Impacts of the COVID-19 pandemic on access to healthcare among people with disabilities: evidence from six low- and middle-income countries.

BACKGROUND: The pandemic has placed considerable strain on health systems, especially in low- and middle-income countries (LMICs), leading to reductions in the availability of routine health services. Emerging evidence suggests that people with disabilities have encountered marked challenges in accessing healthcare services and supports in the context of the pandemic. Further research is needed to explore specific barriers to accessing healthcare during the pandemic, and any strategies that promoted continued access to health services in LMICs where the vast majority of people with disabilities live. METHODS: Qualitative in-depth interviews were conducted with persons with disabilities in Ghana, Zimbabwe, Viet Nam, Türkiye (Syrian refugees), Bangladesh, and India as part of a larger project exploring the experiences of people with disabilities during the COVID-19 pandemic and their inclusion in government response activities. Data were analysed using thematic analysis. RESULTS: This research found that people with disabilities in six countries - representing a diverse geographic spread, with different health systems and COVID-19 responses - all experienced additional difficulties accessing healthcare during the pandemic. Key barriers to accessing healthcare during the pandemic included changes in availability of services due to systems restructuring, difficulty affording care due to the economic impacts of the pandemic, fear of contracting coronavirus, and a lack of human support to enable care-seeking. CONCLUSION: These barriers ultimately led to decreased utilisation of services which, in turn, negatively impacted their health and wellbeing. However, we also found that certain factors, including active and engaged Organisations of Persons with Disabilities (OPDs) and Non-Governmental Organizations (NGOs) played a role in reducing some of the impact of pandemic-related healthcare access barriers.

Evaluation of Dakshata, a scale-up WHO SCC and mentoring-based program, for improving quality of intrapartum care in public sector in Rajasthan, India: repeated mixed-methods surveys.

BACKGROUND: The Dakshata program in India aims to improve resources, providers' competence, and accountability in labour wards of public sector secondary care hospitals. Dakshata is based on the WHO Safe Childbirth Checklist coupled with continuous mentoring. In Rajasthan state, an external technical partner trained, mentored and periodically assessed performance; identified local problems, supported solutions and assisted the state in monitoring implementation. We evaluated effectiveness and factors contributing to success and sustainability. METHODS: Using three repeated mixed-methods surveys over an 18-month period, we assessed 24 hospitals that were at different stages of program implementation at evaluation initiation: Group 1, training had started and Group 2, one round of mentoring was complete. Data on recommended evidence-based practices in labour and postnatal wards and in-facility outcomes were collected by directly observing obstetric assessments and childbirth, extracting information from case sheets and registers, and interviewing postnatal women. A theory-driven qualitative assessment covered key domains of efficiency, effectiveness, institutionalization, accountability, sustainability, and scalability. It included in-depth interviews with administrators, mentors, obstetric staff, and officers/mentors from the external partner. RESULTS: Overall, average adherence to evidence-based practices improved: Group 1, 55 to 72%; and Group 2, 69 to 79%, (for both p < 0.001) from baseline to endline. Significant improvement was noted in several practices in the two groups during admission, childbirth, and within 1 hour of birth but less in postpartum pre-discharge care. We noted a dip in several evidence-based practices in 2nd assessment, but they improved later. The stillbirth rate was reduced: Group 1: 1.5/1000 to 0.2; and Group 2: 2.5 to 1.1 (p < 0.001). In-depth interviews revealed that mentoring with periodic assessments was highly acceptable, efficient means of capacity building, and ensured continuity in skills upgradation. Nurses felt empowered, however, the involvement of doctors was low. The state health administration was highly committed and involved in program management; hospital administration supported the program. The competence, consistency, and support from the technical partner were highly appreciated by the service providers. CONCLUSION: The Dakshata program was successful in improving resources and competencies around childbirth. The states with low capacities will require intensive external support for a head start.

Effect of WHO-SCC based intra-department mentoring program on quality of intrapartum care in public sector secondary hospitals in Andhra Pradesh, India: Pre-post mixed methods evaluation.

Quality of intrapartum care is essential for improving pregnancy outcomes; several models for improving performance are tested, globally. Dakshata is one such WHO SCC-based national program-improving resources, providers' competence, and accountability-in public sector secondary care hospitals of India. Andhra Pradesh state devised strategy of mentoring by the handpicked member from within the obstetric team, supported by external technical partner. We evaluated the effectiveness and assessed contextual factors to success of the program. We conducted pre and post mentoring mixed-method surveys to evaluate the change in evidence-based intrapartum and newborn care practices and stillbirth rates, across 23 of 38 eligible hospitals. We directly observed obstetric assessments and childbirth, extracted data from casesheets and registers, interviewed beneficiaries and conducted facility surveys. We in-depth interviewed stakeholders from state, district and facility managers, mentors and obstetric staff, and external managers for theory-driven qualitative assessment. After one year we found, average adherence to practices sustained high during admission (81%, 81%); improved during childbirth (78%, 86%; p = 0.016); moderate within one hour of birth (72%, 71%), and poor postpartum care before discharge (46% to 43%). Stillbirths reduced from 11(95% CI, 9-13) to 4(3-5) per 1000 births (p<0.001). Some practices did not improve even after sustained reinforcement. Commitment from state, engaging district officers, monitoring and feedback by external managers enabled supportive setting. The structured training and mentoring package, and periodic assessments delivered under supervision ensured the standards of mentoring. The mentoring model is acceptable, effective, less costly and scalable; appears sustainable if state commits to institutionalising a long-term mentoring with adequate monitoring. We conclude that the SCC-based mentoring and skill building program showed improvement in practices during childbirth while it sustained high levels of care during admission, but no improvement in postpartum care. The state needs to monitor and ensure continuous mentoring with required infrastructural support.

Cultivating distress: cotton, caste and farmer suicides in India.

Nearly 4,00,000 farmers committed suicide in India between 1995 and 2018. This translates into approximately 48 suicides every day. The majority of suicides were those from 'backwarded' castes including Dalit farmers. This ethnographic study on cotton farmer suicide reports narratives of surviving Dalit families. The results reveal that financial and moral debt when accrued within a web of family and caste-related relationships result in patterns of personal and familial humiliation, producing a profound sense of hopelessness in the Self. This loss of hope and pervasive humiliation is 'cultivated' by a cascade of decisions taken by others with little or no responsibility to the farmers and the land they hope to cultivate as they follow different cultural and financial logic. Suicide resolves the farmers' humiliation and is a logical conclusion to the farmer's distress, which results from a reconfiguration of agricultural spaces into socially toxic places, in turn framing a local panopticon. The current corona virus pandemic is likely to impact adversely on peoples who are culturally distanced.

Enabling factors for behavior change among people with alcohol dependency: An exploratory study in a mental health-care facility.

BACKGROUND: Alcohol dependence has become a major public health problem with many implications on the lives of dependents and their families. OBJECTIVES: The objectives of this study is to ascertain the enabling factors to seek medical help and continue behavior change among alcohol dependents and to assess the perceptions of health-care providers regarding treatment-seeking behavior of alcohol dependents. METHODS: The present study deployed the transtheoretical model (TTM) as a theoretical framework for analyzing the enabling factors to seek medical help and continue behavior change among alcohol dependents and to understand the perceptions of health-care providers dealing with alcohol dependents at a tertiary care psychiatry hospital in Guntur of Andhra Pradesh. In-depth interviews and desk review of hospital records were done. Respondents included treatment-seeking individuals for alcohol detoxification (action phase), patients attending follow-ups (maintenance phase), and mental health professionals at the study site. The study was conducted during August and September 2017. Qualitative analysis using thematic framework and MS EXCEL for quantitative data was used. RESULTS: Themes and subthemes emerging out of analysis were fitted in stages of TTM of behavior change. In the process of behavior change, there were key supportive elements such as problem awareness (precontemplation), availability and accessibility of services (contemplation), appropriate treatment modality (action), and alcohol anonymous groups (maintenance), which sustained the progress of change and yielded effective outcomes. CONCLUSIONS: Alcoholism needs to be addressed holistically rather than focusing only on biological treatment.

Generating toxic landscapes: impact on well-being of cotton farmers in Telangana, India.

Existing literature demonstrates agro-chemicals result in physical toxicity and damages human health, flora and fauna. However, little is known about how such 'toxicity' relates to mental well-being and social suffering. This paper aims to demonstrate how local, national and international vectors are interlinked to shape social distress among cotton farmers in India. Ethnographic interviews and focus group discussions were conducted in a cotton-growing village of the Warangal district, Telangana state, India. The results advance the concept of counter therapeutic spaces and hypothesise that toxic landscapes emerge through a dynamic interaction between dispersed agencies that interact and reconfigure agricultural spaces into socially toxic places. The paper argues that the disciplines of public health and agriculture suffer from a failure of imagination to forge vital interdisciplinary links that could address farmer suffering. Unpacking local ecologies of farmer suffering offer innovative ways for enhancing mental health policy and interventions in India.

mHealth and the management of chronic conditions in rural areas: a note of caution from southern India.

This article examines challenges facing implementation of likely mHealth programmes in rural India. Based on fieldwork in Andhra Pradesh in 2014, and taking as exemplars two chronic medical 'conditions' - type 2 diabetes and depression - we look at ways in which people in one rural area currently access medical treatment; we also explore how adults there currently use mobile phones in daily life, to gauge the realistic likelihood of uptake for possible mHealth initiatives. We identify the very different pathways to care for these two medical conditions, and we highlight the importance to the rural population of healthcare outside the formal health system provided by those known as registered medical practitioners (RMP), who despite their title are neither registered nor trained. We also show how limited is the use currently made of very basic mobile phones by the majority of the older adult population in this rural context. Not only may this inhibit mHealth potential in the near future; just as importantly, our data suggest how difficult it may be to identify a clinical partner for patients or their carers for any mHealth application designed to assist the management of chronic ill-health in rural India. Finally, we examine how the promotion of patient 'self-management' may not be as readily translated to a country like India as proponents of mHealth might assume.

At the margins of biomedicine: the ambiguous position of 'Registered Medical Practitioners' in rural Indian healthcare.

This analysis challenges a tendency in public health and the social sciences to associate India's medical pluralism with a distinction between biomedicine, as a homogeneous entity, and its non-biomedical 'others'. We argue that this overdrawn dichotomy obscures the important part played by 'informal' biomedical practice, an issue with salience well beyond India. Based on a qualitative study in rural Andhra Pradesh, South India, we focus on a figure little discussed in the academic literature - the Registered Medical Practitioner (RMP) - who occupies a niche in the medical market-place as an informal exponent of biomedical treatment. We explore the significance of these practitioners by tracking diagnosis and treatment of one increasingly prominent medical 'condition', namely diabetes. The RMP, who despite the title is rarely registered, sheds light on the supposed formal-informal sector divide in India's healthcare system, and its permeability in practice. We develop our analysis by contrasting two distinctive conceptualisations of 'informality' in relation to the state in India - one Sarah Pinto's, the other Ananya Roy's.

Strengthening diabetes retinopathy services in India: Qualitative insights into providers' perspectives: The India 11-city 9-state study.

CONTEXT: There is a lack of evidence on the subjective aspects of the provider perspective regarding diabetes and its complications in India. OBJECTIVES: The study was undertaken to understand the providers' perspective on the delivery of health services for diabetes and its complications, specifically the eye complications in India. SETTINGS AND DESIGN: Hospitals providing diabetic services in government and private sectors were selected in 11 of the largest cities in India, based on geographical distribution and size. METHODS: Fifty-nine semi-structured interviews conducted with physicians providing diabetes care were analyzed all interviews were recorded, transcribed, and translated. Nvivo 10 software was used to code the transcripts. Thematic analysis was conducted to analyze the data. RESULTS: The results are presented as key themes: "Challenges in managing diabetes patients," "Current patient management practices," and "Strengthening diabetic retinopathy (DR) services at the health systems level." Diabetes affects people early across the social classes. Self-management was identified as an important prerequisite in controlling diabetes and its complications. Awareness level of hospital staff on DR was low. Advances in medical technology have an important role in effective management of DR. A team approach is required to provide comprehensive diabetic care. CONCLUSIONS: Sight-threatening DR is an impending public health challenge that needs a concerted effort to tackle it. A streamlined, multi-dimensional approach where all the stakeholders cooperate is important to strengthening services dealing with DR in the existing health care setup.

Are tuberculosis patients in a tertiary care hospital in Hyderabad, India being managed according to national guidelines?

SETTING: A tertiary health care facility (Government General and Chest hospital) in Hyderabad, India. OBJECTIVES: To assess a) the extent of compliance of specialists to standardized national (RNTCP) tuberculosis management guidelines and b) if patients on discharge from hospital were being appropriately linked up with peripheral health facilities for continuation of anti-Tuberculosis (TB) treatment. METHODS: A descriptive study using routine programme data and involving all TB patients admitted to inpatient care from 1(st) January to 30(th) June, 2010. RESULTS AND CONCLUSIONS: There were a total of 3120 patients admitted of whom, 1218 (39%) required anti-TB treatment. Of these 1104 (98%) were treated with one of the RNTCP recommended regimens, while 28 (2%) were treated with non-RNTCP regimens. The latter included individually tailored MDR-TB treatment regimens for 19 patients and adhoc regimens for nine patients. A total of 957 (86%) patients were eventually discharged from the hospital of whom 921 (96%) had a referral form filled for continuing treatment at a peripheral health facility. Formal feedback from peripheral health facilities on continuation of TB treatment was received for 682 (74%) patients. In a tertiary health facility with specialists the great majority of TB patients are managed in line with national guidelines. However a number of short-comings were revealed and measures to rectify these are discussed.

How do patients who fail first-line TB treatment but who are not placed on an MDR-TB regimen fare in South India?

SETTING: Seven districts in Andhra Pradesh, South India. OBJECTIVES: To a) determine treatment outcomes of patients who fail first line anti-TB treatment and are not placed on an multi-drug resistant TB (MDR-TB) regimen, and b) relate the treatment outcomes to culture and drug susceptibility patterns (C&DST). DESIGN: Retrospective cohort study using routine programme data and Mycobacterium TB Culture C&DST between July 2008 and December 2009. RESULTS: There were 202 individuals given a re-treatment regimen and included in the study. Overall treatment outcomes were: 68 (34%) with treatment success, 84 (42%) failed, 36 (18%) died, 13 (6.5%) defaulted and 1 transferred out. Treatment success for category I and II failures was low at 37%. In those with positive cultures, 81 had pan-sensitive strains with 31 (38%) showing treatment success, while 61 had drug-resistance strains with 9 (15%) showing treatment success. In 58 patients with negative cultures, 28 (48%) showed treatment success. CONCLUSION: Treatment outcomes of patients who fail a first-line anti-TB treatment and who are not placed on an MDR-TB regimen are unacceptably poor. The worst outcomes are seen among category II failures and those with negative cultures or drug-resistance. There are important programmatic implications which need to be addressed.