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Patient-reported measures of encounters in healthcare settings and consideration of their preferences could provide valuable inputs to improve healthcare quality. Although there are increasing reports of user experiences regarding health care in India in recent times, there is a lack of evidence from Indian healthcare settings on the care provided for patients with chronic diseases. We selected diabetes mellitus and cancer as representatives of two common conditions requiring different care pathways. We conducted a scoping review of studies reporting experiences or preferences of patients/caregivers for these conditions, in PubMed, Global Index Medicus and grey literature, from the year 2000 onwards. Both published and emergent themes were derived from the data and summarised as a narrative synthesis. Of 95 included studies (49 diabetes, 46 cancer), 73% (65) were exclusively quantitative surveys, 79% included only patients (75), and 59.5% (44) were conducted in government centres. Studies were concentrated in a few states in India, with the underrepresentation of vulnerable population groups and representative studies. There was a lack of standardised tools and comprehensive approaches for assessing experiences and preferences of patients and caregivers, concerning diabetes and cancers in India. The commonest type of care assessed was therapeutic (74), with 14 cancer studies on diagnosis and nine on palliative care. Repeated visits to crowded centres, drug refill issues, unavailability of specific services in government facilities, and expensive private care characterised diabetes care, while cancer care involved delayed diagnosis and treatment, communication, and pain management issues. There is a need for robust approaches and standardised tools to measure responsiveness of the healthcare system to patient needs, across geographical and population subgroups in India. Health system reforms are needed to improve access to high-quality care for treatment and palliation of cancer and management of chronic diseases such as diabetes.

Malnutrition among children is one of the most pressing health concerns middle- and low-income countries face today, particularly those in Sub-Saharan Africa and South Asia. Early-life malnutrition has been shown to affect long-term health and income. One hypothesized channel linking early-life malnutrition and long-term outcomes is cognitive development. However, there is limited empirical evidence on the relationship between nutritional status and cognitive achievement in middle childhood. As part of the South India Community Health Study (SICHS), we collected educational attainment and anthropometric data from 1,194 children in rural Vellore district of Tamil Nadu, India, and assessed their math and reading skills. We analyzed the relationship between continuous and binary anthropometric measures of nutritional status and three measures of cognitive achievement (reading, math, and grade level), adjusting for potential confounders, using a regression framework. Lower height-for-age and weight-for-age and their corresponding binary measures (stunting, underweight) were associated with lower reading scores, lower math scores, and lower grade level, with the exception of the association between weight-for-age and reading, which was marginally significant. A stunted child had one-third of a grade disadvantage compared to a non-stunted counterpart, whereas an underweight child had one-fourth of a grade disadvantage compared to a non-underweight counterpart. Lower BMI-for-age was associated with grade level and marginally associated with lower math scores, and its binary measure (thinness) was marginally associated with lower math scores. Acute and chronic malnutrition in middle childhood were negatively associated with math scores, reading scores, and educational attainment. Our study provides new evidence that cognitive achievement during middle childhood could be an important mechanism underlying the association between early-life malnutrition and long-term wellbeing.

In order for low and middle income countries (LMIC) to transition to Human Papilloma Virus (HPV) test based cervical cancer screening, a greater understanding of how to implement these evidence based interventions (EBI) among vulnerable populations is needed. This paper documents outcomes of an implementation research on HPV screening among women from tribal, rural, urban slum settings in India. A mixed-method, pragmatic, quasi-experimental trial design was used. HPV screening on self-collected cervical samples was offered to women aged 30-60 years. Implementation strategies were 1) Assessment of contextual factors using both qualitative and quantitative methods like key informant interviews (KII), focus group discussions (FGDs), pre-post population sample surveys, capacity assessment of participating departments 2) enhancing provider capacity through training workshops, access to HPV testing facility, colposcopy, thermal ablation/cryotherapy at the primary health care centers 3) community engagement, counselling for self-sampling and triage process by frontline health care workers (HCWs). Outcomes were assessed using the RE-AIM (Reach, Effectiveness, adoption, implementation, maintenance) framework. Screening rate in 8 months' of study was 31.0%, 26.7%, 32.9%, prevalence of oncogenic HPV was 12.1%, 3.1%, 5.5%, compliance to triage was 53.6%, 45.5%, 84.6% in tribal, urban slum, rural sites respectively. Pre-cancer among triage compliant HPV positive women was 13.6% in tribal, 4% in rural and 0% among urban slum women. Unique challenges faced in the tribal setting led to programme adaptations like increasing honoraria of community health workers for late-evening work and recalling HPV positive women for colposcopy by nurses, thermal ablation by gynaecologist at the outreach camp site. Self-collection of samples combined with HCW led community engagement activities, flexible triage processes and strengthening of health system showed an acceptable screening rate and better compliance to triage, highlighting the importance of identifying the barriers and developing strategies suitable for the setting. CTRI/2021/09/036130.

Background As a frontrunner in introducing cervical screening in India, the state of Tamil Nadu urgently needs to consider how to improve screening rates and switch to Human Papillomavirus (HPV) detection tests. Methods We used a mixed methods design to assess the readiness of the state health system for delivering the current cervical screening program, as well as for future HPV self-collection. Following a desk review, we surveyed 14 government health facilities in three districts of Tamil Nadu and calculated overall and domain-specific (service utilization, service availability, general service, cervical screening) readiness scores as percentages. We conducted four interviews and five focus group discussions with 37 participants [managers, primary care nurses, community health workers (CHWs)] to clarify findings and obtain suggestions regarding the introduction of HPV self-collection in tribal, rural, and urban low-resource settings. Results Scores for general services and readiness to offer visual inspection with acetic acid (VIA) and follow-up were more than 70% in the surveyed facilities. Despite the availability of trained nurses, infrastructure and resources, utilisation was primarily limited to symptomatic women attending health facilities due to poor acceptability of screening that would require facility visits. Most participants felt that self-collection could reduce women’s fear and embarrassment and could be delivered through CHWs in the community or by nurses at facilities. However, motivation for screening may remain low as most asymptomatic women do not perceive a need for screening, and/or fear implications of a positive test. Tertiary laboratories appear ready for HPV testing, given availability of high-throughput PCR equipment, computerised laboratory information management systems, and a planned hub and spoke model of improving access to laboratory tests. Conclusions Despite relatively good infrastructure and staffing for VIA screening in public healthcare facilities, service utilisation was primarily by symptomatic women, contributing to low screening rates. HPV self-collection was highly acceptable to administrative and field staff. Widespread educational approaches to motivate asymptomatic women to screen using self-collection, with decentralised sample collection and treatment, could potentially improve cervical screening rates. Clinical trial number Not applicable.

Background: Chronic periodontitis is a common cause of poor oral health globally. Those at higher risk of this preventable and easily treatable condition need to be identified so that efforts can be taken to decrease disease burden and subsequent consequences. Aims: The aims of the study were (1) To compare the prevalence of chronic periodontitis among individuals with and without type 2 diabetes, aged 35-65 years from a rural block in Vellore, Tamil Nadu and (2) to assess risk factors for chronic periodontitis among individuals with diabetes. Settings and Design: A cross-sectional study was done in nine villages of Kaniyambadi block, Vellore, between October 2015 and July 2016 among participants aged 35-65 years of a previous cross-sectional survey which had identified individuals with and without type 2 diabetes. Materials and Methods: Chronic periodontitis was assessed using the Community Periodontal Index and Treatment Needs index. Oral hygiene was assessed clinically using the Simplified Oral Hygiene Index. Diabetes was defined as on medication for type 2 diabetes or detected to have fasting blood glucose ≥126 mg/dl (in a previous survey). Statistical Analysis: Chi-square test and odds ratios (adjusted using logistic regression) were used to study risk factors for periodontitis among those with diabetes. Results: Prevalence of chronic periodontitis was 45.9% (95% confidence interval [CI]: 40.88%-50.9%) among 98 individuals with diabetes and 35.6% (95% CI: 30.91-40.29%) among 104 individuals without diabetes. Poor oral hygiene (odds ratio: 8.33, 95% CI: 3.33-25.00), low socioeconomic status (odds ratio: 3.19, 95% CI: 1.00-10.12), and smoking (odds ratio: 3.51, 95% CI: 1.17-10.51) were associated with periodontitis among diabetics. Conclusions: Individuals with type 2 diabetes have a higher prevalence of periodontitis. As poor oral hygiene is a strong risk factor for periodontitis, there is a need for targeted education regarding dental hygiene to reduce this preventable condition.

Background In view of the WHO’s call for the elimination of cervical cancer as a public health problem, and current low screening coverage, Indian policy makers need evidence on how to effectively implement cervical screening programmes, ensuring equity in access. Our study will follow the INSPIRE implementation framework to co-design and test HPV-based screening approaches in two states of India with different health system organisation, based on understanding the status of screening as currently implemented, readiness and challenges to transition to HPV-based screening, and preferences of key stakeholders. Here, we describe our protocol for the formative phase of the study (SHE-CAN). Methods The study population includes women from vulnerable populations, defined as residents of tribal areas, rural villages, and urban slums, in the states of Mizoram and Tamil Nadu. The baseline assessment will use mixed methods research, with desktop reviews, qualitative studies, and surveys. A capacity assessment survey of screening and treatment facilities will be done, followed by interviews with healthcare providers, programme managers, and community health workers. Interviews will be conducted with previously screened women and focus group discussions with under and never-screened women and community members. Stakeholder workshops will be held in each state to co-design the approaches to delivering HPV-based screening among 30–49-year-old women. Discussion The quality and outcomes of existing screening services, readiness to transition to HPV-based screening, challenges in providing and participating in the cervical cancer care continuum, and acceptability of screening and treatment approaches will be examined. The knowledge gained about the current system, as well as recognition of actions to be taken, will inform a stakeholder workshop to co-design and evaluate implementation approaches for HPV-based screening through a cluster randomised implementation trial.

The Achutha Menon Centre Diabetes Risk Score (AMCDRS), which was developed in rural Kerala State, South India, had not previously been externally validated. We examined the performance of the AMCDRS in urban and rural areas in the district of Vellore in the South Indian state of Tamil Nadu, and compared it with other diabetes risk scores developed from India. We used the data from 4,896 participants (30 to 64 years) of a cross-sectional study conducted in Vellore (2010 to 2012), to calculate the AMCDRS scores using age, family history, and waist circumference. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV), and the area under the receiver operating characteristic curve (AROC) were calculated for undiagnosed and total diabetes. Of the 4,896 individuals surveyed, 274 (5.6%) had undiagnosed diabetes and 759 (15.5%) had total diabetes. The AMCDRS, with an optimum cut-point of ≥4, identified 45.0% for further testing with 59.5% sensitivity, 60.5% specificity, 9.1% PPV, 95.8% NPV, and an AROC of 0.639 (95% confidence interval [CI], 0.608 to 0.670) for undiagnosed diabetes. The corresponding figures for total diabetes were 75.1%, 60.5%, 25.9%, 93.0%, and 0.731 (95% CI, 0.713 to 0.750), respectively. The AROC for the AMCDRS was not significantly different from that of the Indian Diabetes Risk Score, the Ramachandran or the Chaturvedi risk scores for total diabetes, but was significantly lower than the AROC of the Chaturvedi score for undiagnosed diabetes. The AMCDRS is a simple diabetes risk score that can be used to screen for undiagnosed and total diabetes in low-resource primary care settings in India. However, it probably requires recalibration to improve its performance for undiagnosed diabetes.

Abstract Background: Breast cancer and cervical cancer are the leading causes of cancer-related mortality in Indian women. As part of the Indian national guidelines for population-based cancer screening, village-level accredited social health activists (ASHAs) are the key mobilizers for encouraging women to undergo cervical and breast cancer screening. Assessing screening rates in these health workers themselves, can improve implementation of the national program by identifying some of the facilitators and barriers for screening. Methods: A cross-sectional study was conducted among ASHAs in Puri, Odisha, in eight primary health centers (PHCs) randomly selected from 10 blocks. Of all 291 ASHAs in these PHCs, 242 (83.2%) who consented, were given a self-administered questionnaire to assess screening and its associated factors. Results: The screening rates for cervical and breast screening in ASHA workers were 9.1% (95% CI: 5.4%-12.8%, 22/242) and 14.9% (95% CI: 10.3%-19.5%, 36/242), respectively. Having undergone screening themselves, was associated with referring others for screening (83.3% of those screened for breast cancer had referred others vs 37.4% of those never screened; 86.4% of those screened for cervical cancer had referred others vs 34.1% of those never screened). Conclusions: ASHAs reported low rates of screening for breast and cervical cancer. History of screening significantly influenced the referral of others for screening. ASHAs need to be empowered with both educational exposure as well as motivation for health-promoting activities for themselves, in order to increase population-wide screening coverage.

Breast cancer and cervical cancer are the leading causes of cancer-related mortality in Indian women. As part of the Indian national guidelines for population-based cancer screening, village-level accredited social health activists (ASHAs) are the key mobilizers for encouraging women to undergo cervical and breast cancer screening. Assessing screening rates in these health workers themselves, can improve implementation of the national program by identifying some of the facilitators and barriers for screening. A cross-sectional study was conducted among ASHAs in Puri, Odisha, in eight primary health centers (PHCs) randomly selected from 10 blocks. Of all 291 ASHAs in these PHCs, 242 (83.2) who consented, were given a self-administered questionnaire to assess screening and its associated factors. The screening rates for cervical and breast screening in ASHA workers were 9.1 (95 CI: 5.4-12.8, 22/242) and 14.9 (95 CI: 10.3-19.5, 36/242), respectively. Having undergone screening themselves, was associated with referring others for screening (83.3 of those screened for breast cancer had referred others vs 37.4 of those never screened; 86.4 of those screened for cervical cancer had referred others vs 34.1 of those never screened). ASHAs reported low rates of screening for breast and cervical cancer. History of screening significantly influenced the referral of others for screening. ASHAs need to be empowered with both educational exposure as well as motivation for health-promoting activities for themselves, in order to increase population-wide screening coverage.

Background & objectives: Surveillance of risk factors is important to plan suitable control measures for non-communicable diseases (NCDs). The objective of this study was to assess the behavioural, physical and biochemical risk factors for NCDs in Vellore Corporation and Kaniyambadi, a rural block in Vellore district, Tamil Nadu, India. Methods: This cross-sectional study was carried out among 6196 adults aged 30-64 yr, with 3799 participants from rural and 2397 from urban areas. The World Health Organization-STEPS method was used to record behavioural risk factors, anthropometry, blood pressure, fasting blood glucose and lipid profile. Multiple logistic regression was used to assess associations between risk factors. Results: The proportion of tobacco users (current smoking or daily use of smokeless tobacco) was 23 per cent in the rural sample and 18 per cent in the urban, with rates of smoking being similar. Ever consumption of alcohol was 62 per cent among rural men and 42 per cent among urban men. Low physical activity was seen among 63 per cent of the urban and 43 per cent of the rural sample. Consumption of fruits and vegetables was equally poor in both. In the urban sample, 54 per cent were overweight, 29 per cent had hypertension and 24 per cent diabetes as compared to 31, 17 and 11 per cent, respectively, in the rural sample. Physical inactivity was associated with hypertension, body mass index (BMI) ≥25 kg/m[2], central obesity and dyslipidaemia after adjusting for other factors. Increasing age, male sex, BMI ≥25 kg/m[2] and central obesity were independently associated with both hypertension and diabetes. Interpretation & conclusions: Diabetes, hypertension, dyslipidaemia, physical inactivity and overweight were higher in the urban area as compared to the rural area which had higher rates of smokeless tobacco use and alcohol consumption. Smoking and inadequate consumption of fruits and vegetables were equally prevalent in both the urban and rural samples. There is an urgent need to address behavioural risk factors such as smoking, alcohol consumption, physical inactivity and inadequate intake of fruits and vegetables through primary prevention.