Enablers & challenges of tribal women & health system for implementation of screening of non-communicable diseases & common cancers: A mixed-methods study in Palghar district of Maharashtra, India

Background & objectives: Non-communicable diseases (NCDs) and cancers of breast, oral cavity and cervix contribute to around 5.87 million (60%) deaths in India. Despite this, there is limited evidence on preparedness of the tribal health system in mitigating these conditions. This mixed-methods study aimed at identifying enablers and challenges using a multistakeholder approach for the screening of NCDs and common cancers in a tribal block of Maharashtra, India. Methods: This study was conducted in a tribal community of Dahanu taluka in Palghar district of Maharashtra. A total of nine focus group discussions (FGDs) among tribal women and accredited social health activists (ASHAs), 13 key informant interviews (KIIs) among auxiliary nurse midwives (ANMs) and community health officers (CHO) and facility surveys of five public health facilities were conducted. The FGDs and KIIs were conducted using guides, recorded digitally, transcribed, analyzed and triangulated to identify emerging themes. Results: The tribal women had limited knowledge about NCDs and common cancers. Paucity of health facilities, out-of-pocket expenditure, misconceptions, belief on traditional healers and inability to prioritize health were identified as major challenges. The ASHAs were recognized as a key connecting link between health system and community while provision of culturally appropriate IEC materials and adequate training were recognized as critical enablers by healthcare providers in implementing screening for NCDs and common cancers. Interpretation & conclusions: The study recommends incorporating socioculturally relevant strategies in the tribal population and strengthening health facilities in terms of infrastructure and training with involvement of ASHAs for successful implementation of the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) through health and wellness centres.

Assessing the potential of self-help group women for improving reproductive health of women in a tribal block of Maharashtra, India

Background & objectives: In the current health system, cash incentives are given to accredited social health activists for referring women to public health facilities for specific maternal and child health services, however many reproductive health problems are not included in these services. The objective of this study was to assess the impact of involvement of self-help groups (SHGs) in improving reproductive health seeking behaviour and service utilization by tribal women. Methods: An experimental study was conducted in two tribal blocks of Nasik district (Kalvan and Surgana) in Maharashtra, India, over a period of 18 months. Interventions included training of SHG women and providing incentives to them for conducting health education sessions for reproductive age group women in the community and referring those with the requisite problems, to the health facilities. Pre- and post-intervention focus group discussions and in-depth interviews among SHG women were conducted. Training of service providers on diagnosis and treatment of reproductive morbidities was done, and health service utilization was assessed. Results: Sixty five per cent of the referred women with reproductive morbidities availed services at the public health facilities. A review of records of women seeking services for reproductive health problems showed that there was a significant improvement in the intent for seeking services in the study block as compared to the control block (?2–9.06, P<0.002). Interpretation & conclusions: This study demonstrates the feasibility of utilizing the potential of SHGs for improving reproductive health seeking behaviour of the tribal women. The results suggest that this model could be scaled up to address the neglected reproductive health needs of women without burdening the existing human resources

An integrated multidisciplinary model of care for addressing comorbidities beyond reproductive health among women with polycystic ovary syndrome in India

Background & objectives: Polycystic Ovary Syndrome (PCOS) is becoming an area of global and national health concern. It requires a life cycle approach from adolescence to menopause. To comprehensively address the wide spectrum of this disorder, a multidisciplinary model of care was established for women with PCOS in a government setting in India with an objective to screen and manage multifaceted manifestations of PCOS and to diagnose and treat associated comorbidities such as metabolic syndrome, dermatologic manifestations and psychological issues. Methods: A model of integrated multidisciplinary PCOS clinic was implemented for services and research at ICMR-National Institute for Research in Reproductive and Child Health (NIRRCH), Mumbai Maharashtra, India. This is a one-stop holistic centre for managing menstrual, cosmetic, infertility, obesity, metabolic and psychological concerns of women affected with PCOS. Two hundred and twenty six women diagnosed with PCOS using the Rotterdam criteria were screened for metabolic comorbidities with anthropometry, ultrasonography, hormonal and biochemical tests and for psychological problems. Analysis was performed using SPSS version 19.0. Results: Mean body mass index (BMI) was 26.1 kg/m2, higher for Asians. Hirsutism was observed in 53.6 per cent of women. Metabolic syndrome was seen among 35.3 per cent and non-alcoholic fatty liver in 18.3 per cent. Psychological issues such as anxiety and depression were identified in majority of the women 31.4 per cent of women could achieve pregnancy at the end of one year of multidisciplinary management. Interpretation & conclusions: The results of the present study suggest that an integrated multidisciplinary approach led to the early identification and treatment of comorbidities of PCOS, especially metabolic syndrome. There is hence an urgent need to implement multidisciplinary PCOS clinics in government health facilities.

Cost of providing family planning services & management of pregnancy outcomes at public health facilities in India

Background & objectives: Lack of costing data is a critical gap that exists in the field of family planning (FP) in India. The aim of this study was to estimate health system costs of FP in India for existing modern methods, and potential newer methods (etonorgestrel implant and levonorgestrel intrauterine device) and pregnancy-related services in India. Methods: A bottom-up micro-costing study was conducted in five public health facilities of an Indian State. Data of last one year were collected from existing hospital records and hospital staff was interviewed. Collected data were analyzed using standard costing methods. Results: Package costs of delivering FP services ranged from ? 807 (95% CI 685, 931) for condoms and ? 10,539 (8796, 12269) for tubal ligation. Estimates of etonorgestrel implant and levonorgestrel intrauterine system were ? 3,200 (2800, 3625) and 3,426 (3232, 3623). Cost of antenatal care along with vaginal delivery, caesarean and abortion were ? 10,916 (8744, 13078), 22,136 (17570, 26910) and 8,574 (6791, 10379), respectively. One way sensitivity analysis showed that the three most influential factors on the costs of FP services were prices of drugs and consumables, number of beneficiaries and health personnel cost. Interpretation & conclusions: The present study has generated package costs for FP and pregnancy-related services in India which could be used by publicly-fu

Changes in Sexual Behavior and Contraceptive Use after HIV Acquisition and Factors Associated with Risky Sexual Practices among People Living with HIV in Selected Indian Cities.

Background: Sexual behavior and contraceptive use among HIV‑infected persons are a neglected issue in public health programs. Objectives: To understand sexual practices and contraceptive use of people living with HIV (PLHIV) before and after being diagnosed with the infection and assess the providers’ perspectives on provision of contraceptives to PLHIV, the quality of services provided and linkages between reproductive health and HIV services. Methods: A mix method design study using a purposive sampling was undertaken enrolling PLHIV from ART centers and PLHIV networks across three cities in India. Doctors and counselors providing HIV services at public hospitals were also interviewed. Results: Use of condoms increased from 35% to 81% after being diagnosed with HIV. Consistent condom use was 69% compared to only 8.7% before being diagnosed with HIV. Nearly 41% (297) of participants indulged in one or more forms of risky sexual behaviors. Significant correlates of risky sexual practices were: participants who were middle‑aged (25–33 years), formerly married, currently not on antiretroviral therapy, and received negligible information on contraception from service providers leading to poor knowledge on safe sex and dual protection. Information from service providers reveals a lack of specific program guidelines to comprehensively address family planning (FP) issues through HIV programs. Conclusion: The study throws light on missed opportunities to address contraceptive needs of PLHIV and recommends training service providers and operationalizing a strategy to link HIV and FP services.

Linking HIV & family planning services to improve dual methods of contraception among women infected with HIV in Mumbai, Maharashtra, India.

Background & objectives: Preventing unintended pregnancies among people living with HIV (PLHIV) is one of the strategies of WHO for preventing parent-to-child transmission (PPTCT). Given the limitation of only condom use, the objective of this study was to improve use of dual contraceptive methods among HIV infected women. Methods: An experimental study among HIV positive women was conducted at two tertiary care level hospitals in Mumbai. Linking HIV with family planning services was the focus of intervention at one site and standard level of care was maintained at the control site. At each site, 150 HIV+ve women attending counselling and testing centres, who did not intend to get pregnant in the next one year and were eligible to use dual methods, were enrolled and followed up to one year. Results: At the end of one year, 60 per cent women in the intervention group reached Family Planning Centres compared to eight per cent in the control group. There was three times more acceptance and continuation of use of dual methods along with increase in consistent use of condoms and less number of unplanned pregnancies in the intervention group than the control group. Interpretation & conclusions: The study findings demonstrate that linking HIV and family planning services may facilitate the uptake of dual methods of contraception without reducing consistent condom use among HIV infected women. The PPTCT programmes need to focus on the component of Prong 2 of PPTCT which aims to prevent unintended pregnancies among HIV positive women.

Level of suboptimal adherence to first line antiretroviral treatment & its determinants among HIV positive people in India.

Background & objectives: National Anti-retroviral treatment (ART) programme in India was launched in 2004. Since then, there has been no published country representative estimate of suboptimal adherence among people living with HIV (PLHIV) on first line ART in public settings. Hence a multicentric study was undertaken in 15 States of India to assess the level of suboptimal adherence and its determinants among PLHIV. Methods: Using a prospective observational study design, 3285 PLHIV were enrolled and followed up to six months across 30 ART centres in India. Adherence was assessed using pill count and self-reported recall method and determinants of suboptimal adherence were explored based on the responses to various issues as perceived by them. Results: sSuboptimal adherence was found in 24.5 per cent PLHIV. Determinants of suboptimal adherence were illiteracy (OR-1.341, CI-1.080-1.665) , on ART for less than 6 months (OR-1.540, CI- 1.280-1.853), male gender (OR for females -0.807, CI- 0.662-0.982), tribals (OR-2.246, CI-1.134-4.447), on efavirenz (EFA) regimen (OR- 1.479, CI - 1.190 - 1.837), presence of anxiety (OR- 1.375, CI - 1.117 - 1.692), non-disclosure of HIV status to family (OR- 1.549, CI - 1.176 - 2.039), not motivated for treatment (OR- 1.389, CI - 1.093 - 1.756), neglect from friends (OR-1.368, CI-1.069-1.751), frequent change of residence (OR- 3.373, CI - 2.659 - 4.278), travel expenses (OR- 1.364, CI - 1.138-1.649), not meeting the PLHIV volunteer/community care coordinator at the ART center (OR-1.639, CI-1.330-2.019). Interpretation & conclusions: To enhance identification of PLHIV vulnerable to suboptimal adherence, the existing checklist to identify the barriers to adherence in the National ART Guidelines needs to be updated based on the study findings. Quality of comprehensive adherence support services needs to be improved coupled with vigilant monitoring of adherence measurement.

Reproductive health problems and help seeking behavior among adolescents in urban India.

OBJECTIVE: To assess their reproductive health problems and help seeking behaviour among urban school going adolescents. METHOD: A sample of 300 urban school going adolescents between 11-14 years were chosen at random and assessed using four tools namely, self administered questionnaire : provision of adolescent friendly services; medical screening and focus group discussions. RESULTS: Seventy two percent girls and 56% boys reported health problems during survey with an average of 1.93 complaints per girl and 0.5 complaints per boy. However, only 43% girls and 35% boys reported to the clinic voluntarily to seek help and only one fifth the amount of problems were reported at the clinic in comparison to the quantum of problems reported in survey, which probably reflects a poor health seeking behaviour. A medical checkup with emphasis on assessment of reproductive health and nutritional status helped in detecting almost the same number of reproductive health problems as reported by them in survey. This intervention helped to increase the client attendance in subsequent period of next one year from 43% to 60% among girls and from 35% to 42% among boys. CONCLUSION: Our study shows that to increase help seeking behaviour of adolescents, apart from health and life skill education, their medical screening with a focus on reproductive health by trained physicians, parental involvement, supported by adolescent friendly centers (AFC) for counseling, referral and follow up are essential.