Prevalence of non-communicable chronic diseases in rural India amongst peri- and post-menopausal women: Can artificial intelligence help in early identification?

AIMS: To identify peri- and post-menopausal women at risk of non-communicable diseases in rural India and to assess their prevalence amongst these groups via the use of artificial intelligence. SETTINGS AND DESIGN: An observational study conducted by the Indian Menopause Society in collaboration with the Government of Maharashtra. The study included rural women residents of three villages in the Latur district of Maharashtra, India. MATERIALS AND METHODS: Accredited social health activist workers identified 400 peri- and post-menopausal women aged 45-60 years. Specific symptoms able to predict the presence of a non-communicable disease were identified through the use of artificial intelligence. STATISTICAL ANALYSIS USED: Descriptive statistics and predictive network charts analysis. RESULTS: The mean age of 316 women included in the analysis was 50.4 years and the majority of them were illiterate (68 %). The prevalence of dyslipidaemia, osteopenia, diabetes mellitus, obesity and hypertension were 58 %, 50 %, 25 %, 25 %, and 20 % respectively. None of their symptoms or laboratory reports could be significantly correlated directly with any of these non-communicable diseases. Hence, we used a cluster of symptoms to suggest the presence of hypertension, diabetes mellitus, osteoporosis and hypothyroidism via predictive network analysis charts. CONCLUSIONS: Screening of at-risk women can be done using an artificial intelligence-based screening tool for early diagnosis, timely referral and treatment of non-communicable diseases with the support of community health workers.

Correspondence article on the research protocol titled ' Towards Health Equity and Transformative Action on tribal health (THETA) study to describe, explain and act on tribal health inequities in India: A health systems research study protocol' published in Wellcome Open Research in December 2019.

Research on indigenous (Tribal) populations is a step towards understanding the various tribal health issues and challenges and paves the way for addressing these issues. However, such populations are categorised as vulnerable and marginalised according to National ethical guidelines by Indian council of medical research. Hence, adequate measures are needed to be ensured by researchers while undertaking any research involving tribal populations to safeguard the rights of research participants. The purpose of this correspondence is to initiate a discussion among the researchers to give due consideration to research ethics especially when the research is being conducted on vulnerable populations and take adequate safeguard measures as suggested by National ethical guidelines to protect the rights of study participants.

Health facility utilization and Healthcare-seeking behaviour of the elderly population in India.

Background: The increasing elderly population in India has generated an unmet need for healthcare services concerning them. To address some of those needs, the study aims to provide the current status of health facility utilization, health-seeking behaviour (HSB), and factors influencing them. Methodology: Data from the Longitudinal Ageing Study in India (LASI)-Wave I was used to conduct multivariate analysis to assess the association between health facility utilization (inpatient and outpatient) and HSB across all age groups of the elderly. Results: The likelihood of utilizing public health facilities increased with age for OPD and decreased with age for IPD. HSB was 23% less in the 80 years and above elderly as compared to other age groups. Healthcare service uptake was higher in the elderly with health insurance in a public health facility. Conclusion: Improving health insurance coverage among the Indian elderly may potentially improve healthcare service uptake in public health facilities.

A systematic review of excess all-cause mortality estimation studies in India during COVID-19 pandemic.

Background: Mortality statistics are fundamental to understand the magnitude of the COVID-19 pandemic. Due to limitation of real-time data availability, researchers had used mathematical models to estimate excess mortality globally during COVID-19 pandemic. As they demonstrated variations in scope, assumptions, estimations, and magnitude of the pandemic, and hence raised a controversy all over the world. This paper aims to review the mathematical models and their estimates of mortality due to COVID-19 in the Indian context. Methods: The PRISMA and SWiM guidelines were followed to the best possible extent. A two-step search strategy was used to identify studies that estimated excess deaths from January 2020 to December 2021 on Medline, Google Scholar, MedRxiv and BioRxiv available until 0100 h, 16 May 2022 (IST). We selected 13 studies based on a predefined criteria and extracted data on a standardised, pre-piloted form by two investigators, independently. Any discordance was resolved through consensus with a senior investigator. Estimated excess mortality was analysed using statistical software and depicted using appropriate graphs. Results: Significant variations in scope, population, data sources, time period, and modelling strategies existed across studies along with a high risk of bias. Most of the models were based on Poisson regression. Predicted excess mortality by various models ranged from 1.1 to 9.5 million. Conclusion: The review presents a summary of all the estimates of excess deaths and is important to understand the different strategies used for estimation, and it highlights the importance of data availability, assumptions, and estimates.

Rapid assessment of NCD services rollout in Health and Wellness Centres in North-Eastern Indian state: A cross- sectional study.

Background: The creation of health and wellness centres (HWCs) to deliver comprehensive primary healthcare (CPHC) is a programmatic response to the changing demographic and epidemiological profile in India. Since the north-eastern (NE) states face distinct challenges to routine healthcare services, and it has been two years since the rollout of non-communicable disease (NCD) services through the HWCs, a rapid assessment of the rollout with respect to all components of CPHC was undertaken in the NE state of Manipur. Methods: The assessment was undertaken using a mixed methodology to assess the rollout of NCD services under CPHC based on the functionality criteria of HWCs. The districts and the facilities were sampled purposively using pre-defined criteria. Primary data were collected using adapted pre-tested semi-structured tools and an interview schedule, which were triangulated with facility-based records and field observations. The data were anonymized, analysed thematically and presented under the domains of CPHC. Results: The assessment aided in identifying progress and challenges in the rollout of NCD services through the HWCs. Overall, the initiative was successful in generating demand and community awareness of the expanded range of services at the primary level. Yet, constraints posed by infrastructural gaps, logistical delays, training gaps, fund flow and weak community-level convergence compounded by the COVID-19 pandemic challenged seamless NCD service delivery. Conclusion: In as much as the attainment of universal health coverage is dependent on NCD prevention and control, the rollout of NCD services is dependent on strong institutional structures, especially at the primary level. The assessment highlights the need to strengthen the HWCs through adequate financing, human resources, logistics for medicines and technology, community participation, citizen engagement and change management.

Mid-level health providers (MLHPs) in delivering and improving access to primary health care services - a narrative review.

Background: For primary healthcare systems to bring care closer to the communities, the availability of appropriate human resources is crucial. The primary care workforce in the world is expanding to include non-physician health workers (NPHWs) to increase its capacity. Also, NPHWs as mid-level health providers (MLHPs) are currently being employed in high- and low-income countries to assist doctors and specialists to make up for the scarcity of health professionals. Given the wide prevalence in the deployment of NPHWs as mid-level health providers, this article collates recent evidence on the role of MLHPs in improving access to primary healthcare services, and their enablers and barriers in integrating them in primary care teams. The article also presents gaps in evidence and recommendations for the way forward. Methods: A systematic search of contemporary literature published from January 2012 to September 2022 was undertaken using two bibliographic databases (PubMed and Cochrane) and hand searching the reference list of retrieved papers. Duplicates, papers older than ten years, and whose focus was not on primary healthcare were excluded. The papers finalised for appraisal were scrutinised for key themes and their summaries were collated for analysis. The papers comprised of twenty-four quantitative, twenty-three qualitative, and nine mixed approach study designs (n = 56) due to which a narrative approach was conducted as per guidelines. Results: The review identified and presents the following themes - task shifting and its effectiveness in service delivery, quality of care, enablers and barriers of NPHWs in primary health care in both HIC and LMIC settings. Conclusion: Task-shifting interventions need effective engagement and constant coordination with relevant stakeholders. For this, policymakers, public health researchers, healthcare professionals of all cadres and community members need to be involved across all stages of introduction and absorption of the cadre into the primary healthcare delivery system.

Effect on essential health services during COVID-19 at the Primary level in India.

Background: Coronavirus diesease (COVID-19) led to increased demand on the Indian health system due to the pandemic as well as other communicable and non-communicable diseases. Guidance was thus issued by the Ministry of Health and Family Welfare (MoHFW), India, in April 2020 to maintain the delivery of essential health services. Objectives: To determine the extent of disruptions of essential healthcare services, identify associated factors, and establish pertinent correlations to address specific needs. Methods: The Mother and child tracking facilitation centre (MCTFC) conducted a telephonic survey with the front-line workers (FLWs) and beneficiaries in 21 Indian states. The sample size was determined using the infinite population sample size formula, and respondents were selected through a computer-generated random sequence technique. Data were quantitatively analysed using STATA-16. Descriptive univariate analysis was conducted using the Chi-square test. Findings: The majority of the essential health services were being satisfactorily delivered by FLWs (N = 1596; accredited social health activist (ASHA) = 798, auxiliary nurse midwife (ANM) = 798), where most of the beneficiaries (N = 1410; Pregnant Women = 708, Postnatal Women = 702) continued accessing services with minor issues concerning referral transport. FLWs reported issues in the provisioning of medicines (P = 0.000) for patients with non-communicable diseases and more ANMs than ASHAs reported it. FLWs commonly experienced challenges in extending services due to community resistance and unavailability of general health services at healthcare facilities, where a greater number of ASHAs faced it (P = 0.000). Both FLWs and beneficiaries (N = 3006; FLWs = 1596, beneficiaries = 1410) demonstrated appropriate COVID-19 knowledge and behavior. Conclusion: Although overwhelmed, the Indian health system performed satisfactorily well during pandemic in terms of essential health services.

Home-based newborn care (HBNC) under the national health mission in urban India - A cross country secondary analysis.

Background: There is a paucity of evidence in the coverage of the home-based newborn care (HBNC) program delivered through the National Urban Health Mission (NUHM). Hence, an analysis was undertaken to identify gaps and progress in its implementation and inform policy and strategies to achieve universal access to newborn services. Objectives: The study aimed to evaluate and understand the status of the HBNC program in urban areas of India through a health systems approach. Methods: Cross-sectional intra-country study was undertaken based on facility records and supporting literature available in the public domain. After categorizing the states into four groups, the programme's status in urban areas was analysed and presented in median and interquartile ranges. Statistical significance in the difference between the medians across the groups was checked using the Kruskal Wallis test. Results: Overall, the median full HBNC coverage was less than one-fifth (< 20%) of the total reported live births (P = 0.17). Excepting the union territories (UTs), the median coverage was found to be less than one-fifth (< 20%) of the reported institutional deliveries (P = 0.16) and more than half (> 50%) of the reported home deliveries (P = 0.83) in urban areas. The differences in the medians across the groups were not statistically significant. Conclusion: The differential coverage calls for strengthening referral linkages to specialized newborn care facilities, ensuring skilled personnel at varying levels of facilities, and improving the engagement of frontline workers in urban communities under the NUHM.

Factors influencing life satisfaction and discrimination among the elderly in India.

India is moving toward a demographic transition which leads to more elderly population than younger. Maximum life satisfaction (LS) and minimum discrimination are necessary to have healthy aging. The secondary data analysis was conducted to assess the perceived LS and discrimination among the elderly based on Longitudinal Aging Study in India (LASI). Data from the LASI-Wave I were used to analyzing to assess the LS and discrimination and factors associated with them. This study reported that the majority of the elderly were satisfied with their life and does not face any kind of discrimination; however, various factors affect them. LS was positively associated with the level of Monthly per capita consumption expenditure quintile, and education, self-rated good health. Furthermore, refraining from alcohol and tobacco positively influence the LS among the elderly. The factors responsible for more LS among the elderly were education, money, social support, and a healthy lifestyle.

What is the out-of-pocket expenditure on medicines in India? An empirical assessment using a novel methodology.

The share of expenditure on medicines as part of the total out-of-pocket (OOP) expenditure on healthcare services has been reported to be much higher in India than in other countries. This study was conducted to ascertain the extent of this share of medicine expenditure using a novel methodology. OOP expenditure data were collected through exit interviews with 5252 out-patient department patients in three states of India. Follow-up interviews were conducted after Days 1 and 15 of the baseline to identify any additional expenditure incurred. In addition, medicine prescription data were collected from the patients through prescription audits. Self-reported expenditure on medicines was compared with the amount imputed using local market prices based on prescription data. The results were also compared with the mean expenditure on medicines per spell of ailment among non-hospitalized cases from the National Sample Survey (NSS) 75th round for the corresponding states and districts, which is based on household survey methodology. The share of medicines in OOP expenditure did not change significantly for organized private hospitals using the patient-reported vs imputation-based methods (30.74-29.61%). Large reductions were observed for single-doctor clinics, especially in the case of 'Ayurvedic' (64.51-36.51%) and homeopathic (57.53-42.74%) practitioners. After adjustment for socio-demographic factors and types of ailments, we found that household data collection as per NSS methodology leads to an increase of 25% and 26% in the reported share of medicines for public- and private-sector out-patient consultations respectively, as compared with facility-based exit interviews with the imputation of expenditure for medicines as per actual quantity and price data. The nature of healthcare transactions at single-doctor clinics in rural India leads to an over-reporting of expenditure on medicines by patients. While household surveys are valid to provide total expenditure, these are less likely to correctly estimate the share of medicine expenditure.

Adding health to years: A review of the National Programme for Health Care of the Elderly (NPHCE) in India.

The global share of elderly persons (60 years and above) is expected to rise from 13.4% in 2020 to 21.3% by 2050. In India, the elderly population accounts for 8.6% of the total population. A large share of responsibility on ensuring the health and well-being befalls on the government. Driven by the vision of healthy ageing, the National Programme for the Health Care of Elderly (NPHCE) was launched in 2011 by the Ministry of Health and Family Welfare. Yet, its effective implementation is challenged by the changing landscapes and epidemiological transitions. This review article explores the progress of elderly care with NPHCE, with a special focus on its implementation status, service delivery, and human resources to provide future directions for the program. It primarily uses the Common Review Mission Reports (2007-2019), archival sources from government websites, and relevant literature from PubMed, MEDLINE, and Google Scholar to provide an informed perspective of elderly care in India. We conclude that NPHCE requires strengthening through collaborative action between the relevant stakeholders. Strong implementation of appropriate policies and programs to address health care challenges of the ageing population is of crucial importance for India to achieve the health care needs of its elderly. As the elderly population is set to grow dramatically in the next few decades, this review article reveals areas needing urgent attention to strengthen elderly care through NPHCE in India.

A rapid review of evidence on the determinants of and strategies for COVID-19 vaccine acceptance in low- and middle-income countries.

BACKGROUND: Vaccine acceptance and hesitancy among the general population and health care workers play an important role in successfully controlling the Coronavirus Disease (COVID)-19 pandemic. While there is evidence for vaccine hesitancy across the globe, wide variation in factors influencing vaccine acceptance has been reported, mainly from High-Income Countries (HIC). However, the evidence from Low- and Middle-Income Countries (LMICs) remains unclear. The objective of this review was to describe the determinants of vaccine acceptance and strategies to address those in an LMIC context. METHODS: The World Health Organization's (WHO) Measuring Behavioral and Social Drivers of Vaccination (BeSD) Increasing Vaccination Model was employed to identify factors that influenced vaccine acceptance. All evidence related to supply-side and demand-side determinants and social and health system processes were examined. A comprehensive search for published literature was conducted in three databases and grey literature in relevant websites of government, multinational agencies, and COVID-19 resource aggregators, followed by a narrative synthesis. RESULTS: Overall, the results showed that the vaccine acceptance rates differed across LMICs, with a wide variety of reasons cited for vaccine hesitancy. Vaccine acceptance was reportedly greater among males, those with higher education, elevated socio-economic status, the unmarried, those employed as health care workers. Evidence suggested that exposure to misinformation about COVID-19 vaccines and public concerns over the safety of vaccines may contribute to lower acceptance rates. Strategies to increase vaccine acceptance rates included direct engagement with communities through influencers, including community leaders and health experts; clear and transparent communication about COVID-19 vaccines, financial and non-financial incentives; and strong endorsement from health care workers. Trust in government was identified as a significant enabler of vaccine acceptance. CONCLUSIONS: There is a need for measures to address public acceptability, trust and concern over the safety and benefit of approved vaccines. Local context is essential to consider while developing programs to promote vaccine uptake. The governments worldwide also need to strategize to develop plans to address the anxiety and vaccine related concerns of community regarding vaccine hesitancy. There is a need for further research to evaluate strategies to address vaccine hesitancy in LMIC.

Is India's public health care system prepared for cervical cancer screening?: Evaluating facility readiness from the fourth round of the District Level Household and Facility Survey (DLHS-4).

India's cervical cancer screening program was launched in 2016. We evaluated baseline facility readiness using nationally representative data from the 2012-13 District Level Household and Facility Survey on 4 tiers of the public health care system - 18,367 sub-health centres (SHCs), 8540 primary health centres (PHCs), 4810 community health centres and 1540 district/sub-divisional hospitals. To evaluate facility readiness we used the Improving Data for Decision Making in Global Cervical Cancer Programmes toolkit on six domains - potential staffing, infrastructure, equipment and supplies, infection prevention, medicines and laboratory testing, and data management. Composite scores were created by summing responses within domains, standardizing scores across domains at each facility level, and averaging across districts/states. Overall, readiness scores were low for cervical cancer screening. At SHCs, the lowest scores were observed in 'infrastructure' (0.55) and 'infection prevention' (0.44), while PHCs had low 'potential staffing' scores (0.50) due to limited manpower to diagnose and treat (cryotherapy) potential cases. Scores were higher for tiers conducting diagnostic work-up and treatment/referral. The highest scores were in 'potential staffing' except for PHCs, while the lowest scores were in 'infection & prevention' and 'medicines and laboratory'. Goa and Maharashtra were consistently among the top 5 ranking states for readiness. Substantial heterogeneity in facility readiness for cervical cancer screening spans states and tiers of India's public healthcare system. Infrastructure and staffing are large barriers to screening at PHCs, which are crucial for referral of high-risk patients. Our results suggest focus areas in cervical cancer screening at the district level for policy makers.