Estimating true burden of disease detected by screening tests of varying validity.

Timely and accurate information on disease load is essential for planning health programs. Unfortunately, complexity, cost and need of skilled personnel limit the use of screening tools of high validity in developing countries. The disease load estimated with tools of low validity differs considerably from true disease load, particularly for diseases of extreme levels of prevalence/incidence. A tool of 70% sensitivity and specificity may yield a prevalence/incidence rate of 34% (CI: 32.23-35.67%) for a disease whose true rate is only 10.0% (CI: 8.94-11.06%). We proposed a procedure to derive the true estimate in such cases, based on the concepts of sensitivity and specificity of a diagnostic/screening test. It is applied on two sets of real data--one pertaining to incidence rate of low birth weight (LBW) and the other to prevalence rate of obesity--where multiple screening tests of varying validity were used to estimate the magnitude. Different screening tests yielded widely varying incidence/prevalence rates of LBW/obesity. The prevalence/incidence rates derived by using the proposed estimation procedure are similar and close to the true estimate obtained by screening tests considered as gold standard. Further, sample size determined on the basis of the results of a tool of low validity may be either larger or smaller than the required sample size. Estimation of true disease load enables determination of correct sample size, thus improving the precision of the estimate and, in some instances, reducing the cost of investigation.

Study of interspouse communication and adoption of family planning and immunization services in a rural block of Varanasi District.

Interspouse communication was studied in some pertinent areas which have an important bearing on day to day transactions. The level of such communication measured on a three-point scale was studied for its role on acceptance of family planning and immunization services. 200 currently married females residing with their husbands in a rural block of Varanasi, in the reproductive age group, with at least one child aged 1-3 years were selected and interviewed. Scores were ascribed for 12 selected items of conversation according to frequency of conversation on a three point scale based on which high, medium and low communicators were delineated. In this study high, medium and low communicators were found to be 14%, 40% and 45% respectively. Topics of importance which never featured in interspouse communication were menstrual problems (44%), when to have first child (82.5%) and birth spacing (48.5%). Interspouse communication was better in upper castes and joint families. Literacy status of both husband and wife and per capita income of the family revealed positive relationship with inter-spouse communication. Adoption and practice of family planning methods as well as full immunization coverage of the child in the family were observed to be higher among high and medium communicators as compared to low degree of communcators (p < 0.001).

A qualitative assessment of ante-natal care provided by auxillary nurse midwives.

Two hundred sixty eight antenatal mothers were observed for the quality of services provided by Auxillary Nurse Midwives (ANMs). History taking was found to be satisfactory in only 2.6% women. Obstetric examination was done unsatisfactorily in majority (52.6%) of the mothers. General physical examination was not done in 69% women. ANMs in all 31 sub-centres were not performing investigation like haemoglobin estimation, urine testing, foetal heart sound monitoring and blood pressure recording.

Screening for obesity in affluent females: body mass index and its comparison with skin fold thickness.

In the present study 625 females above 15 years of age residing in affluent localities of Varanasi city were selected by multi-stage stratified random sampling technique. Body Mass Index (BMI) and Skin-Fold Thickness (SFT) were compared as indices of obesity. Prevalence of obesity by BMI and SFT was 30.24 and 49.12 respectively. SFT gave significantly higher prevalence rate of obesity as compared to BMI. It is possible that western population based SFT cut-off points may not be truly applicable to Indian study. The sensitivity, specificity and predictive value of 'sum of SFT at four sites' were calculated at different cut-off points, and it was observed, that values > or = 90 mm is the best cut-off point instead of 80 mm, for detecting obesity in the Indian context.

Does malnutrition predispose to diarrhoea during childhood? Evidence from a longitudinal study in Matlab, Bangladesh.

It is posited that diarrhoeal illness during one period has influence on diarrhoeal illness in a subsequent period. This relationship may potentially mask the association between malnutrition and subsequent diarrhoea. To test this, we analysed data on cross-sectional anthropometry in combination with data on diarrhoeal morbidity collected longitudinally in a community-based study of 1262 children (aged 6-60 months) during March-December, 1976, in Matlab, Bangladesh. The results confirmed the posited relationship between diarrhoeal morbidities in two consecutive periods and showed that the risks of diarrhoeal attack and longer diarrhoeal illness increased more than threefold during the 2 months following diarrhoeal illness during the preceding 2 months (previous diarrhoea). Children with no previous diarrhoea indicated a positive association between malnutrition and subsequent diarrhoea, but the pattern found among children with previous diarrhoea was not understandable. Logistic regression analyses performed separately for younger and older children showed that controlling for effects of previous diarrhoea, maternal illiteracy and household poverty, severe malnutrition as assessed by weight-for-age was found to be strongly associated with the risk of longer diarrhoeal illness in a 2-month interval in the age group 24-60 months; in the same age group the association with the risk of diarrhoeal attack was significant at the 10 per cent level. No such association for malnutrition, however, was found in the age group 6-23 months.

An action research in the delivery of primary health care through community based distribution.

PIP: In adhering to the spirit of primary health care (PHC), the Varanasi District in India began its community based distribution (CBD) project of oral rehydration solution (ORS) packets in Chiraigaon block in 1979. The CBD later included Cholapur, Kashi Vidyapith, Sewapuri, Araijiline, Haurah, Pindra, and Niyamatabad during 1980-1981. In 1989, an honorary project director headed the project and its cadre of regular paid staff. At the main office, staff included a project coordinator, technical consultant medical officer, field supervisors, and field assistants. 754 depot holders or kendra kalyan sanjojak (KKS) worked at the community level. They came from all segments of the society, e.g., farmers, teachers, individuals in business, etc. The KKS implemented the CBD and its policies. Individuals at the headquarters prepared ORS packets using the standard WHO formula. They included health information brochures about ORS written in the local language in each packet. Field assistants delivered these packets to the KKS each month at a no profit no loss cost. The depot holders then sold the packets at a marginal profit. From 1980-1983, the number of packets increased from 1725-9660. From 1980-1985, CBD workers distributed a total of 29.862 packets to all 8 blocks. Rigid social marketing criteria adopted in 1984 brought about a downturn in distribution, however. The number of families trained in ORS preparation varied from 80 in 1980 to 1688 in 1985. The number of families totaled 6919. Health education activities, such as group discussion and individual contracts, flourished at the community level which stimulated demand for ORS packets.^ieng

Training folk practitioners as PHWs in rural India.

PIP: 4 pilot programs for training folk practitioners to provide specific types of primary health care (PHC) services in villages in the Varanasi area of India were described and evaluated. The programs were developed by staff members of Benaras Hindu University and by members of several other universities. The training programs included 1) 2 courses on the prevention and cure of diarrhea, including oral rehydration therapy; 2) a course providing birth attendants with training in delivery technics, including the use of delivery packs; and 3) a course in the diagnosis and treatment of 11 skin diseases. All programs were developed and taught by physicians, except for 1 of the diarrhea prevention courses which was developed and taught by a social anthropologist. The courses were conducted over a 3-5 day period. Methodology, not course content, was the focus of the discussion. An effort was made to make the practitioners feel accepted by the formal medical system. Courses were conducted in places and at times convenient to the trainees. The general mode of presentation was to give a short formal talk about a specific topic followed by a discussion period and then a review session. Each program was evaluated separately in regard to 1) the degree to which specific health messages were translated into behavioral changes, and 2) the amount of staff time which was required to motivate participation and to prepare and teach the course. In regard to the diarrhea prevention course taught by the physician, 14 practitioners were trained and of the 8 health messages conveyed in the course, 3 were being followed by the practitioners 0-4 weeks following the course. The diffusion rate was, therefore, 38%. Time inputs were 130 hours of medical staff time, including 45 hours of direct teaching time and 80 hours of nonmedical staff time. The message diffusion rate for the other diarrhea prevention course was 20% at 8 weeks following course presentation. 14 practitioners were trained. Staff time amounted to only 21 hours of nonmedical staff time, including 3 hours of direct teaching time. For the skin disease course, diffusion rate was 69% for drug related messages and 18% for health education messages at 0-4 weeks following the course. The course took 114 hours of physician time, including 45 hours of direct teaching time, and 55 hours of nonmedical staff time. 20 practitioners were trained in the course. In reference to the birth attendant course, of the 37 births which occurred in the area during the year following the course, 7 births were delivered with technique taught in the course. The diffusion rate was, therefore, 22%. A total of 19 birth attendants were trained. Time inputs were 46 hours of medical staff time and 88 hours of nonmedical staff time. Recommendations were that some of the approaches and technique developed in the pilot projects would be useful in developing a large scale training program in the Gangetic plain and that simplified courses should be taught by paramedical personnel rather than by physician. However, a physician should be present on the opening day of the course to demonstrate that the formal medical system appreciates and welcomes the assistance of the traditional practitioners. The characteristics of folk practitioners, the impact of the training on the status and income of the practitioner, and program acceptability by the villagers and by the practitioners were also discussed.^ieng