Discourse on Diabetes Mellitus in the Indian Parliament: A Thematic Analysis of Questions Posed in Lok Sabha and Rajya Sabha between 1999 and 2019.

BACKGROUND: Analysis of discourse on diabetes mellitus in Lok Sabha and Rajya Sabha could give insight on the priority attention of policy-makers. OBJECTIVE: Our aim was to elicit trends in discourse on diabetes mellitus in the Indian Parliament that could have shaped and/or resulted from policy and programmatic action over the past two decades, by thematically analyzing the content of Indian parliamentary questions posed to the Ministry of Health and Family Welfare (MOHFW), Government of India on diabetes mellitus during 1999-2019. METHODS: This descriptive study sourced the records of Parliamentary questions from the websites of Lok Sabha and Rajya Sabha during the period of 13th to 16th Lok Sabha (November 1999 to February 2019). Using the keyword, "Diabet," we sampled relevant questions posed to/by MOHFW in this study including their text and other relevant information and used a combination of content as well as thematic analyses approaches to synthesize and interpret the results. RESULTS: We derived a total of 232 question bundles featuring 930 questions. The frequency of questions on diabetes saw an increasing trend over the two decades. Four themes emerged: epidemiology and surveillance, population health programs, policy initiatives, and Research and Development (R and D). Questions posed in the latter years were more specific and solution-oriented unlike the initial years when these were rather broad-based and problem enumerative in nature. Within these themes, parliamentarians focused on the diabetes burden in the community, need for raising awareness, expanding testing facilities, strengthening drug regulation, and improving treatment affordability. There were fewer questions in R and D, rehabilitation, and integration of services themes. CONCLUSION: Trends in the questions posed in both the Houses of the Indian Parliament indicate India's increasing attention to diabetes mellitus in its legislative discourse. However, the number of questions on diabetes taken up in the Parliament is too low to infer on consistent trends in their impact on programmatic and policy action.

Screening Vaccinees for Non-Communicable Diseases and Risk Factors at a Covid-19 Vaccination Center in Vadodara, Gujarat.

Context: Adult population visiting COVID vaccination center is a potential teachable moment for screening and preventive advice on non-communicable diseases. Objectives: The objective of this study was to assess the proportion of vaccinees volunteering for screening and to know the proportion of newly detected hypertensives and diabetics among the screened vaccinees at COVID-19 vaccination center. Setting and Design: This descriptive, cross-sectional, operational research study was carried out at the COVID vaccination center at a medical college in central Gujarat from July to September 2021. Methods: After receiving the vaccine, the vaccinee was offered screening through a community-based assessment checklist for risk factors of non-communicable diseases, blood pressure, and blood sugar measurement. Those volunteering for this screening received a slip mentioning their risk score, blood pressure and blood sugar reading, and relevant health information and disease prevention advice. The study variables were acceptability (proportion of vaccinees volunteering for screening) and yield (newly detected hypertensives and diabetics among those screened). Results: Among vaccinees, 27.7% volunteered for risk scoring and blood pressure measurement, whereas 8.3% volunteered for blood sugar measurement. Around 15.5% of vaccinees had high-risk scores as per the community-based assessment checklist. The yield of freshly detected high blood pressure and high blood sugar was 19.3% and 10.5%, respectively. The yield was similar even among vaccinees under 30 years of age. Conclusions: Vaccinees demonstrated interest in undergoing screening for non-communicable diseases. Yield indicates that such screening is worth the effort.

Efficacy and safety of colchicine in COVID-19: a meta-analysis of randomised controlled trials.

BACKGROUND: Colchicine, an anti-inflammatory drug is prescribed nowadays for COVID-19. In this meta-analysis, we evaluated efficacy and safety of colchicine in patients with COVID-19. METHODS: We searched databases for randomised controlled studies evaluating efficacy and/or safety of colchicine as compared with supportive care in patients with COVID-19. The efficacy outcomes were mortality, ventilatory support, intensive care unit (ICU) admission and length of hospital stay. The safety outcomes were adverse events, serious adverse events and diarrhoea. A meta-analytical summary was estimated using random effects model through Mantle-Hanzle method. An I2 test was used to assess heterogeneity. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach was used to assess quality of evidence for each outcome. RESULTS: Out of 69 full texts assessed, 6 studies (16148 patients with COVID-19) were included in meta-analysis. Patients receiving colchicine did not show significant reduction in mortality (risk difference, RD -0.00 (95% CI -0.01 to 0.01), I2=15%), ventilatory support (risk ratio, RR 0.67 (95% CI 0.38 to 1.21), I2=47%), ICU admission (RR 0.49 (95% CI 0.19 to 1.25), I2=34%), length of hospital stay (mean difference: -1.17 (95% CI -3.02 to 0.67), I2=77%) and serious adverse events (RD -0.01 (95% CI -0.02 to 0.00), I2=28%) than those who received supportive care only. Patients receiving colchicine had higher rates of adverse events (RR 1.58 (95% CI 1.07 to 2.33), I2=81%) and diarrhoea (RR 1.93 (95% CI 1.62 to 2.29), I2=0%) than supportive care treated patients. The GRADE quality of evidence was moderate for most outcomes. CONCLUSION: The moderate quality evidence suggests no benefit of addition of colchicine to the standard care regimen in patients with COVID-19.

Prevalence and predictors of suicide ideation among undergraduate medical students from a medical college of Western India.

BACKGROUND: Looking at the background vulnerability and increasing incidence of suicides among medical students, more information on its burden and causes is needed. METHODS: A cross-sectional study was conducted at a medical college to assess prevalence of suicide ideation and associated factors among medical students. Data were collected through a web-based survey questionnaire using Patient Health Questionnaire-9 and items on suicide cognitions, suicide attempt history and risk factors. Bivariate and multivariate analyses were performed in SPSS. RESULTS: A total of 506 students (69.2%) responded to the survey questionnaire. The 2-week prevalence of depression and suicide ideation was 14% (73/506) and 9% (44/506). Proportion of participants reporting suicidal cognitions in preceding 1 month: life not worth living-13%; death wish-6%; suicidal ideas-4%; and suicide plan-1%. The significant predictors of suicide ideation were female gender (adjusted odds ratio [AOR] = 3.2, 95% confidence interval [CI] 1.6-49.1), alcohol use (AOR = 3.2, 95% CI 1.1-9.7), history of facing any type of abuse (AOR = 3.9, 95% CI 1.2-11.9), academic stress (AOR = 3.3, 95% CI 1-10.9), family-related stress (AOR = 5.6, 95% CI 1.8-17) and relationship-related stress (AOR = 3.5, 95% CI 1.1-10.8). Half of the students reported presence of academic stress as important life stressor. Three-fourth students preferred friends as their source of help in times of need. Web-based survey method for screening was acceptable to students. CONCLUSION: The prevalence of suicide ideation is alarmingly high among medical students. Academic stress, previous experience of abuse, stress originating from family expectations and strained relationship with friends and peers were found to be risk factors or predictors for suicidal ideation.

Image-based assessment in undergraduate dermatology curriculum: A step toward competency-based medical education.

BACKGROUND: Dermatology being a visual branch, there is a need to add a visual element in learning and assessment of dermatology. This study compares the utility of image-based assessment (IBA) as a new tool compared to routinely used semi-structured viva (SSV) in dermatology formative assessment at undergraduate level. METHODS: Comparison was made between batches of students in year 2018 who underwent clinical posting term ending assessment by IBA with the retrospective cohort of batch of students in year 2015 who underwent assessment by SSV. The students' marks in this assessment and their attendance were collected. Feedback was taken from batch of students who had undergone IBA assessment. Faculty feedback was also taken. RESULTS: Correlation of attendance with marks was higher in IBA batch compared to SSV. IBA is better able to assess the diagnostic skills which requires visual element and prescription writing skill. SSV can do an authentic assessment of clinical reasoning skills. IBA had higher variability in marks allotted to students suggesting that it was more objective tool whereas with narrow range of marks SSV was found to be more subjective. Both IBA and SSV had similar acceptability by students and faculty. IBA was more resource intensive at preparation stage while SSV was so in conduction stage. IBA had better educational impact, as it promoted learning through exposure to actual patients. CONCLUSION: IBA fared better in terms of validity, reliability, acceptability, and educational impact. In terms of feasibility IBA and SSV had differing challenges.

A structured mentorship program for medical college faculty on health research.

BACKGROUND: A paradigm shift is required in faculty development programs on research skills, from theory-driven to hands-on practical approach. The objective of this study was to develop and implement a structured mentorship model for training of medical faculties in research skills. METHODS: An interventional study using functional mentorship and experiential learning based on a research project was conducted over a period of one year through two prevalidated modules: protocol and manuscript writing. We included early and mid-career medical faculty as mentees (mentor:mentee ratio-1:2). Module 1 consisted of eight days of active learning and 25 days of refinement period-the end point being submission of research proposal to the ethics committee. Module 2 consisted of six days of active learning and 15 days of refinement period with the end point being manuscript submission to a peer-reviewed journal. Context, Input, Process and Product model of evaluation was used for this program. RESULTS: All eight faculty who participated as mentees in this program completed the first module, developed protocols under this program and processed them through the ethics committee. Six of the eight participants of this original cohort attended the second module and five could submit their manuscript to a peer-reviewed journal within the stipulated date. Participants expressed improvement in their self-rating of research skills, satisfaction with the program and an overall favourable change in attitude towards research. CONCLUSION: Structured mentorship program with the help of local mentors could enhance research skills of medical faculty.

Stigma, Discrimination, and Domestic Violence Experienced by Women Living with HIV: A Cross-sectional Study from Western India.

BACKGROUND: In India, social issues such as stigma and discrimination are still experienced by many women living with HIV (WLHIV) at various levels such as family, community, or health care settings even after a decline trend in HIV prevalence. OBJECTIVES: To assess stigma, discrimination, and domestic violence among WLHIV attending an antiretroviral therapy (ART) center and its association with unsafe sexual practices. MATERIALS AND METHODS: This cross-sectional study was carried out among WLHIV attending an ART center of a tertiary care hospital after obtaining approval from the institutional ethics committee. An interview schedule was used to collect data from WLHIV selected by systematic random sampling method on the day of interview. Data were collected after taking their written informed consent using a semistructured validated study instrument. Stigma and discrimination was assessed by a set of 7 and 11 closed-ended dichotomous-response questions, respectively. We measured self-reported occurrence of domestic violence and unsafe sexual practice. RESULTS: A total of 135 WLHIV were enrolled in this study. As high as 81% perceived stigma in their daily life while 41% reported to be discriminated. Domestic violence was experienced by 50.3% of the respondents. Majority of them (three-fourths) reported the type of violence to be physical as opposed to a quarter reporting sexual violence. Stigma, discrimination, and domestic violence were significantly associated with unsafe sexual practices. CONCLUSION: Social evils in the form of stigma, discrimination, and domestic violence are still faced by a remarkable proportion of WLHIV, and it has been found to be associated with unsafe sexual practices.

Cash transfer scheme for people with tuberculosis treated by the National TB Programme in Western India: a mixed methods study.

OBJECTIVES: This study aimed to assess the coverage and explore enablers and challenges in implementation of direct benefit transfer (DBT) cash incentive scheme for patients with tuberculosis (TB). DESIGN: This is a mixed methods study comprising a quantitative cohort and descriptive qualitative study. SETTING: The study was conducted in City TB Centre, Vadodara, Western India. PARTICIPANTS: We used routinely collected data under the National TB Programme (NTP) on patients with TB notified between April and September 2018 and initiated on first-line anti-tuberculosis treatment (ATT) to assess the coverage of DBT. We interviewed NTP staff and patients to understand their perceptions. PRIMARY AND SECONDARY OUTCOME MEASURES: The study outcomes are receipt of DBT (primary), time to receipt of first instalment of DBT and treatment outcome. RESULTS: Among 1826 patients, 771 (42.2%) had received at least one instalment. Significantly more patients from the public sector had received DBT (at least one instalment) compared with those from private sector (adjusted relative risk (adjRR)=16.3; 95% CI 11.6 to 23.0). Among public sector patients, 7.3% (49/671) had received first instalment within 2 months of treatment initiation. Median (IQR) time to receipt of first instalment was 5.2 (3.4, 7.4) months. Treatment in private sector, residing outside city limits and being HIV non-reactive were significantly (p<0.001) associated with longer time to receipt. Timely and sufficient fund release, adequate manpower and adequate logistics in TB centre were the enablers. Inability of patients to open bank accounts due to lack of identity/residence proof, their reluctance to share personal information and inadequate support from private providers were the challenges identified in implementation. CONCLUSION: During the early phase of DBT implementation, the coverage was low and there were delays in benefit transfer. Facilitating opening of bank accounts for patients by NTP staff and better support from private providers may improve DBT coverage. Repeat assessment of DBT coverage after streamlining of implementation is recommended.

Do primary care physicians require training in core clinical dermatology? A cross sectional needs assessment study from Western India.

BACKGROUND: Primary care physicians play a crucial role in managing patients with common skin disorders who form around one-third of outpatient attendees. AIM: This study aimed to assess the need for dermatology training among primary care physicians by assessing their knowledge, self-perception of ability to diagnose and manage skin disorders, and their difficulties in managing these patients. METHODS: A descriptive, cross-sectional, needs assessment study was done among primary care physicians (n = 61) of rural (n = 34) and urban (n = 27) areas of Vadodara district. A pre-validated semi-structured questionnaire (for self-rating of the ability to diagnose/manage skin disorders and difficulties faced in managing patients) was used along with a photo-quiz (for knowledge assessment) while approaching primary care physicians during their monthly review meeting with prior permission. Data were analyzed by Epi InfoTM software and manual content analysis. RESULTS: The mean score on the photo-quiz was 4.1/10. Forty-three (70.5%) participants rated their ability to diagnose/manage skin disorders as 'average' on a five-point Likert scale. Various difficulties (n = 89) narrated by participants were related to their knowledge/skill, disease factors, patients and administrative aspects. Three-fourths of the participants managed difficulties by referring patients to dermatologists. One-third suggested conducting training in common skin disorders. LIMITATIONS: The study population included primary care physicians from the government healthcare setup only. Knowledge assessment was done using a short ten-item photo-quiz instead of actual patients. CONCLUSIONS: Primary care physicians had poor knowledge of skin disorders, and a majority overrated their own ability for clinical management of these disorders. Most common difficulties faced were related to clinical management. There is a need for training on common skin disorders.

A novel approach to suicide prevention - Educating when it matters.

BACKGROUND: Looking at the burden of suicide, there is a dire need for medical schools to incorporate suicide prevention training. Effective communication helps in early detection and management of suicidal behavior. Medical students can act as a GATEKEEPER if they receive adequate training. METHODOLOGY: This was an educational intervention study done at tertiary care teaching hospital to assess the knowledge and attitude of medical students toward depression and suicide and to impart and assess communication skills for suicide prevention in one of the four batches of students in 4th semester. Pretest was conducted to assess knowledge and attitude toward depression and suicide, followed by training using interactive lectures, demonstration of interview, and hands-on training with patients and role-plays. The posttest and objective structured clinical examination (OSCE) were administered for skill assessment. Feedback was taken regarding this intervention. RESULTS: The mean marks of the pre- and post-test were 8.96 (8.3-9.6) and 14.58 (13.8-15.3), respectively, out of 25. The difference was statistically significant (t = 13.24, P ≤ 0.0001) which suggests improvement in knowledge. We found mixed responses in attitude statements showing limited change. Mean obtained marks on OSCE examination out of 66 was 42.7. Among various components of OSCE, students scored high on rapport building. The most useful components of trainings were role-play, OSCE, and interaction with patients as per their feedback. CONCLUSION: The intervention was found effective in increasing knowledge, changing attitude, and enhancing communication skills of medical students toward suicide prevention. Training of communication skills for suicide prevention in depressed person should be given to every medical student as suggested by feedback.

Attitudes of undergraduate medical students toward mental illnesses and psychiatry.

BACKGROUND: Worldwide, studies show negative attitude among medical students toward psychiatry and mental illness. The knowledge of the attitude and awareness of the undergraduate medical students toward psychiatry, mental health, and psychiatric disorders are most important as they are going to be involved in the care of these patients either directly or indirectly during the later years of their careers. AIM: This study aims to assess attitude toward psychiatry and mental illness among undergraduate medical students. METHODOLOGY: The responses of 67 medical students from the 6th semester (third professional year) batch who completed their 2-week clinical posting of psychiatry in 4th semester (i.e., second professional year) were collected using validated questionnaires, attitude towards mental illness (AMI), and attitude towards psychiatry (ATP) that assessed their attitudes to psychiatry and mental illness. Double data entry and validation were done using EpiData and analysis using Epi Info software. RESULTS: Median AMI score was 54 (out of maximum 100) showing a neutral AMI. Median ATP score was 82 (out of maximum 150) also showing a neutral ATP. The theme-wise analysis showed that the attitude of students toward psychiatrist and psychiatry branch was relatively better compared to their AMI. CONCLUSION: Undergraduate students have a neutral attitude to psychiatry and mental illness. More efforts are needed to change the attitude to favorable side.

'M-TRACK' (mobile phone reminders and electronic tracking tool) cuts the risk of pre-treatment loss to follow-up by 80% among people living with HIV under programme settings: a mixed-methods study from Gujarat, India.

BACKGROUND: In 2016, the National AIDS Control Programme (NACP) in Gujarat, India implemented an innovative intervention called 'M-TRACK' (mobile phone reminders once every week for four weeks after diagnosis and electronic patient tracking tool) to reduce pre-treatment loss to follow-up (LFU) among people living with HIV (PLHIV) in Vadodara district while other districts received standard of care. OBJECTIVES: To assess the effectiveness of M-TRACK in reducing pre-treatment LFU (proportion of diagnosed PLHIV not registering for HIV care by four weeks after diagnosis) and to explore the implementation enablers and challenges from health care providers' and PLHIV perspective. METHODS: An explanatory mixed-methods study design was used wherein the quantitative phase (cohort study with two groups: Vadodara district exposed to M-TRACK and Rajkot district as unexposed) was followed by a qualitative phase (descriptive study involving group interview with 16 health care providers, personal interviews with two programme managers and telephonic interviews with 16 PLHIV). Data were collected during October 2016 to February 2017. RESULTS: During the pre-M-TRACK period (July-September 2016), the LFU proportion was similar [13% (25/191) in Vadodara; 15% (21/141) in Rajkot (p = 0.8)]. During the M-TRACK period (October-December 2016), LFU decreased to 4% (9/209) in Vadodara (exposed), whereas it remained similar at 16% (18/113) in Rajkot (unexposed) district (p = 0.02). PLHIV exposed to M-TRACK had an 80% lower risk of LFU (aRR 0.2; 95% CI: 0.1-0.5) compared with standard care, after adjusting for socio-demographics, time and clustering at district level. During interviews, M-TRACK was welcomed by both PLHIV and the counsellors. The latter felt it saved time by obviating the need for home visits and helped in documentation. Inconvenience of using landline phone available at the health facility, lack of budgets for reimbursement of mobile call expenses and internet connectivity problems were the key implementation challenges. CONCLUSION: M-TRACK was highly effective in reducing the gap between diagnosis and treatment. It may be considered for scale-up after addressing the challenges noted.

Process evaluation of child health services at outreach sites during health and nutrition day (Mamta Day) in urban slums of Western India.

INTRODUCTION: Health indicators of rural and urban India show a wide variation. Rural areas have received large focus in child health services, but on the flip side, urban areas have been the last to receive such attention. MATERIALS AND METHODS: A cross-sectional study was conducted to include one randomly selected outreach session from all the 19 urban primary health centers of Vadodara city from April 2013 to May 2014. Nineteen session sites were observed for the process evaluation of three components of child health care, namely, "planning of Health and Nutrition Day," "availability of vaccines/logistics," and "direct observation of actual immunization process" at the site using a structured checklist. RESULTS: Most of the vaccines and logistics were present at all 19 sites visited, but adverse events following immunization kit were observed at ten sites (52%) only. Open vial policy, no-touch technique, and immediate cutting of syringe with hub cutter were implemented at all sites; however, completely filled Mamta Card was observed at 9 (47%) sites only. All four key messages were given at 5 (26%) sites only. CONCLUSION: Immunization services such as proper vaccine administration with no-touch technique and open vial policy were mainly focused; however, other services such as biomedical waste management, record keeping, and delivery of all four key messages need to be strengthened during Mamta Divas. Strengthening of other child health care services such as growth monitoring, Integrated Management of Neonatal and Childhood Illnesses, and referral services is required in urban areas.

Is "modular" the way to go for small group learning in community medicine in undergraduate clinical postings?

CONTEXT: There is a need to shift from the didactic lecture-based instruction to more student-centered active learning methods for undergraduate teaching in community medicine. AIMS: To compare didactic and modular method of learning on Level 1 and 2 on Kirkpatrick's training evaluation model. SETTINGS AND DESIGN: This was a two-arm educational intervention study for a small group of the 2(nd) year MBBS students in their 4(th) semester during clinical posting in the subject of community medicine. SUBJECTS AND METHODS: The topic chosen was "rabies prophylaxis" in the 2(nd) clinical posting during 4(th) semester. With permission from Institutional Ethics Committee, first batch of 17 students was taught this topic by didactic method. Next batch of 22 students was taught by the modular method. A self-reading module was prepared for this study and validated by three teachers. What was different in modular teaching was a circular sitting arrangement, module reading by students, video presentation, and exercise using case vignettes. STATISTICAL ANALYSIS USED: Student's t-test was used for pre- and post-test score comparison and Mann-Whitney U-test for students' responses on Likert scale. RESULTS: The mean gain in obtained marks after modular learning (7.9/15) was significantly higher as compared to gain after didactic teaching (5.9/15) (P = 0.0038); more students asserted to be confident to manage a case in modular group compared to the didactic group (P < 0.05) indicating a higher level of learning through modular teaching. CONCLUSIONS: Modular teaching fares better than didactic method and hence should be used more frequently in community medicine clinical posting.

A survey on oral hygiene methods practiced by patients attending Dentistry Department at a Tertiary Care Hospital from Central Gujarat.

OBJECTIVE: Oral hygiene is important not only for maintaining health of teeth and gingivae in an individual but also for good and uneventful regeneration and healing of tissues, when one has undergone one or other dental treatments. This makes it important to have an understanding of oral hygiene practices employed by the population. MATERIALS AND METHODOLOGY: This descriptive cross-sectional hospital-based survey was carried out to know oral hygiene methods practiced by patients who visited Department of Dentistry at a Tertiary Care Hospital attached to medical college from Central Gujarat. While examining and recording their history, their mode of oral hygiene practice was also noted. Recorded data were entered in Microsoft Excel and analyzed in SPSS Statistics Version 17.0. The study reports proportions of the variables under study in percentages. RESULTS: The patients ranged from 4 to 80 years in age with equal numbers from both genders. The number of participants using modern and scientific material and instrument for oral hygiene was good. However, majority of them performed it only once a day, and none after every meal or at bed time. CONCLUSION: There is a need to improve the frequency of oral hygiene procedure among the studied population as well as use of dental floss needs to be increased.

Evaluation of input and process components of quality of child health services provided at 24 × 7 primary health centers of a district in Central Gujarat.

CONTEXT: With the critical Indian challenge on child survival and health, time is ripe to initiate focus on quality of services apart from measuring coverage, to bring about improvements. AIMS: To assess the quality of child health services provided at 24 × 7 Primary Health Centers of Vadodara District in Gujarat in terms of Input and Process Indicators. SETTINGS AND DESIGN: The study was carried out in 12 randomly chosen 24 × 7 Primary Health Centers (PHCs) of Vadodara district using a modified quality assessment checklist of the Program on District Quality Assurance for Reproductive and Child Health (RCH) services with use of scores from May 2010 to June 2011. SUBJECTS AND METHODS: Inputs assessment was done by facility survey. Process assessment for the four child health service components used actual observation of service, review of records and interview of service providers and clients. RESULTS: The mean obtained score for facilities in Input section was 65%. Highest score was obtained for Drugs and Consumables (86%) followed by Equipments and Supplies (74%). The score obtained for Infrastructure facility was 65%, Personnel and training was 56% and Essential protocols and guidelines scored 43%. The mean obtained score in the process section was 55%. Highest scores were obtained for immunization at 76%. This was followed by newborn care (52%), growth monitoring (52%). management of sick child (41%). CONCLUSION: Quality improvement efforts should focus not only on resource-intensive structural improvements, but also on cost-effective measures at improving service delivery process, especially adherence to service guidelines by providers.