Intersectional social-economic inequalities in breast cancer screening in India: analysis of the National Family Health Survey

Background
Breast cancer incidence rates are increasing in developing countries including India. With 1.3 million new cases of cancer been diagnosed annually, breast cancer is the most common women’s cancer in India. India’s National Family Health Survey (NFHS-4) data 2015–2016 shows that only 9.8% of women between the ages of 15 and 49 had ever undergone breast examination (BE). Further, access to screening and treatment is unequally distributed, with inequalities by socio-economic status. It is unclear, however, if socio-economic inequalities in breast examination are similar across population subgroups.

Methods
We compared BE coverage in population sub-groups categorised by place of residence, religion, caste/tribal groups, education levels, age, marital status, and employment status in their intersection with economic status in India. We analysed data for 699,686 women aged 15–49 using the NFHS-4 data set conducted during 2015–2016. Descriptive (mean, standard errors, and confidence intervals) of women undergoing BE disaggregated by dimensions of inequality (education, caste/tribal groups, religion, place of residence) and their intersections with wealth were computed with national weights using STATA 12. Chi-square tests were performed to assess the association between socio-demographic factors and breast screening. Additionally, the World Health Organisation’s Health Equity Assessment Toolkit Plus was used to compute summary measures of inequality: Slope index for inequality (SII) and Relative Concentration Indices (RCI) for each intersecting dimension.

Results
BE coverage was concentrated among wealthier groups regardless of other intersecting population subgroups. Wealth-related inequalities in BE coverage were most pronounced among Christians (SII; 20.6, 95% CI: 18.5–22.7), married (SII; 14.1, 95% CI: 13.8–14.4), employed (SII: 14.6, 95%CI: 13.9, 15.3), and rural women (SII; 10.8, 95% CI: 10.5–11.1). Overall, relative summary measures (RCI) were consistent with our absolute summary measures (SII).

Conclusions
Breast examination coverage in India is concentrated among wealthier populations across population groups defined by place of residence, religion, age, employment, and marital status. Apart from this national analysis, subnational analyses may also help identify strategies for programme rollout and ensure equity in women’s cancer screening.

Outcomes of Renal Trauma in Indian Urban Tertiary Healthcare Centres: A Multicentre Cohort Study

Background
Renal trauma is present in 0.5–5% of patients admitted for trauma. Advancements in radiologic imaging and minimal-invasive techniques have led to decreased need for surgical intervention. We used a large trauma cohort to characterise renal trauma patients, their management and outcomes.

Methods
We analysed “Towards Improved Trauma Care Outcomes in India” cohort from four urban tertiary public hospitals in India between 1st September 2013 and 31st December 2015. The data of patients with renal trauma were extracted using International Classification of Diseases 10 codes and analysed for demographic and clinical details.

Results
A total of 16,047 trauma patients were included in this cohort. Abdominal trauma comprised 1119 (7%) cases, of which 144 (13%) had renal trauma. Renal trauma was present in 1% of all the patients admitted for trauma. The mean age was 28 years (SD-14.7). A total of 119 (83%) patients were male. Majority (93%) were due to blunt injuries. Road traffic injuries were the most common mechanism (53%) followed by falls (29%). Most renal injuries (89%) were associated with other organ injuries. Seven of the 144 (5%) patients required nephrectomy. Three patients had grade V trauma; all underwent nephrectomy. The 30-day in-hospital mortality, in patients with renal trauma, was 17% (24/144).

Conclusion
Most renal trauma patients were managed nonoperatively. 89% of patients with renal trauma had concomitant injuries. The renal trauma profile from this large cohort may be generalisable to urban contexts in India and other low- and middle-income countries.

Training programme in gasless laparoscopy for rural surgeons of India (TARGET study) – Observational feasibility study

Background
Benefits of laparoscopic surgery are well recognised but uptake in rural settings of low- and middle-income countries is limited due to implementation barriers. Gasless laparoscopy has been proposed as an alternative but requires a trained rural surgical workforce to upscale. This study evaluates a feasibility of implementing a structured laparoscopic training programme for rural surgeons of North-East India.

Methods
A 3-day training programme was held at Kolkata Medical College in March 2019. Laparoscopic knowledge and Fundamentals of Laparoscopic Skills (FLS) were assessed pre and post simulation training using multiple choice questions and the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), respectively. Competency with an abdominal lift device was assessed using the Objective Structured Assessment of Technical Skills (OSATS) and live operating performance via the Global Operative Assessment of Laparoscopic Skills (GOALS) scores during live surgery. Costs of the training programme and qualitative feedback were evaluated.

Results
Seven rural surgeons participated. There was an improvement in knowledge acquisition (mean difference in MCQ score 5.57 (SD = 4.47)). The overall normalised mean MISTELS score for the FLS tasks improved from 386.02 (SD 110.52) pre-to 524.40 (SD 94.98) post-training (p = 0.09). Mean OSATS score was 22.4 out of 35 (SD 3.31) indicating competency with the abdominal lift device whilst a mean GOALS score of 16.42 out of 25 (SD 2.07) indicates proficiency in performing diagnostic laparoscopy using the gasless technique during live operating. Costs of the course were estimated at 354 USD for trainees and 461 USD for trainers.

Conclusion
Structured training programme in gasless laparoscopy improves overall knowledge and skills acquisition in laparoscopic surgery for rural surgeons of North-East India. It is feasible to deliver a training programme in gasless laparoscopy for rural surgeons. Larger studies are needed to assess the benefits for wider adoption in a similar context.

Counselling and pregnancy outcomes in women with congenital heart disease- current status and gap analysis from Madras Medical College Pregnancy And Cardiac disease (M-PAC) registry

Introduction
Congenital heart disease (CHD) is becoming an increasingly important cause of heart disease in pregnancy in low- and middle – income countries (LMICs). Preconception and contraception counselling based on risk stratification has the potential to reduce maternal complications. Data is lacking from LMICs on the availability and effectiveness of preconception counselling (PCC) in women with CHD (WWCHD).

Methods
Madras Medical College Pregnancy and Cardiac disease (M-PAC) Registry is a single center prospective observational registry conducted at a tertiary referral institution in South India from July 2016 to December 2019. Baseline features and feto-maternal outcomes were compared in WWCHD with and without PCC. Predictors of post-delivery contraception were identified.

Results
Of the 107 eligible pregnancies with data on counselling, only 49.5% had received PCC. Pregnancies involving women with corrected CHDs (62.3% vs 33.3%; P ​= ​0.006) and cyanotic CHD (20.8% vs 11.1%; P ​= ​0.042) were more likely to get PCC. High risk mWHO categories were non-significantly less likely to get PCC (32% vs 39%). Primary outcome of death or heart failure was non-significantly low in the PCC group (3.8% vs 7.4% P ​= ​0.4). Patients with high risk m WHO categories were less likely to get Tier I contraceptives post-delivery (46% vs 79.7% P ​= ​0.004).

Conclusion
Preconception and post conception counselling, which have the potential to improve outcome in WWCHD, are being underused in LMICs. Health care systems should ensure multidisciplinary pregnancy and heart team approach to offer timely lesion specific pre-conceptional counselling, shared decision making and appropriate peri-pregnancy care for WWCHD.

Evaluation and usability study of low-cost laparoscopic box trainer “Lap-Pack”: a 2-stage multicenter cohort study

Introduction:
Laparoscopic training is restricted in low resource settings due to limited access to specialist training equipment and financial constraints. This study aimed to evaluate simulation skills and usability of an original low-cost laparoscopic trainer, the “Lap-Pack,” developed at the University of Leeds, UK.

Methods:
Stage I evaluation was conducted in Kolkata (India) between March, 12 and 14, 2019. Laparoscopic simulation training was based on the 5 domains of fundamentals of laparoscopic surgery (FLS), which assessed skill acquisition across 7 rural surgeons from North-East India. The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) criteria was used to statistically analyze trainee performance between pretraining and posttraining sessions. Also, Lap-Pack was qualitatively compared with a commercial box trainer, Inovus Pyxus HD (IPHD). Stage II involved a multi-center usability study in 2 centers of India and the United Kingdom (2019). Seventy-eight participants performed 2 FLS tasks using Lap-Pack and provided scores on a 25-point questionnaire, including a preestablished Face-Validity Criteria and 4 evaluation categories—Usability, Camera, View, and, Material.

Results:
In stage I, the total posttraining MISTELS score for Lap-Pack was higher, that is 773.37 (SD: 183.67) than pretraining score, that is 351.2 (SD: 471.5). The posttraining scores showed laparoscopic skill acquisition with statistically significant (P<0.05) difference for precision cutting, intracorporeal and extracorporeal knot. In stage II, Lap-Pack scored highly in Face-Validity with a combined mean score of 4.81 [95% confidence interval (CI): 4.52–5.09, P<0.05] out of a possible 6. It scored highest (scale: 1=low to 7=high) in Usability 6.14 (95% CI: 6.05–6.22, P<0.05) and Camera 6.14 (95% CI: 6.01–6.27, P<0.05). The “Lightweight” (6.46, 95% CI: 6.32–6.60, P<0.05) and “Portability” (6.35, 95% CI: 6.18–6.51, P<0.05) features of Lap-Pack were appreciated.

Conclusion:
The Lap-Pack is a suitable low fidelity simulator for laparoscopic training in a low-resource setting.

Empowering The Rural Surgeons, The Way Forward For Meeting The Surgical Needs Of Rural Areas

Globally, 60% of the surgical procedures are carried out for 15% of the world population in developed countries. The Lancet commission on Global surgery estimates that a population of 100000 would ideally require 5000 surgical procedures every year. Although the national average is about 800 in most of the rural areas in India, in the North-eastern states it varies from 30 to 300. We look at the various models and options available for empowering the surgeons in the rural areas. Short Term Medical Missions have been used for a long time including those with structured programs. Pioneering long term medical missions are few and difficult to sustain. Empowering surgeons working in rural areas with modern surgical techniques is a sustainable solution with high impact. Empowering the rural surgeons with training in Gas Insufflation Less Laparoscopic Surgeries and Endoscopic Urology surgeries helped the surgical coverage in the target population of the 8 rural hospitals studied go up from 1287 per 100000 per year to 2880 the next year and 3739 the following year. It is a financially sustainable model that could be scaled up by funding travel of the trainers and equipment for the trainees.

Readiness to Provide Antenatal Corticosteroids for Threatened Preterm Birth in Public Health Facilities in Northern India

Introduction:
In 2014, the Government of India (GOI) released operational guidelines on the use of antenatal corticosteroids (ACS) in preterm labor. However, without ensuring the quality of childbirth and newborn care at facilities, the use of ACS in low- and middle-income countries is potentially harmful. This study assessed the readiness to provide ACS at primary and secondary care public health facilities in northern India.

Methods:
A cross-sectional study was conducted in 37 public health facilities in 2 districts of Haryana, India. Facility processes and program implementation for ACS delivery were assessed using pretested study tools developed from the World Health Organization (WHO) quality of care standards and WHO guidelines for threatened preterm birth.

Results:
Key gaps in public health facilities’ process of care to provide ACS for threatened preterm birth were identified, particularly concerning evidence-based practices, competent workforce, and actionable health information system. Emphasis on accurate gestational age estimation, quality of childbirth care, and quality of preterm care were inadequate. Shortage of trained staff was widespread, and a disconnect was found between knowledge and attitudes regarding ACS use. ACS administration was provided only at district or subdistrict hospitals, and these facilities did not uniformly record ACS-specific indicators. All levels lacked a comprehensive protocol and job aids for identifying and managing threatened preterm birth.

Conclusions:
ACS operational guidelines were not widely disseminated or uniformly implemented. Facilities require strengthened supervision and standardization of threatened preterm birth care. Facilities need greater readiness to meet required conditions for ACS use. Increasing uptake of a single intervention without supporting it with adequate quality of maternal and newborn care will jeopardize improvement in preterm birth outcomes. We recommend updating and expanding the existing GOI ACS operational guidelines to include specific actions for the safe and effective use of ACS in line with recent scientific evidence.

Severe impact of COVID-19 pandemic on non-COVID patient care and health delivery: An observational study from a large multispecialty hospital of India

OBJECTIVES:
The COVID-19 pandemic has severely impacted health-care delivery globally, especially for non-COVID diseases. These cases received suboptimal attention and care during the pandemic. In this observational cohort study, we have studied the impact of the COVID-19 pandemic on various aspects of medical and surgical practices.

MATERIAL AND METHODS:
This observational, cross-sectional cohort study was performed on the data of a 710 bedded, multispecialty, and tertiary care corporate hospital of the national capital of India. The data of the pandemic period (April 1, 2020–March 31, 2021) were divided into three main groups and were then compared with the patient data of the preceding non-pandemic year (April 1, 2019–March 31, 2020) of more than six hundred thousand cases.

RESULTS:
From the data of 677,237 cases in these 2 years, we found a significant effect of COVID-19 pandemic on most spheres of clinical practice (P < 0.05), including outpatient attendance and surgical work. The specialties providing critical and emergency care were less affected. Although the total hospital admissions reduced by 34.07%, these were not statistically significant (P = 0.506), as the number of COVID-19 admissions took place during this time and compensated for the drop. CONCLUSION: The COVID-19 pandemic has significantly impacted health-care delivery to non-COVID cases across all the major medical and surgical specialties. Still, major urgent surgical and interventional work for cases was undertaken with due precautions, without waiting for the ongoing pandemic to end, as the delay in their treatment could have been catastrophic.

Empanelment of health care facilities under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) in India

Introduction
India’s Pradhan Mantri Jan Arogya Yojana (PM-JAY) is the world’s largest health assurance scheme providing health cover of 500,000 INR (about USD 6,800) per family per year. It provides financial support for secondary and tertiary care hospitalization expenses to about 500 million of India’s poorest households through various insurance models with care delivered by public and private empanelled providers. This study undertook to describe the provider empanelment of PM-JAY, a key element of its functioning and determinant of its impact.

Methods
We carried out secondary analysis of cross-sectional administrative program data publicly available in PM-JAY portal for 30 Indian states and 06 UTs. We analysed the state wise distribution, type and sector of empanelled hospitals and services offered through PM-JAY scheme across all the states and UTs.

Results
We found that out of the total facilities empanelled (N = 20,257) under the scheme in 2020, more than half (N = 11,367, 56%) were in the public sector, while 8,157 (40%) facilities were private for profit, and 733 (4%) were private not for profit entities. State wise distribution of hospitals showed that five states (Karnataka (N = 2,996, 14.9%), Gujarat (N = 2,672, 13.3%), Uttar Pradesh (N = 2,627, 13%), Tamil Nadu (N = 2315, 11.5%) and Rajasthan (N = 2,093 facilities, 10.4%) contributed to more than 60% of empanelled PMJAY facilities: We also observed that 40% of facilities were offering between two and five specialties while 14% of empanelled hospitals provided 21–24 specialties.

Conclusion
A majority of the hospital empanelled under the scheme are in states with previous experience of implementing publicly funded health insurance schemes, with the exception of Uttar Pradesh. Reasons underlying these patterns of empanelment as well as the impact of empanelment on service access, utilisation, population health and financial risk protection warrant further study. While the inclusion and regulation of the private sector is a goal that may be served by empanelment, the role of public sector remains critical, particularly in underserved areas of India.

Analysing a Global Health Education Framework for Public Health Education Programs in India

Academic global health is of increasing interest to educators and students in public health but competency domains as well as education pathways that deliver this training, are still being identified and refined. This thesis was undertaken using an education program development paradigm and aimed to analyse the factors shaping global health education in India by examining multistakeholder perspectives. The research framework consisted of four components: curriculum and content, students, faculty and key experts, and employers. Studies captured the perspectives of students through a survey and focus group discussions, faculty and other key experts through semi-structured interviews, and employers through job advertisement analysis. We identified eleven global health competency domains focussed on three aspects: foundational competencies, core public health skills and soft skills. Global health and public health were seen as interconnected, with global health having transnational context and public health having a more national focus. Global health was seen as a nascent concept in India and although integration of global health education into the public health curriculum was supported, there were concerns given that public health is still too new a discipline in India. Global health competencies were seen as a ‘step up’ from the public health competencies. Based on the results, a two-level approach to global health education is proposed for Indian public health institutions. The first approach, targeted at recent graduates, focuses on a ‘foundational global health education’ within public health programs such as an MPH. The second approach is an ‘Executive Global Health Certificate Program’, aimed at experienced public health professionals planning to enter the global health workforce. This thesis has outlined a framework for Indian and other LMIC institutions looking to expand the scope of public health education and intend to develop global health education programs.