Local government stewardship for TB elimination in Kerala, India.

SETTING: The southern Indian state of Kerala has implemented 'Kerala Tuberculosis Elimination Mission' as 'People's Movement against TB' under the stewardship of local governments (LGs). The state has been certified by the Government of India for being on track to attain the UN Sustainable Development Goals related to TB elimination. OBJECTIVE: To document the role of LG stewardship in the successful implementation of the TB elimination activities in Kerala. DESIGN: 1) Key informant interviews with four state officials, 2) desk review of available documents, 3) in-depth interviews with seven LG leaders, three mid-level programme managers and three health department field staff. RESULTS: LG involvement led to the establishment of solutions based on local problems, enhanced outreach of services to the socially vulnerable individuals, improved treatment support to patients with TB, increased community ownership of TB elimination activities, reduced TB-related stigma and social determinants being addressed. Institutional mechanisms such as LG TB elimination task forces, formal guidance in planning interventions and appreciation of their performance in the form of awards were facilitators for LG involvement. CONCLUSION: LG stewardship can accelerate TB elimination. A good plan for engagement and institutional mechanisms are crucial for LG involvement.

CONTEXTE: L'État du Kérala, situé dans le sud de l'Inde, a mis en place la « Kerala Tuberculosis Elimination Mission ¼ dans le cadre du « People's Movement Against TB ¼, sous l'égide des gouvernements locaux (LG). Le gouvernement indien a certifié que le Kérala était sur la bonne voie pour atteindre les objectifs de développement durable des Nations unies en matière d'élimination de la TB. OBJECTIF: Documenter le rôle de l'intendance des LG dans la bonne mise en œuvre des activités d'élimination de la TB au Kérala. MÉTHODES: 1) Entretiens avec des informateurs clés (quatre responsables gouvernementaux), 2) analyse des documents disponibles, 3) entretiens approfondis avec sept responsables de LG, trois responsables de programme de niveau intermédiaire et trois membres du personnel de terrain du département de la santé. RÉSULTATS: L'implication des LG a permis d'établir des solutions au vu des problèmes locaux, d'améliorer l'accès aux services pour les personnes socialement vulnérables, d'améliorer le soutien au traitement des patients atteints de TB, de renforcer l'appropriation par la communauté des activités d'élimination de la TB, de réduire la stigmatisation liée à la TB et d'agir sur les déterminants sociaux. Les mécanismes institutionnels, tels que les groupes de travail pour l'élimination de la TB mis en place par les LG, les conseils officiels reçus pour planifier les interventions et l'appréciation des performances sous forme de récompenses ont facilité l'implication des LG. CONCLUSION: L'intendance des LG peut permettre d'accélérer l'élimination de la TB. Une bonne planification de l'engagement et des mécanismes institutionnels sont essentiels à l'implication des LG.

Local governments and community-based rehabilitation for developmental disabilities: leaving no one behind.

SETTING: The BUDS (not an acronym) institutions comprise a community-based rehabilitation initiative for children and families affected by developmental disabilities in Kerala, India. OBJECTIVE: To explore the role of local governments in the establishment and functioning of BUDS institutions. DESIGN: We used qualitative approaches comprising document review and in-depth interviews with trainers, parents of children with developmental disabilities and elected representatives. RESULTS: BUDS was created by Kudumbasree, a decentralised women empowerment and poverty alleviation initiative. Our findings illustrate the role of local governments in facilitating expansion through the establishment of infrastructure, therapy equipment, transportation and financial allocation for these, as well as through the development of human resources, assistance with enrolment for financial assistance and insurance programmes, and coordination with education and health sectors. Programme implementation varied considerably regarding available infrastructure, staffing and services among the institutions studied. The institutions were physically closed during the COVID-19 pandemic but continued to function in alternative ways. CONCLUSION: Despite variable implementation, local governments have supported the expansion of BUDS institutions, thereby creating more spaces for inclusive and integrated education and rehabilitation of persons with disabilities in Kerala. The expansion over the past two decades and measures during the COVID-19 pandemic suggest resilience and sustainability of the model.

CONTEXTE: Les institutions BUDS (ceci n'est pas un acronyme) ont mis en place une initiative communautaire pour la réhabilitation des enfants et familles touchés par des troubles du développement au Kérala, Inde. OBJECTIF: Analyser le rôle des gouvernements locaux dans la fondation et le fonctionnement des institutions BUDS. MÉTHODES: Nous avons utilisé des approches qualitatives fondées sur une analyse documentaire et sur des entretiens approfondis avec des formateurs, des parents d'enfants atteints de troubles du développement et des représentants élus. RÉSULTATS: BUDS a été créé dans le cadre d'une initiative décentralisée de réduction de la pauvreté et d'autonomisation des femmes, dénommée Kudumbasree. Nos résultats illustrent le rôle des gouvernements locaux dans la facilitation de l'expansion par la mise à disposition d'infrastructures, d'équipements thérapeutiques, de transports et l'allocation de fonds pour ceux-ci, ainsi que par le développement des ressources humaines, l'inclusion dans des programmes d'assistance financière et d'assurances, et la coordination avec les secteurs de l'éducation et de la santé. De grandes différences de mise en œuvre du programme ont été observées entre les institutions à l'étude, en matière d'infrastructures disponibles, de personnel et de services. Les institutions ont fermé leurs portes pendant la pandémie de COVID-19, mais elles continuaient de fonctionner de manière alternative. CONCLUSION: En dépit d'une mise en œuvre variable, les gouvernements locaux ont soutenu le développement des institutions BUDS et ainsi élargi l'espace pour une éducation et une réhabilitation inclusives et intégrées des personnes porteuses de handicaps au Kérala. Le développement de ces institutions au cours des 20 dernières années et les mesures instaurées pendant la pandémie de COVID-19 laissent transparaître la résilience et le caractère durable du modèle.

Decentralisation, health and Sustainable Development Goal 3.

SETTING: Kerala State, India, implemented decentralising reforms of healthcare institutions 25 years ago through transfer of administrative control and a sizeable share of the financial allocation. OBJECTIVE: To describe the main impacts of decentralisation in Kerala on local policy formulation, programme implementation and service delivery for sustainable health systems. DESIGN: This was part of a broader qualitative study on decentralisation and health in Kerala. We conducted 25 in-depth interviews and reviewed 31 government orders or policy documents, five related transcripts and five thematic reports from the main study. RESULTS: Liaising between health system and local governments has improved over time. A shift from welfare-centric projects to infrastructure, human resources and services was evident. Considerable heterogeneity existed due to varying degrees of involvement, capacity, resources and needs of the community. State-level discourse and recent augmentation efforts for moving towards the UN Sustainable Development Goals (SDGs) strongly uphold the role of local governments in planning, financing and implementation. CONCLUSION: The 25-year history of decentralised healthcare administration in Kerala indicates both successes and failures. Central support without disempowering the local governments can be a viable option to allow flexible decision-making consistent with broader system goals.

CONTEXTE: L'État du Kerala, en Inde, a mis en œuvre des réformes de décentralisation des établissements de santé il y a 25 ans, en transférant le contrôle administratif et une part importante de l'allocation financière. OBJECTIF: Décrire les principaux impacts de la décentralisation au Kerala sur la formulation de politiques locales, la mise en œuvre de programmes et la prestation de services pour des systèmes de santé durables. MÉTHODE: Cette étude faisait partie d'une étude qualitative plus vaste sur la décentralisation et la santé au Kerala. Nous avons mené 25 entretiens approfondis et examiné 31 décrets ou documents de politique du gouvernement, cinq transcriptions connexes et cinq rapports thématiques de l'étude principale. RÉSULTATS: La liaison entre le système de santé et les gouvernements locaux s'est améliorée au fil du temps. Une réorientation des projets centrés sur le bien-être vers les infrastructures, les ressources humaines et les services était évidente. Une hétérogénéité considérable existe en raison des différents degrés d'implication, de capacité, de ressources et de besoins de la communauté. Le discours au niveau de l'État et les récents efforts d'augmentation en vue d'atteindre les objectifs de développement durable (SDG) de l'ONU soutiennent fortement le rôle des gouvernements locaux dans la planification, le financement et la mise en œuvre. CONCLUSION: Les 25 ans d'histoire de l'administration décentralisée des soins de santé au Kerala révèlent à la fois des réussites et des échecs. Un soutien central sans déresponsabiliser les gouvernements locaux peut être une option viable pour permettre une prise de décision flexible et cohérente avec les objectifs plus larges du système.

Palliative care management committees: a model of collaborative governance for primary health care.

SETTING: The community-based primary palliative care programme in Kerala, India, has received international acclaim. Programme functioning is supported through Palliative Care Management Committees (PMCs) at the local government (LG) level. OBJECTIVE: To study the functioning of the PMCs within the decentralised governance space to identify achievements, gaps and notable innovations. DESIGN: This qualitative study included seven key informant interviews (KIIs), 28 in-depth interviews and a review of relevant publicly available policies and documents. Major themes were recognised from the KII transcripts. Codes emerging from the document review and in-depth interview transcripts were mapped into the identified thematic areas. RESULTS: Successful PMCs raised resources like money, human resource, equipment, had good skilled care options for symptom relief and facilitated reduced out-of-pocket expenditure by providing home care and free medicines, and improved access to interventions that addressed the social determinants of suffering like poverty. PMCs had varying managerial and technical capacities. In some LGs, the programme was weak and mostly limited to the supply of medicines, basic aids and appliances to patients' homes. CONCLUSION: Despite varied implementation patterns, PMCs in Kerala are examples of state-supported, community-owned care initiatives, that can potentially address medical and social determinants of suffering.

CONTEXTE: Le programme communautaire de soins palliatifs primaires du Kérala, Inde, a été applaudi sur la scène internationale. Le fonctionnement du programme est soutenu par des Comités de gestion des soins palliatifs (PMC) au niveau des gouvernements locaux (LG). OBJECTIF: Évaluer le fonctionnement des PMC au sein de l'espace de gouvernance décentralisée, afin d'identifier les réussites, les lacunes et les principales innovations. MÉTHODES: Dans le cadre de cette étude qualitative, sept entretiens avec des informateurs clés (KIIs), 28 entretiens approfondis et une analyse des politiques et documents accessibles au public ont été réalisés. Les transcriptions des KII ont permis de faire émerger les thèmes principaux. Les codes émergeant de l'analyse documentaire et des transcriptions des entretiens approfondis ont été associés aux domaines thématiques identifiés. RÉSULTATS: Les PMC les plus performants ont pu mobiliser des ressources, telles que de l'argent, des ressources humaines ou des équipements. Ils proposaient également des options de soins de qualité pour soulager les symptômes, facilitaient la réduction des frais à la charge du patient en fournissant des soins à domicile et des médicaments gratuits, et ont permis d'améliorer l'accès aux interventions qui s'attaquaient aux déterminants sociaux de la souffrance, tels que la pauvreté. Les capacités techniques et de gestion variaient d'un PMC à l'autre. Le programme de certains LG était faible, principalement limité à la fourniture de médicaments et d'aides et de matériels de base pour le domicile des patients. CONCLUSION: Malgré des schémas de mise en œuvre variés, les PMC du Kérala sont des exemples d'initiatives communautaires de santé soutenues par l'état qui peuvent potentiellement s'attaquer aux déterminants sociaux et médicaux de la souffrance.

Effectiveness of an oral health education intervention among 6-12-year-old children: A cluster randomized controlled trial.

OBJECTIVES: Literature on the effectiveness of theory-based oral health education on the oral hygiene of children is limited. We aimed to determine the effectiveness of an health behaviour theory-based school oral health education intervention on 1) oral hygiene and 2) oral health-related knowledge, attitude and practices among 6-12-year-old children in Kerala, India. METHODS: Cluster randomized controlled trial. Sixteen class divisions (clusters) were randomized into intervention and control groups of 225 and 228 children respectively. Primary and secondary outcomes were plaque score as measured using the simplified oral hygiene index (OHI-S) and oral health-related knowledge, attitude and practices respectively. The intervention group received structured oral health education classes for three months and materials including pamphlets. Children in the control group were not given the classes or materials. RESULTS: Post-intervention OHI-S scores in the intervention group and control groups were 1.65 and 2.17 respectively (difference = -0.52, 95%CI -0.86, -0.18). All the secondary outcomes improved in the intervention group compared to the control group. CONCLUSIONS: The intervention improved the oral hygiene status, oral health-related knowledge, attitude and practices of the children. Longer term follow-up and economic appraisal are needed to help policymakers plan and develop OHEI based on health behaviour theories.

Treatment in a Stroke Unit and Risk Factor Control Reduce Recurrent Stroke Risk.

INTRODUCTION: Risk factor control is an important predictor of risk of stroke recurrence. The attributable fraction which estimates the excess risk among the exposed stroke survivors has not been studied previously. We studied the attributable fraction for stroke recurrence in consecutive incident cases of recurrent stroke. METHODS: A case-control study with incident cases of recurrent stroke and controls matched for age and poststroke period was done. A structured interview was done to collect data on sociodemographic variables, lifestyle, and medication adherence. The risk factors, treatment of index stroke, and outcome were collected. Logistic regression analysis was done to find out the factors associated with stroke recurrence. Attributable fraction and average attributable fraction were calculated. RESULTS: Among the 103 matched pairs, more than 70% were rural residents. Male gender (OR 2.59; 95% CI 1.05-6.42), the presence of depression (OR 8.67; 95% CI 2.80-26.84), memory problem (OR 10.12; 95% CI 2.48-41.34), uncontrolled diabetes (OR 3.19; 95% CI 1.42-7.19), cardioembolic stroke (OR 4.45; 95% CI 1.12-17.62), and index stroke not being treated in a stroke unit (OR 6.60; 95% CI 2.86-15.23) were associated with increased risk of stroke recurrence. The maximum average attributable fraction for stroke recurrence risk was attributed to index stroke not being treated in the stroke unit and uncontrolled diabetes. CONCLUSION: The index stroke treated in a comprehensive stroke care unit and control of risk factors can reduce recurrent stroke risk among stroke survivors. This population-attributable risk is important in planning secondary stroke prevention strategies.

Consumption of fruits, vegetables and salt in the context of control of type 2 diabetes and hypertension in Kerala, India.

BACKGROUND: Proper diet is necessary to control hypertension and diabetes. This paper describes the combined fruit and vegetable, and salt intake of adults (>=18 years) who were detected to have hypertension or diabetes. METHODS: We analysed the data from a state-wide survey of 12012 adults using the World Health Organization STEPs for NCD risk factor surveillance. We evaluated the recommended intake of fruit and vegetable (>=5 servings/day) and salt (<5 gm/day) across participants divided into four strata, and the probabilities were also estimated using the fitted multiple binary logistic regression models. RESULTS: Overall, 13.9% (95%CI: 12.2%-15.9%) and 29.4% (95%CI: 28%-30.8%) of participants consumed the recommended level of fruit and vegetable, and salt, respectively. Adjusted odds ratios were not significantly different across the four strata based on the status of treatment and control of diabetes or hypertension. The likelihood of following the recommended fruit and vegetable intake was highest for 50-69-year-old females with above high school education, obese, under treatment for diabetes or hypertension, and had normal values of FBS and BP (0.28). The likelihood for recommended salt intake was highest for 50-69-year-old males with above high school education and had normal BMI, under treatment for diabetes or hypertension, and had normal values of FBS and BP (0.69). CONCLUSION: The status of diabetes or hypertension did not show considerable influence in the fruit, vegetable, and salt intake of adults in general. A detailed exploration of the accessibility and acceptability of such recommended intakes in the Kerala context is warranted.

Facilitators and barriers to medication adherence among stroke survivors in India.

Strict compliance with medication and life style modification are integral to secondary stroke prevention. This study was undertaken to find out medication adherence among stroke survivors and factors associated with it. Cross sectional survey among stroke survivors was conducted. Interview based self-reported medication adherence was defined as consumption at least >80% of their medications for last two weeks, based on last prescription. Structured interview using pretested interview schedule was done to collect other data. Sequential step wise logistic regression analysis was done to find out the facilitators and barriers to medication adherence. Two hundred and forty stroke survivors (mean age 58.64 ± 10.96 years; 25.4% females) with a mean post-stroke period of 6.65 ± 3.36 months were participated. Overall medication adherence was 43.8% (n = 105). Medication adherence was 34.3% (n = 134), 52.6% (n = 190) and 56.7% (n = 224) for antidiabetics, antihypertensives and statins respectively and was associated with risk factor control (Diabetes: Odds Ratio (OR) = 4.85; 95% Confidence Interval (CI) 2.12-11.08, Hypertension: OR = 3.42; 95% CI 1.83-6.4, Dyslipidaemia: OR = 3.88; 95% CI 1.96-4.04). Having daily routine (OR = 2.82; 95% CI 1.52-5.25), perceived need of medication (OR = 2.33; 95% CI 1.04-5.2) and perceived poor state of health (OR = 2.65; 95% CI 1.30-5.40) were facilitators. Memory issues (OR = 0.34; 95% CI 0.16-0.71), side effects (OR = 0.24; 95% CI 0.11-0.42) and financial constraints (OR = 0.46; 95% CI 0.24-0.91) were barriers to medication adherence. Establishing daily routines, periodic reminders, financial supports to buy medicines and patient education can enhance medication adherence to prevent future strokes.

Life Style and Behavioural Factors are Associated with Stroke Recurrence Among Survivors of First Episode of Stroke: A Case Control Study.

BACKGROUND: Secondary stroke prevention treatment is associated with an 80% reduction in risk of recurrent stroke. But one out of every four strokes are recurrent. Adherence to pharmacological therapy and strict control of risk factors are essential for prevention of recurrent strokes. METHODS: Pair matched incident case control study was done to find out the factors associated with stroke recurrence after first ever stroke. Incident cases of recurrent strokes and age and post stroke period matched controls were recruited prospectively. The estimated sample size for the study was 70 matched pairs. Data collected from medical records and by visiting their homes. Analysis was done using R statistical software. RESULTS: Bivariate analysis showed cardio embolic stroke subtype, poor lipid control, unhealthy diet, physical inactivity, medication nonadherence, presence of depression, memory problems no discharge advice at index admission and low income were associated increased risk of recurrence. Higher mean NIHSS score and a greater number of days of hospitalisation during index stroke had less risk of recurrence. Conditional logistic regression analysis revealed non adherence to medication (OR 7.46, 1.67-33.28) and not receiving discharge advice at index admission (OR 10.79, 2.38-49.02) were associated with increased risk of recurrence whereas lacunar stroke (OR 0.08, 0.01-0.59) and a greater number of days of hospitalization during index stroke (OR 0.82, 0.67-0.99) were associated with less risk of recurrence. CONCLUSION: Individualised patient education regarding stroke, recurrence risk, medication adherence, healthy lifestyle and risk factor control can reduce stroke recurrence risk.

Using open-source data to explore distribution of built environment characteristics across Kerala, India.

BACKGROUND: Built environment characteristics in the neighborhood are of utmost priority for a healthy lifestyle in the fast-urbanizing countries. These characteristics are closely linked to the disease burden and challenges in low- and middle-income countries (LMICs), which have been unexplored using open-source data. The present technology offers online resources and open source software that enable researchers to explore built environment characteristics with health and allied phenomena. OBJECTIVES: This article intends to delineate methods to capture available and accessible objective built environment variables for a state in India and determine their distribution across the state. METHODS: Built environment variables such as population density and residential density were collated from the Census of India. Safety from crime and traffic were captured as crime rates and pedestrian accident rates, respectively, acquired from State Crime Records Bureau. Greenness, built-up density, and land slope were gathered from open-source satellite imagery repository. Road intersection density was derived from OpenStreetMap. Processing and analysis differed for each dataset depending on its source and nature. RESULTS: Each variable showed a distinct pattern across the state. Population and residential density were found to be closely related to each other across both districts and subdistricts. They were both positively related to crime rates, pedestrian accident rates, built-up density, and intersection density, whereas negatively related to land slope and greenness across the subdistricts. CONCLUSION: Delineating the distribution of built environment variables using available and open-source data in resource-poor settings is a first in public health research among LMICs. Cost-effectiveness and reproducible nature of open-source solutions could equip researchers in resource-poor settings to identify built environment characteristics and patterns across regions.

The ethical responsibility of healthcare providers to advise patients with diabetes on lifestyle modifications.

There is clear evidence of a link between health and physical activity (PA). PA is universally prescribed as a primary treatment for most chronic diseases. However, studies show that not many health professionals advise patients about PA. The current study examines how a cost-effective tool to improve population health has been completely neglected in professional practice in a state with maximum healthcare availability. Is this malfeasance in practice or a violation of human rights? Are healthcare providers exempted from their responsibilities because they choose to neglect them? Who should be held responsible for the increasing disease-related deaths that are easily preventable? Keywords: physical activity, inactivity, advice, low- and middle-income country, health professionals, providers, chronic disease, diabetes, lifestyle modification, counselling.

The household economic burden of non-communicable diseases in 18 countries

BACKGROUND: Non-communicable diseases (NCDs) are the leading cause of death globally. In 2014, the United Nations committed to reducing premature mortality from NCDs, including by reducing the burden of healthcare costs. Since 2014, the Prospective Urban and Rural Epidemiology (PURE) Study has been collecting health expenditure data from households with NCDs in 18 countries. METHODS: Using data from the PURE Study, we estimated risk of catastrophic health spending and impoverishment among households with at least one person with NCDs (cardiovascular disease, diabetes, kidney disease, cancer and respiratory diseases; n=17 435), with hypertension only (a leading risk factor for NCDs; n=11 831) or with neither (n=22 654) by country income group: high-income countries (Canada and Sweden), upper middle income countries (UMICs: Brazil, Chile, Malaysia, Poland, South Africa and Turkey), lower middle income countries (LMICs: the Philippines, Colombia, India, Iran and the Occupied Palestinian Territory) and low-income countries (LICs: Bangladesh, Pakistan, Zimbabwe and Tanzania) and China. RESULTS: The prevalence of catastrophic spending and impoverishment is highest among households with NCDs in LMICs and China. After adjusting for covariates that might drive health expenditure, the absolute risk of catastrophic spending is higher in households with NCDs compared with no NCDs in LMICs (risk difference=1.71%; 95% CI 0.75 to 2.67), UMICs (0.82%; 95% CI 0.37 to 1.27) and China (7.52%; 95% CI 5.88 to 9.16). A similar pattern is observed in UMICs and China for impoverishment. A high proportion of those with NCDs in LICs, especially women (38.7% compared with 12.6% in men), reported not taking medication due to costs. CONCLUSIONS: Our findings show that financial protection from healthcare costs for people with NCDs is inadequate, particularly in LMICs and China. While the burden of NCD care may appear greatest in LMICs and China, the burden in LICs may be masked by care foregone due to costs. The high proportion of women reporting foregone care due to cost may in part explain gender inequality in treatment of NCDs. (AU)

Spatial Clusters of Diabetes and Physical Inactivity: Do Neighborhood Characteristics in High and Low Clusters Differ?

This study aims to find spatial clusters of diabetes and physical inactivity among a sample population in Kerala, India, and evaluate built environment characteristics within the high and low spatial clusters. Spatial clusters with a higher and lower likelihood of diabetes and physical inactivity were identified using spatial scan statistic at various radii. Built environment characteristics were captured at panchayat level and 1600 m buffer around participant location using Geographical Information Systems. Comparison of sociodemographic and built environment factors was carried out for participants within high and low spatial clusters using t tests. Ten high and 8 low spatial clusters of diabetes and 17 high and 23 low spatial clusters of physical inactivity were identified in urban and rural areas of Kerala. Significant differences in built environment characteristics were consistent for low spatial clusters of diabetes and physical inactivity in the urban scenario. Built environment characteristics were found to be relevant in both urban and rural areas of Kerala. There is an urgent call to explore spatial clustering of non-communicable diseases in Kerala and undo the one-size-fits-all approach for prevention and control of non-communicable diseases.

Measuring childhood socioeconomic position in health research: Development and validation of childhood socioeconomic position questionnaire using mixed method approach.

Background: There is no single best indicator to assess the childhood socioeconomic position (CSEP) in public health research. The aim of the study is to develop and validate a new questionnaire, with adequate psychometric properties, to measure the childhood SEP of the young adults. Methods: The first phase consisted of a qualitative phase to identify the variables to measure childhood SEP through the in-depth interviews among 15 young adults (18-45 years) of rural Kerala. The second phase was a quantitative phase to validate the questionnaire through a cross sectional survey among 200 young adults of Kerala. We did content validity, reliability tests and construct validity by using exploratory factor analysis of the questionnaire to demonstrate its psychometric properties. Results: The qualitative analysis reported 26 variables spread across 5 domains to measure the CSEP. Finally, the questionnaire has 11 questions with 3 domains named as value added through paternity, maternal occupation-related factors and parental education. The questionnaire has good reliability (Cronbach's α=0.88) also. Conclusion: We have developed a reliable and valid questionnaire to measure the childhood SEP of younger adults and can be used in various public health research.

Incidence of type 2 diabetes mellitus and prediabetes in Kerala, India: results from a 10-year prospective cohort.

BACKGROUND: Kerala, the southern state of India, has experienced sudden rise in the prevalence estimates of diabetes. A cohort study on the incidence of type 2 diabetes mellitus (T2DM) in Kerala state thus aptly bridges the lacuna of incidence estimate of T2DM from a population at risk. METHODS: A 10-year prospective cohort study was carried out in two urban wards of central Kerala. The individuals who participated in the baseline survey in 2007 were again invited for a follow-up study in 2017. The data was analyzed using IBM SPSS Statistics for windows (version 21.0). Logistic regression analysis was used to estimate odds ratios and 95% confidence intervals. Findings are based on the 10-year follow-up data from 869 participants from the cohort. RESULTS: The overall follow-up and response rate of the study was 68.9 and 86.9% respectively. During the follow-up period, 190 people (21.9%) developed T2DM. The incidence rate of T2DM and impaired fasting glucose (IFG) were 24.5 per 1000 person years and 45.01 per 1000 person years respectively. Nearly 60% of participants with baseline IFG were converted to T2DM group in the follow-up period. Age > 45 years, family history of T2DM, BMI ≥ 25 kg/m2 and presence of central obesity emerged as important risk factors for incident T2DM. CONCLUSION: High incidence of prediabetes over diabetes observed in this study shows an epidemic trend of T2DM in Kerala, India. It requires an immediate public health action.

Oxide thin films as bioactive coatings.

Growth and survival of biological cells (eukaryotes and prokaryotes) on artificial environments often depend on their interactions with the specific surface. Various organic materials can be coated on substrates to assist cells' adhesion and other subsequent cellular processes. However, these coatings are expensive, degrade over short time period, and may even interfere with the cells' signaling processes. Therefore, the use of inorganic surfaces in order to control cellular interactions is of scientific importance from fundamental and application perspectives. Among inorganic materials, oxide thin films have received considerable attention. Thin films of oxides have the advantage of tailoring the surfaces for cellular interactions while using a negligible amount of the oxide material. Here, we review the lesser known application of inorganic oxide coatings as biocompatible and implantable platforms for different purposes, such as biofilm inhibition, cell culture and implant enhancements.

Gender differences in the relationship between built environment and non-communicable diseases: A systematic review.

Non-communicable diseases are on the rise globally. Risk factors of non-communicable diseases continue to be a growing concern in both developed and developing countries. With significant rise in population and establishment of buildings, rapid changes have taken place in the built environment. Relationship between health and place, particularly with non-communicable diseases has been established in previous literature. This systematic review assesses the current evidence on influence of gender in the relationship between built environment and non-communicable diseases. A systematic literature search using PubMed was done to identify all studies that reported relationship between gender and built environment. All titles and abstracts were scrutinised to include only articles based on risk factors, prevention, treatment and outcome of non-communicable diseases. The Gender Analysis Matrix developed by the World Health Organization was used to describe the findings of gender differences. Sex differences, biological susceptibility, gender norms/ values, roles and activities related to gender and access to/control over resources were themes for the differences in the relationship. A total of 15 out of 214 articles met the inclusion criteria. Majority of the studies were on risk factors of non-communicable diseases, particularly cardiovascular diseases. Gender differences in physical access to recreational facilities, neighbourhood perceptions of safety and walkability have been documented. Men and women showed differential preferences to walking, engaging in physical activity and in perceiving safety of the neighbourhood. Girls and boys showed differences in play activities at school and in their own neighbourhood environment. Safety from crime and safety from traffic were also perceived important to engage in physical activity. Gender norms and gender roles and activities have shown basis for the differences in the prevalence of non-communicable diseases. Sparse evidence was found on how built environment affects health seeking behaviour, preventive options or experience with health providers. Though yet unexplored in the developing or low/middle income countries, there seems to be a major role in the gendered perception of how men and women are affected by noncommunicable diseases. Large gaps still exist in the research evidence on gender-based differences in non-communicable diseases and built environment relationship. Future research directions could bring out underpinnings of how perceived and objective built environment could largely affect the health behaviour of men and women across the globe.

Metformin attenuates effects of cyclophilin A on macrophages, reduces lipid uptake and secretion of cytokines by repressing decreased AMPK activity.

Growing evidence implicates cyclophilin A secreted by vascular wall cells and monocytes as a key mediator in atherosclerosis. Cyclophilin A in addition to its proliferative effects, during hyperglycemic conditions, increases lipid uptake in macrophages by increasing scavenger receptors on the cell's surface. It also promotes macrophage migration across endothelial cells and conversion of macrophages into foam cells. Given the known effects of metformin in reducing vascular complications of diabetes, we investigated the effect of metformin on cyclophilin A action in macrophages. Using an ex vivo model of cultured macrophages isolated from patients with type 2 diabetes with and without coronary artery disease (CAD), we measured the effect of metformin on cyclophilin A expression, lipid accumulation, expression of scavenger receptors, plasma cytokine levels and AMP-activated protein kinase (AMPK) activity in macrophages. In addition, the effects of metformin on migration of monocytes, reactive oxygen species (ROS) formation, lipid uptake in the presence of cyclophilin A inhibitors and comparison with pioglitazone were studied using THP-1 monocytes. Metformin reduced cyclophilin A expression in human monocyte-derived macrophages. Metformin also decreased the effects of cyclophilin A on macrophages such as oxidized low-density lipoprotein (oxLDL) uptake, scavenger receptor expression, ROS formation and secretion of inflammatory cytokines in high-glucose conditions. Metformin reversed cyclophilin A-induced decrease in AMPK-1α activity in macrophages. These effects of metformin were similar to those of cyclophilin A inhibitors. Metformin can thus function as a suppressor of pro-inflammatory effects of cyclophilin A in high-glucose conditions by attenuating its expression and repressing cyclophilin A-induced decrease in AMPK-1α activity in macrophages.

Lack of association of mirSNP rs11174811 in AVPR1A gene with arterial blood pressure and hypertension in South Indian population.

Epigenetic regulation of arterial blood pressure mediated through mirSNPs in renin-angiotensin aldosterone system (RAAS) genes is a less explored hypothesis. Recently, the mirSNP rs11174811 in the 3'UTR of the AVPR1A gene was associated with higher arterial blood pressure in a large study population from the Study of Myocardial Infarctions Leiden (SMILE). The aim of the present study was to replicate the association of mirSNP rs11174811 with blood pressure outcomes and hypertension in a south Indian population. Four hundred and fifteen hypertensive cases and 416 normotensive controls were genotyped using a 5' nuclease allelic discrimination assay. Logistic regression was used to test the association of mirSNP rs11174811 with the hypertension phenotype. Censored normal regression was used to test the association of the polymorphism with continuous blood pressure outcomes such as systolic and diastolic blood pressure. The mirSNP rs11174811 did not show any significant association with hypertension. The adjusted odds ratio was 1.02, with 95% CI of 0.72 to 1.45 (p = 0.909). The mean systolic and diastolic blood pressure values were not significantly different across the three genotypic groups, between hypertensives and normotensives, or when stratified by gender. Despite having a similar minor allele frequency (MAF) of 14.5% compared with the SMILE cohort, our results did not support an association of the mirSNP rs11174811 with the hypertension phenotype or with continuous blood pressure outcomes in the south Indian population.