Chandrakant Lahariya

Pathway of care among psychiatric patients attending a mental health institution in central India

Introduction: Only a limited proportion of patients with psychiatric disorders attend the healthcare facilities, and that too when the condition becomes severe. Treatment from unqualified medical practitioners and faith healers is a common practice, and is attributable to the delay in proper treatment. Materials and Methods: A cross-sectional study was conducted to understand the pathway of care adopted by psychiatric patients and its relationship with the socio-demographic determinants in the study population. The subjects were selected from urban specialty psychiatric hospitals and interviewed using a pre-tested, semi-structured interview schedule. The data was analyzed using SPSS v10.0 software. The Chi square test, T test, and Kruskall Wallis Test were used, as needed. Results: A total of 295 patients (203 males) were included in this study. The majority of the patients (45%) were suffering from Bipolar affective disorders (45%), followed by schizophrenia (36%). The majority, 203 (68%), were from the rural area, with 94 patients being illiterate. The mean distance traveled for treatment was 249 km. The majority of these (69%) had first contacted faith healers and a qualified psychiatrist was the first contacted person for only 9.2% of the patients. Conclusion: A large proportion of psychiatric patients do not attend any health facility due to a lack of awareness about treatment services, the distance, and due to the fear of the stigma associated with treatment. The psychiatric patients first seek the help of various sources prior to attending a psychiatric health facility. The pathway adopted by these patients need to be kept in mind at the time of preparation of the mental health program.

Practical observations from an epidemiological investigation of a measles outbreak in a district of India.

Background: Measles is a major cause of childhood morbidity and mortality, accounting for nearly half of the morbidity associated with global vaccine preventable diseases. Regular outbreaks of Measles are reported in India, of which only a few are investigated. This study was conducted in the Shivpuri District of Madhya Pradesh (India) to investigate and asses various epidemiological factors associated with measles outbreak. Materials and Methods: A cross-sectional study was carried out in 30 randomly selected sub-centers in 8 blocks of the Shivpuri District of Madhya Pradesh, covering 212 villages, selected by cluster sampling. The villages, which had reported measles cases, were extensively investigated by the field teams through extensive house-to-house surveys during 12-19 May 2004. Results: A total of 1204 cases with 14 deaths were reported with an attack rate of 6.2% and a case fatality rate of 1.2%. In this study, 17.7% of the cases reported post-measles complications with diarrhea as the most common post measles complication. The routine measles vaccine and Vitamin A supplementation in the area was also less than 30%. Conclusions: The majority of the cases had occurred in the unvaccinated children and in under 5 year old population. There are repeated outbreaks and a long delay in reporting of the cases. The occurrence of cases, in a reasonable proportion of the vaccinated population, points toward the fact that there is a possibility of a vaccine failure in older children. This study calls for an improved surveillance system, an improvement in the cold chain, and enhancements for measles vaccination if India is to achieve the goal of measles elimination.

Measles related complications and the role of vitamin A supplementation

Purpose. Measles is associated with high rate of complications and contributes to a major proportion of childhood morbidity and mortality. The role of vitamin A supplementation (VAS) in the case management of measles and prevention of complications is partially understood and not sufficiently supported by epidemiological data. This paper analyses the possible role of vitamin A supplementation in prevention of measles related complications and associated fatalityMethods. A cross sectional study was carried out during an outbreak of measles in Shivpuri, India. A total population of 193,000 was covered by house to house visit and, the caregivers of total 1204 measles cases, including 214 cases with complications, were interviewed using a semi structured interview schedule. The analysis of data was done using Epi InfoResults. The attack rate of 6.7% and rate of complications at 17.8% were found in this investigation. The coverage with routine measles vaccine and the vitamin A supplementation was 18.3% and 28.9% respectively. The management of measles cases was poor with only 15.8% cases receiving therapeutic doses of vit A. Both complications and case fatality rate was higher amongst children who had not received vit A supplementation in previous 6 months (p<0.05). Measles vaccine also found to have preventive effect on development of complications (p<0.05)Conclusions. Routine vitamin A supplementation and measles vaccination reduces the chances of complications amongst measles cases. The role of VAS becomes more important when the case management is poor. While, measles is frequently associated with complications in Indian setting, there is a need of enhancing the efforts to improve the delivery of vit A supplementation and measles vaccine to the children in rural areas

Vaccine epidemiology: A review

This review article outlines the key concepts in vaccine epidemiology, such as basic reproductive numbers, force of infection, vaccine efficacy and effectiveness, vaccine failure, herd immunity, herd effect, epidemiological shift, disease modeling, and describes the application of this knowledge both at program levels and in the practice by family physicians, epidemiologists, and pediatricians. A case has been made for increased knowledge and understanding of vaccine epidemiology among key stakeholders including policy makers, immunization program managers, public health experts, pediatricians, family physicians, and other experts/individuals involved in immunization service delivery. It has been argued that knowledge of vaccine epidemiology which is likely to benefit the society through contributions to the informed decision-making and improving vaccination coverage in the low and middle income countries (LMICs). The article ends with suggestions for the provision of systematic training and learning platforms in vaccine epidemiology to save millions of preventable deaths and improve health outcomes through life-course.

Additional cash incentive within a conditional cash transfer scheme: a 'controlled before and during' design evaluation study from India.

BACKGROUND Conditional Cash Transfer (CCT) schemes have shown largely favorable changes in the health seeking behavior. This evaluation study assesses the process and performance of an Additional Cash Incentive (ACI) scheme within an ongoing CCT scheme in India, and document lessons. MATERIAL AND METHODS A controlled before and during design study was conducted in Madhya Pradesh state of India, from August 2007 to March 2008, with increased in institutional deliveries as a primary outcome. In depth interviews, focus group discussions and household surveys were done for data collection. RESULTS Lack of awareness about ACI scheme amongst general population and beneficiaries, cumbersome cash disbursement procedure, intricate eligibility criteria, extensive paper work, and insufficient focus on community involvement were the major implementation challenges. There were anecdotal reports of political interference and possible scope for corruption. At the end of implementation period, overall rate of institutional deliveries had increased in both target and control populations; however, the differences were not statistically significant. No cause and effect association could be proven by this study. CONCLUSIONS Poor planning and coordination, and lack of public awareness about the scheme resulted in low utilization. Thus, proper IEC and training, detailed implementation plan, orientation training for implementer, sufficient budgetary allocation, and community participation should be an integral part for successful implementation of any such scheme. The lesson learned this evaluation study may be useful in any developing country setting and may be utilized for planning and implementation of any ACI scheme in future.

Health system approach for improving immunization program performance

Immunization programs are one of the most well-recognized and successful public health programs across the world. The immunization programs have achieved significant successes in a number of countries; however, the coverage with available vaccines remains sub-optimal in many low- and middle-income countries (LMICs). This article, based upon extensive review of literature and using universal immunization program (UIP) in India as a case study, summarizes the latest developments and initiatives in the area of vaccination and immunization in the last few years. The article analyzes initiatives under UIP in India from the “health system approach” and argues that it is possible to increase coverage with available vaccines and overall program performance by focused attention on various functions of health systems. It also discusses the emerging evidence that health systems could be strengthened prior to the introduction of new interventions (vaccines included) and the introduction of new interventions (including vaccines) could be planned in a way to strengthen the health systems. It concludes that immunization programs could be one of the entry points for strengthening health systems in the countries and lessons from vaccine introduction could pave pathway for scaling up other health interventions and therefore, could contribute to advancing Universal Health Coverage (UHC).

Child survival and the need for wider dissemination of health research

The Bellagio meeting on child survival was held in February 2003, where first reliable estimates on child morbidity and mortality were made and, the effective preventive and treatment interventions for reducing under five child deaths were identified. The meeting gave a momentum to child survival efforts across the world. This review summarizes the child survival series published thereafter and outlines the evidences generated. The author argues that the meeting was a landmark step, and the need for these interventions is still the same as it was five years back. The author adds that health research has ever since been on the agenda of international community; however, the equally important step of wider dissemination of available knowledge, to fill the “delivery gap”, has almost been neglected. This paper provides evidences of how health research and its wider access to policy makers and implementers can improve the child survival. The author also calls for an immediate mechanism to make health research easily available and accessible, to the practitioners in the developing nations.

Chasing viruses feverishly

A number of viral diseases have emerged and re-emerged in India and globally, in the last few years. Effective prevention and control of these diseases require, in addition to a functioning disease surveillance system, interventions both before and after disease occurrence, and a combination of personal and population services. However, the current efforts to control emerging viral diseases in India has major therapeutic focus (and attention on diagnostic and curative services) and there is limited attention on preventive and promotive components. It is proposed that for an effective and successful control, a systematic approach is adopted with an appropriate selection of personal and population health services, delivered by government through participation of private sector. This is possible through commitment and leadership of Government and other public health agencies, supplemented by multi agency coordination, sufficient funding and an accountability mechanism.

Policy and System Approach (PSA): A primer

A number of public health challenges have emerged at global and national level in the last two decades. The response to these challenges has rarely been swift and often “knee-jerk.” The national and state level program officials responsible for the activities often apportion the blame on weak health systems or fragmented health service delivery mechanisms, amongst other. In India, the viral illnesses (including those due to dengue and chikungunya) are becoming the increasing realities. The Public health response of early identification, disease surveillance, reporting and the preventive and curative measures, remains suboptimal. The health challenges which require multidimensional interventions are usuallyattempted to be resolved through piece meal solutions. This article proposes “policy and system approach (PSA),” combining concepts of “Health in all policies” for intersectoral coordination and “health system approach” for intra-sectoral tackling of the emerging and existing health challenges.