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    Table of Contents - Current issue
Coverpage
October-December 2018
Volume 43 | Issue 4
Page Nos. 251-328

Online since Friday, December 21, 2018

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EDITORIAL COMMENTARY  

Integration of medical education with health-care delivery system in India for competency-based learning p. 251
Sunder Lal
DOI:10.4103/ijcm.IJCM_358_18  PMID:30662174
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VIEWPOINT Top

Sustainable development goals: Leveraging the global agenda for driving health policy reforms and achieving universal health coverage in India p. 255
Rajeev Gera, Rajesh Narwal, Manish Jain, Gunjan Taneja, Sachin Gupta
DOI:10.4103/ijcm.IJCM_41_18  PMID:30662175
Universal Health Coverage (UHC) is now the critical yardstick for countries to measure and track progress toward the “Sustainable Development Goals (SDGs).” Being a signatory, India has started taking measures to attain the targets laid out within the SDG framework and achieving the UHC. With India's National Health Policy (NHP) – 2017 in place, the policy environment for transforming country's health landscape coincides with that of the global approach toward strengthening of health systems and achieving UHC. It is imperative that for achieving the desired outcomes laid down in the SDGs and NHP-2017, coordinated actions are required including political action for making health an individual's right; effective stewardship from the National Ministry of Health and Family Welfare; reorganization of health-care service delivery implementing a “systems approach;” ensuring financial protection against health-care costs; and enhancing community participation and accountability. Undertaking these steps, imbibing the learning, and dwelling upon global experiences can help the country strongly move forward towards achieving global and national targets, thereby ensuring UHC for all its citizens.
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ORIGINAL ARTICLES Top

Development of the sexually transmitted infection service evaluation tool: Use of Delphi approach p. 260
Bansari L Chawada, Jayendrakumar K Kosambiya, Vipul P Chaudhari, Kristen J Wells
DOI:10.4103/ijcm.IJCM_20_18  PMID:30662176
Background: With the wide variation in sexually transmitted infection (STI) services, it is a challenge to devise strategies for ensuring effective service delivery. The objectives of this study were to develop a standard tool for STI services evaluation and use the Delphi method to derive a weighted factor for each parameter of the tool. Methods: A review of existing guidelines for quality care STI services were conducted, and parameters were selected to form the content of the measurement tool. Delphi technique was used to derive weighted factor for each STI service delivery parameter by using the Likert scale of 0–7. A heterogeneous group of 18 anonymous experts was invited to rate the parameters. All the responses were collected online. Cronbach's alpha level ≥0.8 was selected to define consensus the experts. Results: The STI service evaluation tool (SSET) was created including ten parameters to evaluate the performance of clinic with the help of standard National guidelines. The SSET was standardized by deriving weighted factor for each evaluation parameter. Three rounds of Delphi were required to achieve consistency. Response rates for each Delphi round were 77.78%, 100%, and 78.57%, respectively. Each parameter, such as workforce, materials, consumables, consultation, counseling, coverage, referral, records, information education and communication, and supervision, was assigned weighted factor derived by converting the final score into the total standard score of 100. Conclusion: The Delphi method represents a novel approach to develop standardized tools to evaluate the performance of service delivery.
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Salt reduction and low-sodium salt substitutes: Awareness among health-care providers in Mangalore, Karnataka p. 266
K Afshaan Fathima, Madhavi Bhargava
DOI:10.4103/ijcm.IJCM_22_18  PMID:30662177
Introduction: Hypertension is an important noncommunicable disease of global significance. Low-sodium salt substitutes (LSSS) are increasingly being used for hypertensive persons. The sodium content of these salts is reduced by substituting varying proportion of sodium with potassium. Materials and Methods: The present study was done to assess the awareness of ideal salt intake, knowledge of the availability of LSSS, their indications, and contraindications among 165 doctors of Mangalore, Dakshina Kannada. Results: The knowledge of correct upper limit of salt as 5 g/day was present in 46.7% of the participants and that for the availability of LSSS in 71%. Knowledge about the mechanism of sodium reduction with potassium substitution was found to be correct in 17.6% participants. LSSS were prescribed by 31 (18.8%), and 118 (71.5%) participants did not know about their contraindications in patients with renal disease, cardiac problems, and diabetes and patients on K-sparing diuretics and painkillers. Conclusions: The study underlines the importance of knowledge about salt reduction, LSSS, their indications, and contraindications in doctors. Regulated availability of these salts and widespread information for the primary care physicians to prevent mishaps following their use is recommended.
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Street-level bureaucracy in tobacco control: A qualitative study of health department in district Jalandhar, Punjab p. 270
Shaveta Menon
DOI:10.4103/ijcm.IJCM_82_18  PMID:30662178
Background: The implementers of the tobacco control policy in the field have been neglected by the policymakers. They are the ones who have first-hand knowledge and their experiences in the field are not being used to bring about changes in the area of tobacco control. Objective: The objective of this paper is to critically examine how Michael Lipsky's concept of street-level bureaucracy can be used to address tobacco control in the health department in district Jalandhar of Punjab. Methods: Semi-structured interview schedules were used to interview Senior Medical Officers/Nodal Officers and Health Supervisors/Sanitary inspectors in four out of ten Community Health Centers and District hospital in Jalandhar. Data so collected were subjected to the process of inductive analysis and themes developed within the framework given by Lipsky. Results: The street-level bureaucrats (SLBs) were not given adequate training, and various organizational resources for tobacco control are missing in the district. There are threats and challenges which are faced by them in the field, and they do not exercise decision-making power to handle these barriers for effective implementation of the tobacco control program. Conclusion: The government needs to be inclusive in the process of policymaking meaning that it can be more accommodative of the suggestions given by the SLBs and provide them with discretionary powers to exercise their role efficiently.
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Predictors of inconsistent condom use among female sex workers: A Community-based study in a red-light area of Kolkata, India p. 274
Kajari Bandyopadhyay, Sitikantha Banerjee, Dipendra Narayan Goswami, Aparajita Dasgupta, Smarajit Jana
DOI:10.4103/ijcm.IJCM_84_18  PMID:30662179
Background: Condom is an integral part of all interventions for female sex workers (FSWs). However, certain situations hinder them from practicing consistent condom use. This paper aims at identifying the situations that predict inconsistent condom use by FSWs of Sonagachi red-light area, Kolkata. Subjects and Methods: The cross-sectional community-based observational study was conducted among 296 brothel-based FSWs of Sonagachi. Outcome variable, that is, inconsistent condom use was said to be present if any sex act with any type of partner was not protected by condom. Association with sociodemographic, occupational, and behavioral characteristics of FSWs was examined. Results: Inconsistent condom use was present among 37.5% of the study participants, and this was predicted by the presence of a nonpaying partner (NPP) (adjusted odds ratio [AOR] [95% confidence interval (CI)]: 15.04 [7.52–30.08]), violence (AOR [95% CI]: 2.08 [1.07–4.03]) and sexual intercourse under the influence of alcohol (AOR [95% CI]: 1.86 [1.02–3.39]). The major cause behind nonuse of condom as reported by the participants was trust on partner. Conclusion: NPPs need to be given emphasis in program strategies for FSWs. The FSWs should constantly be motivated for safe sex emphasizing the fact that trust on partner may be detrimental for their health.
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Determinants of stunting, wasting, and underweight in five high-burden pockets of four Indian states p. 279
Rajesh Kumar Sinha, Richa Dua, Vasundhara Bijalwan, Shivani Rohatgi, Praveen Kumar
DOI:10.4103/ijcm.IJCM_151_18  PMID:30662180
Objectives: Prevalence of under-nutrition is very high in India. Under-nutrition is a result of interplay between different immediate, underlying, and basic causes. The study was conducted with the objective to identify significant predictors of stunting, wasting, and underweight. Methods: Cross-sectional studies with 2299 children from five high-burden pockets of four Indian states were conducted. Primary data on their anthropometric measurements along with their households' demographic and socioeconomic characteristics were collected. Binary logistic regression analyses were performed to examine the predictors of stunting, wasting, and underweight. Results: Results show very high prevalence of stunting, wasting, and underweight in all five regions covered in the study. Multivariate analyses show that food security, use of toilets, and low body mass index status of mothers were the major predictors of stunting and underweight among children. Acute respiratory infection disease was the major predictor of underweight and diarrhea was the major predictor of stunting. Younger children (<24 months) had lower odds of underweight and stunting compared to older children (24–59 months). The analyses showed higher odds of wasting among male children. Regional variations were also seen in the study with higher odds of underweight and wasting in Khuntpani block and higher odds of stunting in Naraini block. Conclusion: The above findings indicate that for comprehensively addressing child under-nutrition, it is very important to address maternal nutrition, improve food security, and reduce poverty status, provide better water and sanitation facility to the community, control infections, and address regional disparity.
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Family planning adoption and unmet needs: Spousal agreement in rural Varanasi p. 284
Neeti Purwar, Hari Shankar, Kalpana Kumari
DOI:10.4103/ijcm.IJCM_153_18  PMID:30662181
Background: There have been very few studies in India where both partners' involvement in family planning is seen. The present study was undertaken to assess the spousal agreement level regarding family planning adoption and unmet needs. Materials and Methods: Married couples where wife was in reproductive age group (15–44 years) were included. A pretested, semi-structured interview schedule was used for the study. Sterilized couples were excluded. Interview of both husband and wife was done on the same day but in isolation. Results: There was excellent to poor agreement was reported among husbands and wives in fertility desire (κ = 0.769), current use of contraception (κ = 0.581), unmet need for family planning (κ = 0.416), ideal family size (Spearman correlation = 0.329), and approval for the use of contraception (κ = 0.300). In 6.1% of cases, husband-only unmet need was reported. Conclusion: There is need to encourage spousal communication so that they can make informed decisions on contraceptive choice. Husband-only unmet need for family planning was found, so man may be a potential entry point of national demographic health surveys to improve the contraceptive usage among couples and reduce the unmet need of them.
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Postmenopausal bleeding among rural women in Tamil Nadu, India: Mixed methods study p. 288
R Sindhuri, Amol R Dongre
DOI:10.4103/ijcm.IJCM_162_18  PMID:30662182
Introduction: Postmenopausal bleeding (PMB) is a common and early symptom of cervical and endometrial cancer. Its early detection can improve the cure rate and reduces mortality. Objectives: The objective of the study is to find out the prevalence and determinants of PMB in a rural community setting and the reasons for not undergoing cervical cancer screening among postmenopausal women. Materials and Methods: A sequential exploratory mixed methods study where qualitative (group interviews) phase followed quantitative (survey) phase in the community. The survey was undertaken among the representative sample of 1,530 postmenopausal women in 34 villages of Villupuram district, Tamil Nadu. Data were collected by house-to-house survey. Analysis: Bivariate and multivariate analysis was done using SPSS 24 software package. Results: The prevalence of PMB was found to be 1.8%. Only 5.6% women had undergone screening. The majority did not go for screening due to lack of awareness, or they did not have any symptoms or feared about negative results. Occupation (daily wage laborers), use of oral contraceptive pills at least for 1 year, recurrent abortions (> three abortions), reproductive tract infection (more than 10 episodes in lifetime), abdominal obesity (increased waist–hip ratio), and underweight were identified as significant risk factors for PMB. Conclusion and Recommendations: Nearly 2% of women have PMB, and most of the factors identified as determinants are preventable. Cervical cancer screening rate was poor among the respondents and lack of awareness was stated as the major reason for it. Hence, the promotion of healthy lifestyles and contraceptives in early reproductive life and awareness for the need of early screening is recommended.
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Peak expiratory flow rate, blood oxygen saturation, and pulse rate among the mine tailing community p. 294
Usha G Shenoy, Karthiyanee Kutty
DOI:10.4103/ijcm.IJCM_185_18  PMID:30662183
Background: Chronic inhalation of dust impairs lung function and may cause respiratory symptoms. Very little attention has been paid to the health of community exposed to dust raised by mine tailing which is deposited for many years without precautionary measures. Therefore, a study of peak expiratory flow rate (PEFR), oxygen saturation (SPO2), and their control groups in Kolar Gold Fields and Kolar was carried out. Materials and Methods: Ventilatory function tests were done using 400 exposed community participants with the unexposed of same from Kolar who stayed in the mine tailing town for >3 years and aged 18–60 years. Their weight and height were taken and matched with controls who were not exposed to any known air pollutant. The percentage of SPO2of both the participants and their control population was determined using a pulse oximeter. Results: Respirable dust level in the test sites was 1.492 ± 0.336 mg/m3 and it was significant with the control sites, which was 0.531 ± 0.783 mg/m3 with P < 0.05. There was highly significant difference in the mean values of SPO2, pulse rate, and PEFR between the test and control participants with P < 0.001. Conclusion: There is an increase in air pollution by increase in particulate matter <2.5 in the gold mining township, and the residents here had decreased PEFR, decreased SPO2, and increased pulse rate. This proves that the mine tailing community people without precautionary measures may predispose to respiratory symptoms.
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Formative evaluation and learning achievement in epidemiology for preclinical medical students p. 298
Varisara Luvira, Sauwanan Bumrerraj, Sompong Srisaenpang
DOI:10.4103/ijcm.IJCM_191_18  PMID:30662184
Background: Teaching epidemiology and biostatistics is a challenge for medical teachers. Formative evaluation has been shown to improve the learning outcomes in various medical subjects. However, the effectiveness of formative evaluation in the subject of epidemiology has yet to be clearly demonstrated. Objective: The aim of this study is to investigate the association between formative evaluation and learning outcomes of medical students. Materials and Methods: We retrospectively reviewed the prospectively collected learning data of 266 third-year medical students who were enrolled in an epidemiology course in 2016. All learning data and outcomes were analyzed. Results: Nearly all students (97.4%) attended the formative evaluation. Learning outcomes were deemed unsatisfactory in 9.8% of cases. Multivariate analysis revealed that gender, the students' medical training program, laboratory attendance, and the amount of calculation students do during the formative examination were factors that were associated with learning outcomes. Conclusion: The formative evaluation was effective at improving learning outcomes in the subject of epidemiology. The parameters indicated that the attention of the medical students, such as laboratory attendance, and the amount of calculation done during the formative examination, were associated with learning outcomes.
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Prevalence of diabetes mellitus and its predictors among tuberculosis patients currently on treatment p. 302
Deepak Sharma, Naveen Krishan Goel, Munish Kumar Sharma, Dinesh Kumar Walia, Meenal Madhukar Thakare, Rajiv Khaneja
DOI:10.4103/ijcm.IJCM_230_18  PMID:30662185
Background: Tuberculosis (TB) and diabetes are the world's leading public health issues. They are the cause of morbidity, mortality, and pose a burden on the healthcare system. Aims and Objectives: The aim and objective of this study were to study the prevalence of diabetes and its predictors among TB patients currently on treatment. The secondary objective was to examine the self-reported blood glucose monitoring and antidiabetic drug adherence practice among diabetic TB patients. Methodology: This cross-sectional study was undertaken on 275 TB cases enrolled from selected designated microscopy centers. Self-reported information on diabetes, tobacco usage, and family history of TB was collected by trained investigators. In addition, for diabetic tubercular patients, the study investigators inquired about the type of treatment taken (allopathic/traditional), frequency of getting blood sugar tested, and daily drug adherence. For comparison between the “diabetes TB comorbidity” and “TB only group,” Chi-square test of significance was used, and odds ratios were reported. Data were analyzed using Epi Info software (CDC Atlanta). Results: The prevalence of diabetes among TB patients was found to be 13.1% (known diabetics –9.1% and new diabetics –4.0%). There were 25.5% of current/former smokers (70/275) and 13.1% of current/former smokeless tobacco users (36/275). In logistic regression analysis, age 50 years and above emerged as a significant predictor for diabetes TB comorbidity (adjusted odds ratio = 9.8 [4.3–22.3]). Conclusion: Diabetes is prevalent comorbidity in TB patients. Age more than 50 years significantly increases the odds of this twin morbidity.
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Catastrophic health-care expenditure and willingness to pay for health insurance in a metropolitan city: A cross-sectional study p. 307
Rujuta Sachin Hadaye, Jerome Gnanasigamony Thampi
DOI:10.4103/ijcm.IJCM_252_18  PMID:30662186
Background: Health insurance can be a very useful strategy to mitigate the disabling effects of catastrophic health expenditure in India. Objectives: The aim of the study is to estimate catastrophic health expenditure incurred and the willingness to pay and ability to pay for health insurance among the unsubscribed. Materials and Methods: A total of 201 principal earning members of households belonging to the 25–45 years age group were interviewed in a community-based household survey in a conveniently selected ward in Mumbai with the help of a pretested, semi-structured interview schedule. Results: The proportion of households with catastrophic health expenditure was 22.4% (total expenditure estimate) and 17.4% (nonfood expenditure estimate). There was a statistically significant association between socioeconomic class and occurrence of catastrophic health expenditure. The average amount the respondents were willing to pay as premium for health insurance per month was ₹272 and the average amount they were able to pay was ₹259. Conclusion: Catastrophic health expenditure continues to be a disastrous problem in around 20% of Indian households. Targeted health insurance schemes with different premiums and coverages for different income and employment groups should be considered.
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SHORT COMMUNICATIONS Top

Factors determining the enrolment in community-based health insurance schemes: A cross-sectional study from coastal South India p. 312
Bhageerathy Reshmi, Bhaskaran Unnikrishnan, N Sreekumaran Nair, Vasudev Guddattu
DOI:10.4103/ijcm.IJCM_118_18  PMID:30662187
Background: Community-based health insurance (CBHI) has been one of the options of health financing in India for a large number of population from the informal sector constituting about 90% of the total population. The objective of this study was to find out what are the factors which have influenced the beneficiaries to enroll in the schemes and also compared them to a noninsured group. Methods: A cross-sectional household survey, on 1639 households, was carried out, which had 1108 insured household and 530 noninsured households with a 2:1 ratio. A multivariate analysis was used to find out the determinants of enrolment. Results: The multivariate analysis revealed that household variables such as gender of household head, religion, and family size were determinants of enrolment. Conclusion: The sociodemographic characteristics of the households do influence the acceptability of the CBHI schemes.
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Diabetes distress and marriage in Type-1 diabetes p. 316
Deepak Khandelwal, Lovely Gupta, Sanjay Kalra, Amit Vishwakarma, Priti Rishi Lal, Deep Dutta
DOI:10.4103/ijcm.IJCM_74_18  PMID:30662188
Background: In spite of the large number of people with Type-1 diabetes mellitus (T1DM) in India, India is not a diabetes-friendly society. The society suffers from lots of myths regarding diabetes and insulin use. This review highlights challenges faced by young people living with T1DM with regards to marriage, associated diabetes distress, and suggests potential solutions. Methods: PubMed, Medline, and Embase search for articles published up to October 2017, using the terms “marriage” (MeSH Terms) OR “diabetes distress” (All Fields) OR “depression” (All Fields) AND “diabetes” (All Fields). The reference lists of the articles thus identified were also searched. The search was not restricted to English-language literature. Results: Misconception regarding social, occupational, marital abilities, fertility, genetics, quality of life, sexism in young people living with T1DM raises major barriers to marriage, resulting in significant diabetes distress, depression, and psychological issues in them. People with T1DM are wrongly assumed to be sick, disabled, dependent persons, unsuitable for marriages, and likely to have complicated pregnancies with the possibility of having children with diabetes. Counseling at the level of individual, spouse, family, and society can help in obviating such issues. Conclusion: Diabetes distress and psychological issues are major problems related to marriage in young people with T1DM. Counseling of patients, family, relatives, prospective spouse, and increasing social awareness regarding diabetes through mass communication are the keys to their resolution.
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LETTERS TO EDITOR Top

The importance of integrating palliative care in Universal Health Coverage discourse in India p. 320
GS Adithyan, Abhijith Jose
DOI:10.4103/ijcm.IJCM_304_17  PMID:30662189
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Infection-induced hyperglycemia in tuberculosis patients at selected health institutions in North India p. 322
Mitasha Singh, Ashok Kumar Bharadwaj, Dinesh Kumar
DOI:10.4103/ijcm.IJCM_77_18  PMID:30662190
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Managing diabetes in the era of financial crisis: Need to look beyond the obvious p. 324
Theocharis Koufakis, Christina-Maria Trakatelli, Maria Grammatiki, Kalliopi Kotsa
DOI:10.4103/ijcm.IJCM_246_18  PMID:30662191
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Utility of mid-upper arm circumference in detection of maternal acute malnutrition p. 325
Umesh Kapil, Ajeet Singh Bhadoria
DOI:10.4103/ijcm.IJCM_285_18  PMID:30662192
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Response from the Authors (Kumar P et al)[1] p. 326
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Characteristics of fall among older people in rural Puducherry p. 327
L Padmavathy, Amol R Dongre
DOI:10.4103/ijcm.IJCM_160_18  PMID:30662194
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