Kathiresan Jeyashree

Kuppuswamy’s Socioeconomic Status Scale 2010—The Need for Periodic Revision

Sir,Socioeconomic status (SES) refers to an individual’sposition within a hierarchical social structure, which isone of the important determinants of health status.Composite scales are generally used to measure the SES,which has a combination of social and economic variables.The Kuppuswamy scale proposed in 1976, measures theSES of an individual based on three variables namely,education and occupation of the head of the household andincome of the family [1]. Of the three variables, educationand occupation of the head of the household do not changefrequently with time. However, the steady inflation and theresultant devaluation of the rupee necessitate periodicrevisions of the income variable. The previous revisionsof the scale were done in the years 1998 and 2007 [2, 3].The changes in the income scale are proportional to thechange in the Consumer Price Index Numbers for IndustrialWorkers—CPI (IW). The CPI values are interpreted withreference to a particular base year. The previous base yearswere 1960, 1982 and 2001. The latest CPI-(IW) availablefor December 2010 has been calculated taking 2001 as thebase year.We have attempted updating the income scale forDecember 2010 using the corresponding CPI-(IW) value. Tobegin with we calculated the income scale for the selectedyears 1982 and 2001 which coincides with change in baseyear for calculation of CPI by applying the appropriateconversion factors on the original scale (Table 1).We have presented the values for the current base year2001, which facilitates the easier updations of the incomescale every year or even every month based on the CPIrevisions. The researcher has to calculate the multiplicationfactor for the period of research by dividing the CPI valuefor the period by 100 (base value at 2001). The incomescale of 2001 is then multiplied by the multiplication factorto update the scale for the desired period. For example, theCPI value as on December 2010 is 185. So the multipli-cation factor for December 2010 is 185/100=1.85. Multi-plying the income scale of 2001 by 1.85 updates the scalefor December 2010 (Table 1).It is the responsibility of the researchers to take note ofthe periodic revisions in the CPI values before attemptingsocioeconomic classification of their study population [4].The method proposed by us makes it easy for the researcherto update the income scale to the latest available CPIvalues.

Multiple treatment and indirect treatment comparisons: An overview of network meta-analysis.

Randomized control trials and its meta-analysis has occupied the pinnacle in levels of evidence available for research. However, there were several limitations of these trials. Network meta-analysis (NMA) is a recent tool for evidence-based medicine that draws strength from direct and indirect evidence generated from randomized control trials. It facilitates comparisons across multiple treatment options, direct comparisons of which have not been attempted till date due to multitude of reasons. These indirect treatment comparisons of randomized controlled trials are based on similarity and consistency assumptions that follow Bayesian or frequentist statistics. Most NMAuntil date use Microsoft Windows WinBUGs Software for analysis which relies on Bayesian statistics. Methodology of NMA is expected to undergo further refinements and become robust with usage. Power and precision of indirect comparisons in NMA is a concern as it is dependent on effective number of trials, sample size and complete statistical information. However, NMA can synthesize results of considerable relevance to experts and policy makers.

The potential use of DREEM in assessing the perceived educational environment of postgraduate public health students

In many medical schools, students undergo an integrated basic sciences/ clinical course from Year 1. Interestingly, despite the years of training at both an undergraduate and postgraduate level, it is clear that many of us rarely practice the strategy of prevention being better than cure. From a hospital perspective, junior doctors, for example, can easily treat an exacerbation of COPD or an episode of decompensated liver disease, but rarely do they spend time discussing the grave implications of smoking or continued alcohol misuse. Similarly, many patients are often admitted following repeated drug overdoses, but once over the withdrawal phase patients are often waved farewell with words to the effect of, ‘We can’t force you to stop doing what you are doing, the decision rests with you.’ The same can also be said for those heavily obese patients with their associated complications of hypertension and diabetes. I wonder how much time is actually spent encouraging individuals to lose weight when they are admitted with a systolic of 200 mm Hg or excessively high blood sugars? Now I am sure all medically trained individuals have a more than adequate understanding of the importance of public health, but it is something that is rarely touched upon during medical school and even practiced later on in postgraduate training. Maybe as doctors we shy away from areas we may view as ‘soft medicine’. Or is it due to the fact that as a result of limited training, we do not feel confident in engaging with our patients at length about its importance.

Social mapping: A potential teaching tool in public health

Background: Mapping is a fundamental way of displaying spatial human cognition. It is a rapid technique of summarising and presenting large amount of information. Social map is a technique that finds use as a participatory rural appraisal tool. Aim: To evaluate the feasibility of using social mapping as a public health teaching tool. Methods: A resident doctor posted in the Urban Health Training Centre was assigned to do social mapping of an urban resettlement colony. The area was first divided into segments. The mapping was done by people residing in each segment and compiled with the assistance of the resident doctor. Results: Social mapping helped the student acquire various cognitive, affective and psychomotor skills. It also helped in understanding the geographical area, people, language, cultural practices, social networks and interactions. It trained the student in using rapid appraisal techniques, cartography, effective and succinct summarising and presentation of data of social relevance. The different language and cultural background of the community was the main challenge encountered. Conclusion: Social mapping is an excellent learning and a very practical teaching tool in public health, especially when the researcher/health care provider has little knowledge about his/her field practice area.

Effect of glycemic control and type of diabetes treatment on unsuccessful TB treatment outcomes among people with TB-Diabetes: A systematic review

Background Stringent glycemic control by using insulin as a replacement or in addition to oral hypoglycemic agents (OHAs) has been recommended for people with tuberculosis and diabetes mellitus (TB-DM). This systematic review (PROSPERO 2016:CRD42016039101) analyses whether this improves TB treatment outcomes. Objectives Among people with drug-susceptible TB and DM on anti-TB treatment, to determine the effect of i) glycemic control (stringent or less stringent) compared to poor glycemic control and ii) insulin (only or with OHAs) compared to ‘OHAs only’ on unsuccessful TB treatment outcome(s). We looked for unfavourable TB treatment outcomes at the end of intensive phase and/or end of TB treatment (minimum six months and maximum 12 months follow up). Secondary outcomes were development of MDR-TB during the course of treatment, recurrence after 6 months and/or after 1 year post successful treatment completion and development of adverse events related to glucose lowering treatment (including hypoglycemic episodes). Methods All interventional studies (with comparison arm) and cohort studies on people with TB-DM on anti-TB treatment reporting glycemic control, DM treatment details and TB treatment outcomes were eligible. We searched electronic databases (EMBASE, PubMed, Google Scholar) and grey literature between 1996 and April 2017. Screening, data extraction and risk of bias assessment were done independently by two investigators and recourse to a third investigator, for resolution of differences. Results After removal of duplicates from 2326 identified articles, 2054 underwent title and abstract screening. Following full text screening of 56 articles, nine cohort studies were included. Considering high methodological and clinical heterogeneity, we decided to report the results qualitatively and not perform a meta-analysis. Eight studies dealt with glycemic control, of which only two were free of the risk of bias (with confounder-adjusted measures of effect). An Indian study reported 30% fewer unsuccessful treatment outcomes (aOR (0.95 CI): 0.72 (0.64−0.81)) and 2.8 times higher odds of ‘no recurrence’ (aOR (0.95 CI): 2.83 (2.60−2.92)) among patients with optimal glycemic control at baseline. A Peruvian study reported faster culture conversion among those with glycemic control (aHR (0.95 CI): 2.2 (1.1,4)). Two poor quality studies reported the effect of insulin on TB treatment outcomes. Conclusion We identified few studies that were free of the risk of bias. There were limited data and inconsistent findings among available studies. We recommend robustly designed and analyzed studies including randomized controlled trials on the effect of glucose lowering treatment options on TB treatment outcomes.

Competency-based tool for evaluation of community-based training in undergraduate medical education in India – a Delphi approach

Introduction A community-based training (CBT) program, where teaching and training are carried out in the community outside of the teaching hospital, is a vital part of undergraduate medical education. Worldwide, there is a shift to competency-based training, and CBT is no exception. We attempted to develop a tool that uses a competency-based approach for assessment of CBT. Methods Based on a review on competencies, we prepared a preliminary list of major domains with items under each domain. We used the Delphi technique to arrive at a consensus on this assessment tool. The Delphi panel consisted of eight purposively selected experts from the field of community medicine. The panel rated each item for its relevance, sensitivity, specificity, and understandability on a scale of 0–4. Median ratings were calculated at the end of each round and shared with the panel. Consensus was predefined as when 70% of the experts gave a rating of 3 or above for an item under relevance, sensitivity, and specificity. If an item failed to achieve consensus after being rated in 2 consecutive rounds, it was excluded. Anonymity of responses was maintained. Results The panel arrived at a consensus at the end of 3 rounds. The final version of the self-assessment tool consisted of 7 domains and 74 items. The domains (number of items) were Public health – epidemiology and research methodology (13), Public health – biostatistics (6), Public health administration at primary health center level (17), Family medicine (24), Cultural competencies (3), Community development and advocacy (2), and Generic competence (9). Each item was given a maximum score of 5 and minimum score of 1. Conclusion This is the first study worldwide to develop a tool for competency-based evaluation of CBT in undergraduate medical education. The competencies identified in the 74-item questionnaire may provide the base for development of authentic curricula for CBT.

Pathway to care of epilepsy patients: Exploratory study from an urban slum in Northern India.

Introduction: Epilepsy is a chronic neurological disorder with major psychosocial correlates. Most epilepsy patients in developing countries are untreated or inadequately treated. It is essential to understand the pathway, to care taken by epilepsy patients in a community, to be able to target appropriate services to them. Materials and Methods: A community based study was conducted on all epilepsy patients in an urban slum in Northern India to study their pathways to care. A list of persons suffering from epilepsy was generated by house to house visits, snowballing, and key informant contacts. In-depth interview and Medical Record Review were used to document their pathway to care. Results: Thirteen of the twenty two patients had contacted a health-care provider for their first episode. The most common first link of care for the patients was secondary level Government hospitals. The next common was private practitioners, followed by Tertiary Care Hospitals, and registered medical practitioners. Eleven out of twenty two patients had to contact a Tertiary Level Center for seeking care. The number of health-care facilities consulted before arriving at their latest point of care ranged from 0 to 5. Traditional or faith healers were consulted at some point of time for cure. Conclusion: There is a need to focus on strengthening and capacity building of the primary care settings for managing epilepsy to enable their better utilization. This shall prevent unnecessary referrals and hence the load on the already burdened higher facilities.

Socio-demographic factors affecting the choice of place of childbirth among migrant and native women – A case control study from Chandigarh, India

OBJECTIVE India is one of the countries with high maternal mortality ratio. Home deliveries persist despite various initiatives, including cash incentives, to promote hospital birth. This study aims to compare the profile of women who deliver at home and those who deliver at institutions with a special focus on migration status. METHODS A list of all women who delivered between January to December 2012 was obtained from the antenatal register of a polyclinic in Chandigarh, India. An unmatched case control study design was used to compare the profile of women who delivered at home and women who delivered in an institution. RESULTS Of 219 women studied, 57 (26%) had delivered at home. Our study identified being a migrant, having lower family income, living in slums, illiteracy of mother, early age at marriage, higher parity and no previous childbirth in an institution as factors favoring home delivery. Ninety three percent of home deliveries were among women who had migrated into Chandigarh from other states. The significant association between migration status and home delivery (Odds ratio (OR) = 3.262, p = 0.026) ceased to exist after adjusting for education (OR = 1.699, p = 0.367) and income (OR = 2.277, p = 0.152). CONCLUSION AND CLINICAL IMPLICATION Most home deliveries had occurred among migrant women. Health-related choices of the migrants apparently reflect the influence of other social determinants of health like education and income. Mainstreaming of the health efforts addressing the complex web of social determinants intertwined with the process of migration is the need of the hour.

Catastrophic costs of tuberculosis care: a mixed methods study from Puducherry, India

ABSTRACT Background: The average expenditure incurred by patients in low- and middle-income countries towards diagnosis and treatment of TB ranges from

Development and psychometric testing of an abridged version of Dundee Ready Educational Environment Measure (DREEM)

55 to