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October-December 2019
Volume 63 | Issue 4
Page Nos. 275-382

Online since Wednesday, December 18, 2019

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EDITORIAL  

Elimination of viral hepatitis: Evolution and India's response Highly accessed article p. 275
Dandu Chandra Sekhar Reddy
DOI:10.4103/ijph.IJPH_581_19  
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ORIGINAL ARTICLES Top

Development, validation and use of appropriate assessment tools for certification of entrustable professional activities in community medicine to produce a competent postgraduate: A pilot study Highly accessed article p. 277
Saurabh Rambiharilal Shrivastava, Thomas V Chacko, Shital Bhandary, Prateek Saurabh Shrivastava
DOI:10.4103/ijph.IJPH_45_19  
Background: Adoption of competence-based medical education (CBME) is the need of the hour. Objectives: The objective of the study is to develop and validate appropriate assessment tools for the community medicine entrustable professional activities (EPAs) and to assess the usefulness of the validated tools in the assessment of postgraduate (PG) students. Methods: An interventional study for 14 months was done in the department of community medicine. After the sensitization of faculty members and PGs, three EPAs were selected through consensus between faculty members and appropriate assessment tools mini-clinical evaluation exercise (Mini-CEX), case-based discussion (CBD), and direct observation of procedural skills (DOPS). Rubrics of milestones were formulated for the selected tools, and the designed tools were validated. These three validated tools were used for the quarterly assessment. Results: The item-content validity index for all three assessment tools was one, while Scale Content Validity Index for Mini-CEX and CBD were 1, and for DOPS, it was 0.87. Three PG students were assessed using the validated tools thrice for the three selected EPAs. The PGs opined that assessment using rubrics made their task-specific, while faculties were quite satisfied with the assessment process as it removed subjectivity. Conclusions: The developed and selected tools of EPAs were found to have a substantial level of both face validity and content validity. The tools were also found to useful for periodic assessment in workplace settings and acceptable to both PG students and internal/external faculty members.
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Burden of care perceived by the principal caregivers of autistic children and adolescents visiting health facilities in Lucknow City p. 282
Aparna Jain, Naim Ahmed, Pooja Mahour, Vivek Agarwal, Kanta Chandra, Nitesh Kumar Shrivatav
DOI:10.4103/ijph.IJPH_366_18  
Background: Autism is extraordinarily difficult for families to cope with for various reasons. Perceived burden and care for the child with autism, available forms of social support, and the interactions between the autistic child and other family members are areas of significant concern for families. Objective: The objective of this study was to determine the burden of care perceived by the principal caregivers of autistic children or adolescent visiting health facilities in Lucknow city. Methods: The cross-sectional study was conducted from October 2016 to September 2017 with a sample of 90 principal caregivers (aged <60 years) of autistic children and adolescents aged 3–19 years and diagnosed with autism, attending government and private health facilities providing treatment for autism in Lucknow, Uttar Pradesh, India. Validated tools were used to assess the burden of care and disability level of autistic children. Data were analyzed using the software SPSS version 16. Results: The caregivers of autistic children and adolescents perceived the burden of care in different domains in varying extent with “caregiver's routine” and “taking responsibility” domains affected the most. The burden perceived was found to be affected by the permanent residence of caregiver, rural/urban dwelling, type of family, socioeconomic status, age at which diagnosis was made, knowledge about autism and the severity of autism. Conclusions: Availability and easy accessibility of autism treatment facilities must be the most probable reason for less burden perceived in three domains, by caregivers of urban settings and those belonging to Lucknow. Furthermore, better knowledge on autism and family and friends' support led to decrease in the burden perceived by the caregivers in various domains. Thus, it was found that the burden perceived can be reduced by universal availability of evidence-based early diagnosis and treatment of autism and improving the knowledge of caregivers about autism.
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Prevalence of anemia among elderly persons residing in old age homes in national capital territory, Delhi, India Highly accessed article p. 288
Abhishek Pathania, Partha Haldar, Shashi Kant, Sanjeev Kumar Gupta, Chandrakant S Pandav, Damodar Bachani
DOI:10.4103/ijph.IJPH_412_18  
Background: Anemia is a common morbidity in elderly persons (aged 60 years or above). In India, in recent years, the number of old age homes (OAHs) and the residents living in them has increased significantly. Objective: The aim of this study was to estimate the prevalence of anemia among elderly persons living in OAHs. Methods: This was a cross-sectional study among individuals living in OAH in Delhi, India. Using combination of location and type of OAH, 28 clusters of almost equal sizes were created, of which 13 clusters were randomly selected, and all elderly persons living therein were selected for the study. Sociodemographic profile was recorded using a self-designed, semistructured interview schedule. Hemoglobin (Hb) was estimated using HemoCue Hb 201+ system. Binary Logistic regression was used to assess the socioeconomic determinants of anemia. Results: The study included 334 elderly persons, with a mean (standard deviation [SD]) age of 75.2 (8.6) years and mean (SD) Hb of 11.6 (1.7) g/dL. The mean (SD) Hb in men was 12.1 (1.7) g/dL compared to 10.9 (1.5) g/dL among women (P < 0.0001). The overall prevalence of anemia was 68.7% (95% confidence interval 63.9, 73.4); among those who were anemic, 47.4% had mild anemia, 47.0% had moderate anemia, and 5.6% had severe anemia. The prevalence of mild anemia was 45% in men compared to 24.8% in women. The odds of anemia among ≥80 years was 2 times that among 60–69 years (P < 0.029). Conclusions: The prevalence of anemia among elderly persons in OAHs is high in Delhi, India and increased with age.
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Are our rural adolescents eating healthy?: Implications for redesigning school health interventions – A cross sectional study in rural Coimbatore p. 293
Subhashini Ganesan, Thomas V Chacko, GM Muhammad
DOI:10.4103/ijph.IJPH_420_18  
Background: Adolescence is a period of transition where independence in thinking and behavior is established and food choices that are made are followed for several years, and this can influence their health in adulthood. Hence, understanding the eating habits are necessary to plan effective nutritional interventions in adolescents. Objectives: The main objective of the study is to find out the extent of malnutrition among rural adolescents as well as evaluate their eating habits against recommended dietary food groups and to compare eating habits across gender and age groups. Methods: A cross-sectional study was done among 1425 adolescents from 13 rural schools from 2014 to 2015, and the variables considered in this study were age, sex, body mass index (BMI), and the eating habits of the adolescents. Results: Undernutrition was seen among 23% and overweight/obesity among 8% of adolescents. The habit of taking milk and milk products, fruits, and green leafy vegetables were very poor among the adolescents. Significant association was found between eating habits and BMI. Furthermore, late adolescents had better eating habits, and significant gender difference was seen in certain eating habits. Conclusions: The study shows that it is possible to understand the gaps in eating habits of adolescents, and this can be used to plan tailor-made nutritional interventions to adolescent groups as their eating habits are different and have long-term nutritional and health implications.
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Occurrence and predictors of abortion among women of the reproductive age group in a block of Darjeeling District, West Bengal, India p. 298
Pallabi Dasgupta, Romy Biswas, Dilip Kumar Das, Jayanta Kumar Roy
DOI:10.4103/ijph.IJPH_316_18  
Background: Despite being a sensitive and less explored issue, abortion is a major preventable cause of maternal morbidity and mortality affecting millions of women in developing countries. Objectives: The study aimed to determine the occurrence, nature, and predictors of abortion among women in the reproductive age group in Naxalbari block of Darjeeling district. Methods: A community-based cross-sectional study was conducted in Naxalbari block of Darjeeling district, West Bengal, India, from May 2015 to April 2016, among 420 women aged 15–49 years selected from 30 villages by cluster sampling technique. A predesigned, pretested interview schedule validated in the local vernacular was used. Binary logistic regression was used for finding out predictors of abortion among ever-pregnant women. Results: Lifetime occurrence of abortion was 33.6%. Among total 178 events of abortion, 51.7% were spontaneous and 48.3% induced. Majority of spontaneous abortions events were attended by a doctor (73.9%). About 59.3% of induced abortions were illegal, and unwanted pregnancy was major reason (62.4%) for induced abortion. Private facilities and over the counter drugs were preferred. Lower education, nuclear family, number of children <2, not having male child, domestic violence during pregnancy were significant predictors of abortion. Conclusions: Illegal abortions were highly prevalent in the area. Unwanted pregnancies hint toward unmet needs of family planning. Stigma and poor awareness were the root cause of not visiting a health facility in case of abortions. Building up of better infrastructure, better orientation of frontline workers, non-judgemental and confidential services will attract women to in government facilities.
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Evaluation of key survey components of bio-behavioral surveillance among HIV high-risk subpopulation in Western India p. 305
Radhika G Brahme, Sheela V Godbole, Raman R Gangakhedkar, Kuldeep Singh Sachdeva, Vinita Verma, Arun R Risbud
DOI:10.4103/ijph.IJPH_174_18  
Background: High-quality data are of prime importance in any health survey because survey data are considered as a gold standard for nationally representative data. The quality of data collection largely depends on the design of the questionnaire, training, and skills of the interviewer. Objectives: In the present study, we tried to evaluate three key components, such as questionnaire design, human resource and training of the field staff for Integrated Biological and Behavioural Surveillance carried out among the HIV high-risk subpopulation. Methods: A mixed-methods approach was used. Qualitative and quantitative data collection was carried out in the year 2015 with cross-sectional survey design in western states of India. The in-depth interviews of 10 stakeholders, structured interviews of the survey respondents (n = 560), and field investigators (n = 71) were conducted. Data triangulation was used to find out the concurrence of the qualitative and quantitative data. Results: Comprehensive and standardized survey questionnaire, structured training agenda, and strategic preparation for recruiting human resources were the overall strengths of the survey. However, during the implementation of the survey, there were some difficulties reported in data collection process. Overall, the respondents and investigators felt that the questionnaire was long and exhaustive. Difficulties were faced while collecting data on sexual history. The field staffs were not adequately experienced to work with sensitive population. Conclusions: In order to have accurate, reliable data, especially on sexual behavior; emphasis should be given on simple questionnaire with the use of community-friendly language, skilled and experienced interviewers for data collection, and extensive field training.
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Psychological risk factors associated with internet and smartphone addiction among students of an Indian dental institute p. 313
Sumeet Bhatt, Ambika Gaur
DOI:10.4103/ijph.IJPH_330_18  
Background: The internet and smartphones have a strong potential for addiction. Excessive use of these technologies can have adverse effects on psychological well-being of the users. Objectives: The objective of the study is to find out the effects of internet addiction (IA) and smartphone addiction (SA) on psychological outcomes of dental students in an Indian institute. Methods: In this cross-sectional study, 320 dental students were assessed for their internet and smartphone habits using the Young's IA test (YIAT) and the SA scale (SAS), respectively. Psychological outcomes were evaluated using the insomnia severity index, the Depression, Anxiety and Stress Scale, and the Rosenberg Self-Esteem Scale. Results: The median YIAT score was 35 and interquartile range (IQR) of 24–49 with 23% subjects reporting potential IA. The median SAS score was 108 (IQR 91.25–128). Both IA and SA were significantly associated with participants' year of the study. Significant correlations were observed between IA and SA with psychological parameters. Conclusions: The association of IA and SA with psychological parameters shows how these habits can affect the users' mental well-being. Public especially young adults should be made aware about potential harmful effects of the internet and smartphones.
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A qualitative comparative analysis of healthcare Supply–Demand side barriers under the publicly funded health insurance scheme in India p. 318
Nitya Saxena, Prabal Singh, Abhishek Mishra
DOI:10.4103/ijph.IJPH_409_18  
Background: India recently launched Ayushman Bharat – National Health Protection Mission – an upgraded version of Rashtriya Swasthya Bima Yojna (RSBY), which is projected as world's largest public insurance scheme by numbers. The new scheme can certainly draw learning from the former (RSBY) to ensure better reach and success. RSBY has been extensively analyzed for supply-side barriers but sparsely for demand and supply-side barriers simultaneously. Objectives: Through this study, authors intend to determine causality as well as configurations (pathways) of demand and supply barriers that make beneficiary vulnerable even under the scheme. The study explores the interaction of barriers that lead to patient dis/satisfaction, overcharging for a medical procedure and high disease severity among beneficiaries. Methods: The study uses RSBY insurance claim records from 2013 to 2015 backed up by posthospitalization survey of the state of Chhattisgarh, India. It employs a fuzzy set qualitative comparative analysis to determine causality and configuration (path-way) of parameters leading to the outcome. Results: Provision of medicine emerges as a necessary condition for patient satisfaction. Waiting time did not appear as a necessary parameter of satisfaction. Overcharging the cashless card in case of minor surgical procedures is observed irrespective of beneficiaries' education and occupation status. Urban male and rural female appear to bear high disease severity. Conclusions: Results have implication for policymakers and implementors to recognize the segment that remains vulnerable under the scheme and gain insights on the parameters of patient satisfaction.
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Bio-eco-social determinants of Aedes breeding in field practice area of a medical college in Pune, Maharashtra p. 324
Gurpreet Singh, Rina Tilak, SK Kaushik
DOI:10.4103/ijph.IJPH_296_18  
Background: Major determinant of dengue incidence is interaction between ecology, vector bionomics, and social factors. Objectives: The objective of the study is to find out bio-eco-social determinants of Aedes breeding. Methods: Background, household, entomological, and knowledge, attitude, and practice (KAP) surveys were undertaken post- and premonsoon showers from May to June 2016 in urban and rural practice area of medical college. Results: A total of 181 and 204 households, 131 and 137 individuals, and 1250 and 1268 water-holding containers were included in household survey, KAP survey, and larval survey in urban slum and rural area, respectively. In both locations, maximum water-holding containers were indoors (41.4% and 61.8%, respectively); however, maximum positivity was peridomestic (63.6% and 83.1%, respectively). Pupae per container were 0.9 and 1.9 in respective locations and pupae per person were 1.2 and 2.3, respectively. Container positivity was seen in containers with rain as water source (8.8%) as well as among those who were never used (10.7%). Irregular water supply was significantly more in rural area (P < 0.05). KAP survey revealed that majority (90.1% and 71.5%, respectively) had heard about dengue, with significantly higher knowledge in urban slum, and television was the main source of information. Majority (89% and 83%, respectively) were unaware that peak biting time of Aedes is daytime. Use of mosquito repellent coils was the predominant preventive practice (46.6% and 61.2%, respectively). Pupae were reared; all were found to be Aedes aegypti. Conclusions: Despite enhanced awareness campaigns, an integrated vector management approach is required for prevention of dengue.
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Overweight and obesity among the boys of primary public schools of Baish City in Jazan Province, Saudi Arabia: A cross-sectional study p. 330
Mohammed Ibrahim Fakeeh, Mohd Shanawaz, Fahad Khan Azeez, Ibrahim Ali Arar
DOI:10.4103/ijph.IJPH_355_18  
Background: Overweight and obesity are important modifiable risk factors for various noncommunicable diseases. The link between obesity, poor health outcomes, and all-cause mortality is well established. Overweight and obesity during childhood increases the likelihood of diabetes, hypertension, coronary heart disease, stroke, certain cancers, obstructive sleep apnea, and osteoarthritis more early in younger age groups. Objectives: The aim of the study was to estimate the prevalence and some correlates of overweight and obesity in the study population. Methods: The present study was a cross-sectional study conducted during October 2017 among 300 boys of primary public schools from Baish City of Jazan Province, Saudi Arabia. A semi-structured questionnaire was used for data collection. Weight and height were measured using standard tools. The WHO Z-score reference values of body mass index-for-age were used for the screening of overweight and obesity. Analysis was done using the Statistical Package for the Social Sciences (SPSS version 19.0). Results: The prevalence of overweight and obesity was 10.1% and 12.4%, respectively, among the study participants. There was a significant difference in the overweight and obesity between urban and rural study population. Overweight and obesity was found higher among children who took frequently junk food. Conclusions: Overweight and obesity was substantially prevalent among primary schoolboys with a significant rural–urban difference.
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Immunization coverage among under-five children living along a school student through child-to-child and child-to-parent information, education and communication strategy p. 334
Radha Vaidyanathan
DOI:10.4103/ijph.IJPH_424_18  
Background: In spite of being a principal producer and exporter of vaccines and billions spent over decades, India is home to one-third of the world's under-five children (U5C) with no immunization. Objectives: The objective of this study was to find the outcome of child-to-child and child-to-parent Information, Education and Communication (IEC) strategy on the current percentage of immunization coverage (IC). Methods: A mixed design research with multilevel concurrent sampling was conducted in Pune. Based on school students' households, 44 clusters having U5C were divided randomly into 11 experimental/control groups each. IEC strategy to students was independent variable and IC among U5C was dependent variable. Data were collected from 1092 students and 2352 U5C parents over 6 years. Vaccination card and Bacillus Calmette–Guérin mark were considered as evidence to conclude on full, partial and no IC. Change in knowledge quotient (KQ) among students/parents and U5C IC before and after IEC strategy assessed. Results: Rural/urban age-appropriate full IC of U5C was 51% and 67% before and 88% and 85% in post-IEC, respectively. The mean KQ change score of 8–12/20 in students is likely to increase full IC by 37% and 18%, decrease partial coverage at 14% and 12%, and improve none coverage at 23% and 16%, from its existing level positively in experimental groups. Numerous factors discouraged parents to pursue their U5C immunization. Conclusions: Advocacy through school students can be an economically viable alternative marketing strategy for inadequate U5C IC than billions spent on treating vaccine-preventable diseases and impractical options.
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Protein calorie intakes and growth profiles in ashram school students in Nashik district in Maharashtra p. 341
Shyam Vinayak Ashtekar, Manasi Shekhar Padhyegurjar, Jagdish Powar
DOI:10.4103/ijph.IJPH_417_18  
Background: Tribal ashram schools provide accommodation, food, and other services from 1st to 12th standards to children from marginalized sections of the society. Nutrition and growth are important aspects of this age group. Objectives: This study aims to estimate average macronutrient intakes in private and public ashram schools and to compare the growth of tribal with urban children and national standards. Methods: This is a cross-sectional cluster-based study in Nashik district of Maharashtra in ashram schools with an urban day school for comparison. The study was conducted from November 2017 to February 2018. The study includes 1510 students in four rural ashram schools and 322 urban school day scholars. Daily food amounts used by the school kitchens were analyzed. Height and weight of students were recorded with standard methods. Excel was used to estimate nutrient intakes and Epi Info for analysis of growth parameters. Results: Protein intakes were 76.5 g/student (2.9–3.1 g/kg body weight), with staples contributing 42%–50% and legumes and pulses contributing 22%–25%. Energy intakes were 2519 kcal/student (100–120 kcal/kg body weight) with oils contributing 13%. Boys ate 1.5–2 times than girls going by average intake of Chapattis. Height and weight of students at entry and exit age, respectively, of 7 and 15 years were significantly lower than urban students, ICMR and IAP standards. However, entry-level stunting had reduced by 15 years by 40%–50% in girls and boys. Conclusions: Macronutrient intakes in the ashram schoolchildren were sufficient, but growth gap persisted till adolescence. Protein quality in private schools needs improvement.
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Assessment of compliance to treatment of hypertension and diabetes among previously diagnosed patients in urban slums of Belapur, Navi Mumbai, India p. 348
Sneha Pratap Kotian, Prasad Waingankar, Virendra J Mahadik
DOI:10.4103/ijph.IJPH_422_18  
Background: Nonadherence to treatment is a challenge in managing the increasing burden of chronic noncommunicable diseases in India. The issue is not limited only to people having limited access to health-care services, but for a variety of reasons, a typical pattern of nonadherence is being seen. Objective: The objective was to assess the compliance and to find out the reasons of noncompliance to treatment of diabetes/hypertension among previously diagnosed patients from urban slums. Methods: This is a community-based, cross-sectional study conducted during October 2017–February 2018 in urban slums of Belapur, Navi Mumbai, selecting all cases of diabetes and hypertension diagnosed for >1 year by house-to-house survey, covering a population of 4125. A structured and pretested questionnaire including sociodemographic details, treatment details, and compliance pattern was administered. Results: The study included 208 individuals, of which 164 were under treatment for hypertension and 85 for diabetes. All the patients revealed discontinuation of medication for a significant period at some point since diagnosis. The most common reasons of noncompliance were lack of money (50.58% patients with diabetes, 73.78% patients with hypertension) and difficulty to remember to take daily medication due to work or forgetfulness (49.41% patients with diabetes, 26.21% patients with hypertension). Only 56.5% of patients with diabetes and 64.6% of patients with hypertension were aware that discontinuation of treatment can cause complications, whereas 95.3% of patients with diabetes and 99.4% of patients with hypertension feel that remembering medication at work is difficult. Conclusions: As the nonadherence is too high, there is an urgent need of attention to this aspect, and remedial measures such as proper counseling to the patient, involvement of family members, and use of low-cost drugs for treatment should be sought.
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Perceived stress and eating behavior among professional and nonprofessional undergraduate students in Udupi District, Karnataka p. 353
Rintu Thomas, Sangeetha Priyadarshini, K Jeyalakshmi
DOI:10.4103/ijph.IJPH_449_18  
Background: Stress is an unavoidable part of our life. Certain amount of stress is needed for our survival. Stress is one of the factors, which affects the health and eating habits of a person. Objectives: The aim of the study was to compare the perceived stress among professional and nonprofessional undergraduate students and to find out the relationship between eating behavior and perceived stress of undergraduate students. Methods: A comparative descriptive study was conducted from November 2017 to April 2018, among 400 undergraduate students from selected professional and nonprofessional colleges in Udupi District, Karnataka. Students were recruited using proportionate sampling technique. Data were collected using a self-administered questionnaire after obtaining informed consent of the study participants. Results: Statistically significant difference was found in perceived stress of professional and nonprofessional students (Z = −2.397, P = 0.017). There was a weak positive correlation between perceived stress and uncontrolled eating of professional students (ρ= 0.162, P = 0.022) and nonprofessional students (ρ= 0.183, P = 0.009). There was no association found between perceived stress and selected demographic variables such as age, gender, study course, year of study, type of family, and occupation of parents (P > 0.05). Conclusions: Perceived stress of professional students is more compared to nonprofessional students. Uncontrolled eating behavior is influenced by increase in stress, and perceived stress is independent of demographic variables.
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Onsite mentoring of special newborn care unit to improve the quality of newborn care p. 357
YN Prashantha, A Shashidhar, BC Balasunder, B Pradeep Kumar, P N Suman Rao
DOI:10.4103/ijph.IJPH_419_18  
Background: It has been possible to set up special newborn care units (SNCUs) and to improve the survival of newborns in India. However, several challenges remain affecting their effective functioning. Different approaches have been attempted and several policies have also been implemented to address this issue. Objectives: To evaluate the feasibility of implementing best practices in neonatal care by onsite mentoring in an SNCU over 4 months. Methods: The mentoring team was from a tertiary care hospital in Karnataka. The SNCU was functioning at the district hospital, catering to approximately 3500 live births per year. Onsite mentoring was carried out from August 2016 to November 2016. This was a prospective implementation research. Framework focused on infection control, preterm care, care at birth, advocacy for infrastructure and resources, and facility-based refresher training. Results: A total of 16 visits were done by the mentoring team and 2 weeks of in-house residency. There were improvements in hand hygiene compliance from 0% to 87.5%, in cleaner IV site (from 50% to 100%), decreased unnecessary oxygen administration (from 75% to 33.3%), decreased antibiotic usage (from 70.5% to 35.5%), decrease in the number of babies receiving >5 days of antibiotics (from 41.6% to 0%), and increased kangaroo mother care initiation rate from 0% to 41.6%. The facility got level IIA accreditation by the end of the intervention period. Conclusions: Onsite mentorship program of SNCU is feasible and planning should be contextual. With the problems being uniform across most facilities, the model could be replicated across the country.
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REVIEW ARTICLES Top

A critical review of new competency-based curriculum for community medicine using various curricular review frameworks p. 362
Amol R Dongre, Thomas V Chacko
DOI:10.4103/ijph.IJPH_141_19  
The purpose of the present review is to examine the new competency-based undergraduate curriculum in community medicine against the established frameworks and criteria and suggest the way forward for achieving competencies expected of the Indian Medical Graduate (IMG). The new Graduate Medical Education Regulations, 2018, is based on Harden's concept of the curriculum. Hence, we reviewed the components of new curriculum against Harden's conceptualization of various components of the curriculum, and since it claims it is competency-based, we used Tyler's Goal/Objective-Based Evaluation. The new undergraduate curriculum has shown a move toward integration of course content and defined the competencies in more measurable terms. However, it appears that the earlier information-based curriculum corresponding to book chapters (”topics”) has been modified to specify higher cognitive domains with no explicit link between the IMG level curriculum outcomes to subject level intended learning outcomes (ILOs). The mechanism to link ILOs to assessment is also not clear and so needs more clarity. The assessment system hinted at in the current document is mostly based on the existing conventional system of 50% as pass cutoff, etc., against criterion-referenced assessment applicable to competencies that need to be performed. Furthermore, there is no guidance on the creation of educational opportunities and environment for students and faculty – perhaps it is left to “Curriculum Implementation Support Programme (CISP) Workshops.” Hence, the need for preparing a roadmap/blueprint to learning experiences and assessment methods and levels and milestones to be reached at various phases of MBBS and during internship is required.
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Predictors of adherence to antiretroviral therapy among PLHIV p. 367
Arjunahalli Eswarachar Paramesha, Leena Kunnath Chacko
DOI:10.4103/ijph.IJPH_376_18  
Adherence to antiretroviral therapy (ART) is of paramount importance to achieve the optimum control of viral load and progression of disease among people living with HIV (PLHIV). An overview of systematic reviews to summarize the factors influencing adherence to ART was not found in the literature; hence, the systematic review of systematic reviews was conducted to provide global view of factors influencing adherence to ART. Systematic reviews ever published till May 2018 were searched and retrieved between May 2015 and May 2018 from Cochrane and PubMed databases. Among 88 studies initially chosen based on inclusion and exclusion criteria, 22 were selected for further analysis. Qualitative analysis of included reviews was made through narrative synthesis approach. Results of the study show that among the 60 factors enlisted, 5 were most highly significant, 7 were highly significant, 19 were moderately significant, and 29 were emerged as significant factors. Substance abuse, financial constraints, social support, HIV stigma, and depressive symptoms were the most highly significant factors influencing the adherence, whereas age, employment status, long distance, side effects of drugs, pill burden, education, and mental health were regarded as highly significant factors influencing ART. Fatigue, away from home, being too busy in other things, simply forgot, and beliefs about the necessity of ART emerged as significant factors. The study concludes that findings from the overview give global insight into the factors determining adherence to ART which would further influence the innovations, program, and policy-making to mitigate the problem of nonadherence.
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BRIEF RESEARCH ARTICLES Top

Reasons for the delay in the initiation of treatment and initial default among drug-resistant tuberculosis patients in Ahmedabad corporation area p. 377
A Bhagyalaxmi, Shikha Jain, Parimal Patel, Divya Barot
DOI:10.4103/ijph.IJPH_26_19  
The emergence of drug-resistant tuberculosis (DR-TB) has become a significant health problem in India. Delays in diagnosis and treatment initiation are frequently observed among patients with DR-TB, resulting in an increased risk of disease complications and high mortality and pretreatment lost to follow-up rates. To understand the factors associated with delays between the diagnosis and treatment, the study was carried out in Ahmedabad Municipal Corporation Area. A total of 177 DR-TB patients diagnosed in the year 2014 who had a delay in the initiation of treatment, and 23 initial defaulters were studied using a structured questionnaire. Fifty-four DOTS providers were also interviewed. Of 177 patients, 62.15% initiated treatment between 7 and 15 days and nearly 12% of them started the treatment after a month. The median duration of delay was 12 days (range: 8–144 days and interquartile range: 9–20 days). The most common reason for the delay in the initiation and initial default was the social and personal factors (48.80%), and in 34 (20%) of the patients, the delay was attributed to the effect of the previous treatment.
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An exploratory study on violence among the college students in Urban Bengaluru, Karnataka, India p. 380
N R Ramesh Masthi, AR Manasa
DOI:10.4103/ijph.IJPH_230_18  
Violence often blights people's lives for decades, leading to drug addiction, depression, suicide, school dropout, unemployment, and recurrent relationship difficulties. This exploratory study was conducted among professional degree colleges in urban Bengaluru from January to March 2017; the objectives were to find the magnitude, forms, and substance use in violence. A total of 450 students were studied. One hundred and twenty-three (27.3%) students experienced some kind of violence in the past 1 year and 77 (62.6%) were males. Verbal abuse (65.0%), pushing around (23.6%), and slapping (18.7%) were common forms of violence observed. Substance use was significantly associated with violence.
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