Are people at high risk for diabetes visiting health facility for confirmation of diagnosis? A population-based study from rural India.

BACKGROUND: India is witnessing a rising burden of type 2 diabetes mellitus. India's National Programme for Prevention and Control of Diabetes, Cancer, Cardiovascular diseases and Stroke recommends population-based screening and referral to primary health centre for diagnosis confirmation and treatment initiation. However, little is known about uptake of confirmatory tests among screen positives. OBJECTIVE: To estimate the uptake of confirmatory tests and identify the reasons for not undergoing confirmation by those at high risk for developing diabetes. METHODS: We analysed data collected under project UDAY, a comprehensive diabetes and hypertension prevention and management programme, being implemented in rural Andhra Pradesh, India. Under UDAY, population-based screening for diabetes was carried out by project health workers using a diabetes risk score and capillary blood glucose test. Participants at high risk for diabetes were asked to undergo confirmatory tests. On follow-up visit, health workers assessed if the participant had undergone confirmation and ask for reasons if not so. RESULTS: Of the 35,475 eligible adults screened between April 2015 and August 2016, 10,960 (31%) were determined to be at high risk. Among those at high risk, 9670 (88%) were followed up, and of those, only 616 (6%) underwent confirmation. Of those who underwent confirmation, 'lack of symptoms of diabetes warranting visit to health facility' (52%) and 'being at high risk was not necessary enough to visit' (41%) were the most commonly reported reasons for non-confirmation. Inconvenient facility time (4.4%), no nearby facility (3.2%), un-affordability (2.2%) and long waiting time (1.6%) were the common health system-related factors that affected the uptake of the confirmatory test. CONCLUSION: Confirmation of diabetes was abysmally low in the study population. Low uptake of the confirmatory test might be due to low 'risk perception'. The uptake can be increased by improving the population risk perception through individual and/or community-focused risk communication interventions

Process evaluation protocol for a cluster randomised trial of a complex, nurse-led intervention to improve hypertension management in India.

INTRODUCTION: India has high prevalence of hypertension but low awareness, treatment and control rate. A cluster randomised trial entitled 'm-Power Heart Project' is being implemented to test the effectiveness of a nurse care coordinator (NCC) led complex intervention to address uncontrolled hypertension in the community health centres (CHCs). The trial's process evaluation will assess the fidelity and quality of implementation, clarify the causal mechanisms and identify the contextual factors associated with variation in the outcomes. The trial will use a theory-based mixed-methods process evaluation, guided by the Consolidated Framework for Implementation Research. METHODS AND ANALYSIS: The process evaluation will be conducted in the CHCs of Visakhapatnam (southern India). The key stakeholders involved in the intervention development and implementation will be included as participants. In-depth interviews will be conducted with intervention developers, doctors, NCCs and health department officials and focus groups with patients and their caregivers. NCC training will be evaluated using Kirkpatrick's model for training evaluation. Key process evaluation indicators (number of patients recruited and retained; concordance between the treatment plans generated by the electronic decision support system and treatment prescribed by the doctor and so on) will be assessed. Fidelity will be assessed using Borrelli et al's framework. Qualitative data will be analysed using the template analysis technique. Quantitative data will be summarised as medians (IQR), means (SD) and proportions as appropriate. Mixed-methods analysis will be conducted to assess if the variation in the mean reduction of systolic blood pressure between the intervention CHCs is influenced by patient satisfaction, training outcome, attitude of doctors, patients and NCCs about the intervention, process indicators etc. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the ethics committees at Public Health Foundation of India and Deakin University. Findings will be disseminated via peer-reviewed publications, national and international conference presentations. TRIAL REGISTRATION NUMBER: NCT03164317; Pre-results

A Photovoice Study to Reveal Community Perceptions of Highly Processed Packaged Foods in India.

India is experiencing a nutrition transition, with sales of packaged and processed foods rapidly increasing in recent years. This study sought to understand the views and experiences of self-help groups about highly processed, packaged food in Visakhapatnam, India, using the Photovoice method. Participants were able to record, reflect on and critique their environments through participatory analysis, identifying key themes, and offering a critical lens on their food environment and experiences. On an average eight and 14 members participated in the Photovoice workshops held in urban and rural Visakhapatnam respectively. The key themes emerging from the photos and text data are that participants experienced highly processed packaged foods as being: 1) democratic (easily available and consumed by all, affordable and accessible; 2) convenient (easy to prepare) and 3) unhealthy (for human consumption and for environmental sustainability). These data demonstrate the challenges facing public health nutritionists in wishing to shift dietary behaviors to healthy habits: on the surface participants acknowledged their unhealthy characteristics, however these products may now be embedded in dietary culture. Traditional methods for changing dietary habits may not be able to capture the complexity and systems approach is required to explore the most effective entry points for affecting change

Co-Benefits of Largescale Organic farming On huMan health (BLOOM)::Protocol for a cluster-randomised controlled evaluation of the Andhra Pradesh Community-managed Natural Farming programme in India

The BLOOM study (co-Benefits of Largescale Organic farming On huMan health) aims to determine if a government-implemented agroecology programme reduces pesticide exposure and improves dietary diversity in agricultural households. To achieve this aim, a community-based, cluster-randomised controlled evaluation of the Andhra Pradesh Community-managed Natural Farming (APCNF) programme will be conducted in 80 clusters (40 intervention and 40 control) across four districts of Andhra Pradesh state in south India. Approximately 34 households per cluster will be randomly selected for screening and enrolment into the evaluation at baseline. The two primary outcomes, measured 12 months post-baseline assessment, are urinary pesticide metabolites in a 15% random subsample of participants and dietary diversity in all participants. Both primary outcomes will be measured in (1) adult men ≥18 years old, (2) adult women ≥18 years old, and (3) children <38 months old at enrolment. Secondary outcomes measured in the same households include crop yields, household income, adult anthropometry, anaemia, glycaemia, kidney function, musculoskeletal pain, clinical symptoms, depressive symptoms, women’s empowerment, and child growth and development. Analysis will be on an intention-to-treat basis with an a priori secondary analysis to estimate the per-protocol effect of APCNF on the outcomes. The BLOOM study will provide robust evidence of the impact of a large-scale, transformational government-implemented agroecology programme on pesticide exposure and dietary diversity in agricultural households. It will also provide the first evidence of the nutritional, developmental, and health co-benefits of adopting agroecology, inclusive of malnourishment as well as common chronic diseases

Environmental risk factors for reduced kidney function due to undetermined cause in India

Background: An epidemic of chronic kidney disease is occurring in rural communities in low-income and middle-income countries that do not share common kidney disease risk factors such as diabetes and hypertension. This chronic kidney disease of unknown etiology occurs primarily in agricultural communities in Central America and South Asia. Consequently, environmental risk factors including heat stress, heavy metals exposure, and low altitude have been hypothesized as risk factors. We conducted an environmental epidemiological analysis investigating these exposures in India which reports the disease. Methods: We used a random sample population in rural and urban sites in Northern and Southern India in 2010, 2011, and 2014 (n = 11,119). We investigated associations of the heat index, altitude, and vicinity to cropland with estimated glomerular filtration rate (eGFR) using satellite-derived data assigned to residential coordinates. We modeled these exposures with eGFR using logistic regression to estimate the risk of low eGFR, and linear mixed models (LMMs) to analyze site-specific eGFR-environment associations. Results: Being over 55 years of age, male, and living in proximity to cropland was associated with increased risk of low eGFR [odds ratio (OR) (95% confidence interval (CI) = 2.24 (1.43, 3.56), 2.32 (1.39, 3.88), and 1.47 (1.16, 2.36)], respectively. In LMMs, vicinity to cropland was associated with low eGFR [-0.80 (-0.44, -0.14)]. No associations were observed with temperature or altitude. Conclusions: Older age, being male, and living in proximity to cropland were negatively associated with eGFR. These analyses are important in identifying subcommunities at higher risk and can help direct future environmental investigations

UDAY: A comprehensive diabetes and hypertension prevention and management program in India.

INTRODUCTION: Diabetes and hypertension are two leading non-communicable conditions, which are suboptimally managed in India. Thus, innovative comprehensive approaches that can concomitantly improve their detection, prevention and control are warranted. METHODS AND ANALYSIS: UDAY, a 5-year initiative, aims to reduce the risk of diabetes and hypertension and improve management by implementing a comprehensive intervention programme in the two selected study sites, Sonipat and Visakhapatnam (Vizag). It has a pre-post evaluation design with representative cross-sectional surveys before and after intervention. Within these two sites, urban and rural subsites each with a total population of approximately 100 000 people each were selected and a baseline and postintervention assessment was conducted deploying five surveys [among general population (including body measurements or biosamples), patients, healthcare providers including physicians and pharmacists, health facilities], which will determine the knowledge levels about diabetes and hypertension, the proportion treated and controlled; the patient knowledge and self-management skills; healthcare providers' management practices; the level of access and barriers to obtaining care.The interventions will include: tailored health promotion for improving public knowledge; screening of adults aged ≥ 30 years for identifying those at high risk of diabetes and/or hypertension for linkage to the healthcare system; patient education using technology enabled community health workers, geographic information system (GIS) based mapping of the communities, healthcare provider training on management guidelines, community based diabetes registry and; advocacy to improve access to healthcare. The baseline surveys have been completed, the study areas mapped using GIS and the interventions are being implemented. UDAY is expected to increase over baseline the levels of: public knowledge about diabetes and hypertension; those treated and controlled; patient self-management skills; the use of guideline based management by providers and; access to healthcare, leading to improved health outcomes and inform development of a India relevant chronic care model. ETHICS AND DISSEMINATION: Ethical clearance for conduct of the study was obtained from the Institutional Ethics Committee (IEC) of the Public Health Foundation of India. The findings will be targeted primarily at public health policymakers and advocates, but will be disseminated widely through other mechanisms including conference presentations and peer-reviewed publications, as well as to the participating communities

Changes in take-home aerated soft drink purchases in urban India after the implementation of Goods and Services Tax (GST): An interrupted time series analysis.

OBJECTIVES: Taxes on sugar-sweetened beverages (SSB) are increasingly being implemented as public health interventions to limit the consumption of sugar and reduce associated health risks. In July 2017, India imposed a new tax rate on aerated (carbonated) drinks as part of the Goods and Services Tax (GST) reform. This study investigates the post-GST changes in the purchase of aerated drinks in urban India. METHODS: An interrupted time series analysis was conducted on state-level monthly take-home purchases of aerated drinks in urban India from January 2013 to June 2018. We assessed changes in the year-on-year growth rate (i.e. percentage change) in aerated drink purchases with controls for contextual variables. RESULTS: We found no evidence of a reduction in state-level monthly take-home aerated drink purchases in urban India following the implementation of GST. Further analysis showed that the year-on-year growth rate in aerated drink purchases increased slightly (0.1 percentage point per month, 95%CI = 0.018, 0.181) after the implementation of GST; however, this trend was temporary and decreased over time (0.008 percentage point per month, 95%CI = -0.015, -0.001). CONCLUSIONS: In India, a country currently with low aerated drink consumption, the implementation of GST was not associated with a reduction in aerated drink purchase in urban settings. Due to the lack of accurate and sufficiently detailed price data, it is not possible to say whether this finding is driven by prices not changing sufficiently. Furthermore, the impact of GST reform on industry practice (reformulation, marketing) and individual behaviour choices (substitution) is unknown and warrants further investigation to understand how such taxes could be implemented to deliver public health benefits

Towards the Three Dimensions of Sustainability for International Research Team Collaboration: Learnings from the Sustainable and Healthy Food Systems Research Programme

This paper highlights the potential for learning and virtual collaboration in international research teams to contribute towards sustainability goals. Previous research confirmed the environmental benefits of carbon savings from international virtual conferences. This paper adds the social and economic dimensions by using a combination of qualitative and quantitative methods to measure the constraints and benefits for personal development, economic costs, efficiency and team learning of holding international virtual conferences (VCs). Using the Sustainable and Healthy Food Systems (SHEFS) research programme as a case study, we analysed VC participant survey data to identify strengths, weaknesses, opportunities, and threats of VCs. We estimated ‘saved’ GHG emissions, costs, and time, of using VCs as an alternative for a planned in-person meeting in Chennai, India. Hosting VCs reduced North–South, gender, and researcher inclusivity concerns, financial and travelling time costs, and substantially reduced emissions. For one international meeting with 107 participants, changing to a virtual format reduced the per capita GHG emissions to half the annual global average, and avoided 60% of travel costs. The benefits of VCs outweighed weaknesses. The main strengths were inclusivity and access, with 20% more early/mid-career researchers attending. This study identified opportunities for international research partnerships to mitigate their carbon footprint (environmental benefit) and enhance inclusivity of early/mid-career, women and Global South participants (social benefit), whilst continuing to deliver effective collaborative research meetings (economic benefit). In doing so, we present a holistic view of sustainability opportunities for virtual collaboration