Arun Kumar Aggarwal

Prevalence of metabolic syndrome in adolescents from a north Indian population

Aims  To estimate the prevalence and distribution of the metabolic syndrome (MS) in adolescents attending school in the north Indian city of Chandigarh.

Body temperatures of home delivered newborns in North India

In this prospective study, the axillary temperature of newborns delivered at home were recorded by a field worker once within a period of 24 h after the birth in 10 villages of Haryana, India, during 1992–1993. Room air temperature was measured at the same time. Family members were interviewed to record newborn care practices. Of the 189 babies, 11.1% were found to be hypothermic (temperature <35.6°C) and 22.8% were hyperthermic (temperature >37.3°C). During winter months 19.1% were hypothermic as compared to only 3.1% in summer whereas 8.5% were hyperthermic in winter compared to 36.8% in summer. Room air temperature of <24°C was recorded in 41%. A strong correlation was observed between room air temperature and neonatal temperature. At the time of birth, 13.2% of the delivery rooms in summer and 73.6% in winter were reported to have heat source: 58.2% babies were reported to be wiped soon after birth; 97.3% were wrapped in cloth; the head was covered in 59.1% cases in winter and 10.5% in summer; 97.3% babies were kept with mother in same bed but not in skin-to-skin contact; and 65% were bathed within 24 h after delivery. Neonatal hypothermia is a common problem in developing countries. It is important that information, education and communication strategy about appropriate technologies for prevention and management of neonatal hypothermia is provided at domiciliary level. A significant proportion of babies are likely to suffer from hyperthermia in warm countries, specially in summer. Therefore, guidelines for thermal control in home births should be tailored to the specific environmental situation.

Reproductive Health Education Intervention Trial

Objective: To measure the effectiveness of a reproductive health education package in improving the knowledge of adolescent girls aged 15–19 years in Chandigarh (India).Methods: A reproductive health education package, developed in consultation with parents, teachers and adolescents, was delivered to randomly sampled classes of two senior secondary schools and one school was selected as control. In one school, a nurse conducted 15 sessions for 94 students in three batches using conventional education approach. In another school she conducted sessions for a selected group of 20 adolescents who later disseminated the messages informally to their 84 classmates (peer education). Using a 70-item structured questionnaire the knowledge of 95 adolescents from conventional, 84 from peer, and 94 from control school were assessed before and one month after the last session. Change in the score in intervention and control groups was tested by ANOVA taking age and socio-economic status as covariates.Results: Teachers, parents and students overwhelmingly (88%, 95.5% and 93% respectively) favoured reproductive health education program. Five percent of the respondents reported that someone in their class is having sexual relations, and 13% of the girls approved of pre-marital sexual relations. Reproductive health knowledge scores improved significantly after intervention in conventional education (27.28) and peer education group (20.77) in comparison to the controls (3.64). Post-test scores were not significantly different between peer education group and conventional education group (43.65 and 40.52 respectively) though the time consumed in delivering the peer education intervention was almost one third of the time taken to implement conventional education.Conclusion: Peer education and conventional education strategies were effective in improving the reproductive health knowledge of adolescent girls but peer strategy was less time consuming

Validity of verbal autopsy for ascertaining the causes of stillbirth

OBJECTIVE To validate the verbal autopsy tool for stillbirths of the World Health Organization (WHO) by using hospital diagnosis of the underlying cause of stillbirth (the gold standard) and to compare the fraction of stillbirths attributed to various specific causes through hospital assessment versus verbal autopsy. METHODS In a hospital in Chandigarh, we prospectively studied all stillbirths occurring from 15 April 2006 to 31 March 2008 whose cause was diagnosed within 2 days. All mothers had to be at least 24 weeks pregnant and live within 100 km of the hospital. For verbal autopsy, field workers visited mothers 4 to 6 weeks after the stillbirth. Autopsy results were reviewed by two independent obstetricians and disagreements were resolved by engaging a third expert. Causes of stillbirths as determined by hospital assessment and verbal autopsy were compared in frequency. FINDINGS Hospital assessment and verbal autopsy yielded the same top five underlying causes of stillbirth: pregnancy-induced hypertension (30%), antepartum haemorrhage (16%), underlying maternal illness (12%), congenital malformations (12%) and obstetric complications (10%). Overall diagnostic accuracy of verbal autopsy diagnosis versus hospital-based diagnosis for all five top causes of stillbirth was 64%. The areas under the receiver operator characteristic curve (ROC) were, for congenital malformations, 0.91 (95% confidence interval, CI: 0.83-0.97); pre-gestational maternal illness, 0.75 (95% CI: 0.65-0.84); pregnancy-induced hypertension, 0.76 (95% CI: 0.69-0.81); antepartum haemorrhage, 0.76 (95% CI: 0.67-0.84) and obstetric complication, 0.82 (95% CI: 0.71-0.93). CONCLUSION The WHO verbal autopsy tool for stillbirth can provide reasonably good estimates of common underlying causes of stillbirth in resource-limited settings where a medically certified cause of stillbirth may not be available.

Epidemiological transition in a rural community of northern India: 18-year mortality surveillance using verbal autopsy

Background Information on causes of death is vital for planning of health services. However, vital events registration systems are weak in developing countries. Therefore, verbal autopsy (VA) tools were incorporated in a community-based surveillance system to track causes of death. Method and Findings Trained fieldworker identified all deaths and interviewed a living relative of those who had died during 1992–2009, using VA, in eight villages of Haryana (11 864 populations). These field reports detailing events preceding death were reviewed by two trained physicians, who independently assigned an International Classification of Disease-10 code to each death. Discrepancies were resolved through reconciliation and, if necessary, adjudication. Non-communicable conditions were the leading causes of death (47.6%) followed by communicable diseases including maternal, perinatal and nutritional conditions (34.0%), and injuries (11.4%). Cause of death could not be determined in 6.9% cases. Deaths due to cardiovascular diseases showed a significant rise, whereas deaths due to diarrhoeal diseases have declined (p<0.01). Majority (90.0%) of the deceased had contacted a healthcare provider during illness but only 11.5% were admitted in hospital before death. Conclusion Rising trend of cardiovascular diseases observed in a rural community of Haryana in India calls for reorientation of rural healthcare delivery system for prevention and control of chronic diseases.

The effect of interrupted 5-day training on Integrated Management of Neonatal and Childhood Illness on the knowledge and skills of primary health care workers

The conventional 8-day Integrated Management of Neonatal and Childhood Illness (IMNCI) training package poses several operational constraints, particularly due to its long duration. A 5-day training package was developed and administered in an interrupted mode of 3 days and 2 days duration with a break of 4 days in-between, in a district of Haryana state in northern India. Improvement in the knowledge and skills of 50 primary health care workers following the interrupted 5-day training was compared with that of 35 primary health care workers after the conventional 8-day IMNCI training package. The average score increased significantly (P < 0.05) from 46.3 to 74.6 in 8-day training and from 40.0 to 73.2 in 5-day training. Knowledge score improved for all health conditions, like anaemia, diarrhoea, immunization, malnutrition, malaria, meningitis and possible severe bacterial infection, and for breastfeeding in 8-day as well as in 5-day training. Average skills score for respiratory problems increased from 38 to 57 in 8-day training and from 41 to 91 in 5-day training. Corresponding increases in skill scores for diarrhoea assessment were from 28 to 67 and 48 to 75, and for breastfeeding assessment from 33 to 84 and 42 to 86 in 8-day and 5-day training, respectively. Average counselling skill score also rose from 42 to 89 in 8-day and from 37 to 70 in 5-day training. A direct cost saving of US

Accuracy of WHO verbal autopsy tool in determining major causes of neonatal deaths in India.

813 for a batch of 25 trainees and an indirect cost saving of 3 days per trainee and resource person makes the interrupted 5-day IMNCI training more cost-effective.

Outpatient satisfaction and quality of health care in North Indian medical institute

OBJECTIVES This study was conducted to evaluate the performance of World Health Organisation (WHO) verbal autopsy tool in determining major causes of neonatal deaths. METHODS From a tertiary care hospital and a government multispecialty hospital, the attending paediatricians ascertained a clinical cause of death for 371 neonatal deaths. Trained field workers conducted verbal autopsy (VA) interviews. Two independent paediatricians, who had no access to the clinical information, assigned cause of death as per verbal autopsy. Analysis was based on 313 cases in which both clinical diagnosis and VA diagnosis was obtained. FINDINGS As per the clinical diagnosis, four most common causes of neonatal deaths were sepsis (29.1%), preterm birth (27.8%), birth asphyxia (27.2%), and congenital anomalies (11.5%). Cause specific mortality fractions by VA diagnosis were statistically similar to those obtained by clinical diagnosis except for birth asphyxia (16.3%). Diagnostic accuracy of verbal autopsy diagnosis against clinical diagnosis ranged from 78% to 92% in ascertaining different underlying causes of death. Area under the Receiver-Operator Characteristics curve (95% confidence interval) was 0.75 (0.69-0.80) for sepsis, 0.74 (0.68-0.80) for preterm birth, 0.73 (0.65-0.82) for congenital anomaly and 0.70 (0.64-0.75) for birth asphyxia. Kappa for all four causes was moderate (0.46-0.55). INTERPRETATION The WHO verbal autopsy tools can provide reasonably good estimates of predominant causes of neonatal deaths in countries where neonatal mortality is high. Caution is required to interpret cause specific mortality fraction (CSMF) for birth asphyxia by VA because it is likely to be an underestimate.

Knowledge and skills of primary health care workers trained on integrated management of neonatal and childhood illness: Follow-up assessment 3 years after the training

PURPOSE Outpatient departments (OPDs) need to monitor the quality of care and patient satisfaction for continuous quality improvement. Additionally, there is a need for an increase in focused literature on patient satisfaction and quality of health care at a tertiary care level. The purpose of this paper is to attempt to fulfil this need. DESIGN/METHODOLOGY/APPROACH A cross-sectional hospital-based study among OPD patients was undertaken, where investigators conducted interviews with 120 patients at entry (registration), 120 patients at the OPD clinic (60 doctor-patient interactions and 60 exit interviews), and a further 120 patients at investigation facilities. Patient satisfaction, client convenience facilities, prescription quality, doctor-patient interaction and other quality elements as described in the study were given score of 0 or 1. FINDINGS At exit, 52 (86.6 percent) patients were satisfied with the OPD care. The mean total quality score was 80.9 percent of the total scores. It was above 90 percent of the total score for patient convenience facilities and for doctor-patient interaction, 76 percent for the prescription quality of the doctors and 43.3 percent for signage display. The mean score for patient-doctor interaction was found to be significantly lower (3.6/5) among dissatisfied patients compared to the satisfied patients (4.7/5). Satisfied patients reported a significantly higher consultation time (12.4 minutes) with a doctor compared to dissatisfied patients (8.5 minutes) (p = 0.04). RESEARCH LIMITATIONS/IMPLICATIONS Not using a Likert scale to measure patient satisfaction could be considered a limitation However, the authors also arrived at similar conclusions with their tools as with the use of Likert scales in other studies. Furthermore, findings are limited to medicine and surgery general OPDs in a tertiary care setting. Any interpretation beyond this frame may be done with caution. PRACTICAL IMPLICATIONS Hospitals should encourage good patient-doctor interaction as it has emerged as the key factor associated with patient satisfaction. SOCIAL IMPLICATIONS Quality improvements in public sector health institutes can lead to better utilization of health care by the poor and compromised sections of society and can lead to a reduction in the inequity associated with health care. ORIGINALITY/VALUE This paper fulfils the need to evaluate quality of hospital care in public sector hospitals at the tertiary care level. The methods and tools used are simple and extensive enough to capture information at multiple service points.

Dietary intake in third trimester of pregnancy and prevalence of LBW: A community-based study in a rural area of Haryana

BACKGROUND The primary health care workers of a district in northern India were trained in the year 2006 for Integrated Management of Neonatal and Childhood Illness (IMNCI) using two different training methods: conventional 8-day training and new interrupted 5-day training. Knowledge and skills may decline over a period of time. Rate of decline may be associated with the type of training. A study was thus conducted to see the retention of knowledge and skills in the two training groups, 3 years after the initial training. MATERIALS AND METHODS This study was done in the Panchkula district of Haryana state in northern India. In the year 2006, 50 primary health care workers were given new interrupted 5-day training and another 35 workers were given conventional 8-day training on IMNCI. Knowledge and skills of the same workers were evaluated in the year 2009, using the same methodology and tools as were used in the year 2006. Data analysis was done to see the extent of decline in knowledge and skills in these 3 years and whether decline was more in any particular training group. RESULTS Compared to post-training score in the year 2006, composite knowledge and skill scores for Auxilliary Nurse Midwives (ANMs) and Anganwari workers (AWWs) together declined significantly in the year 2009 from 74.6 to 58.0 in 8-day training group and from 73.2 to 57.0 in 5-day training group (P < 0.001). Follow-up composite scores in the two training groups were similar. Whereas the decline was more for knowledge scores in 8-day training group and for skill score in 5-day training group, the pattern of decline was inconsistent for different health conditions and among ANMs and AWWs. CONCLUSION Long-term retention of knowledge and skills in 5-day group was equivalent to that in 8-day training group. Refresher trainings may boost up the decline in the knowledge and skills.