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Background There is substantial interest in leveraging digital health technology to support hypertension management in low- and middle-income countries such as India. The potential for healthcare infrastructure and broader context to support such initiatives in India has not been examined. We evaluated existing healthcare infrastructure to support digital health interventions and examined epidemiologic, socioeconomic, and geographical contextual correlates of healthcare infrastructure in 544 districts covering 29 states and union territories across India. Methods The study was a cross-sectional analysis of India’s Fourth District Level Household and Facility Survey (DLHS-4; 2012–2014), the most up-to-date nationally representative district-level healthcare infrastructure data. Facilities were the unit of analysis, and analyses accounted for clustering within states. The main outcome was healthcare system infrastructural context to implement hypertension management programs. Domains included diagnostics (functional BP instrument), medications (anti-hypertensive medication in stock), essential clinical staff (e.g., staff nurse, medical officer, pharmacist), and IT specific infrastructure (regular power supply, internet connection, computer availability). Descriptive analysis was conducted for infrastructure indicators based on the Indian Public Health Standards, and logistic regression was conducted to estimate the association between epidemiologic and geographical context (exposures) and the composite measure of healthcare system. Results Data from 32,215 government facilities were analyzed. Among lowest-tier subcenters, 30% had some IT infrastructure, while at the highest-tier district hospitals, 92% possessed IT infrastructure. At mid-tier primary health centres and community health centres, IT infrastructure availability was 28 and 51%, respectively. For all but sub-centres, the availability of essential staff was lower than the availability of IT infrastructure. For all but district hospitals, higher levels of blood pressure, body mass index, and urban residents were correlated with more favorable infrastructure. By region, districts in Western India tended towards having the best prepared health facilities. Conclusions IT infrastructure to support digital health interventions is more frequently lacking at lower and mid-tier healthcare facilities compared with apex facilities in India. Gaps were generally larger for staffing than physical infrastructure, suggesting that beyond IT infrastructure, shortages in essential staff impose significant constraints to the adoption of digital health interventions. These data provide early benchmarks for state- and district-level planning.

This study aims to provide evidence on how the COVID-19 pandemic has impacted chronic disease care in diverse settings across Asia. Cross-sectional surveys were conducted to assess the health, social, and economic consequences of the pandemic in India, China, Hong Kong, Korea, and Vietnam using standardized questionnaires. Overall, 5672 participants with chronic conditions were recruited from five countries. The mean age of the participants ranged from 55.9 to 69.3 years. A worsened economic status during the COVID-19 pandemic was reported by 19% to 59% of the study participants. Increased difficulty in accessing care was reported by 8% to 24% of participants, except Vietnam: 1.6%. The worsening of diabetes symptoms was reported by 5.6% to 14.6% of participants, except Vietnam: 3%. In multivariable regression analyses, increasing age, female participants, and worsened economic status were suggestive of increased difficulty in access to care, but these associations mostly did not reach statistical significance. In India and China, rural residence, worsened economic status and self-reported hypertension were statistically significantly associated with increased difficulty in access to care or worsening of diabetes symptoms. These findings suggest that the pandemic disproportionately affected marginalized and rural populations in Asia, negatively affecting population health beyond those directly suffering from COVID-19.

Using primary data from 479 farmer households, this study examined the associations between agricultural and socioeconomic factors and farmer household dietary diversity in Visakhapatnam and Sonipat. Cropping intensity was positively associated with farmers’ household dietary diversity score (HDDS), suggesting that higher cropping intensity may expand the gross cropped area and improve food security among subsistence farmers. Distance to food markets was also significantly associated with farmer HDDS, which suggests that market integration with rural households can improve farmer HDDS in Visakhapatnam. In Sonipat, wealth index had a positive association with farmer HDDS, targeting the income pathway by improving farmer HDDS in this region. Considering the relative contribution of these factors, distance to food markets, cropping intensity, and crop diversity were the three most important factors affecting farmer HDDS in Visakhapatnam, whereas wealth index, cropping intensity, and distance to food markets emerged as the top three important factors contributing to farmer HDDS in Sonipat. Our study concludes that the associations between agricultural and socioeconomic factors and farmer HDDS are complex but context- and location-specific; therefore, considering the site- and context-specific circumstances, different connections to HDDS in India can be found to better support policy priorities on the ground.

Background The growing burden of hypertension and diabetes is one of the major public health challenges being faced by the health system in India. Clinical Decision Support Systems (CDSS) that assist with tailoring evidence-based management approaches combined with task-shifting from more specialized to less specialized providers may together enhance the impact of a program. We sought to integrate a technology “CDSS” and a strategy “Task-shifting” within the Government of India’s (GoI) Non-Communicable Diseases (NCD) System under the Comprehensive Primary Health Care (CPHC) initiative to enhance the program’s impact to address the growing burden of hypertension and diabetes in India. Methods We developed a model of care “I-TREC” entirely calibrated for implementation within the current health system across all facility types (Primary Health Centre, Community Health Centre, and District Hospital) in a block in Shaheed Bhagat Singh (SBS) Nagar district of Punjab, India. We undertook an academic-community partnership to incorporate the combination of a CDSS with task-shifting into the GoI CPHC-NCD system, a platform that assists healthcare providers to record patient information for routine NCD care. Academic partners developed clinical algorithms, a revised clinic workflow, and provider training modules with iterative collaboration and consultation with government and technology partners to incorporate CDSS within the existing system. Discussion The CDSS-enabled GoI CPHC-NCD system provides evidence-based recommendations for hypertension and diabetes; threshold-based prompts to assure referral mechanism across health facilities; integrated patient database, and care coordination through workflow management and dashboard alerts. To enable efficient implementation, modifications were made in the patient workflow and the fulcrum of the use of technology shifted from physician to nurse. Conclusion Designed to be applicable nationwide, the I-TREC model of care is being piloted in a block in the state of Punjab, India. Learnings from I-TREC will provide a roadmap to other public health experts to integrate and adapt their interventions at the national level. Trial registration CTRI/2020/01/022723.

Supplemental Digital Content is available in the text., Background: An epidemic of chronic kidney disease is occurring in rural communities in low-income and middle-income countries that do not share common kidney disease risk factors such as diabetes and hypertension. This chronic kidney disease of unknown etiology occurs primarily in agricultural communities in Central America and South Asia. Consequently, environmental risk factors including heat stress, heavy metals exposure, and low altitude have been hypothesized as risk factors. We conducted an environmental epidemiological analysis investigating these exposures in India which reports the disease. Methods: We used a random sample population in rural and urban sites in Northern and Southern India in 2010, 2011, and 2014 (n = 11,119). We investigated associations of the heat index, altitude, and vicinity to cropland with estimated glomerular filtration rate (eGFR) using satellite-derived data assigned to residential coordinates. We modeled these exposures with eGFR using logistic regression to estimate the risk of low eGFR, and linear mixed models (LMMs) to analyze site-specific eGFR-environment associations. Results: Being over 55 years of age, male, and living in proximity to cropland was associated with increased risk of low eGFR [odds ratio (OR) (95% confidence interval (CI) = 2.24 (1.43, 3.56), 2.32 (1.39, 3.88), and 1.47 (1.16, 2.36)], respectively. In LMMs, vicinity to cropland was associated with low eGFR [−0.80 (−0.44, −0.14)]. No associations were observed with temperature or altitude. Conclusions: Older age, being male, and living in proximity to cropland were negatively associated with eGFR. These analyses are important in identifying subcommunities at higher risk and can help direct future environmental investigations.

Aim To estimate the prevalence, socio-demographic determinants, common disease combinations, and health impact of multimorbidity among a young rural population. Methods We conducted a cross-sectional survey among participants aged ≥30 years in rural Punjab, North India, from Jan 2019 to April 2019. Multimorbidity was defined as the coexistence of ≥two conditions using a 14-condition tool validated in India. We also calculated a multimorbidity-weighted index (MWI), which provides a weight to each disease based on its impact on physical functioning. Logistic regression was conducted to evaluate the association with sociodemographic variables, mental health (PHQ-9), physical functioning (ADL scale), and self-rated health (SRH). Results We analyzed data from 3213 adults [Mean age 51.5 (±13), 54% women]. Prevalence of single chronic condition, multimorbidity, and MWI was 28.6, 18% and − 1.9 respectively. Age, higher wealth index and ever use alcohol were significantly associated with multimorbidity. Overall, 2.8% of respondents had limited physical functioning, 2.1% had depression, and 61.5% reported low SRH. Poorer health outcomes were more prevalent among the elderly, women, less educated, and those having lower wealth index and multimorbidity, were found to be significantly associated with poor health outcomes. Conclusions The burden of multimorbidity was high in this young rural population, which portends significant adverse effects on their health and quality of life. The Indian health system should be reconfigured to address this emerging health priority holistically, by adopting a more integrated and sustainable model of care.

To estimate the prevalence of chronic obstructive pulmonary disease (COPD) and chronic bronchitis in eight countries in South Asia through a systematic review and meta-analysis.We searched MEDLINE® Complete, Web of Science, Embase®, Scopus, CINAHL and reference lists of screened studies for research on the prevalence of COPD and chronic bronchitis in South Asian countries published between January 1990 and February 2021. We used standardized diagnostic criteria for definitions of COPD and chronic bronchitis. Two reviewers undertook study screening, full-text review, quality appraisal and data extraction.Of 1529 studies retrieved, 43 met the inclusion criteria: 32 provided data from India; four from Bangladesh; three from Nepal; two from Pakistan; and two from both India and Sri Lanka. Twenty-six studies used standardized diagnostic definitions and 19 were included in the meta-analysis. The estimated pooled prevalence of COPD was 11.1% (95% confidence interval, CI: 7.4-14.8%), using the Global Initiative for Chronic Obstructive Lung Disease fixed criteria and 8.0% (95% CI: 5.6-10.4%) using the lower limit of normal criteria. The prevalence of COPD was highest in north India (19.4%) and Bangladesh (13.5%) and in men. The estimated pooled prevalence of chronic bronchitis was 5.0% (95% CI: 4.1-6.0%) in India and 3.6% (95% CI: 3.1-4.0%) in Pakistan.Included countries have a high prevalence of COPD although it varied by geographical area and study characteristics. Future research in South Asia should use standardized diagnostic criteria to examine the contribution of setting-specific risk factors to inform prevention and control strategies.Estimer la prévalence de la bronchopneumopathie chronique obstructive (BPCO) et de la bronchite chronique dans huit pays d'Asie du Sud par le biais d'une revue systématique et d'une méta-analyse.Nous avons exploré les bases de données MEDLINE® Complete, Web of Science, Embase®, Scopus et CINAHL, ainsi que des listes de référence d'études sélectionnées, afin de compiler les recherches sur la prévalence de la BPCO et de la bronchite chronique dans les pays d'Asie du Sud publiées entre janvier 1990 et février 2021. Nous avons défini la BPCO et la bronchite chronique en nous fondant sur des critères de diagnostic normalisés. Enfin, deux réviseurs ont trié les études, examiné le texte intégral, évalué la qualité et extrait les données.Sur 1529 études récupérées, 43 correspondaient aux critères d'inclusion: 32 fournissaient des informations sur l'Inde; quatre sur le Bangladesh; trois sur le Népal; deux sur le Pakistan et deux sur l’Inde et le Sri Lanka. Au total, 26 études reposaient sur une définition standard du diagnostic, et 19 étaient intégrées dans la méta-analyse. La prévalence groupée de la BPCO a été estimée à 11,1% (intervalle de confiance de 95%, IC: 7,4–14,8%) selon les critères fixés par l'Initiative mondiale contre la bronchopneumopathie chronique obstructive, et à 8,0% (IC de 95%: 5.6–10.4%) selon la limite inférieure des critères normaux. C'est dans le nord de l'Inde (19,4%) et au Bangladesh (13,5%) que la prévalence la plus élevée a été observée pour la BPCO, et surtout chez les hommes. De son côté, la prévalence groupée de la bronchite chronique a été estimée à 5,0% (IC de 95%: 4,1–6,0%) en Inde et à 3,6% (IC de 95%: 3,1–4,0%) au Pakistan.Les pays pris en considération présentent une forte prévalence de la BPCO, bien qu'il existe des variations en fonction des zones géographiques et des caractéristiques des études. Les futures recherches menées en Asie du Sud devraient utiliser des critères de diagnostic normalisés pour examiner le rôle des facteurs de risque propres au contexte, afin d'orienter les stratégies de prévention et de lutte.Estimar la prevalencia de las enfermedades pulmonares obstructivas crónicas (EPOC) y de la bronquitis crónica en ocho países del sur de Asia mediante una revisión sistemática y un metanálisis.Se realizaron búsquedas en MEDLINE® Complete, Web of Science, Embase®, Scopus, CINAHL y en las listas de referencias de los estudios seleccionados en busca de investigaciones sobre la prevalencia de las EPOC y de la bronquitis crónica en los países del sur de Asia publicadas entre enero de 1990 y febrero de 2021. Se utilizaron criterios de diagnóstico estandarizados para las definiciones de EPOC y bronquitis crónica. Dos revisores realizaron la selección de los estudios, la revisión del texto completo, la valoración de la calidad y la extracción de los datos.De los 1529 estudios recuperados, 43 cumplían los criterios de inclusión: 32 proporcionaron datos de la India; cuatro de Bangladesh; tres de Nepal; dos de Pakistán; y dos tanto de la India como de Sri Lanka. Veintiséis estudios utilizaron definiciones diagnósticas estandarizadas y 19 se incluyeron en el metanálisis. La prevalencia conjunta estimada de las EPOC fue del 11,1 % (intervalo de confianza del 95 %, IC: 7,4-14,8 %), utilizando los criterios fijos de la Iniciativa Mundial para las Enfermedades Pulmonares Obstructivas Crónicas y del 8,0 % (IC del 95 %: 5,6-10,4 %) utilizando los criterios del límite inferior de la normalidad. La prevalencia de las EPOC fue mayor en el norte de la India (19,4 %) y en Bangladesh (13,5 %) y en los varones. La prevalencia conjunta estimada de bronquitis crónica fue del 5,0 % (IC del 95 %: 4,1-6,0 %) en la India y del 3,6 % (IC del 95 %: 3,1-4,0 %) en Pakistán.Los países incluidos tienen una alta prevalencia de EPOC, aunque esta varía según la zona geográfica y las características del estudio. Las investigaciones futuras en el sur de Asia deberían utilizar criterios de diagnóstico estandarizados para analizar la contribución de los factores de riesgo específicos del entorno con el fin de fundamentar las estrategias de prevención y control.تقدير مدى انتشار مرض الانسداد الرئوي المزمن (COPD)، والتهاب الشعب الهوائية المزمن في جنوب آسيا من خلال مراجعة منهجية وتحليل تلوي.قمنا بالبحث في MEDLINE® Complete، وWeb of Science، وEmbase®‎، وScopus، وCINAHL، وقوائم مرجعية للدراسات التي تم فحصها بغرض الأبحاث عن انتشار مرض الانسداد الرئوي المزمن (COPD)، والتهاب الشعب الهوائية المزمن في دول جنوب آسيا، والتي تم نشرها في الفترة ما بين يناير/كانون ثاني 1990 وفبراير/شباط 2021. كما قمنا باستخدام معايير التشخيص القياسية لتعريفات مرض الانسداد الرئوي المزمن (COPD)، والتهاب الشعب الهوائية المزمن. تولى اثنان من المراجعين فحص الدراسة، ومراجعة النص الكامل، وتقييم الجودة، واستخراج البيانات.من بين الـ 1529 دراسة تم استرجاعها، استوفت 43 منها معايير الاشتمال: قدمت 32 منها بيانات من الهند؛ وأربعة من بنغلاديش؛ وثلاثة من نيبال؛ واثنتان من باكستان؛ واثنتان من كل من الهند وسري لانكا. استخدمت ستة وعشرون دراسة تعريفات تشخيصية قياسية، وتم تضمين 19 منها في التحليل التلوي. كان معدل الانتشار المجمّع التقديري لمرض الانسداد الرئوي المزمن (COPD) هو 11.1% (بفاصل ثقة مقداره: 7.4 إلى 14.8%)، باستخدام المعايير الثابتة للمبادرة العالمية لمرض الانسداد الرئوي المزمن، و8.0% (بفاصل ثقة 95%: 5.6 إلى 10.4%) باستخدام حد أقل للمعايير العادية. كان معدل انتشار مرض الانسداد الرئوي المزمن (COPD) هو الأعلى في شمال الهند (19.4%) وبنغلاديش (13.5%) وفي الرجال. كان معدل الانتشار المجمّع التقديري لمرض التهاب الشعب الهوائية المزمن هو 5.0% (بفاصل ثقة مقداره 95%: 4.1 إلى 6.0%) في الهند و3.6% (بفاصل ثقة مقداره 95%: 3.1 إلى 4.0%) في باكستان.كان لدى البلدان المشمولة نسبة عالية من معدل انتشار مرض الانسداد الرئوي المزمن (COPD) على الرغم من أنها تختلف حسب المنطقة الجغرافية وخصائص الدراسة. يجب أن تستخدم الأبحاث المستقبلية في جنوب آسيا معايير تشخيصية قياسية لفحص مساهمة عوامل الخطر ذات الأوضاع المحددة لزيادة التوعية باستراتيجيات الوقاية والسيطرة.旨在通过系统评价和元分析来评估南亚八个国家的慢性阻塞性肺疾病 (COPD) 和慢性支气管炎的患病率。.我们搜索了 MEDLINE® Complete、科学网、Embase®、Scopus、CINAHL 和 1990 年 1 月至 2021 年 2 月期间发布的筛查研究参考文献列表来调查南亚国家的 COPD 和慢性支气管炎的患病率。我们采用规范化的诊断标准来确定 COPD 和慢性支气管炎的定义。由两名评审人员负责研究筛选、全文评审、质量评估和数据提取工作。.在检索到的 1529 项研究中，有 43 项符合纳入标准：其中 32 项数据来自印度；4 项来自孟加拉国；3 项来自尼泊尔；2 项来自巴基斯坦；其余两项分别来自印度和斯里兰卡。二十六项研究采用规范化诊断定义，19 项被纳入元分析中。我们采用《慢性阻塞性肺疾病全球倡议》修订版标准评估的 COPD 汇总患病率是 11.1%（95% 置信区间，CI：7.4–14.8%），采用正常标准的下限评估的患病率是 8.0% (95% CI: 5.6–10.4%)。COPD 在北印度 (19.4%) 和孟加拉国 (13.5%) 以及男性间的患病率最高。印度的 COPD 汇总患病率估计值是 5.0% (95% CI: 4.1–6.0%)，巴基斯坦的估计值是 3.6% (95% CI: 3.1–4.0%)。.尽管患病率因地理区域和研究特征而异，但研究所纳入国家的 COPD 患病率较高。南亚地区未来的研究应该采用规范化的诊断标准来检验特定环境的风险因素影响程度，为制定预防和管控策略提供理论依据。.Оценить распространенность хронической обструктивной болезни легких (ХОБЛ) и хронического бронхита в восьми странах Южной Азии посредством систематического обзора и метаанализа.Авторы провели поиск по базам данных MEDLINE® Complete, Web of Science, Embase®, Scopus, CINAHL и по спискам литературы отобранных исследований, опубликованных в период с января 1990 года по февраль 2021 года, для определения распространенности ХОБЛ и хронического бронхита в странах Южной Азии. Для определения ХОБЛ и хронического бронхита авторы использовали стандартизированные диагностические критерии. Два рецензента провели скрининг исследования, обзор полного текста, оценку качества и выборку данных.Из 1529 полученных исследований 43 соответствовали критериям включения: 32 исследования предоставили данные из Индии; четыре — из Бангладеш; три — из Непала; два — из Пакистана и два — из Индии и Шри-Ланки вместе.. В 26 исследованиях использовались стандартизированные диагностические определения, а 19 исследований были включены в метаанализ. Показатель объединенной распространенности ХОБЛ составил 11,1% (95%-й доверительный интервал, ДИ: 7,4–14,8%) при использовании фиксированных критериев Глобальной инициативы по хронической обструктивной болезни легких, и 8,0% (95%-й ДИ: 5,6–10,4%) при использовании нижней границы нормы критериев. Распространенность ХОБЛ была самой высокой среди мужчин в северной Индии (19,4%) и Бангладеш (13,5%). Показатель объединенной распространенности хронического бронхита составил 5,0% (95%-й ДИ: 4,1–6,0%) в Индии и 3,6% (95%-й ДИ: 3,1–4,0%) в Пакистане.Включенные страны имеют высокую распространенность ХОБЛ, хотя она варьировалась в зависимости от географического региона и характеристик исследования. Чтобы разработать стратегии по профилактике и борьбе с заболеванием, в будущих исследованиях в Южной Азии следует использовать стандартизированные диагностические критерии для изучения вклада факторов риска, зависимых от условий.

Public health care facilities in Sonipat District, Haryana State, India.To assess 1) the proportion of tuberculosis (TB) patients screened for diabetes mellitus (DM) and vice versa, 2) factors associated with screening, and 3) the enablers, barriers and solutions related to screening.A mixed-methods study with quantitative (cohort study involving record reviews of patients registered between November 2016 and April 2017) and qualitative (interviews of patients, health care providers [HCPs] and key district-level staff) components.Screening for TB among DM patients was not implemented, despite documents indicating that it had been. Of 562 TB patients, only 137 (24%) were screened for DM. TB patients registered at tertiary and secondary health centres were more likely to be screened than primary health centres. Low patient awareness, poor knowledge of guidelines among HCPs, lack of staff and inadequate training were barriers to screening. Enablers were the positive attitude of HCPs and programme staff. The key solutions suggested were to improve awareness of HCPs and patients regarding the need for screening, training of HCPs and wider availability of DM testing facilities.The implementation of bidirectional screening was poor. Adequate staffing, regular training, continuous laboratory supplies for DM diagnosis and widespread publicity should be ensured.Structures de santé publiques du district de Sonipat, état d’Haryana, Inde.1) Evaluer la proportion de patients avec la tuberculose (TB) ayant eu une recherche de diabète (DM) et vice-versa, 2) les facteurs associés à ce dépistage ; et 3) les facilitateurs, les contraintes et les solutions relatifs au dépistage.Une étude à méthodes mixtes comportant des composants quantitatifs (étude de cohorte basée sur une revue des dossiers des patients enregistrés entre novembre 2016 et avril 2017) et qualitatifs (entretiens avec des patients, des prestataires de soins de santé [HCP] et du personnel clé du district).Le dépistage de la TB parmi les patients DM n’a pas été mis en œuvre, malgré les documents indiquant qu’il l’avait été. Sur 562 patients TB, seulement 137 (24%) ont été dépistés à la recherche de DM. Les patients TB enregistrés dans des centres de santé tertiaires et secondaires ont été plus susceptibles d’être dépistés, comparés à ceux des centres de santé primaires. La faible sensibilisation des patients, une connaissance médiocre des directives parmi les HCP, le manque de personnel et une formation insuffisante ont été les contraintes au dépistage. L’attitude positive des HCP et du personnel du programme a favorisé le dépistage. Les solutions principales suggérées ont été d’améliorer la sensibilisation des HCP et des patients en matière de nécessité du dépistage, de la formation des HCP et de la plus grande disponibilité des structures de recherche du DM.La mise en œuvre du dépistage bidirectionnel a été médiocre. Il faut assurer suffisamment de personnel, une formation régulière, des fournitures de laboratoire continues pour le diagnostic du DM ainsi qu’une vaste propagande.Establecimientos de atención de salud en el distrito Sonipat, del estado de Haryana en la India.1) Evaluar la proporción de pacientes con tuberculosis (TB) en quienes se practica el tamizaje de la diabetes (DM) y vice versa; 2) los factores asociados con la práctica del tamizaje; y 3) los factores facilitadores, los obstáculos y las soluciones en materia de detección sistemática.Fue este un estudio de métodos mixtos con componentes cuantitativos (estudio de cohortes a partir de las historias clínicas de los pacientes registrados de noviembre del 2016 a abril del 2017) y componentes cualitativos (entrevistas a los pacientes, los proveedores de atención de salud [HCP] y miembros clave del personal distrital).La detección sistemática de la TB en los pacientes con diagnóstico de DM no se practicaba, pese a los documentos que afirmaban lo contrario. De los 562 pacientes con TB, solo en 137 (24%) se practicó el tamizaje de la DM. La probabilidad de recibir el tamizaje fue mayor en los pacientes con TB registrados en los centros de atención terciaria y secundaria, que en los registrados en centros de atención primaria. Los obstáculos al tamizaje fueron la escasa sensibilización de los pacientes, el desconocimiento de las directrices por parte de los HCP, la escasez de personal y la capacitación deficiente. Los factores que facilitaron la práctica del tamizaje fueron la actitud positiva de los HCP y del personal del programa. Las principales soluciones propuestas fueron reforzar la sensibilización de los HCP y los pacientes con respecto a la necesidad del tamizaje, la capacitación de los HCP y una mayor disponibilidad de establecimientos que practiquen las pruebas de la DM.La ejecución de la detección sistemática recíproca era deficiente. Es necesario procurar una dotación adecuada de personal, realizar capacitaciones periódicas y velar por un abastecimiento continuo de suministros de laboratorio para el diagnóstico de la DM, además de realizar extensas campañas de comunicación.

Prashant Jarhyan,1– 3 Anastasia Hutchinson,1,2 Rajesh Khatkar,1 Dimple Kondal,1 Mari Botti,2 Dorairaj Prabhakaran,1,3,4 Sailesh Mohan1– 3 1Centre for Chronic Conditions and Injuries (CCCI), Public Health Foundation of India, Gurgaon, India; 2Institute of Health Transformation, Faculty of Health, Deakin University, Burwood, Melbourne, Australia; 3Centre for Chronic Disease Control (CCDC), Delhi, India; 4Department of Epidemiology, London School of Hygiene and Tropical Medicine, London, UKCorrespondence: Sailesh MohanPublic Health Foundation of India, Plot 47, Sector-44, Gurgaon, 122002, IndiaTel +91 1244781400Fax +91 124-4781601Email smohan@phfi.orgPurpose: Undiagnosed Chronic Obstructive Pulmonary Disease (COPD) results in high morbidity, disability and mortality in India. Effective strategies for active COPD screening in community settings are needed to increase early identification, risk reduction and timely management. The objective of this study was to test the diagnostic accuracy of a sequential two-step screening strategy to detect COPD, implemented by community health workers (CHWs), among adults aged ≥ 40 years in a rural area of North India.Patients and Methods: Trained CHWs screened all consenting (n=3256) eligible adults in two villages using the Lung Function Questionnaire (LFQ) to assess their COPD risk and conducted pocket spirometry on 268 randomly selected (132 with high risk ie LFQ score ≤ 18 and 136 with low risk ie LFQ score > 18) individuals. Subsequently, trained researchers conducted post-bronchodilator spirometry on these randomly selected individuals using a diagnostic quality spirometer and confirmed the COPD diagnosis according to the Global Initiative for Obstructive Lung Disease (GOLD) criteria (FEV1/FVC ratio < 0.7).Results: This strategy of using LFQ followed by pocket spirometry was sensitive (78.6%) and specific (78.8%), with a positive predictive value of 66% and negative predictive value of 88%. It could accurately detect 67% of GOLD Stage 1, 78% of GOLD Stage 2, 82% of GOLD Stage 3 and 100% of GOLD Stage 4 individuals with airflow limitation.Conclusion: COPD can be accurately detected by trained CHWs using a simple sequential screening strategy. This can potentially contribute to accurate assessment of COPD and thus its effective management in low-resource settings.Keywords: COPD, sensitivity and specificity, screening, community health workers, spirometry

Background People with chronic conditions are disproportionately prone to be affected by the COVID-19 pandemic but there are limited data documenting this. We aimed to assess the health, psychosocial and economic impacts of the COVID-19 pandemic on people with chronic conditions in India. Methods Between July 29, to September 12, 2020, we telephonically surveyed adults (n = 2335) with chronic conditions across four sites in India. Data on participants’ demographic, socio-economic status, comorbidities, access to health care, treatment satisfaction, self-care behaviors, employment, and income were collected using pre-tested questionnaires. We performed multivariable logistic regression analysis to examine the factors associated with difficulty in accessing medicines and worsening of diabetes or hypertension symptoms. Further, a diverse sample of 40 participants completed qualitative interviews that focused on eliciting patient’s experiences during the COVID-19 lockdowns and data analyzed using thematic analysis. Results One thousand seven hundred thirty-four individuals completed the survey (response rate = 74%). The mean (SD) age of respondents was 57.8 years (11.3) and 50% were men. During the COVID-19 lockdowns in India, 83% of participants reported difficulty in accessing healthcare, 17% faced difficulties in accessing medicines, 59% reported loss of income, 38% lost jobs, and 28% reduced fruit and vegetable consumption. In the final-adjusted regression model, rural residence (OR, 95%CI: 4.01,2.90–5.53), having diabetes (2.42, 1.81–3.25) and hypertension (1.70,1.27–2.27), and loss of income (2.30,1.62–3.26) were significantly associated with difficulty in accessing medicines. Further, difficulties in accessing medicines (3.67,2.52–5.35), and job loss (1.90,1.25–2.89) were associated with worsening of diabetes or hypertension symptoms. Qualitative data suggest most participants experienced psychosocial distress due to loss of job or income and had difficulties in accessing in-patient services. Conclusion People with chronic conditions, particularly among poor, rural, and marginalized populations, have experienced difficulties in accessing healthcare and been severely affected both socially and financially by the COVID-19 pandemic.

ImportanceThere is substantial interest in leveraging digital health technology to support hypertension management in low- and middle-income countries such as India. The potential for healthcare infrastructure and broader context to support such initiatives in the public healthcare system in India has not been examined.ObjectiveWe evaluated existing healthcare infrastructure to support digital health interventions and examined epidemiologic, socioeconomic, and geographical contextual correlates of healthcare infrastructure in 544 districts covering 29 states and union territories across India.DesignCross-sectional analysis of India’s Fourth District Level Household and Facility Survey (DLHS-4; 2012-2014), the most up-to-date district-level healthcare infrastructure data. Facilities were the unit of analysis and analyses accounted for clustering within states.SettingNationally representative data of health facilities across India.ParticipantsThe target sample was all health facilities within the government healthcare system.ExposuresEpidemiologic, socioeconomic, and geographical context.Main Outcome(s) and Measure(s)Healthcare system infrastructural context to implement hypertension management programs. Domains included diagnostics (functional BP instrument) medications (anti-hypertensive medication in stock), essential clinical staff (e.g., staff nurse, medical officer, pharmacist), and IT specific infrastructure (regular power supply, internet connection, computer availability). Infrastructure indicators were based on the Indian Public Health Standards.ResultsData from 32,215 government facilities were analyzed. Among lowest-tier subcenters, 30% had some IT infrastructure, while at the highest-tier district hospitals, 92% possessed IT infrastructure. At mid-tier primary health centres and community health centres, IT infrastructure availability was 29% and 51%, respectively. For all but sub-centres, the availability of essential staff was lower than the availability of IT infrastructure. For all but district hospitals, higher levels of blood pressure, body mass index, and urban residents were correlated with more favorable infrastructure. By region, districts in Western India tended towards having the best prepared health facilities.Conclusions and RelevanceIT infrastructure to support digital health interventions is more frequently lacking at lower and mid-tier healthcare facilities compared with apex facilities in India. Gaps were generally larger for staffing than physical infrastructure, suggesting that beyond IT infrastructure, shortages in essential staff pose as significant constraints to the adoption of digital health interventions. These data provide early benchmarks for state- and district level planning.

Background Hypertension and diabetes are among the most common and deadly chronic conditions globally. In India, most adults with these conditions remain undiagnosed, untreated, or poorly treated and uncontrolled. Innovative and scalable approaches to deliver proven-effective strategies for medical and lifestyle management of these conditions are needed. Methods The overall goal of this implementation science study is to evaluate the Integrated Tracking, Referral, Electronic decision support, and Care coordination (I-TREC) program. I-TREC leverages information technology (IT) to manage hypertension and diabetes in adults aged ≥30 years across the hierarchy of Indian public healthcare facilities. The I-TREC program combines multiple evidence-based interventions: an electronic case record form (eCRF) to consolidate and track patient information and referrals across the publicly-funded healthcare system; an electronic clinical decision support system (CDSS) to assist clinicians to provide tailored guideline-based care to patients; a revised workflow to ensure coordinated care within and across facilities; and enhanced training for physicians and nurses regarding non-communicable disease (NCD) medical content and lifestyle management. The program will be implemented and evaluated in a predominantly rural district of Punjab, India. The evaluation will employ a quasi-experimental design with mixed methods data collection. Evaluation indicators assess changes in the continuum of care for hypertension and diabetes and are grounded in the Reach, Effectiveness, Adoption Implementation, and Maintenance (RE-AIM) framework. Data will be triangulated from multiple sources, including community surveys, health facility assessments, stakeholder interviews, and patient-level data from the I-TREC program’s electronic database. Discussion I-TREC consolidates previously proven strategies for improved management of hypertension and diabetes at single-levels of the healthcare system into a scalable model for coordinated care delivery across all levels of the healthcare system hierarchy. Findings have the potential to inform best practices to ultimately deliver quality public-sector hypertension and diabetes care across India. Trial registration The study is registered with Clinical Trials Registry of India (registration number CTRI/2020/01/022723). The study was registered prior to the launch of the intervention on 13 January 2020. The current version of protocol is version 2 dated 6 June 2018.

Purpose: Diabetes is rapidly increasing in India. This study aimed to determine the current prevalence of diabetes and its management in rural and urban India. Methods: We conducted a large population based cross-sectional survey among 12284 participants aged ≥30 years residing in rural and urban North and South India. Participants were selected using a multistage cluster random sampling technique. Trained personnel collected the data using a questionnaire, measured blood pressure, conducted anthropometry and collected bio-samples. Diabetes was defined as FPG ≥ 126 mg/dl or HbA1C ≥ 6.5% or self-reported physician diagnosis or being on treatment. Control was defined as HbA1C < 7%. Results: The mean (±SD) age of participants was 49.2 (±12.6) years, women comprised 53% of the sample. The age-standardized prevalence of diabetes was 17.4% (95% CI: 16.7-18.1). The prevalence was higher among men [19.3% (18.3-20.3)], elderly i.e., ≥ 60 years [26.8% (25.1-28.6)], urban residents [23.1% (22.1-24.2)] and in those with higher socioeconomic status [22.5% (21.0-24.1)]. Nearly, one-third participants had prediabetes [29.7% (28.9-30.5)] and there were no rural-urban, gender or socioeconomic differences. The awareness and treatment [49.1% (46.8-51.4), 43.3% (41.0-45.5)] rates respectively, were poor among diabetics, who were young (41.9%, 36.0%), rural residents (37.8%,31.5%) and those with lower socioeconomic status (30.1%,28.4%). Overall control rate was 45.5% (42.9-48.1) with no significant differences between the aforementioned groups. Conclusions: Despite the increasing burden of both diabetes and prediabetes in India, the awareness, treatment and control rates remain suboptimal. Active screening and tailored public education to increase awareness, are essential for promoting early detection and improving management, especially among poor rural populations. Disclosure S. Mohan: None. P. Jarhyan: None. G. Sharnngadharan: None. D. Prabhakaran: None.

Background Hypertension is the most common cause of the rising cardiovascular disease (CVD) epidemic in India. However, despite availability of proven therapies management remains sub-optimal. Purpose To determine the hypertension control rates and associated factors among adults with known hypertension in urban and rural India. Methods We conducted a representative population based cross-sectional survey among 12243 participants aged ≥30 years residing in rural and urban North and South India. Participants were selected using a multistage cluster random sampling technique. Trained personnel collected the data using an interviewer administered questionnaire, measured blood pressure, conducted anthropometry and collected bio-samples. Hypertension was defined as known hypertension (self-report of physician diagnosis) or systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg. Control was defined as SBP Results The mean (±SD) age of participants was 47.7 (±12.5) years, women comprised 54%. The age-standardized prevalence of hypertension was 29.0% (95% CI: 28.2- 29.8) and known hypertension was 14.0% (13.4- 14.6). Among all hypertensives 38.6% (37.0–40.2) were on treatment and 26.2% (24.6–28.0) had their blood pressure controlled, while among known hypertensives 79.8% (77.8–81.7) were on treatment and 55.7% (53.3–58.1) had their blood pressure controlled. In multivariate analysis, participants from North Indian site [OR: 1.9 (1.6–2.3)], urban residents [1.3 (1.1–1.6)], younger participants [1.5 (1.2–1.8)], men [2.0 (1.5–2.6)], those with low socio-economic status [1.6 (1.1–2.3)], without comorbidities and those without a family history hypertension were more likely to be unaware about their hypertensive status and less likely to take treatment. Hypertension control was significantly higher in participants from South Indian site [1.5 (1.2–1.0)], the highly educated [1.6 (1.1–2.4)], those without heart diseases [1.8 (1.1–3.1)], those without central obesity [1.4 (1.1–1.9)], physically active individuals [1.5 (1.1–2.0)] and current non-alcohol users [1.9 (1.3–2.6)]. Conclusions Many individuals with hypertension remain unaware and sub-optimally managed. This warrants the implementation of tailored public education to raise awareness, complemented by active screening for the early detection and effective management of hypertension, in order to stem the rising tide of preventable CVD in India. Acknowledgement/Funding Unrestricted educational grant from Eli Lilly under the Lilly NCD Partnership

IntroductionAlthough deaths due to chronic kidney disease (CKD) have doubled over the past two decades, few data exist to inform screening strategies for early detection of CKD in low-income and middle-income countries.MethodsUsing data from three population-based surveys in India, we developed a prediction model to identify a target population that could benefit from further CKD testing, after an initial screening implemented during home health visits. Using data from one urban survey (n=8698), we applied stepwise logistic regression to test three models: one comprised of demographics, self-reported medical history, anthropometry and point-of-care (urine dipstick or capillary glucose) tests; one with demographics and self-reported medical history and one with anthropometry and point-of-care tests. The ‘gold-standard’ definition of CKD was an estimated glomerular filtration rate 2 or urine albumin-to-creatinine ratio ≥30 mg/g. Models were internally validated via bootstrap. The most parsimonious model with comparable performance was externally validated on distinct urban (n=5365) and rural (n=6173) Indian cohorts.ResultsA model with age, sex, waist circumference, body mass index and urine dipstick had a c-statistic of 0.76 (95% CI 0.75 to 0.78) for predicting need for further CKD testing, with external validation c-statistics of 0.74 and 0.70 in the urban and rural cohorts, respectively. At a probability cut-point of 0.09, sensitivity was 71% (95% CI 68% to 74%) and specificity was 70% (95% CI 69% to 71%). The model captured 71% of persons with CKD and 90% of persons at highest risk of complications from untreated CKD (ie, CKD stage 3A2 and above).ConclusionA point-of-care CKD screening strategy using three simple measures can accurately identify high-risk persons who require confirmatory kidney function testing.

Over the past few decades diabetes prevalence has rapidly increased across India. However, limited information is available on the levels of awareness, treatment and control, particularly in epidemiologically transitioning communities. We estimated the prevalence, awareness, treatment and control rates of diabetes in a large representative population sample aged ≥ 30 years, selected using a multistage cluster random sampling technique, residing in rural and urban areas of North and South India. Trained interviewers administered a questionnaire to collect data on socio-demographics, lifestyle characteristics and phlebotomists collected venous blood samples to estimate fasting plasma glucose (FPG) and HbA1C. Diabetes was defined as FPG ≥ 126 mg/dl or HbA1C ≥ 6.5% or self-report of physician diagnosis or being on treatment. Participants were considered to be aware of diabetes if they reported a diagnosis or being on treatment. Control was defined as HbA1C < 7%. In total 12243 participants (6208 in North and 6035 in South) were surveyed. The mean (±SD) age was 47.7 (±12.5) years. Women constituted 54%. The age-standardized prevalence of diabetes was 14.2 (95% CI: 13.6 - 14.9), with significant difference between urban (21.4%; 20.4-22.5) and rural (7.5%; 6.8-8.2) areas. Among those with diabetes, the awareness, treatment and control rates were 49.4% (46.6-52.2), 38.6% (35.9-41.3) and 12.6% (10.9-14.5) respectively. Compared to urban residents, rural counterparts were less likely to be aware (35% Vs. 55%), treated (26% Vs. 43%) and controlled (8% Vs. 14%). Similarly, patients in the lowest tertile of wealth index had lower awareness (33% Vs. 55%), treatment (22% Vs. 43%) and control rates (5% Vs. 15%) compared to those in the highest tertile. Despite a high burden, management of diabetes is sub-optimal in India. Health system strengthening to better manage diabetes with a focus on rural residents and the poor is imperative to stem the rising burden and improve diabetes related health outcomes. Disclosure S. Mohan: None. N.S. Venkateshmurthy: None. P. Jarhyan: None. G. Sharnngadharan: None.

ObjectivePeople with chronic conditions are known to be vulnerable to the COVID-19 pandemic. This study aims to describe patients’ lived experiences, challenges faced by people with chronic conditions, their coping strategies, and the social and economic impacts of the COVID-19 pandemic.Design, setting and participantsWe conducted a qualitative study using a syndemic framework to understand the patients’ experiences of chronic disease care, challenges faced during the lockdown, their coping strategies and mitigators during the COVID-19 pandemic in the context of socioecological and biological factors. A diverse sample of 41 participants with chronic conditions (hypertension, diabetes, stroke and cardiovascular diseases) from four sites (Delhi, Haryana, Vizag and Chennai) in India participated in semistructured interviews. All interviews were audio recorded, transcribed, translated, anonymised and coded using MAXQDA software. We used the framework method to qualitatively analyse the COVID-19 pandemic impacts on health, social and economic well-being.ResultsParticipant experiences during the COVID-19 pandemic were categorised into four themes: challenges faced during the lockdown, experiences of the participants diagnosed with COVID-19, preventive measures taken and lessons learnt during the COVID-19 pandemic. A subgroup of participants faced difficulties in accessing healthcare while a few reported using teleconsultations. Most participants reported adverse economic impact of the pandemic which led to higher reporting of anxiety and stress. Participants who tested COVID-19 positive reported experiencing discrimination and stigma from neighbours. All participants reported taking essential preventive measures.ConclusionPeople with chronic conditions experienced a confluence (reciprocal effect) of COVID-19 pandemic and chronic diseases in the context of difficulty in accessing healthcare, sedentary lifestyle and increased stress and anxiety. Patients’ lived experiences during the pandemic provide important insights to inform effective transition to a mixed realm of online consultations and ‘distanced’ physical clinic visits.

Introduction Diabetes and hypertension are two leading non-communicable conditions, which are suboptimally managed in India. Thus, innovative comprehensive approaches that can concomitantly improve their detection, prevention and control are warranted. Methods and analysis UDAY, a 5-year initiative, aims to reduce the risk of diabetes and hypertension and improve management by implementing a comprehensive intervention programme in the two selected study sites, Sonipat and Visakhapatnam (Vizag). It has a pre-post evaluation design with representative cross-sectional surveys before and after intervention. Within these two sites, urban and rural subsites each with a total population of approximately 100 000 people each were selected and a baseline and postintervention assessment was conducted deploying five surveys [among general population (including body measurements or biosamples), patients, healthcare providers including physicians and pharmacists, health facilities], which will determine the knowledge levels about diabetes and hypertension, the proportion treated and controlled; the patient knowledge and self-management skills; healthcare providers’ management practices; the level of access and barriers to obtaining care. The interventions will include: tailored health promotion for improving public knowledge; screening of adults aged ≥ 30 years for identifying those at high risk of diabetes and/or hypertension for linkage to the healthcare system; patient education using technology enabled community health workers, geographic information system (GIS) based mapping of the communities, healthcare provider training on management guidelines, community based diabetes registry and; advocacy to improve access to healthcare. The baseline surveys have been completed, the study areas mapped using GIS and the interventions are being implemented. UDAY is expected to increase over baseline the levels of: public knowledge about diabetes and hypertension; those treated and controlled; patient self-management skills; the use of guideline based management by providers and; access to healthcare, leading to improved health outcomes and inform development of a India relevant chronic care model. Ethics and dissemination Ethical clearance for conduct of the study was obtained from the Institutional Ethics Committee (IEC) of the Public Health Foundation of India. The findings will be targeted primarily at public health policymakers and advocates, but will be disseminated widely through other mechanisms including conference presentations and peer-reviewed publications, as well as to the participating communities.