Does rapid urbanization aggravate health disparities? Reflections on the epidemiological transition in Pune, India

Background: Rapid urbanization in low- and middle-income countries reinforces risk and epidemiological transition in urban societies, which are characterized by high socioeconomic gradients. Limited availability of disaggregated morbidity data in these settings impedes research on epidemiological profiles of different population subgroups. Objective: The study aimed to analyze the epidemiological transition in the emerging megacity of Pune with respect to changing morbidity and mortality patterns, also taking into consideration health disparities among different socioeconomic groups. Design: A mixed-methods approach was used, comprising secondary analysis of mortality data, a survey among 900 households in six neighborhoods with different socioeconomic profiles, 46 in-depth interviews with laypeople, and expert interviews with 37 health care providers and 22 other health care workers. Results: The mortality data account for an epidemiological transition with an increasing number of deaths due to non-communicable diseases (NCDs) in Pune. The share of deaths due to infectious and parasitic diseases remained nearly constant, though the cause of deaths changed considerably within this group. The survey data and expert interviews indicated a slightly higher prevalence of diabetes and hypertension among higher socioeconomic groups, but a higher incidence and more frequent complications and comorbidities in lower socioeconomic groups. Although the self-reported morbidity for malaria, gastroenteritis, and tuberculosis did not show a socioeconomic pattern, experts estimated the prevalence in lower socioeconomic groups to be higher, though all groups in Pune would be affected. Conclusions: The rising burden of NCDs among all socioeconomic groups and the concurrent persistence of communicable diseases pose a major challenge for public health. Improvement of urban health requires a stronger focus on health promotion and disease prevention for all socioeconomic groups with a holistic understanding of urban health. In order to derive evidence-based solutions and interventions, routine surveillance data become indispensable

From habits of attrition to modes of inclusion: enhancing the role of private practitioners in routine disease surveillance

Background:Private practitioners are the preferred first point of care in a majority of low and middle-income countries and in this position, best placed for the surveillance of diseases. However their contribution to routine surveillance data is marginal. This systematic review aims to explore evidence with regards to the role, contribution, and involvement of private practitioners in routine disease data notification. We examined the factors that determine the inclusion of, and the participation thereof of private practitioners in disease surveillance activities.Methods:Literature search was conducted using the PubMed, Web of Knowledge, WHOLIS, and WHO-IRIS databases to identify peer reviewed and gray full-text documents in English with no limits for year of publication or study design. Forty manuscripts were reviewed.Results: The current participation of private practitioners in disease surveillance efforts is appalling. The main barriers to their participation are inadequate knowledge leading to unsatisfactory attitudes and misperceptions that influence their practices. Complicated reporting mechanisms with unclear guidelines, along with unsatisfactory attitudes on behalf of the government and surveillance program managers also contribute to the underreporting of cases. Infrastructural barriers especially the availability of computers and skilled human resources are critical to improving private sector participation in routine disease surveillance.Conclusion:The issues identified are similar to those for underreporting within the Integrated infectious Disease Surveillance and Response systems (IDSR) which collects data mainly from public healthcare facilities. We recommend that surveillance program officers should provide periodic training, supportive supervision and offer regular feedback to the practitioners from both public as well as private sectors in order to improve case notification. Governments need to take leadership and foster collaborative partnerships between the public and private sectors and most importantly exercise regulatory authority where needed

Knowledge, attitude, and practices with respect to disease surveillance among urban private practitioners in Pune, India

BACKGROUND: Participation of private practitioners in routine disease surveillance in India is minimal despite the fact that they account for over 70% of the primary healthcare provision. We aimed to investigate the knowledge, attitudes, and practices of private practitioners in the city of Pune toward disease surveillance. Our goal was to identify what barriers and facilitators determine their participation in current and future surveillance efforts. DESIGN: A questionnaire-based survey was conducted among 258 practitioners (response rate 86%). Data were processed using SPSS™ Inc., Chicago, IL, USA, version 17.0.1. RESULTS: Knowledge regarding surveillance, although limited, was better among allopathy practitioners. Surveillance practices did not differ significantly between allopathy and alternate medicine practitioners. Multivariable logistic regression suggested practicing allopathy [odds ratio (OR) 3.125, 95% confidence interval (CI) 1.234–7.915, p=0.016] and availability of a computer (OR 3.670, 95% CI 1.237–10.889, p=0.019) as significant determinants and the presence of a laboratory (OR 3.792, 95% CI 0.998–14.557, p=0.052) as a marginal determinant of the practitioner's willingness to participate in routine disease surveillance systems. Lack of time (137, 55%) was identified as the main barrier at the individual level alongside inadequately trained subordinate staff (14, 6%). Main extrinsic barriers included lack of cooperation between government and the private sector (27, 11%) and legal issues involved in reporting data (15, 6%). There was a general agreement among respondents (239, 94%) that current surveillance efforts need strengthening. Over a third suggested that availability of detailed information and training about surveillance processes (70, 33%) would facilitate reporting. CONCLUSIONS: The high response rate and the practitioners’ willingness to participate in a proposed pilot non-communicable disease surveillance system indicate that there is a general interest from the private sector in cooperating. Keeping reporting systems simple, preferably in electronic formats that minimize infrastructure and time requirements on behalf of the private practitioners, will go a long way in consolidating disease surveillance efforts in the state. Organizing training sessions, providing timely feedback, and awarding continuing medical education points for routine data reporting seem feasible options and should be piloted

Involving private healthcare practitioners in an urban NCD sentinel surveillance system: lessons learned from Pune, India

Background: Despite the rising impact of non-communicable diseases (NCDs) on public health in India, lack of quality data and routine surveillance hampers the planning process for NCD prevention and control. Current surveillance programs focus largely on communicable diseases and do not adequately include the private healthcare sector as a major source of care in cities. Objective: The objective of the study was to conceptualize, implement, and evaluate a prototype for an urban NCD sentinel surveillance system among private healthcare practitioners providing primary care in Pune, India. Design: We mapped all private healthcare providers in three selected areas of the city, conducted a knowledge, attitude, and practice survey with regard to surveillance among 258 consenting practitioners, and assessed their willingness to participate in a routine NCD surveillance system. In total, 127 practitioners agreed and were included in a 6-month surveillance study. Data on first time diagnoses of 10 selected NCDs alongside basic demographic and socioeconomic patient information were collected onsite on a monthly basis using a paper-based register. Descriptive and regression analyses were performed. Results: In total, 1,532 incident cases were recorded that mainly included hypertension (n622, 41%) and diabetes (n460, 30%). Dropout rate was 10% (n13). The monthly reporting consistency was quite constant, with the majority (n63, 50%) submitting 110 cases in 6 months. Average number of submitted cases was highest among allopathic practitioners (17.4). A majority of the participants (n104, 91%) agreed that the surveillance design could be scaled up to cover the entire city. Conclusions: The study indicates that private primary healthcare providers (allopathic and alternate medicine practitioners) play an important role in the diagnosis and treatment of NCDs and can be involved in NCD surveillance, if certain barriers are addressed. Main barriers observed were lack of regulation of the private sector, cross-practices among different systems of medicine, limited clinic infrastructure, and knowledge gaps about disease surveillance. We suggest a voluntary augmented sentinel NCD surveillance system including public and private healthcare facilities at all levels of care

Challenges to the surveillance of non-communicable diseases – a review of selected approaches

Background: The rising global burden of non-communicable diseases (NCDs) necessitates the institutionalization of surveillance systems to track trends and evaluate interventions. However, NCD surveillance capacities vary across high- and low- and middle-income countries. The objective of the review was to analyse existing literature with respect to structures of health facility-based NCD surveillance systems and the lessons low- and middle-income countries can learn in setting up and running these systems. Methods: A literature review was conducted using Pub Med, Web of Knowledge and WHOLIS databases to identify citations published in English language between 1993 and 2013. In total, 20 manuscripts met inclusion criteria: 12 studies were analysed in respect to the surveillance approach, eight supporting documents in respect to general and regional challenges in NCD surveillance. Results: Eleven of the 12 studies identified were conducted in high-income countries. Five studies had a single disease focus, three a multiple NCD focus and three covered communicable as well as non-communicable diseases. Nine studies were passive assisted sentinel surveillance systems, of which six focused on the primary care level and three had additional active surveillance components, i.e., population-based surveys. The supporting documents reveal that NCD surveillance is rather limited in most low- and middle-income countries despite the increasing disease burden and its socioeconomic impact. Major barriers include institutional surveillance capacities and hence data availability. Conclusions: The review suggests that given the complex system requirements, multiple surveillance approaches are necessary to collect comprehensive information for effective NCD surveillance. Sentinel augmented facility-based surveillance, preferably supported by population-based surveys, can provide improved evidence and help budget scarce resources. Electronic supplementary material: The online version of this article (doi:10.1186/s12889-015-2570-z) contains supplementary material, which is available to authorized users

Dynamic Regulation of H3K27 Trimethylation during Arabidopsis Differentiation

During growth of multicellular organisms, identities of stem cells and differentiated cells need to be maintained. Cell fate is epigenetically controlled by the conserved Polycomb-group (Pc-G) proteins that repress their target genes by catalyzing histone H3 lysine 27 trimethylation (H3K27me3). Although H3K27me3 is associated with mitotically stable gene repression, a large fraction of H3K27me3 target genes are tissue-specifically activated during differentiation processes. However, in plants it is currently unclear whether H3K27me3 is already present in undifferentiated cells and dynamically regulated to permit tissue-specific gene repression or activation. We used whole-genome tiling arrays to identify the H3K27me3 target genes in undifferentiated cells of the shoot apical meristem and in differentiated leaf cells. Hundreds of genes gain or lose H3K27me3 upon differentiation, demonstrating dynamic regulation of an epigenetic modification in plants. H3K27me3 is correlated with gene repression, and its release preferentially results in tissue-specific gene activation, both during differentiation and in Pc-G mutants. We further reveal meristem- and leaf-specific targeting of individual gene families including known but also likely novel regulators of differentiation and stem cell regulation. Interestingly, H3K27me3 directly represses only specific transcription factor families, but indirectly activates others through H3K27me3-mediated silencing of microRNA genes. Furthermore, H3K27me3 targeting of genes involved in biosynthesis, transport, perception, and signal transduction of the phytohormone auxin demonstrates control of an entire signaling pathway. Based on these and previous analyses, we propose that H3K27me3 is one of the major determinants of tissue-specific expression patterns in plants, which restricts expression of its direct targets and promotes gene expression indirectly by repressing miRNA genes

Netzwerklernen im Katastrophenschutz: Wie Behörden und Organisationen mit Sicherheitsaufgaben gemeinsam aus Katastrophenschutzübungen lernen

Außergewöhnliche Schadensereignisse und Katastrophen zeichnen sich durch eine zunehmende Häufigkeit und Komplexität aus. Dabei können Extremereignisse nur durch eine koordinierte Zusammenarbeit von verschiedenen im Katastrophenschutz mitwirkenden Einsatzorganisationen und Behörden erfolgreich bewältigt werden. Zur Stärkung der Resilienz im Katastrophenschutz bedarf es folglich regelmäßiger interdisziplinärer Simulationstrainings. In der vorliegenden Arbeit befasst sich die Autorin mit dem Netzwerklernen von Behörden und Organisationen mit Sicherheitsaufgaben (BOS) im Rahmen von simulationsgestützten Einsatztrainings. Aus systemtheoretischer Sicht werden die übergreifenden Fragestellungen untersucht, welchen Beitrag Katastrophenschutzübungen zum Netzwerklernen von BOS leisten und wie dieses Netzwerklernen beschrieben werden kann. Zur Beantwortung der Forschungsfragen wurde eine Katastrophenschutzübung wissenschaftlich begleitet. Unter Verwendung von komplementären Methoden und Verfahren der empirischen Sozialforschung konnte eine schwache Verdichtung des kollektiven Wissenssystems nachgewiesen werden. Ebenso konnten die Phasen und Einflussfaktoren von Netzwerklernen detailliert rekonstruiert bzw. beschrieben werden. Die Erkenntnisse liefern Anknüpfungspunkte für die Erhöhung des Lern-Werts von Katastrophenschutzübungen sowie für weitere Forschungsarbeiten.:1 Einleitung 2 Theoretische Grundlagen der Katastrophenforschung 3 Theoretisches Vorverständnis für die Herleitung des Bezugsrahmens 4 Forschungsmodell und Arbeitshypothesen 5 Empirische Untersuchung 6 Zusammenfassung und AusblickUnexpected extreme events are characterized by increasing frequency and complexity. In this context, extreme events can only be successfully managed through coordinated cooperation between various emergency response organizations and agencies involved in disaster management. Consequently, regular interdisciplinary simulation-based response training is needed to strengthen resilience in disaster management. In this paper, the author deals with the network learning of agencies and organizations with security tasks from emergency response exercises. From a systems theory perspective, the overarching questions of what contribution disaster response exercises make to network learning of the actors participating in the network and how this network learning can be described are investigated. To answer the research questions, a simulation-based disaster response exercise was scientifically accompanied. Using complementary methods and procedures of empirical social research, a weak condensation of the collective knowledge system could be demonstrated. Likewise, the phases and influencing factors of network learning could be reconstructed or described in detail. The findings provide starting points for increasing the learning value of disaster management exercises as well as for further research.:1 Einleitung 2 Theoretische Grundlagen der Katastrophenforschung 3 Theoretisches Vorverständnis für die Herleitung des Bezugsrahmens 4 Forschungsmodell und Arbeitshypothesen 5 Empirische Untersuchung 6 Zusammenfassung und Ausblic

Netzwerklernen im Katastrophenschutz: Wie Behörden und Organisationen mit Sicherheitsaufgaben gemeinsam aus Katastrophenschutzübungen lernen

Außergewöhnliche Schadensereignisse und Katastrophen zeichnen sich durch eine zunehmende Häufigkeit und Komplexität aus. Dabei können Extremereignisse nur durch eine koordinierte Zusammenarbeit von verschiedenen im Katastrophenschutz mitwirkenden Einsatzorganisationen und Behörden erfolgreich bewältigt werden. Zur Stärkung der Resilienz im Katastrophenschutz bedarf es folglich regelmäßiger interdisziplinärer Simulationstrainings. In der vorliegenden Arbeit befasst sich die Autorin mit dem Netzwerklernen von Behörden und Organisationen mit Sicherheitsaufgaben (BOS) im Rahmen von simulationsgestützten Einsatztrainings. Aus systemtheoretischer Sicht werden die übergreifenden Fragestellungen untersucht, welchen Beitrag Katastrophenschutzübungen zum Netzwerklernen von BOS leisten und wie dieses Netzwerklernen beschrieben werden kann. Zur Beantwortung der Forschungsfragen wurde eine Katastrophenschutzübung wissenschaftlich begleitet. Unter Verwendung von komplementären Methoden und Verfahren der empirischen Sozialforschung konnte eine schwache Verdichtung des kollektiven Wissenssystems nachgewiesen werden. Ebenso konnten die Phasen und Einflussfaktoren von Netzwerklernen detailliert rekonstruiert bzw. beschrieben werden. Die Erkenntnisse liefern Anknüpfungspunkte für die Erhöhung des Lern-Werts von Katastrophenschutzübungen sowie für weitere Forschungsarbeiten.:1 Einleitung 2 Theoretische Grundlagen der Katastrophenforschung 3 Theoretisches Vorverständnis für die Herleitung des Bezugsrahmens 4 Forschungsmodell und Arbeitshypothesen 5 Empirische Untersuchung 6 Zusammenfassung und AusblickUnexpected extreme events are characterized by increasing frequency and complexity. In this context, extreme events can only be successfully managed through coordinated cooperation between various emergency response organizations and agencies involved in disaster management. Consequently, regular interdisciplinary simulation-based response training is needed to strengthen resilience in disaster management. In this paper, the author deals with the network learning of agencies and organizations with security tasks from emergency response exercises. From a systems theory perspective, the overarching questions of what contribution disaster response exercises make to network learning of the actors participating in the network and how this network learning can be described are investigated. To answer the research questions, a simulation-based disaster response exercise was scientifically accompanied. Using complementary methods and procedures of empirical social research, a weak condensation of the collective knowledge system could be demonstrated. Likewise, the phases and influencing factors of network learning could be reconstructed or described in detail. The findings provide starting points for increasing the learning value of disaster management exercises as well as for further research.:1 Einleitung 2 Theoretische Grundlagen der Katastrophenforschung 3 Theoretisches Vorverständnis für die Herleitung des Bezugsrahmens 4 Forschungsmodell und Arbeitshypothesen 5 Empirische Untersuchung 6 Zusammenfassung und Ausblic