Assessing the implementation of a mobile App-based electronic health record: A mixed-method study from South India.

BACKGROUND: Government of India recognizes the use of "information, communication, and technology" in the provision of comprehensive primary healthcare. In 2014-2015, Karuna Trust, a nongovernmental organization, Bengaluru, India, introduced an electronic health record (EHR) innovation, namely "Comprehensive Public Health Management" application (CPHM App). Data could be entered in an offline mode followed by syncing with cloud. The CPHM App was piloted in primary health center (PHC) Gumballi, in Karnataka, with focus on household survey and maternal and child health (MCH) services. OBJECTIVES: To compare the consistency of selected MCH process indicators for Health Management Information System [HMIS] available from paper-based records and those generated through the CPHM App (2016-2017). We also explored the implementation enablers, barriers, and suggested solutions from the user perspective. METHODS: A sequential mixed-method study design was followed. Quantitative phase involved aggregate data analysis looking into the consistency of selected MCH process indicators available from paper-based records and those generated through the CPHM App (2016-2017) followed by thematic analysis of in-depth interviews of healthcare providers. Consistency was defined as a percentage where the numerator was the HMIS-related process indicator data from CPHM App and denominator was the data from paper-based records. RESULTS: Three out of 12 selected MCH indicators had consistency of >80%. The quarterly consistency reduced over the 2 years. Dual burden of entry and regular monitoring of paper-based records by district health and family welfare department were the reasons why more importance was given to entry in paper-based records. Ability to generate aggregate indicators with CPHM App, easy to use and retrieve data in the field, and reminder facility for planned health activities were some of the factors facilitating CPHM implementation. The key barriers were limited technical expertise and support from the technical team and no internet connectivity in the field and traveling to PHC to sync the data. Provision of real-time technical support and availability of data connectivity in the field were some of the solutions suggested. CONCLUSION: There should be a minimum of 1-2 years of simultaneous use of EHR and paper-based records after which one must shift to EHR.

Potential contributions of an on-site nurse mentoring program on neonatal mortality reductions in rural Karnataka state, South India: evidence from repeat community cross-sectional surveys.

BACKGROUND: We assessed the effects of a nurse mentoring program on neonatal mortality in eight districts in India. METHODS: From 2012 to 2015, nurse mentors supported improvements in critical MNCH-related practices among health providers at primary health centres (PHCs) in northern Karnataka, South India. Baseline (n = 5240) and endline (n = 5154) surveys of randomly selected ever-married women were conducted. Neonatal mortality rates (NMR) among the last live-born children in the three years prior to each survey delivered in NM and non-NM-supported facilities were calculated and compared using survival analysis and cumulative hazard function. Mortality rates on days 1, 2-7 and 8-28 post-partum were compared. Cox survival regression analysis measured the adjusted effect on neonatal mortality of delivering in a nurse mentor supported facility. RESULTS: Overall, neonatal mortality rate in the three years preceding the baseline and endline surveys was 30.5 (95% CI 24.3-38.4) and 21.6 (95% CI 16.3-28.7) respectively. There was a substantial decline in neonatal mortality between the survey rounds among children delivered in PHCs supported by NM: 29.4 (95% CI 18.1-47.5) vs. 9.3 (95% CI 3.9-22.3) (p = 0.09). No significant declines in neonatal mortality rate were observed among children delivered in other facilities or at home. In regression analysis, among children born in nurse mentor supported facilities, the estimated hazard ratio at endline was significantly lower compared with baseline (HR: 0.23, 95% CI: 0.06-0.82, p = 0.02). CONCLUSION: The nurse mentoring program was associated with a substantial reduction in neonatal mortality. Further research is warranted to delineate whether this may be an effective strategy for reducing NMR in resource-poor settings.

Retrospective Analysis of 162 Mandibular Fractures: An Institutional Experience.

OBJECTIVES: The objective was to evaluate the age, gender distribution, side and site distribution, etiology, and common patterns of the mandibular fractures. MATERIALS AND METHODS: This was a systematic retrospective review of records of 94 patients with 162 mandibular fractures treated in a single institution. RESULTS: Of 94 patients, 72 male and 22 female patients belong to the age group of 4-62 years (average 31.57 years). Among the various etiologies, i.e., assault, road traffic accident (RTA), self-fall, workplace injury, and sports-related injury, RTA accounts for 62.76% and self-fall for 18.08% of cases. Of the 100 fractures analyzed, 46% are unilateral fractures and 54% are bilateral. Sides affected among these are left (58%), right (39%), and symphysis or midline (3%). The site distribution is as follows: symphysis - 5; parasymphysis - 64; body - 13; angle - 43; and subcondylar - 37. The most common fracture pattern is the ipsilateral parasymphysis with contralateral angle (21 cases). Open reduction and internal fixation was the predominant modality of treatment. Complications were observed in 27.65% of patients. CONCLUSION: Surveys play a vital role in better understanding the biomechanics of the mandible fractures. Furthermore, analysis of the treatment modalities used and their respective outcomes are of paramount importance in guiding surgeons to evaluate their efficacy.

Advantages, Disadvantages, Indications, Contraindications and Surgical Technique of Laryngeal Airway Mask.

The beauty of the laryngeal mask is that it forms an air tight seal enclosing the larynx rather than plugging the pharynx, and avoid airway obstruction in the oropharynx. The goal of its development was to create an intermediate form of airway management face mask and endotracheal tube. Indication for its use includes any procedure that would normally involve the use of a face mask. The laryngeal mask airway was designed as a new concept in airway management and has been gaining a firm position in anesthetic practice. Despite wide spread use the definitive role of the laryngeal mask airway is yet to be established. In some situations, such as after failed tracheal intubation or in oral surgery its use is controversial. There are several unresolved issues, for example the effect of the laryngeal mask on regurgitation and whether or not cricoids pressure prevents placement of mask. We review the techniques of insertion, details of misplacement, and complications associated with use of the laryngeal mask. We then attempt to clarify the role of laryngeal mask in air way management during anesthesia, discussing the advantages and disadvantages as well as indications and contraindications of its use in oral and maxillofacial surgery.

Crystalloid glomerulopathy in monoclonal gammopathy of renal significance (MGRS).

We report a case of monoclonal gammopathy of renal significance in a 63-year-old man who presented with nephrotic-range proteinuria and renal insufficiency. The kidney biopsy showed a membranoproliferative glomerulonephritis pattern with extensive crystalloid deposits in the glomerular capillary endothelial cells and very few in the tubular epithelial cells. The immunoperoxidase staining showed kappa light chain restriction. Subsequently, the bone marrow showed 6% plasma cells which confirmed the diagnosis of monoclonal gammopathy of renal significance. He responded well to bortezomib treatment with resolution of the nephrotic syndrome and normalization of renal function after 7 months.

Rationalizing antibiotic use to limit antibiotic resistance in India.

Antibiotic resistance, a global concern, is particularly pressing in developing nations, including India, where the burden of infectious disease is high and healthcare spending is low. The Global Antibiotic Resistance Partnership (GARP) was established to develop actionable policy recommendations specifically relevant to low- and middle-income countries where suboptimal access to antibiotics - not a major concern in high-income countries - is possibly as severe a problem as is the spread of resistant organisms. This report summarizes the situation as it is known regarding antibiotic use and growing resistance in India and recommends short and long term actions. Recommendations aim at (i) reducing the need for antibiotics; (ii) lowering resistance-enhancing drug pressure through improved antibiotic targeting, and (iii) eliminating antibiotic use for growth promotion in agriculture. The highest priority needs to be given to (i) national surveillance of antibiotic resistance and antibiotic use - better information to underpin decisions on standard treatment guidelines, education and other actions, as well as to monitor changes over time; (ii) increasing the use of diagnostic tests, which necessitates behavioural changes and improvements in microbiology laboratory capacity; (iii) setting up and/or strengthening infection control committees in hospitals; and (iv) restricting the use of antibiotics for non-therapeutic uses in agriculture. These interventions should help to reduce the spread of antibiotic resistance, improve public health directly, benefit the populace and reduce pressure on the healthcare system. Finally, increasing the types and coverage of childhood vaccines offered by the government would reduce the disease burden enormously and spare antibiotics.

Vitamin B-12, folate, iron, and vitamin A concentrations in rural Indian children are associated with continued breastfeeding, complementary diet, and maternal nutrition.

BACKGROUND: Determinants of vitamin B-12, folate, iron, and vitamin A concentrations in young children in rural south Asia are poorly understood. These micronutrients are crucial for the production of hemoglobin and have other important physiologic functions. OBJECTIVE: We sought to develop explanatory models for concentrations of vitamin B-12, folate, ferritin, and retinol binding protein (RBP) in children aged between 1 and 2 y in rural Karnataka, India. DESIGN: We performed a cross-sectional study in 12-23-mo-old toddlers who lived in 2 rural districts of Karnataka, India. For each child, data concerning dietary, food-security, and sociodemographic and maternal factors were obtained, and serum vitamin B-12, folate, ferritin, and RBP were measured. Multiple regression and structural equation modeling were applied to determine associations with micronutrient concentrations. RESULTS: Of 396 sampled children, 254 children (65.6%) had at least one micronutrient deficiency. With the use of multiple regression, continued breastfeeding was independently associated with the concentration of each micronutrient [(log) vitamin B-12: standardized coefficient of -0.30 (P < 0.001); folate: standardized coefficient of +0.20 (P < 0.001); (log) ferritin: standardized coefficient of -0.18 (P = 0.004); (log) RBP: standardized coefficient of-0.21 (P < 0.001)]. Children who continued to breastfeed received less nutrition from complementary foods and belonged to poorer families with higher food insecurity. A structural equation model for children's vitamin B-12 concentrations was developed that highlighted the interrelation between wealth, continued breastfeeding, complementary diet, and vitamin B-12 concentrations in children. CONCLUSIONS: Micronutrient deficiencies are common in this population. Rural Indian children between 1 and 2 y of age who continue to breastfeed should be especially targeted during micronutrient-supplementation programs. This trial was registered in the Australian and New Zealand Clinical Trials Registry as ACTRN12611000596909.

Factors influencing receipt of iron supplementation by young children and their mothers in rural India: local and national cross-sectional studies.

BACKGROUND: In India, 55% of women and 69.5% of preschool children are anaemic despite national policies recommending routine iron supplementation. Understanding factors associated with receipt of iron in the field could help optimise implementation of anaemia control policies. Thus, we undertook 1) a cross-sectional study to evaluate iron supplementation to children (and mothers) in rural Karnataka, India, and 2) an analysis of all-India rural data from the National Family Health Study 2005-6 (NFHS-3). METHODS: All children aged 12-23 months and their mothers served by 6 of 8 randomly selected sub-centres managed by 2 rural Primary Health Centres of rural Karnataka were eligible for the Karnataka Study, conducted between August and October 2008. Socioeconomic and demographic data, access to health services and iron receipt were recorded. Secondly, NFHS-3 rural data were analysed. For both studies, logistic regression was used to evaluate factors associated with receipt of iron. RESULTS: The Karnataka Study recruited 405 children and 377 of their mothers. 41.5% of children had received iron, and 11.5% received iron through the public system. By multiple logistic regression, factors associated with children's receipt of iron included: wealth (Odds Ratio (OR) 2.63 [95% CI 1.11, 6.24] for top vs bottom wealth quintile), male sex (OR 2.45 [1.47, 4.10]), mother receiving postnatal iron (OR 2.31 [1.25, 4.28]), mother having undergone antenatal blood test (OR 2.10 [1.09, 4.03]); Muslim religion (OR 0.02 [0.00, 0.27]), attendance at Anganwadi centre (OR 0.23 [0.11, 0.49]), fully vaccinated (OR 0.33 [0.15, 0.75]), or children of mothers with more antenatal health visits (8-9 visits OR 0.25 [0.11, 0.55]) were less likely to receive iron. Nationally, 3.7% of rural children were receiving iron; this was associated with wealth (OR 1.12 [1.02, 1.23] per quintile), maternal education (compared with no education: completed secondary education OR 2.15 [1.17, 3.97], maternal antenatal iron (2.24 [1.56, 3.22]), and child attending an Anganwadi (OR 1.47 [1.20, 1.80]). CONCLUSION: In rural India, public distribution of iron to children is inadequate and disparities exist. Measures to optimize receipt of government supplied iron to all children regardless of wealth and ethnic background could help alleviate anaemia in this population.

Good governance and corruption in the health sector: lessons from the Karnataka experience.

Strengthening good governance and preventing corruption in health care are universal challenges. The Karnataka Lokayukta (KLA), a public complaints agency in Karnataka state (India), was created in 1986 but played a prominent role controlling systemic corruption only after a change of leadership in 2001 with a new Lokayukta (ombudsman) and Vigilance Director for Health (VDH). This case study of the KLA (2001-06) analysed the:Scope and level of poor governance in the health sector; KLA objectives and its strategy; Factors which affected public health sector governance and the operation of the KLA. We used a participatory and opportunistic evaluation design, examined documents about KLA activities, conducted three site visits, two key informant and 44 semi-structured interviews and used a force field model to analyse the governance findings. The Lokayukta and his VDH were both proactive and economically independent with an extended social network, technical expertise in both jurisdiction and health care, and were widely perceived to be acting for the common good. They mobilized media and the public about governance issues which were affected by factors at the individual, organizational and societal levels. Their investigations revealed systemic corruption within the public health sector at all levels as well as in public/private collaborations and the political and justice systems. However, wider contextual issues limited their effectiveness in intervening. The departure of the Lokayukta, upon completing his term, was due to a lack of continued political support for controlling corruption. Governance in the health sector is affected by positive and negative forces. A key positive factor was the combined social, cultural and symbolic capital of the two leaders which empowered them to challenge corrupt behaviour and promote good governance. Although change was possible, it was precarious and requires continuous political support to be sustained.

Determinants of anemia among young children in rural India.

OBJECTIVE: More than 75% of Indian toddlers are anemic. Data on factors associated with anemia in India are limited. The objective of this study was to determine biological, nutritional, and socioeconomic risk factors for anemia in this vulnerable age group. METHODS: We conducted a cross-sectional study of children aged 12 to 23 months in 2 rural districts of Karnataka, India. Children were excluded if they were unwell or had received a blood transfusion. Hemoglobin, ferritin, folate, vitamin B(12), retinol-binding protein, and C-reactive protein (CRP) levels were determined. Children were also tested for hemoglobinopathy, malaria infection, and hookworm infestation. Anthropometric measurements, nutritional intake, family wealth, and food security were recorded. In addition, maternal hemoglobin level was measured. RESULTS: Anemia (hemoglobin level < 11.0 g/dL) was detected in 75.3% of the 401 children sampled. Anemia was associated with iron deficiency (low ferritin level), maternal anemia, and food insecurity. Children's ferritin levels were directly associated with their iron intake and CRP levels and with maternal hemoglobin level and inversely associated with continued breastfeeding and the child's energy intake. A multivariate model for the child's hemoglobin level revealed associations with log(ferritin level) (coefficient: 1.20; P < .001), folate level (0.05; P < .01), maternal hemoglobin level (0.16; P < .001), family wealth index (0.02; P < .05), child's age (0.05 per month; P < .005), hemoglobinopathy (-1.51; P < .001), CRP level (-0.18; P < .001), and male gender (-0.38; P < .05). Wealth index and food insecurity could be interchanged in this model. CONCLUSIONS: Hemoglobin level was primarily associated with iron status in these Indian toddlers; however, maternal hemoglobin level, family wealth, and food insecurity were also important factors. Strategies for minimizing childhood anemia must include optimized iron intake but should simultaneously address maternal anemia, poverty, and food insecurity.

A community based field research project investigating anaemia amongst young children living in rural Karnataka, India: a cross sectional study.

BACKGROUND: Anaemia is an important problem amongst young children living in rural India. However, there has not previously been a detailed study of the biological aetiology of this anaemia, exploring the relative contributions of iron, vitamin B12, folate and Vitamin A deficiency, inflammation, genetic haemoglobinopathy, hookworm and malaria. Nor have studies related these aetiologic biological factors to household food security, standard of living and child feeding practices. Barriers to conducting such work have included perceived reluctance of village communities to permit their children to undergo venipuncture, and logistical issues. We have successfully completed a community based, cross sectional field study exploring in detail the causes of anaemia amongst young children in a rural setting. METHODS AND DESIGN: A cross sectional, community based study. We engaged in extensive community consultation and tailored our study design to the outcomes of these discussions. We utilised local women as field workers, harnessing the capacity of local health workers to assist with the study. We adopted a programmatic approach with a census rather than random sampling strategy in the village, incorporating appropriate case management for children identified to have anaemia. We developed a questionnaire based on existing standard measurement tools for standard of living, food security and nutrition. Specimen processing was conducted at the Primary Health Centre laboratory prior to transport to an urban research laboratory. DISCUSSION: Adopting this study design, we have recruited 415 of 470 potentially eligible children who were living in the selected villages. We achieved support from the community and cooperation of local health workers. Our results will improve the understanding into anaemia amongst young children in rural India. However, many further studies are required to understand the health problems of the population of rural India, and our study design and technique provide a useful demonstration of a successful strategy.

Tuberculosis control programme in rural area: experiences from the field.

PIP: According to the Indian National Tuberculosis Program (NTP), only 30% of tuberculosis (TB) patients receiving conventional treatment and 52% of those receiving short-course chemotherapy (SCC) complete the treatment. Incompletely cured patients return to the community, and each sputum-positive case can infect 10-14 people in the course of a year. Direct monitoring of chemotherapy is a must for success, especially if rifampicin is used after accurate diagnosis based on bacteriological examination. The National Leprosy Eradication Program, which has involved voluntary organizations, provides an example to be followed by NTP. This example was considered when the Karuna Trust, a voluntary organization, launched a TB control program on January 1, 1992, for Yelandur taluk, covering a population of 69,484 in 40 villages. A staff consisting of a medical officer, a supervisor, a smear technician, and paramedical workers had undergone training at the National TB Institute in Bangalore. Detection of cases was carried out by house-to-house visits, which could detect about 65% of cases. It was also found that TB treatment had been started without a sputum examination, sputum-positive cases had been on rifampicin, and data recording was incomplete. Up to October 1994, a total of 231 cases were registered and compliance was ensured by home visits. Private practitioners were carrying out harmful activities by not enforcing full patient compliance and thereby contributing to the increasing number of drug-resistant cases. In contrast, this program had a default of only 19.1% among sputum-positive cases, but even these can be recovered with an interaction with private practitioners. Treatment failure amounted to 10.1%, all having been on rifampicin. Retreatment requires more expensive second-line drugs. Drug collection will be decentralized for the convenience of patients; and an adequate supply of drugs was secured. Some suggestions were also made concerning adequate resources, integration of the program, monitoring, and involving nongovernmental organizations in implementation and evaluation.^ieng