Elimination of avoidable blindness due to cataract: where do we prioritize and how should we monitor this decade?

BACKGROUND: In the final push toward the elimination of avoidable blindness, cataract occupies a position of eminence for the success of the Right to Sight initiative. AIMS: Review existing situation and assess what monitoring indicators may be useful to chart progress towards attaining the goals of Vision 2020. SETTINGS AND DESIGN: Review of published papers from low and middle income countries since 2000. MATERIALS AND METHODS: Published population-based data on prevalence of cataract blindness/visual impairment were accessed and prevalence of cataract blindness/visual impairment computed, where not reported. Data on prevalence of cataract blindness, cataract surgical coverage at different visual acuity cut offs, surgical outcomes, and prevalence of cataract surgery were analyzed. Scatter plots were used to look at relationships of some variables, with Human Development Index (HDI) rank. Available data on Cataract Surgical Rate (CSR) was plotted against prevalence of cataract surgery reported from surveys. RESULTS: Worse HDI Ranks were associated with higher prevalence of cataract blindness. Most studies showed that a significant proportion of the blind were covered by surgery, while a fifth showed that a significant proportion, were operated before they went blind. A good visual outcome after surgery was positively correlated with higher surgical coverage. CSR was positively correlated with cataract surgical coverage. CONCLUSIONS: Cataract surgical coverage is increasing in most countries at vision <3/60 and visual outcomes after cataract surgery are improving. Establishing population-based surveillance of cataract surgical need and performance is a strong monitoring tool and will help program planners immensely

A study of infant deaths in tribal area of Andhra Pradesh, India

Objectives This study aimed to determine the prevalence of neonatal deaths and its underlying correlates in tribal area of Andhra Pradesh, India Methods We conducted a two phase cross-sectional study (N=230). Semi-structured questionnaire schedules (in the vernacular-Telugu) were used in the initial qualitative phase, to obtain specific information from mothers who delivered in a one year period prior to the study. Information from the analysed qualitative data was used to construct a questionnaire-schedule for the 2nd phase which used quantitative survey techniques. Results It was observed that Infant Mortality ratio (IMR) in Vizianagaram district was 239 per 1000 live births in the tribal areas under study. This was ten times higher than that reported by the district (22/1000) and 4-5 times higher than SRS data of 2011 for AP. It was observed that 28% of infants died within first day, 68% within first week (including the first day) and 81% within first month. Conclusions The high IMR observed in the within first month of life in tribal areas, interventions to tackle them should be prioritized in this ‘golden period’. The health workers should be re-trained to identify and manage the early warning signs of neonatal complications

'Decision support system (DSS) for prevention of cardiovascular disease (CVD) among hypertensive (HTN) patients in Andhra Pradesh, India'--a cluster randomised community intervention trial.

RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are.BACKGROUND: Very few studies having decision support systems as an intervention report on patient outcomes for cardiovascular disease in the Western world. The potential role of decision support system for the management of blood pressure among Indian hypertensives remains unclear. We propose a cluster randomised trial that aims to test the effectiveness and cost effectiveness of DSS among Indian hypertensive patients. METHODS: The trial design is a cluster randomised community intervention trial, in which the participants would be adult male and female hypertensive patients, in the age group of 35 to 64 years, reporting to the Primary Health Care centres of Mahabubnagar district, Andhra Pradesh, India. The objective of the study is to test the effectiveness and compare the cost effectiveness and cost utility among hypertensive subjects randomized to receive either decision support system or a chart based algorithmic support system in urban and rural areas of a district in the state of Andhra Pradesh, India (baseline versus 12 months follow up). The primary outcome would be a comparison of the systolic blood pressure at 0 and 12 months among hypertensive patients randomized to receive the decision support system or the chart based algorithmic support system. Computer generated randomisation and an investigator and analyser blinded method would be followed. 1600 participants; 800 to each arm; each arm having eight clusters of hundred participants each have been recruited between 01 August 2011 - 01 March 2012. A twelve month follow up will be completed by March 2013 and results are expected by April 2013. DISCUSSION: This cluster randomized community intervention trial on DSS will enable policy makers to find out the effectiveness, cost effectiveness and cost utility of decision support system for management of blood pressure among hypertensive patients in India. Most of the previous studies on decision support system have focused on physician performance, adherence and on preventive care reminders. The uniqueness of the proposed study lies in finding out the effectiveness of a decision support system on patient related outcomes. TRIAL REGISTRATION: CTRI/2012/03/002476, Clinical Trial Registry - India

Multiple barriers to participation for people with psychosocial disability in Dehradun district, North India: a cross-sectional study.

OBJECTIVES: This study used a population-based cross-sectional survey to describe the prevalence of psychosocial disability and unmet need for access to services in North India. SETTING: This study was conducted in Dehradun district, Uttarakhand, in 2014. PARTICIPANTS: A population-based sample of 2441 people over the age of 18 years. PRIMARY OUTCOME MEASURES: The Rapid Assessment of Disability survey tool identified people with disability and used an adapted version of the Kessler scale to identify those with psychosocial disability. It additionally collected information on socioeconomic variables, access to community services and barriers to participation. Prevalence of psychosocial disability and unmet needs and descriptions of barriers to services were calculated, and multivariable logistic regression was used to assess associations between risk factors and psychosocial disability. RESULTS: Prevalence of psychosocial disability was 4.8% and 75% of participants with psychological distress also reported comorbid functional impairments. Adjusted ORs for depression of more than two were found for people who were unschooled, unemployed and of moderate or poor socioeconomic status. The unmet need for access to services was significantly higher in every domain for people with psychosocial disability and was more than 25% in the areas of employment, health service access and community consultation. People with psychosocial disability encountered greater barriers in each domain compared with controls. CONCLUSIONS: People who are poor, uneducated and unemployed are two to four times more likely to have psychosocial disability in Dehradun district. They face unmet needs in accessing community services and perceive negative social attitudes, lack of physical accessibility and lack of information as barriers limiting their participation. Social policy must increase access to education and reduce poverty but additionally ensure action is taken in all community services to increase information, physical accessibility and social inclusion of people with psychosocial and other forms of disability

Access to Services and Barriers faced by People with Disabilities: A Quantitative Survey

Purpose: In low- and middle-income middle-income countries, reliable and disaggregated disability data on prevalence, participation and barriers are often unavailable available. This study aimed to estimate disability prevalence, determine associated socio-demographic factors and compare access in the community between people with and without disability in Dehradun district of Uttarakhand, India, using the Rapid Assessment of Disability survey. Methods: A cross-sectional population-based survey was conducted on a sample of 2431 adults, selected using a two-stage cluster randomised sampling technique. The survey comprised an interviewer-administered household survey and an individual survey measuring disability, wellbeing and participation. For each person with disability, an age-and sex-matched control (without disability) was selected. In addition to prevalence, the differences in participation and barriers faced by people with and without disability were analysed. Results and Conclusions: The prevalence of disability was 6.8% (95% CI 5.8-7.8) with significant associations with age, sex, economic status, education and employment. Psychosocial distress (4.8%) and mobility impairment (2.7%) were the most common disabilities identified. The study showed that people with disabilities had significantly less access to services than those without disability, and the barriers reported most often were lack of information, transport and physical inaccessibility

Glaucoma-associated long-term mortality in a rural cohort from India: the Andhra Pradesh Eye Disease Study.

AIM: To evaluate glaucoma-associated mortality in a rural cohort in India. METHODS: The study cohort comprised individuals aged 40 years and above who took part in the Andhra Pradesh Eye Disease Study (APEDS1) during 1996-2000. All participants underwent detailed comprehensive eye examination. Glaucoma was defined using International Society of Geographic and Epidemiologic Ophthalmology criteria. This cohort was followed up after a decade (June 2009 to January 2010; APEDS2). Mortality HR analysis for ocular risk factors was performed using Cox proportional hazards regression after adjusting for sociodemographic, lifestyle and clinical variables. RESULTS: In APEDS1, 2790 individuals aged more than or equal to 40 years were examined. 47.4% were male. Forty-five participants had primary open angle glaucoma (POAG) and 66 had primary angle closure disease (PACD). Ten years later, 1879 (67.3%) were available, 739 (26.5%) had died and 172 (6.2%) had migrated; whereas 22 of the 45 (48.8%) with POAG and 22 of the 66 (33.3%) with PACD had died. In univariate analysis, a higher mortality was associated with POAG (HR 1.9; 95% CI 1.23 to 2.94), pseudoexfoliation (HR 2.79; 95% CI 2.0 to 3.89), myopia (HR 1.78; 95% CI 1.54 to 2.06) and unit increase in cup:disc ratio (HR 4.49; 95% CI 2.64 to 7.64). In multivariable analysis, only cup:disc ratio remained independently associated with mortality (HR 2.5; 95% CI 1.3 to 5.1). The association remained significant when other ocular parameters were included in the model (HR 2.1; 95% CI 1.03 to 4.2). CONCLUSIONS: This is the first longitudinal study to assess the association of glaucoma and mortality in a rural longitudinal cohort in India. Increased cup:disc ratio could be a potential marker for ageing and would need further validation

Birth prevalence of neural tube defects and orofacial clefts in India: a systematic review and meta-analysis.

BACKGROUND: In the last two decades, India has witnessed a substantial decrease in infant mortality attributed to infectious disease and malnutrition. However, the mortality attributed to birth defects remains constant. Studies on the prevalence of birth defects such as neural tube defects and orofacial clefts in India have reported inconsistent results. Therefore, we conducted a systematic review of observational studies to document the birth prevalence of neural tube defects and orofacial clefts. METHODS: A comprehensive literature search for observational studies was conducted in MEDLINE and EMBASE databases using key MeSH terms (neural tube defects OR cleft lip OR cleft palate AND Prevalence AND India). Two reviewers independently reviewed the retrieved studies, and studies satisfying the eligibility were included. The quality of included studies was assessed using selected criteria from STROBE statement. RESULTS: The overall pooled birth prevalence (random effect) of neural tube defects in India is 4.5 per 1000 total births (95% CI 4.2 to 4.9). The overall pooled birth prevalence (random effect) of orofacial clefts is 1.3 per 1000 total births (95% CI 1.1 to 1.5). Subgroup analyses were performed by region, time period, consanguinity, and gender of newborn. CONCLUSION: The overall prevalence of neural tube defects from India is high compared to other regions of the world, while that of orofacial clefts is similar to other countries. The majority of studies included in the review were hospital based. The quality of these studies ranged from low to moderate. Further well-designed, high quality community-based observational studies are needed to accurately estimate the burden of neural tube defects and orofacial clefts in India

Regional variation in diabetic retinopathy and associated factors in Spectrum of Eye Disease in Diabetes (SPEED) study in India-Report 5.

PURPOSE: To study the zonal variations in diabetic retinopathy (DR) and associated factors in people with known type 2 diabetes mellitus (T2DM) attending large eye care facilities in different regions of India. METHODS: In this cross-sectional eye-care facility-based study, India was divided into five zones; large eye care facilities with a good referral base and offering an entire range of care for patients with DR were invited. First-time T2DM attendees aged ≥18 years were recruited. All subjects received a comprehensive systemic and ophthalmic examination. DR and systemic diseases were classified as per the international/national standards. Findings were compared between the zones and with the national average. RESULTS: Fourteen eye-care facilities (15% public) from five zones participated. In the cohort of 11,173 people, there were more males (59%); the average age was above 45 years, and in 57%, DM had been diagnosed more than 5 years earlier. Compared with the overall study population, the proportion of people with any DR, sight-threatening DR, and blind were higher in the east zone (42.5%, 95% confidence interval [CI]: 40.2-44.8; 24.3%, 95% CI 22.3-26.3, and 11.5%, respectively); diabetic macular edema was more frequent in the south zone (12.2%, 95% CI 11.2-13.2); people with moderate-to-severe visual impairment were more in the west zone (32.1%) and higher proportion of people in the south-central zone had systemic hypertension (56.8%, 95% CI 54.8-58.9). CONCLUSION: The zonal variation in DR and related vision loss could be related to variable health-seeking behavior, availability, and confidence in the available services

Rehabilitation Needs of Stroke Survivors After Discharge From Hospital in India

Objective To assess the rehabilitation needs of stroke survivors in Chennai, India, after discharge from the hospital. Design Mixed-methods research design. Setting Home-based. Participants Stroke survivors (n=50; mean age ± SD, 58.9±10.5y) and primary caregivers of these stroke survivors (n=50; mean age ± SD, 43.1±11.8y) took part in the quantitative survey. A subsample of stroke survivors (n=12), primary caregivers (n=10), and health care professionals (n=8) took part in the qualitative in-depth interviews. Interventions Not applicable. Main Outcome Measure Rehabilitation needs after hospital discharge. Results About 82% of the needs expressed by stroke survivors and 92% of the needs expressed by caregivers indicated that they had a substantial need for information. The proportion of financial needs reported by the stroke survivors and the caregivers was 70% and 75%, respectively. The qualitative data revealed major gaps in access to stroke rehabilitation services. Service providers identified availability and affordability of services as key problems. Stroke survivors and their caregivers identified lack of information about stroke as major barriers to accessibility of stroke rehabilitation services. Caregivers expressed a tremendous need for support to manage family dynamics. Conclusions The study highlights a considerable unmet need for poststroke rehabilitation services. Given the lack of rehabilitation resources in India, developing an accessible, innovative, patient-centered, culturally sensitive rehabilitation intervention is of public health importance. It is crucial for low- and middle-income countries like India to develop technology-driven stroke rehabilitation strategies to meet the growing rehabilitation needs of stroke survivors

A Mixed-Method Study to Determine the Benefits of Periconceptional Folic Acid Supplementation and Effects of Folic Acid Deficiency in Mothers on Birth Outcomes.

BACKGROUND: Evidence from high income countries shows mothers who are supplemented with folic acid in their periconceptional period and early pregnancy have significantly reduced adverse outcomes like birth defects. However, in India there is a paucity of data on association of birth defects and folic acid supplementation. We identified a few important questions to be answered using separate scientific methods and then planned to triangulate the information. OBJECTIVE: In this paper, we describe the protocol of our study that aims to determine the association of folic acid and pregnancy outcomes like neural tube defects (NTDs) and orofacial clefts (OFCs). We decided to fill the gaps in knowledge from India to determine public health consequences of folic acid deficiency and factors influencing dietary and periconceptional consumption of folic acid. METHODS: The proposed study will be carried out in five stages and will examine the questions related to folic acid deficiency across selected locations in South and North India. The study will be carried out over a period of 4 years through the hierarchical evidence-based approach. At first a systematic review was conducted to pool the current birth prevalence of NTDs and orofacial clefts OFCs in India. To investigate the population prevalence, we plan to use the key informant method to determine prevalence of NTDs and OFCs. To determine the normal serum estimates of folic acid, iron, and vitamin B12 among Indian women (15-35 years), we will conduct a population-based, cross-sectional study. We will further strengthen the evidence of association between OFCs and folic acid by conducting a hospital-based, case-control study across three locations of India. Lastly, using qualitative methods we will understand community and health workers perspective on factors that decide the intake of folic acid supplements. RESULTS: This study will provide evidence on the community prevalence of birth defects and prevalence folic acid and vitamin B12 deficiency in the community. The case-control study will help understand the association of folic acid deficiency with OFCs. CONCLUSIONS: The results from this study are intended to strengthen the evidence base in childhood disability for planning and policy initiatives