Vol 5, Issue 2, Apr-Jun, 2015

With the Indian patient becoming more empowered with regards to his disease and its treatment options, many Indian physicians still depend only on disease-related outcome measures to take health-care related decisions, and give minimal importance to patient-centered outcomes pertaining to the effect of the healthcare interventions on the patient’s well-being. Thus, objective lab values and physician intuition are given more importance than the subjective feeling of well-being that the patient is experiencing following the introduction of the intervention. This review presents a concept of integrating patient-centered and patient-reported data with the existing disease-centered and doctor-reported data for making healthcare-related decisions. This concept, termed patient-centered outcomes research, has already become popular in the Western World. Key words: Comparative eff ectiveness research, digital patient, patient-centered outcomes, patient empowerment, patient-reported outcomes

The dream of universal health care demands a much larger and wider approach, engaging not just the public but also the private sector. This paper has attempted mapping the present public-private partnership scenario in India using the WHO health system functions framework, giving an insight into the nature and extent of challenge of the present dominant model. A systematic review methodology was adopted to identify published literature on private-public partnership in India. From an initial pool of 785 articles were identifi ed. Finally a total of 29 published articles meeting the inclusion criteria were included. The descriptive framework of Health system functions by WHO (2000), were used to analyze the data. All papers which were considered for the study were segregated based on the 4 prime health system functions: Financing; Management of non-fi nancial inputs; Health service delivery and Oversight. The literature review reveals that more than half of the papers (51.72%) selected for the study were focused on health service delivery functions and quite thin literature were available for other 3 functions, which includes fi nancing, management of non-fi nancial inputs and oversight functions as per WHO. This fi nding raise an important question if the genesis of most of the public-private partnerships is out of the inability of the public sector in reaching out to a particular target group by virtue of its geographical position or diffi culty in working with high risk groups. Considering the limitations of the present model of engagement of private and public sectors, it demands for an alternative model of engagement where the mutual strength that exists with each one of the partners, could be harnessed and complemented. An alternate model is to engage in tri-partite partnership (TPP) between the government, non-government and the corporates. Key words: Health system functions, partnership, public-private partnership, tripartite- partnership

Objectives: To study the factors impacting on the tobacco use patterns and tobacco related behavior among lower middle and lower classes in a resettlement colony in Delhi. Materials and Methods: The study was conducted in the year 2011, between the months of March and October. It was done as a community based, cross sectional, house to house survey in a resettlement colony in South Delhi, involving interviews with present tobacco users as per a structured interview guide wherein majority of the questions were closed ended and a few open ended questions. Results: Study enrolled 1698 subjects in all with males constituting 90.8% of the sample while women constituted 8.7%. Median age of the study subjects was 37 years while the mean age was 40 yrs. 87 percent of the respondents were educated to less than or equal to higher secondary level. Some of the other salient fi ndings of the study are as under. Overall, both smoked and smokeless forms of tobacco were found to be almost equally used in the community. While 14% of the males consumed both the smoked and non-smoked forms of tobacco, similar percentage among women was only 1%. Age seemed to be an important determinant of the form of tobacco used. After controlling for literacy levels, it was found that variation in the consumption of different forms of smoked tobacco was statistically signifi cant (P = .001) across different age categories. While cigarette smoking was commoner among the younger age groups, beedis were more popular among the older respondents. However, smokeless tobacco was the most commonly used form of tobacco among the youth. Age and income levels came out as two important determinants of the intensity of smoking. While there was a statistically signifi cant increase in the intensity of smoking with increasing age (P = .001); there was statistically signifi cant decline in the intensity of smoking (P = .001) with rise in income levels. However, there was no statistically signifi cant relationship between intensity of smoking and income suffi ciency or stability, or indebtedness status. There was a statistically signifi cant decline in tobacco expenditure with rise in income levels and decline in tobacco consumption among the friend circle. Peer pressure and easy availability were among the two commonest reasons for people to get hooked on the tobacco use. After meals, while resting and when in a happy mood were the three commonest occasions in that order, when people indulged in tobacco usage. Implications of these fi ndings have been discussed in detail. Key words: Intensity of smoking, literacy status, smoked, smokeless, tobacco expenditure

Introduction: Menopause is said to be universal reproductive phenomenon. Menopause although not a disease is associated with annoying physiological changes and varied symptoms such as hot fl ushes, night sweats, urinary and genital changes, dyspareunia, insomnia and many psychological dysfunctions such as anxiety, depression, lack of concentration and decreased self-esteem. Every woman’s experience of the menopause is unique; she may experience all of the symptoms or none of them. Some fi nd the transition barely noticeable while others fi nd it life altering. Materials and Methods: A cross-sectional study was conducted among peri and postmenopausal women aged 40-60 years residing at Government colony, Bandra, Mumbai, Maharashtra for a period of 1-year. A predesigned and pretested questionnaire was used for collecting data. A booklet on “care during menopause” was used for giving health education. Results: In this study, mean age at natural menopause was 45.32 years (standard deviation ±2.79). Our study participants reported mostly muscular and joint pain (44.86%), urological symptoms (23.43%), vasomotor symptoms (21.14%), vulvovaginal symptoms (19.43%), psychological symptoms (15.14%), weight gain (14.86%), psychosexual symptoms (11.43%) and hirsutism (1.43%). Conclusions: There is a necessity of a multidisciplinary approach to the problems of menopause with more stress on promotive and preventive interventions. There should be provision of relevant health services, health education and promotional activities to cope up with the health needs of women in their postmenopausal years. Key words: Health problems, perimenopausal women, postmenopausal women

Background: Secondary school students are exposed to risky sexual behaviors that put them at certain risk of negative consequences. The aim of this study was to investigate the sociodemographic factors as predictors of sexual behavior of secondary school students in Lagos State, Nigeria. Materials and Methods: A survey design was used for the study. The data were collected using self-developed structured questionnaire called youth sexual behavior questionnaire, the co-variates collected in the questionnaire were: Gender, age and sociological factors. The instrument had test-retest reliability co-effi cient of 0.78 while purposive sampling technique was used to select the schools and respondents. Totally, 2720 students were randomly selected for the study and inferential statistics of multiple regression, mean, t-test and ANOVA were used to analyze the data. Results: Results indicated that all the three co-variates used in the study were signifi cant. Which shows a signifi cant value for gender, age and sociological factors respectively (t = 6.753, P < 0.05), F(3, 2350) (79.930, P < 0.05) and F(4, 2394) (260.020 P < 0.05). Majority of the students were of the opinion that they engaged in premarital sexual activities despite its attendant consequences. Conclusion: Gender, age and sociological factors could infl uence the sexual behavior of secondary school students in Lagos State signifi cantly; it was also observed that most of these factors negatively infl uence youth’s sexual activities. Key words: Secondary school students, sexual behavior, sociodemographic

Introduction: Private sector is the largest provider of health care services in India. But it is expensive. Self-driven corporate social responsibility (CSR) providing free or subsidised services will be useful to the elderly. There are no published data reporting the pattern or types of health care services provided to elderly by the private health care sector of India through CSR initiative. So this study was undertaken. Objectives: To know the pattern (Subsidised/free) and type (Medical, Surgical etc.,) of Health care services received by the elderly people as a part of CSR. Materials and Methods: A questionnaire based cross-sectional study conducted among all private health care providers of Mangalore city. List of all private health care providers which included various types of hospitals (corporate hospitals, multispecialty hospitals etc...) were obtained from the local chapter of Indian Medical Association. The data was collected form hospitals fulfi lling the study criteria. The data was analysed using SPSS software for windows, version 16.0. Results are presented as frequencies and proportions in appropriate tables. Results: Totally 24 hospitals had participated in this study. Most (n = 16, 66.7%) reported providing some free or subsidised services. Among them only 7 (29.2%) were providing free services like: Health check-up camps, subsidised medical and surgical treatment. However most of them did not respond to the “criteria for selecting of the elderly for such free services.” Conclusion: Most of the private hospitals in Mangalore do not provide free or subsidised health care services to the elderly through a self-driven CSR initiative. Key words: Corporate social responsibility, elderly, health care

Objective: To analyze the rationality of antimicrobial (AM) and respiratory (RP) fi xed dose combinations (FDCs) available in Indian market. Materials and Methods: Antimicrobial and RP FDCs enlisted in Indian Drug Review 2010 and 2013 respectively were analyzed by a pretested validated 8 point criteria tool. Each FDC was assessed for number of active pharmacological ingredients, approval by regulatory authority, listing in World Health Organization (WHO) essential medicine list (EML) or National List of Essential Medicine. While effi cacy, safety, pharmacokinetic and pharmacodynamic interactions and advantages of each FDC were analyzed by evidence based literature search. Each criterion was scored one for positive and minus one for negative or unfavorable observation. The total score for the tool was 12 and score ≥7 was considered rational. Results: Of 209 FDCs, 108 were AMs and 101 were RPs. The mean rationality score was 5.41 ± 1.63 (95% CI, 2.15-8.67). Majority of FDCs were irrational (174) while 35 were rational, and only 12 of these were listed in WHO EML 2013. Out of 108 AM FDCs, 21 (19%) were rational while 87 (81%) were irrational. Out of 101 RP FDCs, 14 (14%) were rational while 87 (86%) were irrational and 24 (24%) with unfavorable pharmacodynamic interactions. Majority of the rational AM FDCs were antiretroviral (6) agents while RP FDCs were indicated for chronic obstructive pulmonary diseases. While majority of irrational FDCs were AM plus steroids, β2 agonists plus antihistaminics/expectorants/anticholinergics/mast cell stabilizers/leukotriene receptor antagonists. Conclusion: Rationality assessment of AM and RP FDCs reveals that a substantial number of these FDCs in Indian market are irrational. This calls for a close scrutiny of marketed FDCs and educating prescribers to use them with great care and caution. This also indicates a serious review of the regulatory framework for drug manufacturing and marketing. Key words: Antimicrobial, fi xed dose combination, rationality, respiratory

Background: Janani Suraksha Yojana (JSY) is a maternal protection scheme that promotes institutional delivery by providing cash incentive to the mothers who deliver their babies in a health facility. With the purpose of improving maternal and neo-natal mortality and morbidity indicators, the investment and emphasis on JSY is continued. Utilization pattern and perception in the community regarding a particular health program is important to study for assessing the success or failure of the program. Objectives: To assess the utilization of JSY and its perception among mothers and health care providers. Materials and Methods: A descriptive, crosssectional, community based study was Conducted at Agra district of Uttar Pradesh, among 246 married women of reproductive age group who had childbirth after JSY implementation for assessing their utilization pattern and perception regarding JSY services. Perception regarding the strengths and weaknesses of JSY among the health care providers was also studied. Results: Nearly half (53.25%) of the mothers studied had an institutional delivery and were eligible for the JSY benefi ts. Postnatal home visits by Accredited Social Health Activists were done in 48% of home and 100% of institutional deliveries. Nearly half (48.09%) of the benefi ciaries were benefi ted by free transport facility under JSY. Although all of the health care providers perceived JSY as benefi cial for improving maternal health, 44% of them had the notion that cash incentives under JSY can have a negative effect on family planning practices. Conclusion: The utilization rate of the JSY services was found to be low in certain aspects like institutional deliveries, transport facility etc., and there is scope for improvement. Key words: Institutional delivery, Janani Suraksha Yojana, perception, utilization

Background and Objectives: Palmar creases may become as pale as the surrounding skin in severe anemia. However, its sensitivity for assessing severe anemia is questionable, especially in Indian perspective. The study was conducted to evaluate the value of palmar creases in detecting severe anemia. Materials and Methods: Patients with laboratory confi rmed anemia were assessed for pallor of palmar creases without information of patientfs hemoglobin (Hb) value to the observer. Sensitivity and specifi city of palmar creases pallor were assessed for severe anemia. Role of clinical signs such as severe pallor of conjunctiva, tongue and nail-beds and pulmonary ejection systolic murmur were also assessed for predicting severe anemia. Results: Of 200 patients, 50 had severe anemia (Hb <7 g/dL). Only six patients with Hb <7 g/dL were found to have creases looking similar pale to surrounding skin. Average Hb level of them was 4.05 } 0.82 g/dL. No patients with Hb .7 g/dL had pale palmar creases. In severely anemic patients, its sensitivity is only 12%, but specifi city is 100%, and positive likelihood ratio is >1200. Severe pallor of conjunctiva, tongue and nail-beds and pulmonary ejection systolic murmur were more sensitive, but specifi city of them was less for severe anemia. Conclusions: Color of palmar creases is a poorly sensitive indicator of the severe anemia especially in Indians due to the pigmentation of creases. Hence, the absence of palmar crease pallor is not likely to be of use in ruling out severe anemia. Key words: Conjunctiva, hemoglobin, nail-bed, pallor, tongue

Background: Tobacco use in different forms has become a growing public health problem. It contributes to increased non communicable disease burden. Females tend to use smokeless tobacco in various forms. Material and methods: It was a cross sectional study conducted in the fi eld practice area of Rural Health Training Centre of Dr. D Y Patil Medical College, Pimpri, Pune. Pretested, semistructured proforma was used to collect the information regarding the age of initiation and reasons for its use and other parameters of mishri use after taking informed consent from women >10 years of age . At the end of the study all the subjects were given active education in group setting. Results: Total 256 rural women were studied. 59.8% were <45 yrs, majority were Hindu, married and housewives. 50.4% belonged to joint families, 46.1% from nuclear families. Majority (55%) were from socioeconomic class II and III. 38% initiated its use from 11 to 20 yrs, 49% left it on teeth for a duration of less than 5 minutes, 38% of them used the amount as 1 tsf per day while another 37% used the amount as 1-2 tsf of mishri per day. 45.3% gave reasons for initiation of mishri as to clean teeth. Reasons for continuing use were noted as experienced a kick, gave energy, relieved tension, etc. Positive correlation was observed between quantity of mishri used at a single time and age as well as with duration of use (r = 0.258, P < 0.001 and r = 0.335, P < 0.001 respectively). Conclusion: There is a need to make the rural women aware about hazardous effects of use of mishri through health education sessions to wean them out of this addiction. Key words: Mishri, risk factors for noncommunicable diseases, tobacco

Background: Hepatitis B virus (HBV) infection is a global problem and >350 million HBV carriers in the world. Objectives: The aim was to assess awareness, practice of selected high risk health care workers (HCW) regarding risk for contracting hepatitis B and self-reported vaccination status. Materials and Methods: A cross-sectional study was conducted among 300 selected HCW of AGMC and GBP Hospital, TMC and Dr BRAM Teaching Hospital and Indira Gandhi Memorial Hospital, Agartala during Jan to March 2014. Results: About 72.1% respondents were females with overall mean age of 24.10 (standard deviation ±7.011). 67.5% females were within the age group of 18-23 years. Majority (70.4%) of the participants were nursing students and Hindu (92.5%) nuclear families (54.6%). Majority (69.3%) of them were aware that hepatitis B transmission was possible through unsafe sex, infected blood/body fluid, contaminated syringe, needle and scalpel, 19.6% knew through infected blood and body fl uids, 5.7% knew through contaminated syringe, needle and scalpel, 1.8% knew through unsafe sex. 59.3% had a history of contact with known hepatitis B case. 62.2% were vaccinated with three doses of hepatitis B vaccine. Majority of the participants had exposed to hepatitis B positive case while at work (P = 0.001). The exposed persons with known hepatitis B cases have consulted doctor, vaccinated and treated with medicines (P = 0.002); used needle destroyer (P = 0.012); vaccinated with 3 doses of hepatitis B vaccine (P = 0.001); and used sterile gloves while performing work (P = 0.000), especially while dealing with blood and body fluid. Conclusion: In spite of having good knowledge, the way they practice for prevention of hepatitis B infections were inadequate and need further improvement. Key words: Health care workers, hepatitis B, knowledge, practice, tertiary care hospitals

Introduction: The prevalence of obesity has increased internationally over the last decades, and it was in the 1990s the World Health Organization considered it as a global epidemic. The link between obesity and a series of diseases has been confi rmed, particularly cardiovascular diseases and diabetes. The main cause of obesity is unhealthy or unbalanced diet combined with the lack of exercise. Obesity is also associated with periodontal disease, tooth loss, overall poor oral and general health. Obesity can be measured by measuring the body mass index (BMI). Prpiæ et al. stated that persons with an increased BMI had slightly worse dental health, as represented by higher dental index (caries, periodontitis, periapical lesions, and missing teeth) regardless of their tooth brushing routines. Aim: To correlate the association between obesity and oral health in Indian population. Study Design:A total of 100 subjects were equally divided into two groups (50 study and 50 control group). The study group comprised of individuals with BMI 25-29.99 (overweight), BMI >30 (obese) and the control group comprises of individuals with BMI 18.5-24.99 (normal). Individuals with any systemic disease and any kind of deleterious habits were excluded from the study. Oral examination was performed on the subjects, which included plaque index (PI), gingival index, periodontal index, decayed missing fi lled teeth index and the overall oral health. A food frequency questionnaire validated with a monthly dietary record was conducted for each patient. Tooth brushing habits were also recorded. Statistical Analysis Used: Statistical analysis was performed by Chi-square test and student (unpaired) t-test. Results and Conclusion: There was a signifi cant correlation between the BMI and oral health of obese individuals. The oral hygiene of obese patients was poor when compared to normal individuals. Key words: Body mass index, decayed missing fi lled teeth, obesity, oral health, periodontitis

Background: Healthcare profession is known to be at high risk for work related musculoskeletal disorders (WMSDs). It is estimated that almost one-third of all cases of sick leave among healthcare workers are related to WMSDs. Many studies are conducted, which measured the variety of factors across a range of occupations at different levels of risk. However, relation of current exposure to the risk of developing WMSDs is indeed an area to be looked into. Hence, the current study evaluated current exposure and risk of developing WMSDs among different groups of healthcare professionals. Materials and Methods: This was a cross-sectional exposure-risk assessment study, conducted on 140 healthcare professionals, including dentists, laboratory technicians, nurses, physicians and physiotherapists of various clinical departments in a tertiary care hospital in Chennai, India from January to June 2013. Face-to-face interviews and observational analysis of various job tasks were employed. Different combinations of validated and standardized questionnaires were used for collecting different types of data. Results: The exposure and risk assessment on occurrence of WMSDs indicates that nurses are at the highest risk for developing WMSDs, followed by dentists and physiotherapists whereas laboratory technicians and physicians have the least. Among the participants who reported MSDs pain, more than half of the cases were related to work. Conclusion: Among all the healthcare professions, nurses were found to be the high risk group, whereas physicians were found to be the low risk group. We recommend that education, awareness, and training programs on prevention and coping strategies for MSDs be made mandatory for healthcare professionals. Key words: Exposure, healthcare professionals, risk, work related musculoskeletal disorders

Context: As doctors who are also teachers we must be aware of the various learning styles used by our students. Each style is unique in how a student takes in knowledge. Thus to maximize output, we need to facilitate their learning process as teachers. Aims: This study was undertaken to assess the predominant learning style of 2nd year medical students and to compare the learning modality used with the academic performance. Settings and Design: Cross-sectional study undertaken in a Government Medical college of Bangalore, Karnataka, India. Materials and Methods: A total of 210 second year medical undergraduates in a Government Medical College, Bangalore were asked to fi ll a pre tested and pre validated visual, auditory, read/ write, kinesthetic questionnaire, version 7.3 developed by Neil Fleming. The students were then scored to assess the predominant learning modality used. Statistical Analysis Used: Data were analyzed using SPSS version 20. Descriptive statistics, Chi-square test, Fisher’s test and unpaired (two sample) t-test were used to study the variables. Results: Majority of the students were multimodal (61%). Kinesthetic was the predominant modality used, both among unimodal (56.8%) and multimodal (31.8%) learners. There was no signifi cant difference in the learning modalities of male and female students. There was also no difference in academic performance of uni- and multi-modal learners. Conclusions: Current teaching styles do not support the student fraternity that is predominantly multimodal. Various workshops must be conducted to train teachers to adapt their teaching styles. Multiple methods must be used simultaneously deliver knowledge and information to the students to improve their acceptance. Key words: Learning styles, medical students, multimodal, unimodal, visual auditory read/write kinesthetic

A 35-year-old male painter presented with left sided pleuritic chest pain and exertional dyspnea. A chest radiograph revealed left pleural effusion with pleural thickening. This condition is suspected to be caused by chronic exposure to zinc dichromate and history of exposure was >13 years. Pleural effusion with pleural thickening can be both benign and malignant. Biopsy remains gold standard investigation for exclusion. Pleural fl uid cytology and pleural biopsy revealed lymphocytic pleural effusion with few macrophages in proteinaceous fl uid background and negative for malignant cells, which was suggestive of benign chronic infl ammatory reaction and exclude any malignant changes. Pleural fl uid drained and symptomatic treatment provided and patient counseled. Further follow-up needed to diagnosis early malignant changes. Key words: Occupational lung disease, pleural eff usion, pleural thickening, zinc dichromate chronic exposure

Urinary tract infection (UTI) is mostly caused by members of the Enterobacteriaceae family. Escherichia coli is the most common urinary pathogen of community-acquired infection accounting approximately 80% of infection. Whereas, in the hospital acquired UTI E. coli accounts approximately 50% and the rest by other member of Enterobacteriaceae, Enterococcus, Staphylococcus and nonfermenting Gram-negative bacilli.[1] We report an unusual organism from the urine of immunocompetent patient. A 58-year-old male patient reported in medicine outpatient department with history of burning micturition and dysuria since last 10 days. He had visited to a private hospital and was put on norfl oxacin and amoxiclavulanic acid for 7 days. However, there was no relief of symptoms. There was a history of retention of urine for which he was catheterized. Per rectal examination revealed benign prostate hypertrophy. Urine was sent for microscopic examination and culture. On microscopic examination of urine showed fi eld full of pus cells and on culture nonlactose fermenting colonies on cystine lactose electrolyte defi cient media after 24 h of incubation were seen. Isolate was identifi ed as Sphingomonas paucimobilis by standard biochemical tests and Vitek Systems, (bioMerieux). Antibiotic sensitivity was performed as per CLSI guidelines[2] and it was found sensitiveto cotrimoxazole and resistant to norfl oxacin, levofl oxacin, ampicillin/sulbactum, amikacin, ceftazidimeceftazidim/clavulinic acid, Piperacillin/ tazobactum, and imipenum. Other laboratory investigations revealed hemoglobin: 10.2 g/dl and total leukocyte count: 13,000/mm3 with 75% neutrophils, 25% lymphocytes. His random and fasting blood sugar levels were 120 mg/dl and 90 mg/dl, respectively.