Vijaya Srinivas

Increasing Antenatal Care and HIV Testing among Rural Pregnant Women with Conditional Cash Transfers to Self-Help Groups: An Evaluation Study in Rural Mysore, India

Background. We describe a one-year evaluation study comparing SCIL intervention of mobile provision of integrated ANC/ HIV testing with an enhanced (SCIL+) intervention of community mobilization strategy providing conditional cash transfers (CCT) to womens SHG for identifying and accompanying pregnant women to mobile clinics. Methods. Twenty pairs of villages matched on population, socioeconomic status, access to medical facilities, and distance from Mysore city were divided between SCIL and SCIL+ interventions. The primary study outcome was the proportion of total pregnancies in these villages who received ANC and HIV testing. Results. Between April 2011 and March 2012, 552 pregnant women participated in SCIL or SCIL+ interventions. Among women who were pregnant at the time of intervention delivery, 181 of 418 (43.3%) women pregnant at the time of intervention delivery received ANC in the SCIL arm, while 371 of 512 (72.5%) received ANC in the SCIL+ arm (P < 0.001); 175 (97%) in the SCIL and 366 (98.6%) in the SCIL+ arm consented to HIV testing (P < 0.001). HIV prevalence of 0.6% was detected among SCIL clinic, and 0.9% among attending SCIL+ clinic attendees. Conclusion. Provision of CCT to womens microeconomic SHG appears to significantly increase uptake of ANC/HIV testing services in rural Mysore villages.

Performance of the OSOM Trichomonas Rapid Test for diagnosis of Trichomonas vaginalis infection among women in Mysore, India

UNLABELLED Background Trichomonas vaginalis is the worlds most common treatable sexually transmissible infection. Currently, wet mount microscopy and syndromic management based on vaginal discharge are the most widely used methods for diagnosing and treating trichomoniasis in resource-constrained settings. Wet mount microscopy requires equipment and trained technicians, who are in short supply. We examined the diagnostic accuracy of the OSOM Trichomonas Rapid Test for detecting T. vaginalis vaginal infection among women in Mysore, India. METHODS During July 2009-August 2010, 450 sexually active women over 18 years seeking care at an urban reproductive health clinic were enrolled in the study. Clinician-collected vaginal swabs were evaluated for trichomonads using wet mount microscopy, InPouch culture and the OSOM test. RESULTS Of the 418 samples included in the analyses, culture detected 68 (16.3%) positive samples, wet mount microscopy detected 56 of the culture-positive samples and four false positive samples. The OSOM test detected 60 of the culture-positive samples plus two false positive cases. Using the composite reference standard (CRS), defined as wet mount- or culture-positive, the sensitivities of wet mount, the OSOM test and culture were 83.3%, 86.1% and 94.4%, respectively. The positive and negative predictive values of the OSOM test were 100% and 97.1% respectively. The Cohens kappa agreement between the OSOM test and the CRS was excellent (κ=0.94). CONCLUSION The OSOM test has high sensitivity, excellent specificity, and excellent positive and negative predictive value compared to a CRS. This simple test can improve screening and diagnosis of T. vaginalis infection in resource-constrained settings where microscopy and culture are unavailable.

Comparison of Culture-dependent and Culture-Independent Molecular Methods for Characterisation of Vaginal Microflora.

Purpose. To date, molecular methods that circumvent the limitations of traditional culture methods have not been used to describe the vaginal microflora in India. Here, we compared culture and culture‐independent molecular methods in characterizing the vaginal microbiota in Indian women. Methodology. Culture methods involved traditional cultivation on Rogosa and sheep blood agar, whereas culture‐independent methods bypassed a culturing step by performing broadrange 16S rDNA PCR on DNA isolated directly from vaginal swabs. Results. A total of 13 women were included in the study, of which five were characterized as healthy, two were bacterial vaginosis intermediate and six were bacterial vaginosis positive according to Nugent scoring. Lactobacillus jensenii was detected most frequently when using culture methods. On the other hand, Lactobacillus iners, which was not detected by culture methods, was the most common Lactobacillus sp. detected using cultivation‐independent methods. Conclusion. We found little overlap between the species found using cultivation‐dependent and cultivation‐independent methods. Rather, culture‐dependent and culture‐independent methods were found to be complementary in describing the vaginal microflora among South Indian women. Culture‐independent methods were found to be superior in detecting clinically relevant vaginal flora.To date, molecular methods that circumvent the limitations of traditional culture methods have not been used to describe the vaginal microflora in India. Here, we compared culture and culture-independent molecular methods in characterising the vaginal microbiota in Indian women. Culture methods involved traditional cultivation on Rogosa and sheep-blood agar, whereas culture-independent methods bypassed a culturing step by performing broad-range 16S rDNA PCR on DNA isolated directly from vaginal swabs. A total of 13 women were included in the study, of which five were characterised as healthy, two were BV-intermediate and six were BV-positive according to Nugent scoring. Lactobacillus jensenii was detected most frequently when using culture methods. On the other hand, Lactobacillus iners, which was not detected by culture methods, was the most common lactobacillus species detected using cultivation-independent methods. We found little overlap between the species found using cultivation-dependent and cultivation-independent methods. Culture-independent methods were found to be superior in detecting clinically relevant vaginal flora.

Birth preparedness and place of birth in rural Mysore, India: A prospective cohort study.

BACKGROUND India accounts for almost a third of the global deaths among newborns on their first day of birth. In spite of making significant progress in increasing institutional births, large numbers of rural Indian women are still electing to give birth at home. The aim of this study was to identify factors associated with place of birth among women who had recently given birth in rural Mysore, India. METHODS Between January 2009 and 2011, 1675 rural pregnant women enrolled in a prospective cohort study in Mysore District completed interviewer-administered questionnaires on maternity care services. Ethical approval of the original study was obtained from the Institutional Review Boards of Vikram Hospital and Florida International University. Logistic regression analyses were conducted to identify factors associated with place of birth among the 1654 (99%) women that were successfully followed up after childbirth. FINDINGS The median age of the women was 20 years; the majority were educated (87%), low-income (52%), and multiparous (56%). The prevalence of home births was low (4%). Half of the women giving birth at home did not adequately plan for transportation (55%), finances (48%), or birthing with a skilled provider (55%). Multiparous women had greater odds of giving birth at home compared to public (adjusted odds ratio [AOR]=7.83, p<0.001) and private institutions (AOR=7.05, p<0.001). Women attending ≥4 antenatal consultations had greater odds of giving birth at public (AOR=2.53, p=0.036) and private institutions (AOR=3.58, p=0.010). Those with higher scores of birth preparedness also had greater odds of giving birth at public (AOR=2.53, p<0.001) and private institutions (AOR=3.00, p<0.001). CONCLUSIONS AND IMPLICATIONS As a means to reduce newborn mortality, maternal health interventions in India and similar populations should focus on increasing birth preparedness and institutional births among rural women, particularly among those from lower socio-economic status.

Implementing community-based cervical cancer screening programs using visual inspection with acetic acid in India: A systematic review

The objective of this review was to systematically appraise the existing published literature about community-based cervical cancer screening programs that have used visual inspection methods using acetic acid (VIA) in India. All peer reviewed journal articles till December 2015 were searched per PRISMA guidelines. Articles reporting results from cervical cancer screening programs in community-based settings, conducted in India, and using VIA were included in this review. The search resulted in 20 articles to be included in the review with a total of 313,553 women at 12 unique urban and rural sites across India. Seventeen (85%) studies were cross-sectional and three studies were randomized controlled trials; most studies compared accuracy of VIA with other screening tests such as visual inspection using Lugols Iodine (VILI), HPV DNA, and cytology. Of studies that reported test accuracy for CIN Grade 2+, the VIA sensitivity values ranged from 16.6-82.6% and specificity ranged from 82.1-96.8%. Women between age groups of 30-59 years were recruited using motivational one-on-one counseling and local support staff. All studies conducted diagnostic follow-up using colposcopy and guided biopsies, when necessary. Three major themes were identified that facilitated implementation of screening programs in a community-based setting: standardized training that maintained competency of test providers; collaborations with community-based organizations that used health education for recruitment of participants; and employing the screen-and-treat method to reduce loss to follow-up. Summarized evidence presented in this review could substantially influence future implementation and sustainment of cervical cancer screening programs at a national level.

Development and characterization of a snapshot Mueller matrix polarimeter for the determination of cervical cancer risk in the low resource setting

Mueller Matrix polarimetry can provide useful information about the function and structure of the extracellular matrix. Mueller Matrix systems are sophisticated and costly optical tools that have been used primarily in the laboratory or in hospital settings. Here we introduce a low-cost snapshot Mueller Matrix polarimeter that that does not require external power, has no moving parts, and can acquire a full Mueller Matrix in less than 50 milliseconds. We utilized this technology in the study of cervical cancer in Mysore India, yet the system could be translated in multiple diagnostic applications.

Determination of cervical cancer risk with a snapshot Mueller matrix polarimeter in Mysore India (Conference Presentation)

Cervical cancer is the fourth most common cancer in women worldwide, with an estimated half a million new cases and 260,000 deaths each year. Developing countries bear about 84% of the global burden of the disease and 80% of the mortality due to a lack of effective screening programs. Cytology-based screening used in industrial countries is both expensive and difficult to implement in lower income countries with poor healthcare infrastructure and a shortage of pathologists. Low-cost optical technologies have been introduced in the low resource setting but to this date they are either hard to use single point measurements or require expert pathologist for image interpretation. Mueller Matrix imaging (MMI) is a novel imaging modality that uses polarized light to highlight subtle changes in cervical collagen structure typical of early stage cervical cancer. Recent ex-vivo work has shown that MMI is capable of up to 83% sensitivity and specificity in separating Cervical Intraepithelial Neoplasia stages. Unfortunately, the methodology requires a costly clinical colposcope with high encumbrance and low portability. We have developed a low cost portable Mueller Matrix imaging colposcope based on Savart platesthat can be deployed in a low resource setting and used by lay personnel. The device was used in the evaluation of cervical cancer risk in a pilot study of twenty-two volunteers in Mysore, India. The Papanicolaou test was used as a gold standard to in the validation of the polarimetric findings. Acceptability of the device by the patients was also ascertained. The development of a low cost and easy to use imaging system for the diagnosis of cervical cancer could be life changing for many women with poor or no access to specialized health care worldwide.

Financial decision making power is associated with moderate to severe anemia: A prospective cohort study among pregnant women in rural South India

OBJECTIVE According to the World Health Organization, about half of all pregnant women in India suffer from some form of anemia. While poor nutrition is the most common cause, social factors, such as gender and religion, also impact anemia status. This study investigates the relationship between anemia and socioeconomic and health-related factors among pregnant women in Mysore, India. DESIGN Prospective cohort study conducted between January 2009 and 2012 SETTING: 144 rural villages ten or more kilometers outside of Mysore City received integrated antenatal care and HIV testing services provided by mobile medical clinic in their communities. PARTICIPANTS 1675 pregnant women from the villages were screened. All women and their infants were then followed up for up to a year after childbirth. METHODS women who provided informed consent underwent an interviewer-administered questionnaire, physical examination by a doctor, and antenatal laboratory investigations including blood test for anemia. Women were followed through pregnancy and 12 months after childbirth to assess mother-infant health outcomes. Anemia was categorised as normal, mild, moderate, and severe, with moderate/severe anemia defined as a hemoglobin concentration of less than 100 g/l. MEASUREMENTS AND FINDINGS two out of three pregnant women were anemic at baseline (1107/1654; 66.9%). Of those women, 32.7% (362) had mild anemia, 64.0% (708) had moderate anemia, and 3.3% (37) had severe anemia. Anemia was associated with lower education among spouses (p = 0.021) and lower household income (p = 0.022). Women living in a household where others had control over household decision-making had lower odds of moderate/severe anemia (Adjusted Odds Ratio: 0.602; 95% Confidence Interval: 0.37-0.97) as compared to women who shared decision-making power with others in the household. CONCLUSION Interventions to reduce anemia should focus on education among men and other household decision makers on the importance of nutrition during pregnancy in India. IMPLICATIONS FOR PRACTICE To our knowledge, this research is one of the first to examine how control of household resources is related to risk for anemia among pregnant women in India. Our data suggests that interventions aimed at reducing anemia may need to address economic factors beyond nutrition and iron status to reduce the burden of anemia among women in developing countries.

Human Papillomavirus Vaccine Acceptability among Parents of Adolescent Girls in a Rural Area, Mysore, India

STUDY OBJECTIVE The purpose of this study was to examine factors predicting human papillomavirus (HPV) vaccine acceptability among parents of adolescent girls in a rural area in Mysore district, India. DESIGN Cross-sectional. SETTING Mysore, India. PARTICIPANTS Parents of school-going adolescent girls. INTERVENTIONS Parents completed a validated self-administered questionnaire. MAIN OUTCOME MEASURES Parental willingness to vaccinate their daughters with HPV vaccine. RESULTS Of the 831 parents who participated in this study, 664 (79.9%) were willing to vaccinate their daughter with HPV vaccine sometime soon if they were invited to receive it. Higher odds of parental willingness to vaccinate their daughters with HPV vaccine was observed among those who believed that HPV vaccine is safe (adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.01-4.45); their daughter might become sexually active (aOR, 1.84; 95% CI, 1.08-3.13); they have support of other family members to vaccinate their daughter (aOR, 2.86; 95% CI, 1.47-5.57); and that HPV infection causes severe health problems (aOR, 1.64; 95% CI, 1.04-2.57). In contrast, parents who believed that there is low risk that their daughter will get cervical cancer (aOR, 0.52; 95% CI, 0.29-0.95); that the family will disapprove of getting their daughter vaccinated (aOR, 0.45; 95% CI, 0.22-0.76); that the injection might cause pain (aOR, 0.53; 95% CI, 0.31-0.89), and were older-age parents (aOR, 0.96; 95% CI, 0.93-0.99) had lower odds of willingness to vaccinate daughters with HPV vaccine. CONCLUSION Acceptance of HPV vaccination for daughters was high among rural parents in Mysore, India. However, health education to reduce the belief that injection is painful and that daughters are at low risk to get cervical cancer is important to further improve parental HPV vaccine acceptability in Mysore. Public health education should target older-aged parents and extended family members.

Determinants of attitudes and beliefs toward human papillomavirus infection, cervical cancer and human papillomavirus vaccine among parents of adolescent girls in Mysore, India

This study examined the determinants of attitudes and beliefs about human papillomavirus (HPV) infection, cervical cancer and HPV vaccine among parents of adolescent girls in Mysore, India.