Twinkle Agrawal

Rationale and design of the Primary pREvention strategies at the community level to Promote Adherence of treatments to pREvent cardiovascular diseases trial number (CTRI/2012/09/002981)

INTRODUCTION Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality in low-income countries including India. There is a need for effective, low-cost methods to prevent CVDs in rural India. One strategy is to identify and implement interventions at high-risk individuals using community health workers (CHWs). There is a paucity of CHW-based CVD intervention trials from low-income countries. METHODS We designed a multicenter, household-level, cluster-randomized trial with 1:1 allocation to intervention and control arms. The CHWs undertook a door-to-door survey and screened 5,699 households in 28 villages from 3 rural regions in India to identify at-risk households. The households were defined as those with ≥1 individual aged ≥35 years and at moderate or high risk for CVD based on the non-laboratory-based National Health and Nutrition Examination Survey score. All at-risk individuals were invited to attend a physician-led village clinic that provided a CVD risk reduction prescription and education about target risk factor levels for CVD control. All households in which at least 1 member at moderate to high risk for CVD had received a risk reduction prescription were eligible for randomization. Households randomized to the CHW-based intervention will receive 1 household visit by a CHW every 2 months, for 12 months. During these visits, CHWs will measure blood pressure, ascertain and reinforce adherence to prescribed therapies, and modify therapy to meet targets. Households randomized to the control arm do not receive CHW visits. At 12 months after randomization, we will evaluate 2 primary outcomes of systolic blood pressure and adherence to antihypertensive drugs and secondary outcomes of INTERHEART risk score, body mass index, and waist-to-hip ratios. At 18 to 24 months after randomization and 6 to 12 months after the last intervention, we will record these outcomes to evaluate sustainability of intervention. RESULTS Community health workers screened a total of 5,033 households that included 9,248 individuals and identified 2,571 households with 3,784 at-risk individuals. We randomized 2,438 households (1,219 to intervention and 1,219 to control groups). CONCLUSION Our large trial of CHWs in rural India will provide important information regarding a promising approach to primary prevention of CVDs.

Prevalence of Malnutrition and Relationship with Scholastic Performance among Primary and Secondary School Children in Two Select Private Schools in Bangalore Rural District (India).

Background: Malnutrition is a serious problem among children in developing countries. In India; a school meal program is in place to combat malnutrition, but only in government schools. This study is an attempt to assess the prevalence of malnutrition in primary and secondary school children in private schools and to also assess the relationship between malnutrition and academic performance. Materials and Methods: All 582 students from class 1-7 from two select schools in rural Bangalore, India were included in the study. Information on age of study subjects were collected from school records. Height and weight measurements were taken. BMI was calculated. Children were clinically examined for pallor. Data on height, weight and BMI was transformed into WHO 2007 Z scores and then was categorized as < -3 SD, -2 to -3 SD, > -2 SD, > 2 SD. Mathematics and English scores of the previous two class tests were taken, average scores were calculated. Statistical tests used were Chi square test, Odds ratio, Chi square for trend. Results: A total of 582 students participated in this study. Males were 54% (315) and females were 46% (267). One hundred and fifty-nine (27%) of the children had pallor, 81 (20%) had under nutrition, 38 (7%) had stunting, 197 (34%) had thinness and 5 (1%) were found to be obese. Positive relationship was found between weight for ageZscores and English as well as Maths; Height for age Z scores with English. Conclusion: Hence we conclude that the prevalence of malnutrition is high among children in private schools also; and the nutritional status of the children is strongly associated with their academic performance.

Reproductive tract infections among women in a peri-urban under privileged area in Bangalore, India: Knowledge, prevalence, and treatment seeking behavior

Introduction: Globally, reproductive tract infections (RTIs) are a major cause of acute and chronic illness with severe consequences. Women are at a greater risk than men and are less likely to seek treatment because of the associated stigma. Objectives: To assess the knowledge and estimate the prevalence of RTIs, and treatment seeking behavior regarding RTI. Materials and Methods: A community-based cross-sectional study was done in a peri-urban underprivileged area, in Bangalore where all ever-married women in the reproductive age group were interviewed using a pre-structured and pre-tested schedule by female medical doctors in the privacy of their homes. Results and Discussion: Of the 179 women who participated in the study, 47.5% were in the age group of 25 to 34 years with the mean age being 29.84 years (±7.92). The mean knowledge score was found to be 3.78 (±2.3) and the maximum score was found to be 10, which indicated poor knowledge regarding RTIs which was similar to other studies done elsewhere. The prevalence of RTI was found to be 26.8%, while the period prevalence of RTI for the last 1 year was 39.1%, and 60% of these women sought some form of treatment. Other studies have reported prevalence ranging from 21.9% to 92% in India. The age-specific prevalence was highest in the 15 to 19 years age group (30%), with most common symptom being white discharge per vagina (43.7%). Conclusions: Knowledge regarding RTI was poor while the prevalence of RTI was high (26.8%) and the treatment-seeking behavior was inadequate.

Adherence to prescribed medications for chronic illnesses among older adults in a rural community, Karnataka, India

To assess adherence to prescribed medications for chronic illnesses and to identify factors associated with it among rural older adults.

Challenges in conducting community- based trials of primary prevention of cardiovascular diseases in resource- constrained rural settings

Cardiovascular diseases account for almost half of all deaths from noncommunicable diseases, and almost 80% of these deaths occur in low- and middle-income countries such as India. The PrePAre (Primary pREvention strategies at the community level to Promote treatment Adherence to pREvent cardiovascular disease) trial was a primary prevention trial of community health workers aimed at improving adherence to prescribed pharmacological and nonpharmacological therapies in cardiovascular diseases. It was conducted at three geographically, culturally and linguistically diverse sites across India, comprising 28 villages and 5699 households. Planning and implementing large-scale community-based trials is filled with numerous challenges that must be tackled, while keeping in mind the local community dynamics. Some of the challenges are especially pronounced when the focus of the activities is on promoting health in communities where treating disease is considered a priority rather than maintaining health. This report examines the challenges that were encountered while performing the different phases of the trial, along with the solutions and strategies used to tackle those difficulties. We must strive to find feasible and cost-effective solutions to these challenges and thereby develop targeted strategies for primary prevention of cardiovascular diseases in resource-constrained rural settings.