Barriers Faced by Healthcare Providers during Home Visits of Palliative Care Patients - A Qualitative Study.

Objectives: We, the Department of Community Medicine, have been training healthcare providers for palliative care in the hospital and community setting. There were many difficulties in providing proper palliative care. The objective is to explore the various difficulties faced by Junior Residents, auxiliary nurse and midwife (ANM) and medical social workers (MSWs) during the home visits of palliative care patients and to address those difficulties in future visits. Materials and Methods: The study was conducted in our peripheral institutions such as the Rural Health Training Centre and the Urban Health Training Centre among Junior Residents, ANMs and MSWs who had provided palliative care for the patients. Qualitative study design includes participatory research action techniques such as force field analysis, cobweb diagram, and pairwise ranking, and Systematic techniques include the Delphi technique. Results: Indicators for difficulties faced by Junior Residents were derived and plotted based on priorities and joined to form a cobweb diagram. Difficulties were time constraints, lack of resources such as medications and transport facilities, need for specialist care, and non-adherence to the advice. Driving force and restraining force for palliative care were derived and plotted on the force field analysis. The favourable factors in providing palliative care services of the healthcare providers are self-satisfaction with treating the patient, satisfaction due to treatment at the doorstep, understanding the patient's psychological or social factors affecting their health, skill development and counselling of the patient. The restraining factors in providing palliative care services of the healthcare providers are time constraints, lack of resources, patient not following the advice properly, improper care by caregivers and unable to fulfill certain needs of the patient. Pairwise scoring/ranking was done for MSWs by plotting the issues faced in palliative care visits in rows and columns. The difficulties were time constraints, lack of resources, lack of proper knowledge of staff and need for specialist care. The possible potential solutions derived from the Delphi technique were proper planning to reduce time constraints and intense counseling of patients on adherence to treatment. Conclusion: It helped to identify the difficulties faced by healthcare providers and to plan for solutions in future palliative home care visits.

Red Ribbon Club inculcation of positive deviance approach to promote blood donation among undergraduate medical college students.

BACKGROUND: Blood is an essential part of human life and blood donation has become a necessity that every society must take into consideration. Health care professionals have a major responsibility in raising community awareness on blood donation. OBJECTIVE: This study aims to find out the knowledge and attitude of undergraduate medical students on blood donation and to determine the effectiveness of positive deviance (PD) approach. METHODOLOGY: This institutional based cross-sectional study was conducted as a part of World AIDS Days celebration by Red Ribbon club among 414 undergraduate students using convenient sampling technique. A baseline and endline survey were conducted using a pre-structured validated questionnaire. To address the knowledge gap PD approach was used for the students who had voluntarily donated blood, volunteered in providing health education, and shared their experience to their peers. Ethical principals were adhered. RESULTS: The mean age of the students was 20.4 ± 1.2 years. Most respondents had moderate knowledge on blood donation and positivity attitude towards the same. The key finding of our study is that about 45 students (10.9%) have donated blood till now. As a result of PD training session more than half of them volunteered to donate blood in the future. CONCLUSION: This study shows that awareness about blood donation were minimal among the medical students with misconceptions. After PD approach, the willingness was increased from 10% to 66%. Thus, PD approach builds capacity and leadership in volunteers is considered as the best approach for behavior change among their own peers.

Factors related to parental COVID-19 vaccine hesitancy for children: An exploratory factor analysis model.

Introduction: This pandemic has been accompanied by an overabundance of information and misinformation, an 'infodemic' on a global scale which have made acceptability of COVID-19 vaccine a major challenge. The objective of the study was to find out the Beliefs of mothers towards COVID-19 vaccine for children and its impact on vaccine hesitancy. Materials and Methods: After obtaining Institutional ethical clearance and informed consent, a total of 360 mothers who were having at least one child from 5 to 18 years were recruited based on simple random sampling. Face-to-face interview was conducted. The questionnaire was based on the WHO-SAGE working group on vaccine hesitancy. Based on Bartlett's test of sphericity, the model was found to be fit (there is adequate number of correlations for factor analysis) and KMO test results imply the samples are adequate for factor analysis. K means cluster analysis was used to divide the samples into three clusters and individual respondent's cluster membership was also identified. Results: It was found 49.4% of mothers were hesitant to vaccine their children against COVID-19. The seven items (reasons for vaccine hesitancy) were grouped into three dimensions (believes in vaccine effectiveness but concerned about side effects, believes in the importance of taking COVID vaccine, trusts information about COVID vaccine), based on how each item loads on to each of three factors. Cluster 1 was that they believe in effectiveness of vaccine but are concerned about side effects (.92094). Conclusion: Mothers' concerns were mainly about the safety and adverse effects of vaccine.

Effectiveness of ayurvedic formulation, NAOQ19 along with standard care in the treatment of mild-moderate COVID-19 patients: A double blind, randomized, placebo-controlled, multicentric trial.

BACKGROUND: Medicines in indigenous systems such as Ayurveda have strong antimicrobial activity but double-blind randomized control trials are infrequent in this system of medicine. The efficacy of a new ayurvedic formulation was evaluated during the pandemic. METHODS: 150 mild-moderate COVID-19 patients were enrolled and randomized in 1:1 to NAOQ19 and placebo group. RT-PCR was done on Day 3, 5 and 7. CBC, CRP, LFT, and KFT were assessed at baseline and exit. Duration of hospital stay was noted and clinical assessment was also performed. RESULT: The results demonstrated more people turning RT-PCR negative in the NAOQ19 group compared to the placebo group on day 3 (p-value = 0.033). The mean time duration to turn RT-PCR negative was significantly lower in the NAOQ19 group (4.6 days) compared to placebo group (5.2 days) (p-value = 0.018). There was significant reduction in hospital stay among patients in the NAOQ19 arm who were discharged earlier (5.6 days) compared to placebo group (6.4 days) (p-value = 0.046). Patients in NAOQ19 arm did not show any adverse life-threatening events. CONCLUSION: The ayurvedic preparation given along with standard of care therapy reduced the duration of hospital stay and there was earlier conversion to RT-PCR negative.The integrated approach can help to reduce patient workload in the hospitals as well as limit the transmission of the virus in the community. STUDY REGISTRATION: CTRI/2021/05/033790.

Effect of Self-Directed Learning Module and Assessment on Learning of National Health Programme by Medical Undergraduates - A Mixed Methods Evaluation.

Background: Competency-based medical education (CBME) curriculum in India has introduced many new concepts like a foundation course, early clinical exposure, and self-directed learning (SDL). Sometimes SDL simply means self-study. Self-directed learning as defined by Knowles is a process in which individuals take the initiative with or without the help of others in diagnosing their learning needs, setting their own learning goals, identifying appropriate learning resources, and selecting appropriate learning strategies. SDL is seen as a prerequisite for life-long learners, especially medical graduates. We found poor uptake of SDL sessions in terms of learning and attendance by students. To develop and assess the effect of the SDL module in Community Medicine for Phase -3 MBBS students. Materials and Methods: The study design was a program development and evaluation design. The program development consists of free listing and Nominal Group Technique (NGT). The evaluation design consists of a formative assessment, an end-of-module assessment, and feedback from undergraduate students, postgraduates, and faculties. Data collection procedure: SDL module was developed, agreed and implemented among undergraduates of Phase - 3 MBBS students. Results: Free listing was conducted among undergraduate students who had completed the phase 3 MBBS examination and Nominal Group Technique was conducted among the faculties (n = 7) and Postgraduates of the Department of Community Medicine (n = 2) to explore the appropriate topics for SDL in Community Medicine. The topic with the highest ranking and which was finalized for preparation of the SDL module was "National Health Programme". Three fourth 118 (75%) of the students scored ≥50% at the end of the module assessment. Manual content analysis for the feedback was categorized into three themes such as facilitating factors, challenges, and solutions. Conclusions: Effective implementation and assessment of SDL sessions are one of the new concepts in the CBME curriculum.

Traditional Newborn Care Practices in a Tribal Community of Tamilnadu, South India: A Mixed Methods Study.

Background and Objectives: Traditional newborn rearing practices play a vital role in neonatal morbidity and mortality. In this context, a concurrent mixed method study was conducted to identify the traditional practices in newborn care in tribal villages of Sittilingi Panchayat of Tamil Nadu, South India. Methods: The quantitative data were collected by a community-based cross-sectional study among 59 mothers of infants. Qualitative component included two focus group discussions (FGD) each with seven mothers and one traditional dai. Results: About 38.9% of newborns received colostrum, and 61.1% had prelacteal feeds. Majority (84.7%) of newborns had received appropriate thermal care. More than two-thirds (71.2%) of newborns were given bath before umbilical cord dropped off. During bathing, 83.1% were massaged and 67.8% had their vernix removed. Practice of blowing into nostrils (45.7%), substance application on the cord (94.9%), tepid sponging during fever (28.8%), sweet flag application over umbilicus for colic (8.5%), herbal medications during diarrhea (40.6%) and cold (25.4%), exposure to sunlight (67.8%) during jaundice, oil instillation in nostrils (76.3%), and ears (32.2%) to protect against infection were reported. Majority reported approaching traditional health practitioners during illness. Similar practices were reported in the FGDs. The beliefs related to these practices were explored. Conclusion: Both beneficial and harmful practices in newborn care were identified. Primary health care workers like ASHAs could be trained to recognize traditional newborn practices in their field areas to deliver appropriate behavior change communication to preserve safe practices and avoid harmful practices to improve newborn health.

Soil-Transmitted Helminth Infections among Antenatal Women in Primary Care Settings in Southern India: Prevalence, Associated Factors and Effect of Anti-Helminthic Treatment.

Community-based studies from India on prevalence of soil-transmitted helminth (STH) infections have reported estimates as high as 50% in children. However, prevalence estimates during pregnancy in India are lacking. We aimed to describe the burden, associated factors of STH and cure rate after deworming in primary care settings. Pregnant women were recruited from four urban and five rural centers in Puducherry, South India, from December 2019 to April 2022. One stool sample was collected from each participant before deworming and one repeat sample was collected from STH positive woman after three weeks of deworming. The samples were processed with saline; iodine wet mount, and microscopic concentration techniques. Cure rate (CR) was assessed using Kato-Katz thick smear. Of 650 women included, 49 (7.5%, 95% CI 5.6-9.8) had one of the STH infections; the prevalence of Ascaris lumbricoides, hookworm and Strongyloides was 5.4%, 1.8% and 0.3%, respectively. The prevalence of any STH was higher among ages 26-30 years (9.1%), working women (8.3%), multigravida (8.3%), urban setting (8.3%), those who did not wash their hands before food (9%) and anemic women (8.9%), compared to their counterparts, but not statistically significant. The CR for hookworm was 100% and Ascaris lumbricoides was 88.6%. To conclude, the prevalence of STH was low among pregnant women compared to school aged children. Continued deworming activities along with improved sanitation could further reduce the burden.

Down referral and assessing comprehensive diabetes care in primary care settings: An operational research from India.

BACKGROUND AND AIMS: In this study, we aimed to refer eligible (patients with stable blood sugar and without any history of cardiovascular events or proliferative retinopathy) and willing persons with diabetes (PwDs) to primary healthcare centers (PHCs) from tertiary care and to compare the care indicators. METHODS: This before-after interventional study was conducted among PwDs aged ≥18 years at a tertiary care hospital in South India. Care indicators (regularity to the clinic, waiting time, and blood sugar control status) were assessed before down referral and after three months of follow-ups at PHCs. RESULTS: Of 204 PwDs referred to PHCs. Among them, 88% (n = 180) registered at PHCs for care and 46% (n = 94, 95% CI 39.1-53.2%) were lost to follow-ups at PHCs. The main reason for loss to follow-ups was the unavailability of medicines at PHCs(n = 41, 44%). Among those who were on regular follow-ups at PHCs, there was no significant difference in fasting blood glucose (FBG) control status compared to tertiary (52%-64.6%, p = 0.083). However, there was a significant improvement in the regularity of clinic visits (75% vs. 100%, p < 0.001), consultation waiting time (90 vs. 60 min, p = 0.028), and waiting time at pharmacy queues (120 vs. 30 min, p < 0.001) between tertiary care and PHCs. However, among those registered at PHCs, only 40.6% (n = 73, 95% CI 33.3-48.1) were willing to continue care at PHCs for their diabetes management. CONCLUSION: Primary care was better than tertiary care in terms of PwD's regularity of clinic visits and waiting time for care.

Exploration of Barriers and Possible Solutions for Nonutilization of Facility-based Integrated Counseling and Testing Center Using the Delphi Technique.

BACKGROUND: A major group of the population, especially antenatal checkup (ANC) mothers and their spouses, people admitted for surgery, and people attending STI clinics, are reluctant to pretest counseling. OBJECTIVES: This study has been taken up to explore the barriers and possible solutions to improve the utilization of Facility based integrated counseling and testing center (F-ICTC) counseling services. MATERIALS AND METHODS: Phase 1: In-depth interview and ranking with stakeholders from the F-ICTC center (n = 13) were conducted to identify the barriers to utilization of F-ICTC and solution for the same. Phase 2. A: Delphi panel with experts (n = 17) was invited through mail to find out the potential solution to improve the utilization of F-ICTC counseling services. RESULTS: Possible barriers from the stakeholders' perspectives were fear of the disease, violate the privacy, unacceptance, gender bias, fear of social stigma and discrimination, and neglect attached to the disease. At third round of Delphi experts had arrived at a consensus regarding of following possible potential solutions: 1. Those who refuse pretest counseling they should be asked to answer a set of questions(which are usually told during counseling), only those questions not answered correctly by them can be corrected, 2.conducive hospital environment, 3.zero discrimination policy, 4. group counseling for ANC mothers and patients in waiting area of the hospital,5. phone counseling for unwilling patients and relocation of testing center and health education camping. CONCLUSION: Context-specific proactive evidence-based intervention will help in improving the proper utilization of the F-ICTC center.

Decentralizing diabetes care from tertiary to primary care: how many persons with diabetes can be down-referred to primary care settings?

BACKGROUND: In a cohort of persons with diabetes (PWDs) seeking care at a tertiary care center, we aimed to determine the proportion of PWDs eligible and willing for down referral to primary health centers (PHCs). METHODS: We conducted a cross-sectional analytical study among PWDs on treatment for at least 1 year. PWDs with stable blood sugar, no history of cardiovascular events and proliferative retinopathy were considered as 'eligible' for primary care management. RESULTS: Of the total 1002 PWDs, mean (SD) age was 56 (12) years; 62% were male and 81% were from rural areas. About half (49%) of them were on insulin, and 52% had comorbidities. In total, 45.6% (95% CI: 42.3-48.8%) were eligible to be managed at PHCs. Among those who were eligible, 46.6% were willing to go back to PHCs. Males (APR = 1.16), people with diabetes for more than 10 years (APR = 1.23), and the presence of comorbidities (APR = 1.13) were significantly associated with unwillingness. Quality of medicines (46%) and poor facilities (40%) at PHCs were the main reasons for unwillingness. CONCLUSIONS: About half of the PWDs availing care at tertiary hospitals can be managed at primary care settings; of those, only half were willing to receive care at PHCs.

A Community-Based Study on Diabetes Medication Nonadherence and its Risk Factors in Rural Tamil Nadu.

CONTEXT: Medication nonadherence is common among diabetics and it is one of the leading public health challenges. AIMS: The aims of this study were to find the prevalence of nonadherence to diabetic medication and to identify various factors associated with it. SETTINGS AND DESIGN: This study was conducted in 34 villages of the field practicing areas of rural health training center. This was a mixed method study design. SUBJECTS AND METHODS: It was conducted among 328 type 2 diabetic patients. The quantitative data were collected from diabetic patients and qualitative data from health-care providers to identify their perceived barriers for patient's nonadherence. STATISTICAL ANALYSIS USED: Collected data were entered in Epi Info (3.5.3) and analyzed using SPSS version 24 software. RESULTS: The prevalence of low adherence to diabetic medication was 45.4% among the study population. Bivariate analysis shows significant association with the patients who are literate (odds ratio [OR] = 0.6, confidence interval [CI] = 0.38-0.95), hypertensive (OR = 1.6, CI = 1.04-2.5), taking treatment from private facility (OR = 0.54, CI = 0.34-0.87), perceived lack of satisfaction with doctor-patient relationship (OR = 3.3, CI = 1.3-8.3), and perceived lack of knowledge about diabetes (OR = 2.03, CI = 1.29-3.1) with low adherence to medication. CONCLUSIONS: The prevalence of nonadherence to medications is common among diabetics in rural areas, and there is a need to strengthen the primary health-care system in addressing barriers to achieve better health outcomes.

Learning experience of undergraduate medical students during ‘model preparation’ of physiological concepts / 한국의학교육

PURPOSE: Learning physiological concepts and their practical applications in the appropriate contexts remains a great challenge for undergraduate medical students. Hence the present study aimed to analyze the learning experience of undergraduate medical students during an active learning process of ‘preparation of models’ depicting physiological concepts. METHODS: A total of 13 groups, involving 55 undergraduate medical students with three to five individuals in each group, were involved in model preparation. A total of 13 models were exhibited by the students. The students shared their learning experiences as responses to an open-ended questionnaire. The students' responses were analyzed and generalized comments were generated. RESULTS: Analysis of the results showed that the act of ‘model preparation’ improved concept understanding, retention of knowledge, analytical skills, and referral habits. Further, the process of ‘model preparation’ could satisfy all types of sensory modality learners. CONCLUSION: This novel active method of learning could be highly significant in students' understanding and learning physiology concepts. This approach could be incorporated in the traditional instructor-centered undergraduate medical curriculum as a way to innovate it.

Evaluation of skill-based training program on rational drug treatment for medical interns.

CONTEXT: A module-based training program for medical interns using World Health Organization guide for good prescription along with the individual feedback on their prescription was developed and implemented. OBJECTIVE: The objective of the study was to obtain the medical interns' reactions to newly developed skill-based training program on rational treatment. STUDY SETTING: This study was conducted at the Department of Community Medicine. PARTICIPANTS: A total of 96 medical interns were included in the study. STUDY DESIGN: A cross-sectional study consisting of retro-prefeedback and open-ended questions about self-assessment of perceived skill on rational treatment. ANALYSIS: Collected data were entered in Epi Info (3.5.4) and analyzed. RESULTS: After training, there was a significant increase in self-perceived posttest scores of setting up the therapeutic objective for the treatment (2.9-4.9), ability to select the correct drug (2.8-5.1), ability to select right dose, schedule, and duration of drugs (2.5-4.9). and overall prescription skill (2.9-4.9). There is a significant decrease in self-perceived scores in the skill of practicing polypharmacy (4.1-2.5). CONCLUSIONS: Overall, the training program was taken well and interns perceived their skill on rational treatment was improved as shown by the feedback.