Raghupathy Anchala

... in a study of adult patients. Irene Berti, MD Giorgio Longo, MD Institute of Child Health Burlo Garofolo 34100 Trieste, Italy berti@burlo.trieste.it Stefano Visintin, Ph.D. Pharmacy Service ASS 2 Isontina 34074 Monfalcone, Italy 1. Boushey HA, Sorkness CA, King TS, et al. ...

There is a lack of information on the practice patterns and available human resources and services for screening for eye complications among persons with diabetes in India. The study was undertaken to document existing health care infrastructure and practice patterns for managing diabetes and screening for eye complications. This cross-sectional, hospital-based survey was conducted in 11 cities where public and private diabetic care providers were identified. Both multispecialty and standalone diabetic care facilities were included. A semi-structured questionnaire was administered to senior representative(s) of each institution to evaluate parameters using the World Health Organization health systems framework. We interviewed physicians in 73 hospitals (61.6% multispecialty hospitals; 38.4% standalone clinics). Less than a third reported having skilled personnel for direct ophthalmoscopy. About 74% had provision for glycated hemoglobin testing. Only a third had adequate vision charts. Printed protocols on management of diabetes were available only in 31.5% of the facilities. Only one in four facilities had a system for tracking diabetics. Half the facilities reported having access to records from the treating ophthalmologists. Direct observation of the services provided showed that reported figures in relation to availability of patient support services were overestimated by around 10%. Three fourths of the information sheets and half the glycemia monitoring cards contained information on the eye complications and the need for a regular eye examination. The study highlighted existing gaps in service provision at diabetic care centers in India.

India has the second largest population of persons with diabetes and a significant proportion has poor glycemic control and inadequate awareness of management of diabetes. Determine the level of awareness regarding management of diabetes and its complications and diabetic care practices in India. The cross-sectional, hospital-based survey was conducted in 11 cities where public and private providers of diabetic care were identified. At each diabetic care facility, 4-6 persons with diabetes were administered a structured questionnaire in the local language. Two hundred and eighty-five persons with diabetes were interviewed. The mean duration since diagnosis of diabetes was 8.1 years (standard deviation ± 7.3). Half of the participants reported a family history of diabetes and 41.7% were hypertensive. Almost 62.1% stated that they received information on diabetes and its management through interpersonal channels. Family history (36.1%), increasing age (25.3%), and stress (22.8%) were the commonest causes of diabetes reported. Only 29.1% stated that they monitored their blood sugar levels at home using a glucometer. The commonest challenges reported in managing diabetes were dietary modifications (67.4%), compliance with medicines (20.5%), and cost of medicines (17.9%). Around 76.5% were aware of complications of diabetes. Kidney failure (79.8%), blindness/vision loss (79.3%), and heart attack (56.4%) were the commonest complications mentioned. Almost 67.7% of the respondents stated that they had had an eye examination earlier. The findings have significant implications for the organization of diabetes services in India for early detection and management of complications, including eye complications.

Available evidence from India shows that the control of diabetes is poor in majority of the population. This escalates the risk of complications. There is no systematic review to estimate the magnitude of diabetic retinopathy (DR) in India. A systematic literature search was carried out in Ovid Medline and EMBASE databases using Mesh and key search terms. Studies which reported the proportion of people with diabetes with DR in a representative community population were included. Two independent reviewers reviewed all the retrieved publications. Data were extracted using a predefined form. Review Manager software was used to perform meta-analysis to provide a pooled estimate. Studies included were assessed for methodological quality using selected items from the STROBE checklist. Seven studies (1999-2014; n = 8315 persons with diabetes) were included in the review. In the meta-analysis, 14.9% (95% confidence interval [CI] 10.7-19.0%) of known diabetics aged ≥30 years and 18.1% (95% CI 14.8-21.4) among those aged ≥50 years had DR. Heterogeneity around this estimate ranged from I(2)= 79-87%. No linear trend was observed between age and the proportion with DR. The overall methodological quality of included studies was moderate. Early detection of DR is currently not prioritized in public health policies for noncommunicable diseases and blindness programs. Methodological issues in studies suggest that the proportion of diabetics with DR is underestimated in the Indian population. Future research should emphasize more robust methodology for assessing diabetes and DR status.

There is a lack of evidence on the subjective aspects of the provider perspective regarding diabetes and its complications in India. The study was undertaken to understand the providers' perspective on the delivery of health services for diabetes and its complications, specifically the eye complications in India. Hospitals providing diabetic services in government and private sectors were selected in 11 of the largest cities in India, based on geographical distribution and size. Fifty-nine semi-structured interviews conducted with physicians providing diabetes care were analyzed all interviews were recorded, transcribed, and translated. Nvivo 10 software was used to code the transcripts. Thematic analysis was conducted to analyze the data. The results are presented as key themes: "Challenges in managing diabetes patients," "Current patient management practices," and "Strengthening diabetic retinopathy (DR) services at the health systems level." Diabetes affects people early across the social classes. Self-management was identified as an important prerequisite in controlling diabetes and its complications. Awareness level of hospital staff on DR was low. Advances in medical technology have an important role in effective management of DR. A team approach is required to provide comprehensive diabetic care. Sight-threatening DR is an impending public health challenge that needs a concerted effort to tackle it. A streamlined, multi-dimensional approach where all the stakeholders cooperate is important to strengthening services dealing with DR in the existing health care setup.

Diabetic retinopathy is a leading cause of visual impairment. Low awareness about the disease and inequitable distribution of care are major challenges in India. Assess perception of care and challenges faced in availing care among diabetics. The cross-sectional, hospital based survey was conducted in eleven cities. In each city, public and private providers of eye-care were identified. Both multispecialty and standalone facilities were included. Specially designed semi-open ended questionnaires were administered to the clients. 376 diabetics were interviewed in the eye clinics, of whom 62.8% (236) were selected from facilities in cities with a population of 7 million or more. The mean duration of known diabetes was 11.1 (±7.7) years. Half the respondents understood the meaning of adequate glycemic control and 45% reported that they had visual loss when they first presented to an eye facility. Facilities in smaller cities and those with higher educational status were found to be statistically significant predictors of self-reported good/adequate control of diabetes. The correct awareness of glycemic control was significantly high among attending privately-funded facilities and higher educational status. Self-monitoring of glycemic status at home was significantly associated with respondents from larger cities, privately-funded facilities, those who were better educated and reported longer duration of diabetes. Duration of diabetes (41%), poor glycemic control (39.4%) and age (20.7%) were identified as the leading causes of DR. The commonest challenges faced were lifestyle/behavior related. The findings have significant implications for the organization of diabetes services in India.

The growing burden of avoidable blindness caused by diabetic retinopathy (DR) needs an effective and holistic policy that reflects mechanisms for early detection and treatment of DR to reduce the risk of blindness. We performed a comprehensive health policy review to highlight the existing systemic issues that enable policy translation and to assess whether India's policy architecture is geared to address the mounting challenge of DR. We used a keyword-based Internet search for documents available in the last 15 years. Two reviewers independently assessed retrieved policies and extracted contextual and program-oriented information and components delineated in national policy documents. Using a "descriptive analytical" method, the results were collated and summarized as per themes to present status quo, gaps, and recommendations for the future. Lack of focus on building sustainable synergies that require well laid out mechanisms for collaboration within and outside the health sector and poor convergence between national health programs appears to be the weakest links across policy documents. To reasonably address the issues of consistency, comprehensiveness, clarity, context, connectedness, and sustainability, policies will have to rely more strongly on evidence from operational research to support decisions. There is a need to involve multiple stakeholders from multiple sectors, recognize contributions from not-for-profit sector and private health service providers, and finally bring about a nuanced holistic perspective that has a voice with implementable multiple sector actions.

ABSTRACT In resource constrained settings, the decision makers in a health system, i.e. health policy planners attempt to distribute the available funds on a priority basis. This leads to a skewed view point since the beneficiaries, i.e. community tries to maximize the aggregated total health benefit conferred. Capsmart project aims to introduce a composite user developed community ‘decision’ marker which takes into account all the perspectives of relevant stakeholders in a healthcare system. The derived perspectives, based on participatory research and a sound scientific methodology, will inform health policy, and provide an alternative tool to analyze the cost effectiveness of health policies, and prioritize the resource allocation to national health programs. The developed composite decision marker will be custom built, validated and developed as a smartphone application for training and building public health capacity of the frontline health workers on health promotion and primary prevention of non-communicable diseases. Pilot testing the applicability, feasibility and sustainability of a smartphone based training package will enable future decisions to be taken on applicability of the mobile computing and health care technology in developing countries, more so in resource constrained low and middle income countries.

The choice of adequate number of subjects that would ensure accurate estimates is an important one in a clinical trial setting. Although complexity of a formula increases with complexity in study design, the basic structure of a sample size calculation formula is very simple. This paper attempts to review the basic requirements for computation of the magic number required to estimate unknown target population quantities and to test treatment differences for continuous as well as binary outcomes. Concepts are demonstrated through simple examples. Using online calculators for sample size is also discussed.

Background Training of the State and district Rapid Response Teams (RRT's), which investigate and respond to an outbreak or an epidemic, has been one of the core functions of Integrated Disease Surveillance Project(IDSP) in India. Traditionally, this human capacity development - training workshops have been different for State and District Surveillance Officers (an epidemiologist or a Medical Officer - the leader of the RRT team) and other team members. Indian Institute of Public Health (IIPH), Hyderabad recently conducted three heterogeneous 'competency based' training workshops to bring in a common training schedule to all the RRT members. Methods Indian Institute of Public Health (IIPH), Hyderabad conducted three heterogeneous 'competency based' training workshops on epidemic investigation, response and control practices for 17 district RRT's (6, 4, 7 districts in three batches) belonging to the state of Andhra Pradesh, India from 29 to 31 May, 2009 and 08...

The Integrated Disease Surveillance Project (IDSP) was launched with the primary aim of detecting early warning signals of impending outbreaks and facilitates the initiation of an effective response in a timely manner. The IDSP data obtained from the State Surveillance Unit during a one year period (December2007-December2008) was analyzed with the aim of showing the region wise distribution of symptoms and the relationship between symptom and disease in the 23 districts of AP. Time Trends, Regionality, endemicity of diseases or syndromes, region-wise distribution of symptoms and the relationship between symptoms and diseases from 16,570 health care centers and laboratories all over Andhra Pradesh, for the period December 2007-December 2008, were analyzed. The results indicated that the proportion of fever was the highest in the Rayalseema region and the proportion of cough was the highest in the Telangana region. The highest number of fever and jaundice cases occurred in the distric...

The Integrated Disease Surveillance Project (IDSP) is a decentralized, state based surveillance program in the country. It is intended to detect early warning signals of impending outbreaks and help initiate an effective response in a timely manner. Data collected under IDSP would also provide a rational basis for decision-making and implementing public health interventions. IDSP data obtained from the State Surveillance Unit during a one year period (December 2007-December 2008) was analyzed with a goal to quantify the reporting frequency of various District Surveillance Units (DSUs) and address the information generation gaps that exist in the State Surveillance Unit of Andhra Pradesh (AP). The frequency of completeness in the reporting of the S, P and L weekly surveillance reports, received from 16,570 health care centers and laboratories all over the state of Andhra Pradesh, for the period December 2007-December 2008, were analyzed. The mean proportion of reporting in AP, from a...

ABSTRACT Background: Nutrition education is used as a way of promoting lifelong healthy eating practices among school adolescents. There is limited published information on the impact of nutrition education programmes in India.Objectives: To assess the knowledge and practices of high school students with respect to healthy diets before and after a nutrition education programme.Design: Pre- and post-intervention questionnaire survey.Setting: Two private schools in Chennai city.Method: This study was conducted among adolescents studying in standard VIII and IX in two private schools in Chennai city. Nutrition education as lectures and interactive discussions were given to students one hour every week for a period of 10 weeks. Information on knowledge and attitude on healthy eating and dietary practices was collected before and after the nutrition education intervention using a questionnaire. Differences in knowledge, attitude and practice of students on healthy diet were measured using the X² test with the level of significance p<0.05.Results: A total of 181 students were involved in the study (response rate 92%). Following the nutrition education programme, satisfactory dietary knowledge significantly improved from 37% to 67% (p<0.001). Similarly, students showing a positive attitude towards healthy diet increased from 18% to 40% (p<0.001). The proportion of students taking soft drinks reduced from 20% to 10% (p<0.01) and ingestion of fast food items through fast food restaurants reduced significantly.Conclusions: This short-term nutrition education programme brought significant improvements in dietary knowledge and reductions in soft drinks and fast foods consumption.

ABSTRACT In resource constrained settings, the decision makers in a health system, i.e. health policy planners attempt to distribute the available funds on a priority basis. This leads to a skewed view point since the beneficiaries, i.e. community tries to maximize the aggregated total health benefit conferred. Capsmart project aims to introduce a composite user developed community ‘decision’ marker which takes into account all the perspectives of relevant stakeholders in a healthcare system. The derived perspectives, based on participatory research and a sound scientific methodology, will inform health policy, and provide an alternative tool to analyze the cost effectiveness of health policies, and prioritize the resource allocation to national health programs. The developed composite decision marker will be custom built, validated and developed as a smartphone application for training and building public health capacity of the frontline health workers on health promotion and primary prevention of non-communicable diseases. Pilot testing the applicability, feasibility and sustainability of a smartphone based training package will enable future decisions to be taken on applicability of the mobile computing and health care technology in developing countries, more so in resource constrained low and middle income countries.