Transforming access to care for serious mental disorders in slums (the TRANSFORM Project) : rationale, design and protocol

This paper introduces the TRANSFORM project, which aims to improve access to mental health services for people with serious and enduring mental disorders (SMDs – psychotic disorders and severe mood disorders, often with co-occurring substance misuse) living in urban slums in Dhaka (Bangladesh) and Ibadan (Nigeria). People living in slum communities have high rates of SMDs, limited access to mental health services and conditions of chronic hardship. Help is commonly sought from faith-based and traditional healers, but people with SMDs require medical treatment, support and follow-up. This multicentre, international mental health mixed-methods research project will (a) conduct community-based ethnographic assessment using participatory methods to explore community understandings of SMDs and help-seeking; (b) explore the role of traditional and faith-based healing for SMDs, from the perspectives of people with SMDs, caregivers, community members, healers, community health workers (CHWs) and health professionals; (c) co-design, with CHWs and healers, training packages for screening, early detection and referral to mental health services; and (d) implement and evaluate the training packages for clinical and cost-effectiveness in improving access to treatment for those with SMDs. TRANSFORM will develop and test a sustainable intervention that can be integrated into existing clinical care and inform priorities for healthcare providers and policy makers

Discommensurations in icosahedral phases

The nature of the icosahedral phase is studied in the presence of competing commensurate ordering terms in the free energy. It is shown that the phase is a discommensurate one with a periodic array of domain walls (discommensurations) separating regions with long-period structure. These long-period structures have local icosahedral symmetry and their diffraction patterns closely resemble those of the icosahedral phase. In the discommensurate state the coherence length of the icosahedral phases would be determined by the domain-wall spacing. Recent experimental observations of antiphase-boundary-type defects in such systems probably indicate that the discommensurate state of the icosahedral phase is the one that is experimentally observed. We discuss the possibility of the discommensurations getting pinned by the lattice and the appearance of metastable states with random distribution of domain walls. These states are known to exhibit certain characteristic properties of glasses

Yielding and large deviations in micellar gels: a model

We present a simple model that can be used to account for the rheological behaviour observed in recent experiments on micellar gels. The model combines attachment detachment kinetics with stretching due to shear, and shows well-defined jammed and flowing states. The large-deviation function (LDF) for the coarse-grained velocity becomes increasingly non-quadratic as the applied force F is increased, in a range near the yield threshold. The power fluctuations are found to obey a steady-state fluctuation relation (FR) at small F. However, the FR is violated when F is near the transition from the flowing to the jammed state although the LDF still exists; the antisymmetric part of the LDF is found to be nonlinear in its argument. Our approach suggests that large fluctuations and motion in a direction opposite to an imposed force are likely to occur in a wider class of systems near yielding

Quasi-experimental Study of Systematic Screening for Family Planning Services among Postpartum Women Attending Village Health and Nutrition Days in Jharkhand, India

Background: Systematic screening helps increase family planning uptake through integration with other services, including immunization. Though successfully demonstrated at health facilities, this strategy has not been demonstrated in communities. This study assessed the effectiveness of systematic screening to increase postpartum family planning use during community health days in India without adversely affecting immunization services. Methods: The study was conducted during 180 individual Village Health and Nutrition Days in Jharkhand, India. All health workers were trained in postpartum family planning counseling. Intervention providers were also trained in systematic screening. 217 postpartum women aged 15–49 years participated in baseline and endline exit interviews and routine service statistics were analyzed from 2,485 facility visits at affiliated health centers. Results: No difference in family planning service use was found in the intervention group, but significantly fewer interviewed women reported receiving family planning services at endline in the comparison group (p = 0.014). Family planning acceptance at affiliated health centers increased significantly in intervention areas (p < 0.001) but not in comparison areas, while immunization service use increased in both groups (p = 0.002 intervention, p < 0.001 comparison). Conclusions: The use of the postpartum systematic screening tool appears to increase acceptance of family planning services when integrated with community-based services in Jharkhand

Providers’ perceptions on postpartum IUCD as an option of postpartum family planning services in India

Background: With high unmet need for family planning in postpartum period new methods like postpartum intrauterine contraceptive device (PPIUCD) can reduce the gap between demand and supply. Role of providers is critical in facilitating a client’s decision to choose an appropriate contraceptive method during her postpartum status. Aims & Objectives: To assess the role of providers in facilitating client’s decision to choose an appropriate contraceptive method during her postpartum status. Material & Methods: This descriptive study was conducted as a multi-centric post-training PPIUCD follow up study of providers in eight states of India. From February 2012 to July 2012, 124 PPIUCD trained providers of sixteen hospitals were interviewed with a standardized questionnaire after informed consent. The providers were interviewed for their perceptions on timing and benefits of family planning counseling, procedure ease, side effects and complications of PPIUCD and their perception of client satisfaction of the method. Proportions and mean (SD) were calculated. Results: 66 doctors, 42 nurses and 16 counselors were interviewed. 95% providers felt IUCD is a suitable method for postpartum women. According to 94% doctors, 55% nurses and 88% counselors, antenatal period was the most preferred period for counselling clients. 89% doctors and 69% nurses felt that ideal time of insertion was immediately after delivery of placenta and most preferred Kelly’s placental forceps for insertion. Expulsion was the commonest perceived complication. More than 70% providers felt that clients were satisfied with their decision of choosing PPIUCD as a method with reasons. Conclusions: The results of this descriptive study on providers’ perceptions for IUCD use during the postpartum period showed a positive inclination of the interviewed PPIUCD trained doctors, nurses and counselors towards the method which will help improve access and availability to this servic

Harmonizing scientific rigor with political urgency: policy learnings for identifying accelerators for scale-up from the safe childbirth checklist programme in Rajasthan, India

Abstract Background Quick scaling-up of innovative and promising interventions in health systems of low and middle-income countries to rapidly achieve population level benefits is a key challenge. While there is consensus on the need for rigorous scientific evidence on effectiveness of interventions before considering scale-up, there can be significant time lag for the want of gold-standard evidence. The Safe Childbirth Checklist (SCC) programme in India, demonstrated how an innovation was robustly evaluated and scaled up nationally, within a short span of time. In this narrative review, we describe the strategies discussed in various published scale-up frameworks and map them against the strategies adopted by the SCC programme to identify accelerators which facilitated its rapid scale up. Methods The narrative review – done from May to June 2017 - involved keyword searches of electronic databases of PubMed, Ovid Medline and Google Scholar. It included the key words ‘pilot’, ‘health innovations’, ‘scale-up’, ‘replication’, ‘expansion’, ‘increased coverage’, ‘conceptual models for scale-up’, ‘frame-works for scale-up’, ‘evidence for scale-up’ in the title of publications,. This search was limited to publications in English after the year 1995. We used snowball sampling approach (by referring to bibliographies of shortlisted publications) to identify additional publications related to scale-up. We then screened the identified publications independently and relevant publications that discussed attributes for a conceptual model for scale-up of public health interventions in low and middle-income countries were shortlisted. We then mapped the strategies we used in SCC program scale up against those described in the shortlisted frameworks to identify seven accelerators which facilitated rapid scale up. Results The identified accelerators were: testing the intervention in real world, resource constrained settings; using an appropriate and time sensitive research design; testing the intervention at substantial scale and in diverse settings; using an adaptive and iterative prototyping approach for implementation; sharing data and evidence with key stakeholders on an ongoing basis; targeting bridge resources through strategic engagement of stakeholders and timely integration of scale-up plans with annual planning and budgeting cycles and systems. Conclusion These accelerators will complement current frameworks and provide guidance to future scale-up initiatives in India and elsewhere

One year continuation of post-partum intrauterine contraceptive device: findings from a retrospective cohort study in India

OBJECTIVE: To evaluate outcomes of a national post-partum (within 48h of delivery) copper intrauterine device placement (PPCuIUD) program in six "high focus states" with high-unmet family planning need in India. STUDY DESIGN: We identified high volume district hospitals that provided PPCuIUD in six (Bihar, Jharkhand, Uttar Pradesh, Uttarakhand, Madhya Pradesh and Chhattisgarh) Indian states (2 per state). Each selected hospital maintained a list of PPCuIUD acceptors with contact phone numbers. We randomly selected 100 women at each site for inclusion in a telephone survey of IUD outcomes at one year. Questions regarded IUD expulsion, discontinuation because of symptoms (e.g. pain, bleeding, discharge), discontinuation for other reasons, and use of alternative contraception if discontinuation reported. RESULTS: We could contact 844 of the 1200 randomly selected women of whom 673 (79.7%) had post-placental insertion (within 10min of delivery) while 171 (20.3%) had an early post-partum insertion (between 10min to 48h after delivery). Of those contacted, 530 women (62.8%) reported continuing with the method beyond one year, 63 (7.5%) reported having an expulsion, 163 (19.3%) reported having removals for associated side effects (bleeding, pain, and discharge) and 88(10.4%) reported having removals for other reasons. After removal or expulsion, almost half of the women (46.5%) did not switch to any other modern contraceptive method. CONCLUSION: PPCuIUD continuation rate at 1year was 62.8%. Most removals within one year were due to associated side effects. Almost half of the women discontinuing PPCuIUD did not switch to an alternative modern contraceptive method. IMPLICATIONS: The 1-year continuation rate of PPCuIUD achieved through a large-scale national program in India is satisfactory. The program though needs to address the low uptake of other modern contraceptive methods after discontinuation

Effectiveness of a quality improvement intervention to increase adherence to key practices during female sterilization services in Chhattisgarh and Odisha states of India

Background In response to longstanding concerns around the quality of female sterilization services provided at public health facilities in India, the Government of India issued standards and quality assurance guidelines for female sterilization services in 2014. However, implementation remains a challenge. The Maternal and Child Survival Program rolled out a package of competency-based trainings, periodic mentoring, and easy-to-use job aids in parts of five states to increase service providers' adherence to key practices identified in the guidelines. Methods The study employed a before-and-after quasi-experimental design with a matched comparison arm to examine the effect of the intervention on provider practices in two states: Odisha and Chhattisgarh. Direct observations of female sterilization services were conducted in selected public health facilities, using a checklist of 30 key practices, at two points in time. Changes in adherence to key practices from baseline to endline were compared at 12 intervention and 12 comparison facilities using a difference in difference analysis. Results Several key practices were well-established prior to the intervention, with adherence levels over 90% at baseline, including hemoglobin and urine testing, use of sterile surgical gloves and instruments, and recommended surgical technique. However, adherence to many other practices was extremely low at baseline. The program significantly increased adherence to nine practices, including those related to ascertaining client's medical eligibility, client-provider interaction, the consent process, and post-operative care. The greatest improvement was observed in the provision of written instructions for clients prior to discharge. At endline, however, adherence remained below 50% for 14 practices. Conclusion Low adherence to key practices at baseline confirmed the need for quality improvement interventions in female sterilization services. While the intervention improved adherence to certain practices around admission and post-operative care, inadequate human resources and infrastructure, among other factors, may have blunted the impact of the intervention