambia and Myanmar. In March 2016 these Clusters met together in an International Forum, to share learnings, experiences, challenges, achievements and to encourage one another. Discussions held throughout the forum suggest that the CHGN model is helping to promote effective, sustainable development and health care provision on both a local and a global scale.

Purpose: People with disability in rural India face multiple barriers accessing healthcare; our hypothesis is that children with intellectual disability suffer the same but little is known about the barriers faced by them. The objectives of the study were to identify the health seeking behaviours of families with children with intellectual disabilities and the barriers they faced accessing healthcare. Methods: This qualitative study involved interviewing caregivers of children with intellectual disability from a pre-existing community development project in the Sahadoli Kadim block of rural Uttar Pradesh. Semi-structured interviews were also conducted with the local practitioners frequented by these caregivers. Results: Barriers identified were grouped under cognitive, structural and financial barriers which were found to be consistent with the Health Care Access Barrier Model (Carrillo, et al., 2011; WHO, 2011). Cognitive barriers included caregivers being unable to identify the complex health needs of their children. Caregivers lacked appropriate knowledge of intellectual disability, with doctors failing to educate them. Structural and financial barriers encompassed poor availability of healthcare providers and contributed to poor access to specialists. Caregivers had no information about government financial aid and healthcare providers did not refer them to these. Conclusion: Children with intellectual disabilities are forced to live with a poor quality of life because of cognitive, structural and financial barriers they face in accessing health care. Results are specific to children with intellectual disability in rural Sahadoli Kadim and could be used to inform policies and strategies to reduce disparities in health care access for these children.