Community Medicine

Strategies for ensuring quality health care in India: Experiences from the field K Madan Gopal Indian Journal of Community Medicine 2019 44(1):1-3

Antimicrobial resistance: Progress in the decade since emergence of New Delhi metallo-β-lactamase in India Avika Dixit, Neeta Kumar, Sanjiv Kumar, Vidyasagar Trigun Indian Journal of Community Medicine 2019 44(1):4-8 Antimicrobial resistance (AMR) has emerged as a major threat to public health estimated to cause 10 million deaths annually by 2050. India carries one of the largest burdens of drug-resistant pathogens worldwide. NDM-1 reported in 2008, rapidly spread to other countries was named after India's capital. India is one of the largest consumers of antibiotics worldwide, and antibiotic sale is increasing rapidly. AMR develops when microbes develop mechanisms to evade the action of antimicrobials. The factors that contribute to AMR include irrational and overuse of antibiotics. In India, various actions have been taken including setting up of a National Task Force on AMR Containment (2010), “Chennai Declaration” by a consortium of the Indian Medical Societies (2012), Setting of Indian Council of Medical Research national surveillance network of laboratories, “Redline” campaign for educating public and National Action Plan on AMR 2017. There is a need integrating AMR education in medical education. India needs to start the subspecialty of infectious diseases and strengthen laboratory services. Every hospital needs to have an AMR policy including infection control, improvement in hygiene, and sanitation and antibiotic use. An element of research needs to be integrated into the AMR policy and encouragement of the pharmaceutical industry to develop “superbug antibiotics.” Unless AMR is addressed effectively the gains made in health are likely to be lost.

Revisiting the relevance of community medicine in undergraduate medical curriculum Anand Krishnan Indian Journal of Community Medicine 2019 44(1):9-11 There have been attempts recently to bring clarity as to the role/functions of the discipline of community medicine. Debates on whether community medicine is a discipline in itself and if so is it a clinical discipline has been there for decades across the world. As the departments of community medicine do not exclusively teach any clinical skill to undergraduate or postgraduates, it is difficult to argue that our discipline is a clinical discipline. Our stalwarts are also known for their work at community and government level and not as clinicians. Our current undergraduate course does not prepare the students adequately for their role in society, profession and health system. Our mandate is to prepare the would-be-doctors as a “finished product” to the country. Our training should address the current crisis that afflicts our profession. A list of learning objectives to be achieved in the three domains of profession, health system, and society and suggestions to improve the teaching of this discipline are provided in this paper.

Role of social support and spouse abuse in low birth weight: A Case–control study from Puducherry, India Yamini Marimuthu, Sonali Sarkar, Shivanand Kattimani, Yuvaraj Krishnamoorthy, Bharathnag Nagappa Indian Journal of Community Medicine 2019 44(1):12-16 Background: Low birth weight (LBW) is a major cause of neonatal morbidity and mortality. In addition to medical/clinical risk factors, various socio-demographic factors also have an impact on birth weight. Objective: The objective of the study is to determine the association of antenatal social support and spouse abuse during pregnancy with LBW in Urban areas of Puducherry. Materials and Methods: A community-based case–control study was conducted in Puducherry. Mothers of 100 LBW infants and normal birth weight infants in 2016 were studied. Functional Social Support Questionnaire and Index of Spouse Abuse scales were used. Conditional logistic regression for matched pair studies was done for multivariate analysis. Results: Mean (± standard deviation) age and education of the study participants was 25.6 (±3.5) and 8.28 (±3.6) years, respectively. The proportion of girl child was 59% and 43% among cases and controls, respectively. Mothers with higher perceived social support (odds ratio [OR] = 0.5; 95% confidence interval [CI]: 0.4–0.7) had lesser odds of LBW. The odds of LBW was 3.6 (adjusted OR [aOR] = 3.6; 95% CI: 1.3–9.9) times and 6.9 (aOR = 6.9; 95% CI: 1.5–31.9) times greater among mothers who experienced nonphysical abuse and had pregnancy-induced hypertension respectively and it was statistically significant after adjusting for child's gender, social support, and parity. Conclusions: The presence of nonphysical abuse during the antenatal period increased the risk of LBW. The awareness should be created in the community to prevent maternal exposure to abuse.

Burden of pulmonary tuberculosis among tribal population: A cross-sectional study in tribal areas of Maharashtra, India Anil J Purty, Amit Kumar Mishra, Ramesh Chand Chauhan, Rajendran Prahankumar, Prabakaran Stalin, Joy Bazroy Indian Journal of Community Medicine 2019 44(1):17-20 Background: It is very important to identify and treat infectious pulmonary tuberculosis (PTB) patients at the earliest to save the life of the patients and to prevent the transmission of infectious agent to others. As per Global Tuberculosis (TB) Report 2017, an estimated 28 lakh new TB cases occur and 4.23 lakh people die due to TB annually. Due to the poor health services and lack of awareness, particularly vulnerable tribal groups are vulnerable or at risk to many diseases including TB. Methodology: A community-based cross-sectional study was conducted to determine the burden of pulmonary TB (PTB) among adult tribal population of Maharashtra. House-to-house visit was conducted to identify the presumptive TB cases and sputum microscopy and chest X-ray were done to confirm the diagnosis. Results: In the survey, 6898 tribal adults were interviewed from 8 tribal clusters, and among them, 144 (2.1%) presumptive TB cases were identified. The most common symptom among the presumptive TB cases was cough for >2 weeks (93.1%). The prevalence of PTB in the study area estimated is 261per lakh tribal population per year. Conclusion: The current study shows that the estimated burden of PTB among tribal population is within the wide variation of prevalence reported from other studies in different tribal communities (133–3294 per lakh population) in India. The current study provides vital information on the burden of TB among the tribal population of Maharashtra which can be used as a baseline data for future epidemiological studies.

Prevalence and determinants of metabolic syndrome among the rural adult population of Puducherry Vinayagamoorthy Venugopal, Amol R Dongre, Sumathi Saravanan Indian Journal of Community Medicine 2019 44(1):21-25 Background: Burden of metabolic syndrome (MS) is rising. There were many previous studies conducted in India on MS, yet it is less studied in Puducherry which has embraced modern culture and lifestyle. Hence, we aimed to study the prevalence and predictors of MS. Materials and Methods: A cross-sectional study was undertaken on a representative sample of 489 adults of age 30 years and above over the period of 18 months. MS was defined according to the International Diabetes Federation (IDF) criteria. Data on sociodemography, lifestyle characteristics, and biochemical parameters were collected by a well-trained health professional using standard methods. Generalized linear models with Poisson distribution and log link function were used to calculate the adjusted prevalence ratio (PR). Results: The prevalence of MS was 39.7% (95% confidence interval [CI]: 35.3–44.1) among the study participants. The most commonly deranged component of MS was central obesity (63.6%). Increasing age, upper socioeconomic status, low fruit intake, physical inactivity, use of refined sunflower oil (PR: 1.40, 95% CI: 1.07–1.83) for cooking, and high perceived stress (PR: 1.77, 95% CI: 1.32–2.37) were found to be associated with MS. Conclusion: The prevalence of MS in Puducherry was high as per the IDF criteria. Usage of refined sunflower oil for cooking and perceived stress was independently associated with an increased risk of MS along with other routinely studied risk factors.

Maternal mortality in rural Varanasi: Delays, causes, and contributing factors Kalpana Kumari, Ratan Kumar Srivastava, Manushi Srivastava, Neeti Purwar Indian Journal of Community Medicine 2019 44(1):26-30 Background: Pregnancy and motherhood are natural processes and considered to be full of positive experiences. However, for various reasons many women end up dying during pregnancy, childbirth, and the postpartum period. Improving maternal health and reducing maternal mortality have been prioritized in several international declarations and national policies. Objectives: The objective of the study is to assess delays, cause, and its contributing factors related to maternal deaths in rural Varanasi. Methodology: Verbal and Social Autopsy have been done for each maternal death occurred between April 2015 and March 2016 in four randomly selected blocks of rural Varanasi. The “3 Delay Model” and “Pathway analysis” concept was used in collection and analysis of data through in-depth interview of three people (family member, neighbor, and a health worker) for each maternal death. Cause of death and delays was identified by two reviewers (obstetrician) independently. Results: In almost half of the autopsied cases two different delays were found, and in one-third case, only one delay was found. Direct obstetric cause found in more than half (54%) cases. Hemorrhage and anemia were found major direct and indirect obstetric cause, respectively. Other causes identified were sepsis (direct), jaundice, and meningitis. A number of social, behavioral, and cultural factors were identified, that had been contributed to different delays related to the maternal deaths. Conclusions: First delay was present in most of (90%) cases. Nonbiological (social, behavioral, and cultural) and health service factors were also identified in this study.

Comparison of performance of digital hemoglobinometer over automated hematology analyzer for hemoglobin estimation and its user-friendliness among the pregnant women in selected district hospitals of Madhya Pradesh Manju Toppo, Dinesh Kumar Pal, Devendra Gour, Veena Melwani, Manju Dubey, Archana Mishra Indian Journal of Community Medicine 2019 44(1):31-34 Context: There is a need for a simple screening method for the detection of anemia that can be used by public health workers in the field. Aims: The aim of this study was to compare two methods for hemoglobin estimation, i.e., automated hematology analyzer and Digital Hemoglobinometer, and to find out the sensitivity and specificity of Digital Hemoglobinometer for the estimation of hemoglobin. Subjects and Methods: A hospital-based cross-sectional study was carried out for 6 months from April to September 2017 in a District Hospital of five High Priority Districts of Madhya Pradesh. Two hundred and sixty antenatal females per district were selected for the study. Results: The mean hemoglobin by autoanalyzer is 10.19, and that by Digital Hemoglobinometer device is 9.89. Overall, sensitivity of Digital Hemoglobinometer for hemoglobin estimation was calculated to be 89.4% and specificity was calculated to be 63.6%. Positive predictive value was found to be 82.6% and negative predictive value was 75.8% compared against AutoAnalyser (gold standard). Conclusions: As the Digital Hemoglobinometer device has high sensitivity and specificity and good diagnostic accuracy, it must be used at the community level in resource-poor setting for hemoglobin estimation. In primary health-care conditions, Digital Hemoglobinometer can significantly reduce misdiagnosis of anemia compared with clinical assessment alone.

A cross-sectional study of gender-based violence against men in the rural area of Haryana, India Jagbir Singh Malik, Anuradha Nadda Indian Journal of Community Medicine 2019 44(1):35-38 Background: Research across the globe highlights rights violations and abuses experienced by women and seldom are channeled toward any atrocities being experienced by men. Objectives: To find the prevalence, characteristics, and sociodemographic correlates of gender-based violence against men. Materials and Methods: It was a community-based, cross-sectional study using multistage random sampling in which a total of 1000 married men in the age group of 21–49 years were interviewed using modified conflict tactics scale. Results: In the present study, 52.4% of men experienced gender-based violence. Out of 1000, males 51.5% experienced violence at the hands of their wives/intimate partner at least once in their lifetime and 10.5% in the last 12 months. The most common spousal violence was emotional (51.6%) followed by physical violence (6%). Only in one-tenth cases, physical assaults were severe. In almost half of the cases, husband initiated physical and emotional violence. Gender symmetry does not exist in India for physical violence. Less family income, education up to middle class, nuclear family setup, and perpetrator under the influence of alcohol were identified as risk factors. Earning spouse with education up to graduation is the risk factor for bidirectional physical violence. Conclusion: Besides women, men are also the victims of gender-based violence. This demands the future investigation and necessary intervention on gender-based violence against men in India.

Effectiveness of color coded diabetic control monitoring charts among elderly diabetics attending outreach primary care geriatric clinics in rural Karnataka: An open label randomized control trial Farah N Fathima, Neethu George, Meera George, Savan Sara Mathew, M Rajitha, Twinkle Agrawal, Arvind Kasturi Indian Journal of Community Medicine 2019 44(1):39-43 Introduction: Type 2 diabetes mellitus problem is progressively rising every day. The adherence to the treatment approaches and health-seeking make major difference in case of diabetics particularly elderly. Visual tools improve the involvement of patients in their care, especially among populations with low health literacy. Objective: To evaluate the effectiveness of color-coded diabetic control monitoring charts on glycemic control among elderly diabetics. Methodology: 144 elderly diabetic patients attending rural primary care geriatric clinics were randomized into two groups. Those randomized to the intervention group received the color-coded diabetic monitoring chart and a health education package in addition to the usual consultation services. Baseline and 1-year follow-up glycated hemoglobin (HbA1C) values were used to assess the effectiveness of the intervention. Results: The results of multivariate linear regression analysis showed that there was an average reduction of 0.265% in HbA1C value in the intervention group when compared to the nonintervention group when adjusted for baseline HbA1C and number of visits during the intervention period (β coefficient = 0.265,P < 0.05). Conclusion: Color-coded diabetes charts are effective in achieving glycemic control among elderly diabetics, and steps should be made to inculcate visually appealing management approaches in case of elderly diabetic patients.