"Getting the water-carrier to light the lamps": Discrepant role perceptions of traditional, complementary, and alternative medical practitioners in government health facilities in India.

The government of India has, over the past decade, implemented the "integration" of traditional, complementary and alternative medical (TCAM) practitioners, specifically practitioners of Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-rigpa, and Homoeopathy (collectively known by the acronym AYUSH), in government health services. A range of operational and ethical challenges has manifested during this process of large health system reform. We explored the practices and perceptions of health system actors, in relation to AYUSH providers' roles in government health services in three Indian states - Kerala, Meghalaya, and Delhi. Research methods included 196 in-depth interviews with a range of health policy and system actors and beneficiaries, between February and October 2012, and review of national, state, and district-level policy documents relating to AYUSH integration. The thematic 'framework' approach was applied to analyze data from the interviews, and systematic content analysis performed on policy documents. We found that the roles of AYUSH providers are frequently ambiguously stated and variably interpreted, in relation to various aspects of their practice, such as outpatient care, prescribing rights, emergency duties, obstetric services, night duties, and referrals across systems of medicine. Work sharing is variously interpreted by different health system actors as complementing allopathic practice with AYUSH practice, or allopathic practice, by AYUSH providers to supplement the work of allopathic practitioners. Interactions among AYUSH practitioners and their health system colleagues frequently take place in a context of partial information, preconceived notions, power imbalances, and mistrust. In some notable instances, collegial relationships and apt divisions of responsibilities are observed. Widespread normative ambivalence around the roles of AYUSH providers, complicated by the logistical constraints prevalent in poorly resourced systems, has the potential to undermine the therapeutic practices and motivation of AYUSH providers, as well as the overall efficiency and performance of integrated health services

Effects of social determinants on children’s health in informal settlements in Bangladesh and Kenya through an intersectionality lens: a study protocol

Introduction Several studies have shown that residents of urban informal settlements/slums are usually excluded and marginalised from formal social systems and structures of power leading to disproportionally worse health outcomes compared to other urban dwellers. To promote health equity for slum dwellers, requires an understanding of how their lived realities shape inequities especially for young children 0–4 years old (ie, underfives) who tend to have a higher mortality compared with non-slum children. In these proposed studies, we aim to examine how key Social Determinants of Health (SDoH) factors at child and household levels combine to affect under-five health conditions, who live in slums in Bangladesh and Kenya through an intersectionality lens. Methods and analysis The protocol describes how we will analyse data from the Nairobi Cross-sectional Slum Survey (NCSS 2012) for Kenya and the Urban Health Survey (UHS 2013) for Bangladesh to explore how SDoH influence under-five health outcomes in slums within an intersectionality framework. The NCSS 2012 and UHS 2013 samples will consist of 2199 and 3173 under-fives, respectively. We will apply Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy approach. Some of SDoH characteristics to be considered will include those of children, head of household, mothers and social structure characteristics of household. The primary outcomes will be whether a child had diarrhoea, cough, fever and acute respiratory infection (ARI) 2 weeks preceding surveys. Ethics and dissemination The results will be disseminated in international peer-reviewed journals and presented in events organised by the Accountability and Responsiveness in Informal Settlements for Equity consortium and international conferences. Ethical approval was not required for these studies. Access to the NCSS 2012 has been given by Africa Population and Health Center and UHS 2013 is freely availabl

Examination of physical activity for health promotion, and attitudes towards aging, among adults - cross-cultural comparisons; healthcare provider recommendations; toolkit evaluation.

Despite the well-known health benefits of physical activity, the majority of adults do not obtain the recommended daily amount. Three studies, using three different research designs, were conducted to examine physical activity, for health promotion and disease prevention, among relatively healthy adults. The Cross-cultural Intergenerational Comparisons of Attitudes towards Aging and Physical Activity study, a cross-sectional survey, examined 475 participants belonging to one of three groups (Indians in India, Indians in the United States, and Americans in the United States) on physical activity level, barriers to physical activity participation, and attitudes towards personal aging. Differences were observed among the groups on self-rated general health, occurrence of preventive examinations, and barriers to physical activity. Physical activity level was positively correlated with optimistic attitudes towards personal aging. The Healthcare Provider Physical Activity Prescription Intervention, a randomized comparison trial, examined the impact, at one month and three months, of written prescriptions of physical activity, with or without additional resources, made by healthcare providers (physicians and diabetes counselors) to patients on preventive care office visits. Self-reported physical activity increased (p=0.04) in the overall sample of 24 patients who completed questionnaires at baseline as well as three months, as well as in the intervention group receiving a physical activity toolkit in addition to the written prescription (p=0.01). The Adoption and Utilization of the “First Step to Active Health” Toolkit in a Healthy Adult Population study, an observational project, examined the adoption and utilization of a physical activity toolkit, comprising a resistance band and instructional materials on its use, in a healthy adult population already enrolled in a 12-week walking program. Physical activity level dropped (p=0.003) from baseline to follow-up, at six to eight weeks, in the nineteen participants who completed the study. The toolkit was well-received by the participants, with most of them finding it useful and versatile. These studies highlight the imperative to address environmental barriers to physical activity, particularly in India, and bolster the social environment, supporting the provision of physical activity recommendations, as well as additional resources, to encourage participation in physical activity

Cross Cultural Comparison of Attitides towards Aging and Physical Activity

An online cross-sectional survey was used to examine 475 adults (239 men and 236 women) on physical activity level, barriers to physical activity participation, and attitudes towards personal aging. Participants were grouped, by citizenship and residence, as Indians in India, Indians in the United States, or Americans in the United States. Cross-cultural differences were observed on self-rated general health, occurrence of preventive examinations, and several barriers to physical activity. Physical activity level was positively correlated with self-rated general health, and with optimism regarding aging, suggesting that enhanced physical activity may hold the key to a higher evaluation of personal health, and more positive expectations of aging

Cultural consonance, constructions of science and co-existence: a review of the integration of traditional, complementary and alternative medicine in low- and middle-income countries.

This review examined the determinants, patterns and imports of official recognition, and incorporation of different traditional, complementary and alternative systems of medicine (TCAM) in the public health establishment of low- and middle-income countries, with a particular focus on India. Public health systems in most countries have tended to establish health facilities centred on allopathy, and then to recognize or derecognize different TCAM based on evidence or judgement, to arrive at health-care configurations that include several systems of medicine with disparate levels of authority, jurisdiction and government support. The rationale for the inclusion of TCAM providers in the public health workforce ranges from the need for personnel to address the disease burden borne by the public health system, to the desirability of providing patients with a choice of therapeutic modalities, and the nurturing of local culture. Integration, mostly described as a juxtaposition of different systems of medical practice, is often implemented as a system of establishing personnel with certification in different medical systems, in predominantly allopathic health-care facilities, to practise allopathic medicine. A hierarchy of systems of medicine, often unacknowledged, is exercised in most societies, with allopathy at the top, certain TCAM systems next and local healing traditions last. The tools employed by TCAM practitioners in diagnosis, research, pharmacy, marketing and education and training, which are seen to increasingly emulate those of allopathy, are sometimes inappropriate for use in therapeutic systems with widely divergent epistemologies, which call for distinct research paradigms. The coexistence of numerous systems of medicine, while offering the population greater choice, and presumably enhancing geographical access to health care as well, is often fraught with tensions related to the coexistence of philosophically disparate, even opposed, disciplines, with distinct and unaligned notions of evidence and efficacy, and ethical and operational challenges of the administration of a plural workforce

Epidemiology of road traffic injury patients presenting to a tertiary hospital in Hyderabad, India

© 2017 Background Road traffic injuries kill more people in India than in any other country in the world, and these numbers are rising with increasing population density and motorization. Official statistics regarding road traffic injuries are likely subject to underreporting. This study presents results of a surveillance program based at a public tertiary hospital in Hyderabad, India. Methods All consenting patients who presented to the casualty ward after a road traffic injury over a 9-month period were enrolled. Interviews were performed and data abstracted from clinical records by trained research assistants. Data included demographics, injury characteristics, risk factors, safety behaviors, and outcomes. Results A total of 5,298 patients were enrolled; their mean age was 32.4 years (standard deviation 13.8) and 87.3% were men; 58.2% of patients were injured while riding a motorcycle or scooter, 22.5% were pedestrians, and 9.2% used motorized rickshaws. The most frequent collision type was skid or rollover (40.9%). Male victims were younger than female victims and were overrepresented among motorized 2-wheeler users. Patients were most frequently injured from 1600 to 2400. A total of 27.3% of patients were admitted. Hospital mortality was 5.3%, and 48.2% of deaths were among motorized 2-wheeler users. Conclusion This is one of the few prospective, hospital-based studies of road traffic injury epidemiology in India. The patient population in this study was similar to prior hospital-based studies. When compared to government surveillance systems, this study showed motorized 2-wheeler users to be more frequently represented among the overall population and among fatalities. Further research should be done to develop interventions to decrease mortality associated with 2-wheeled vehicles in India