Access–Watch Ratio Based on Access, Watch, and Reserve Classification of Antibiotics in Public Health Facilities of Tamil Nadu

The rise in cases of antibiotic resistance can be mainly attributed to the overuse and misuse of antibiotics. To address this issue, the WHO launched Access, Watch, and Reserve (AWaRe) classification of antibiotics in 2017 as a surveillance tool. Many countries have adopted it to monitor and optimize their antibiotic usage. However, implementation of it is yet not seen at a very appreciable level. Through this survey, we tried to explore the prescribing pattern of antibiotics based on the WHO AWaRe classification in selected secondary and tertiary care health facilities of Tamil Nadu. In-patient case sheets were audited in selected departments across 18 health facilities in six districts. Proportionately higher use of the watch group of antibiotics was found in all the districts. A lower access–watch ratio suggests the need for judicious implementation of such tools to safeguard this life-saving good and ensuring its sustainability.

Knowledge, attitudes and utilization of food labels among undergraduate medical students in a medical college in Chennai – A cross sectional survey

Introduction: Food labeling is an important method of providing food-related information on the package of food products, to facilitate people’s choice of safe and appropriate foods. Medical students are potential agents of change in food label utilization behavior in the community. The objectives of this study were to evaluate the knowledge, attitudes, and utilization of food labels among undergraduate medical students in a medical college in Chennai. Material & Methods: We conducted a cross-sectional survey of 200 students studying in the 1st to 3rd year in a medical college through an online Google Forms survey, self-administered by the students after online informed consent was obtained. We gathered information on their knowledge, attitudes, and utilization of food labels. Results: Of 400 students approached, 200 responded to the online survey. They had good knowledge about food labels. Female students had 3.4 (1.59 to 7.25) times better knowledge compared to men. The students had a positive attitude toward food labels, and a majority thought that the food labels are useful. Utilization of food labels to understand the nutritive content (55%), additives (57%), and manufacturer details (47%) was poor. Utilization of food labels was 2.7 times more (1.142–6.587) among those who did regular exercise, and it was 0.2 (0.09 to 0.9) times less among those who were on a strict diet. Conclusion: Medical students had a sound knowledge and good attitude toward food labels, but their food label utilization patterns were still poor. There is a need to incorporate food labeling in the undergraduate medical curriculum and inculcate better food label utilization behavior.

Community gatekeepers and the conundrum of confidentiality and coercion

Sunu Thomas has described a research study in which she gained access through a community health worker to members of the community seeking treatment for infertility. One of the research participants who had undergone such a sensitive treatment and her family were concerned that the community health worker’s presence during the interview would breach the confidentiality of their health information. In this commentary, I will discuss the issues of balancing accessibility versus confidentiality, and of coercion in the process of approaching community members through gatekeepers of the community

Using critical reflection in public health research: Identifying and mitigating emotional harms

Malu Mohan has described the distress faced by the researcher who attempted to study the practice preparedness of recent graduates of a stream of clinical practice through critically reflective diary entries. The graduates realised that they were grossly underprepared for competent and independent clinical practice. The researcher’s distress arises from the dilemma as to whether she has precipitated a sense of “incompetence” and “hopelessness” among the fresh graduates, causing unintended harm. It is commendable that the researcher has introspected seriously on the consequences of her study. I would like to comment on the specific ethical conflict faced by the researcher in this case and the possible mitigative measures that could have been undertaken. I will also try to derive broader inferences for the use of critical reflection in public health research

Crunching numbers mindfully

Hans Rosling, the Swedish physician, statistician, epidemiologist and TED Talk celebrity has a deep and intense connection to India. He studied public health at St. John’s Medical College in Bangalore (now Bengaluru) in 1972. Factfulness is his magnum opus and his last work before his passing away at the age of 68, in February 2018. Hans Rosling was a crusader against “misinformation” and an overdramatic worldview. He was a proponent of careful review of data, updating oneself on data about the world around us and seeing the world for what it is rather than how it is portrayed. In his own words he was a “possiblist”, someone who always liked to look at the various possibilities rather than be guided by extremes.

Ethical complexity versus simple presentation: A tightrope

Taking a cue from the author, I ventured into searching Amazon’s website for the number of books written on ethics. To my amazement, I found more than 200,000 and out of these about 2000 were books on healthcare ethics. Robert Phalen has made an interesting addition to this list. The book is a “survivor’s guide” to research ethics, written as crisp, concise notes on various aspects of the subject, in a manner that is easy to understand and assimilate. The book caters largely to an American readership, with examples and anecdotes from the American research context. It serves as a good handbook for those seeking research ethics certifications mandated by the United States National Institutes of Health for holding their research grants.

Vaccine hesitancy and attitude towards vaccination among parents of children between 1-5 years of age attending a tertiary care hospital in Chennai, India

Vaccination is an effective public health intervention; however, coverage of vaccination is declining in states like Tamil Nadu which have good health indicators. Objective: To evaluate the presence of vaccine hesitancy among parents of children between 1 and 5 years of age attending the paediatric out patient department of a tertiary care hospital in Chennai and to assess its relationship with attitudes towards vaccines. Material & Methods: A cross sectional questionnaire-based survey was conducted among 100 consecutively sampled parents of children between 1 and 5 years of age attending a tertiary care paediatric out-patient department. The Parental Attitude towards Childhood Vaccines scale of vaccine hesitancy and the Beliefs and Attitudes towards Childhood Vaccines scale were used to measure vaccine hesitancy and beliefs and attitudes towards vaccination respectively. The data were analysed descriptively and statistical correlation between vaccination attitudes and vaccination hesitancy were studied. Results: In the predominantly urban, educated, working class population, the prevalence of vaccine hesitancy was 21%. But all the children had received complete vaccination appropriate for age. The major drivers for vaccine hesitancy were suspicions about newer vaccines, concerns about adverse effects of vaccines and the perception that there is no need for vaccines against uncommon diseases. The vaccine hesitancy scores were negatively correlated with the vaccine attitude scores (R = -0.266; p = 0.007). Conclusion: Vaccine hesitancy is present among the sampled mothers and is influenced mainly by concerns regarding safety of newer vaccines. Vaccine hesitancy needs to be clearly addressed for strengthening the Universal Immunization Program.

Theme Editorial: Controlled Human Infection Models: Exploring the landscape in India

Controlled Human Infection Models (CHIMs) refers to the intentional introduction of an infectious agent into a healthy volunteer to deliberately induce the infection under regulated conditions. These studies can be useful in discovering the origin and development of a disease, its immunological responses and natural course, as well as in the evaluation of interventions. CHIMs have yielded data that have informed the development process of several vaccines in recent years. Infectious diseases contribute substantially to the global burden of disease and therefore research and development in the context of infectious diseases is a high priority.

From the bug's point of view

An epidemic changes your life, even if you are not ill” – say Kalpish Ratna1 in yet another interesting book describing the Zika virus disease outbreak that rocked the Americas in early 2015. Epidemics are important not just because of the suffering they cause, but also due to the fear that they incite in people, sometimes distant from the centre of the disease outbreak. Epidemics are not just biomedical and epidemiological phenomena. An epidemic has strong social, political, economic, historical and cultural influences. Kalpish Ratna begin their book with the recent reporting of Zika virus in three patients in May 2017 in India, and its socio-cultural implications in the country.

Placing the "radar" under the radar: ethics of public health surveillance

Public health surveillance (PHS) is an essential public health activity, which entails collecting data on diseases and disease-related states in a timely manner to aid in international health regulations and in local health planning. Opinions differ sharply on whether it is a research or non-research activity. In recent years, most low- and middle-income countries (LMICs) have been establishing their own PHS systems, with or without support from external donors, to comply with the stipulations of international health regulations. With the expansion of the scope and role of PHS in ensuring the health security of countries, it is important to understand the ethical principles of PHS and the specific ethical issues involved in it, as well as the need for ethical oversight of PHS. This paper deals with these aspects of PHS, and highlights the need for specific ethical guidance and oversight mechanisms in LMICs that are setting up their own PHS systems.

Selfless giving in medicine: a study of altruistic attitudes among medical students

Introduction: An important virtue in the medical profession is altruism, which makes a doctor serve without an excess of expectation of return. Objectives: To assess the level of altruism and factors influencing altruism among medical students at a medical college in Chennai Methods: A cross-sectional study was conducted on a sample of 224 students from the first, third and fourth years. We prepared a questionnaire which contained questions from the previously validated Altruistic Personality Scale. After the students’ informed consent was obtained, they were requested to self-administer the questionnaire in the form of a pen-and-paper test. Results: The altruistic attitudes of the students were largely grouped into four categories on the basis of the factor analysis namely, (i) simple acts of altruism, (ii) recognised acts of charity, (iii) altruistic activities that put the self at risk, and (iv) humanitarian acts. From the factor scores obtained in this analysis, we performed a K-means cluster analysis, which showed that the students can be grouped into three clusters, namely, (i) simple altruists (43.3%), (ii) risk-taking altruists (30.8%), and (iii) limited altruists (25.9%). It was further observed that younger students, males, those whose parents donated to charity, those whose friends organised charitable group activities, and those who had role models in college were much more likely to be simple altruists. Conclusion: Altruistic behaviours were infrequent among the sample of students studied, and such behaviours were influenced by their parents, peers and role models in college. An enabling environment should be created to nurture such tendencies and to channelise them through organised activities in medical schools.

Controlled human infection models for vaccine development: Zika virus debate

An ethics panel, convened by the National Institute of Health and other research bodies in the USA, disallowed researchers from the Johns Hopkins University and University of Vermont from performing controlled human infection of healthy volunteers to develop a vaccine against Zika virus infection. The members published their ethical analysis and recommendations in February 2017. They have elaborated on the risks posed by human challenge with Zika virus to the volunteers and other uninvolved third parties and have systematically analysed the social value of such a human challenge experiment. They have also posited some mandatory ethical requirements which should be met before allowing the infection of healthy volunteers with the Zika virus. This commentary elaborates on the debate on the ethics of the human challenge model for the development of a Zika virus vaccine and the role of systematic ethical analysis in protecting the interests of research participants. It further analyses the importance of this debate to the development of a Zika vaccine in India

Medical history given life.

Atul Gawande, Abraham Verghese, Paul Kalanithi, Siddhartha Mukherjee, all have two things in common – surgery and writing. Belonging to the same fraternity, the surgeon-writer duo Kalpana Swaminathan and Ishrat Syed (under the nom de plume – Kalpish Ratna) have produced an excellent book entitled Room 000: Narratives of the Bombay plague. I prepared myself mentally for some serious reading of a tome on medical history, but was pleasantly surprised to be turning the pages in a frenzy. Despite the weight of the hardbound copy of about 500 pages, it was a complete no-put-downer! The authors have to be commended on blending history, medicine, public health, politics, sociology, ethics and literature in the right proportions, which has resulted in a fantastic medico social drama.

The Chennai floods of 2015: urgent need for ethical disaster management guidelines.

India has suffered several natural disasters in recent years. The super cyclone of Orissa in 1999 and the tsunami on the southeastern coast in 2004, both led to major developments in disaster management abilities in the country. Almost a decade after the last major disaster that hit south India, the recent floods in Chennai in 2015 brought to the fore a whole set of ethical considerations. There were issues of inequity in the relief and response activities, conflicts and lack of coordination between the government and non-government relief and response, more emphasis on short-term relief activities rather than rehabilitation and reconstruction, and lack of crisis standards of care in medical services. This paper highlights these ethical issues and the need for ethical guidelines and an ethical oversight mechanism for disaster management and response.

The Chennai floods of 2015 and the health system response.

The Chennai floods of 2015 were a calamity of unexpected proportions. The impact on the lives of the poor has been immense. Thousands needed to abandon their already precarious dwellings on the banks of the Adyar River, and other low-lying areas for temporary shelters. The differential experience and impact of disasters on different segments of the population helps understand the dynamics of sociopolitical structures and supports.

Faith healing and faith in healing.

Sarkar and Seshadri have presented an interesting paper in this issue on the ethical approach that a physician should take when faced with requests for faith healing. The paper describes four approaches that the physician can take. These are rejecting the request, keeping oneself detached from the issue, endorsing the request and trying to understand the practices concerned so as to make a reasoned decision. This commentary attempts to explore the issue of faith healing further, from the point of view of clinical care. It shall discuss five important dimensions which can supplement the arguments by Sarkar and Seshadri. These are the concepts of faith, spirituality and religion and faith healing; the difference between cure and healing; patient-centred care; the various factors influencing a doctor’s response to requests for faith healing; and finally, the ethical issues to be considered while making a decision. Before launching into the discussion, it should be made clear that this commentary refers mainly to those faith healing practices which are not overtly harmful, such as prayers, and wearing rings and amulets.

Trust in the physician–patient relationship in developing healthcare settings: a quantitative exploration

Trust in physicians is the patient’s optimistic acceptance of vulnerability and the expectation that the physician will do what is best for his/her welfare. This study was undertaken to develop a conceptual understanding of the dimensions and determinants of trust in physicians in healthcare settings in resource-poor, developing countries. A cross-sectional household survey was conducted on a sample of 625 men and women from urban and rural areas in Tamil Nadu, India. The sample was selected using a multistage sampling method and a pre-tested structured questionnaire was utilised. The questionnaire covered the five dimensions of trust: perceived competence of the physician, assurance of treatment, confidence in the physician, loyalty towards him/her, and respect for him/her. Items covering four main factors that influence trust, ie shared identity, the physician’s behaviour, personal involvement of the physician and level of comfort with him/her, were included in the questionnaire. A structural equation model was constructed with the dimensions of trust on one hand and the four factors influencing trust on the other. Trust in physicians is based more on notional constructs, such as assurance of treatment (b=0.714, p<0.001) and respect for the physician (b=0.763, p<0.001),than objective assessments, such as the physician’s competence (b=0.607, p<0.001). Feeling comfortable with the physician (b=0.630, p<0.001) and the physician’s communication skills (b=0.253, p<0.001) significantly influence the level of trust. The former is correlated with the personal involvement of the physician (r=0.124, p<0.001), and so is the latter (r=0.152, p<0.001). The overall model has a good statistical fit. The factors that give rise to trust in physicians vary with the sociocultural context.

Trust in healthcare: an evolving concept.

There has been increased interest over the past couple of decades in the public's trust in doctors and in the health system. The fundamental basis of a healthcare relationship is trust, which is the patient's voluntary acceptance of his vulnerability in the expectation that the healthcare provider will do the best for him.

Mainstreaming AYUSH: an ethical analysis.

The National Rural Health Mission has stated as one of its key mandates the mainstreaming of the Ayurveda, Yoga, aturopathy, Unani, Siddha and Homeopathy (AYUSH) systems in order to help solve the human resource shortage in Indian healthcare. This has been planned at the primary level by providing training to AYUSH practitioners on primary care and national health programmes; at the secondary level by establishing departments of AYUSH in the district and taluka level hospitals; and at the tertiary level by establishing AYUSH centres of excellence as referral centres,and research, development and supervision points.