Gender-role behaviour and gender identity in girls with classical congenital adrenal hyperplasia

Introduction
Girls with classical congenital adrenal hyperplasia (CAH) are exposed to excess fetal adrenal androgens in-utero, and often born with masculinised genitalia. They are conventionally reared as females, but show more “boyish” gender-role behaviour (GRB) and gender-identity (GI) issues in childhood and adolescence. Male-rearing is also reported mainly due to delayed treatment and/or socio-cultural factors. We compared GRB/GI in girls with CAH with healthy age matched children, and explored for associations with socio-demographic and diagnosis/treatment related factors.

Methods
GRB and GI were assessed using the Gender Identity Questionnaire for children (GIQC) in 27 girls with classical CAH at a specialised clinic, and compared with 50 age-matched healthy controls, with exploratory-analysis based on socio-demographic and diagnosis/treatment-related factors.

Results
Girls with CAH had lower total GIQC scores compared to healthy children (3.29 vs. 4.04, p = < 0.001) with lower GRB score (3.39 vs. 4.23, p < 0.001), and tendency for lower GI score (3.19 vs. 3.5, p = 0.08). Exploratory analysis showed no differences based on diagnosis/treatment factors including age, degree of virilisation at diagnosis and surgical procedures. and only subtle changes based on ethnicity and maternal education.

Discussion/conclusion
Girls with CAH managed at a specialised centre showed more masculinised GRB and tendency for ambiguous GI, which did not vary upon diagnosis/treatment related factors, suggesting that prenatal androgen exposure was the likely contributor. Clinicians should be vigilant about the increased risk of gender-related problems in girls with CAH, irrespective of sociocultural background and despite early treatment.

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.

Respiratory morbidity and mortality of traumatic cervical spinal cord injury at a level I trauma center in India

Study design
Descriptive retrospective.

Objectives
To evaluate the burden of respiratory morbidity in terms of ventilator dependence (VD) days and length of stay in neurotrauma ICU (NICU) and hospital, and to determine mortality in patients with traumatic cervical spinal cord injury (CSCI) in a low middle-income country (LMIC).

Setting
Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi, India.

Methods
A total of 135 patients admitted with CSCI in the NICU between January 2017 to December 2018 were screened. Information regarding age, gender, American Spinal Injury Association (ASIA) impairment scale (AIS), level of injury, duration of VD, length of NICU, hospital stay, and outcome in terms of mortality or discharge from the hospital were obtained from the medical records.

Results
A total of 106 CSCI patients were analyzed. The mean (SD) age of patients was 40 (±16) years and male: female ratio was 5:1. The duration of VD, duration of NICU, and hospital stay was a median of 8 days (IQR 1127), 6 days (IQR 1118), and 15 days (IQR 3127) respectively. Mortality was 19% (20/106). The mortality was significantly associated with poorer AIS score, VD, and duration of ICU and hospital stay. All patients were discharged to home only after they became ventilator-free.

Conclusions
The ventilator burden, hospital stay, and mortality are high in patients with CSCI in LMICs. Poor AIS scores, prolonged VD, ICU and hospital stay are associated with mortality. There is a need for comprehensive CSCI rehabilitation programs in LMICs to improve outcome.

Burden of Cervical Cancer in the Eastern Mediterranean Region During the Years 2000 and 2017: Retrospective Data Analysis of the Global Burden of Disease Study

Background:
Cervical cancer is a growing health concern, especially in resource-limited settings.

Objective:
The objective of this study was to assess the burden of cervical cancer mortality and disability-adjusted life years (DALYs) in the Eastern Mediterranean Region (EMR) and globally between the years 2000 and 2017 by using a pooled data analysis approach.

Methods:
We used an ecological approach at the country level. This included extracting data from publicly available databases and linking them together in the following 3 steps: (1) extraction of data from the Global Burden of Disease (GBD) study in the years 2000 and 2017, (2) categorization of EMR countries according to the World Bank gross domestic product per capita, and (3) linking age-specific population data from the Population Statistics Division of the United Nations (20-29 years, 30-49 years, and >50 years) and GBD’s data with gross national income per capita and globally extracted data, including cervical cancer mortality and DALY numbers and rates per country. The cervical cancer mortality rate was provided by the GBD study using the following formula: number of cervical cancer deaths × 100,000/female population in the respective age group.

Results:
The absolute number of deaths due to cervical cancer increased from the year 2000 (n=6326) to the year 2017 (n=8537) in the EMR; however, the mortality rate due to this disease decreased from the year 2000 (2.7 per 100,000) to the year 2017 (2.5 per 100,000). According to age-specific data, the age group ≥50 years showed the highest mortality rate in both EMR countries and globally, and the age group of 20-29 years showed the lowest mortality rate both globally and in the EMR countries. Further, the rates of cervical cancer DALYs in the EMR were lower compared to the global rates (2.7 vs 6.8 in 2000 and 2.5 vs 6.8 in 2017 for mortality rate per 100,000; 95.8 vs 222.2 in 2000 and 86.3 vs 211.8 in 2017 for DALY rate per 100,000; respectively). However, the relative difference in the number of DALYs due to cervical cancer between the year 2000 and year 2017 in the EMR was higher than that reported globally (34.9 vs 24.0 for the number of deaths and 23.5 vs 18.1 for the number of DALYs, respectively).

Conclusions:
We found an increase in the burden of cervical cancer in the EMR as per the data on the absolute number of deaths and DALYs. Further, we found that the health care system has an increased number of cases to deal with, despite the decrease in the absolute number of deaths and DALYs. Cervical cancer is preventable if human papilloma vaccination is taken and early screening is performed. Therefore, we recommend identifying effective vaccination programs and interventions to reduce the burden of this disease.

Comparison of Challenges and Problems Encountered in the Practice of Exclusive Breast Feeding by Primiparous and Multiparous Women in Rural Areas of Sindh, Pakistan: A Cross-Sectional Study

Introduction: The UNICEF (United Nations International Children Education Fund) and WHO (World Health Organization) recommend exclusive breastfeeding (EBF) for the first six months of life. EBF is considered to be an important practice for enhancing infant health and wellbeing. Breastfeeding offers a wide range of psychological and physical health benefits in the long-term and short-term for young children, infants, and mothers. This study aims to compare exclusive breastfeeding practice among primiparous and multiparous mothers including reasons for discontinuing exclusive breastfeeding and problems faced during breastfeeding.

Methodology: This cross-sectional study was conducted in rural areas of Sindh, registered with the Maternal Newborn Health Registry (MNHR). The study used a systematic sampling technique for the enrollment of study participants. A survey questionnaire was used to collect data from mothers about the practices of EBF. A total of 397 mothers were interviewed and analyzed.

Results: Among Primiparous mothers, 14.1% of mothers initiated breastfeeding within one hour of birth, while 22.4% of multiparous mothers, initiated breastfeeding within one hour of birth. The difference between the two is statistically insignificant (p-value=0.234). A high percentage of multiparous mothers exclusively breastfed their infants for six months (63.5%) as compared to primiparous mothers (51.5%). The most common reason for introducing pre-lacteal feed before six months among primiparous mothers is the lack of adequate milk production to fulfill baby needs; this was the case for 35.4% of mothers. On the other hand, the baby remaining hungry post breastfeeding was the major reason among multiparous mothers (44.0%) for introducing pre-lacteal feed before six months.

Conclusion: This study helped in the identification of issues faced by primiparous and multiparous mothers during exclusive breastfeeding. Interventions for promoting EBF need to be tailored as per the need and challenges of the population.

Medical and Nursing Students’ Perception and Experience of Virtual Classrooms during the COVID-19 Pandemic in Nepal

Background: On March 9, 2020, the government of Nepal declared suspension of all academic activities in line with a nationwide lockdown following the COVID-19 outbreak. To keep pace with the academic calendar, medical universities resumed their teaching and learning activities through virtual means on account of nonfeasibility of holding physical classes. The present study sought to identify the perception and experiences of undergraduate medical and nursing students regarding the virtual classrooms.
Methods: We adopted a sequential explanatory mixed method design whereby data were collected in two phases. Quantitative data were gathered from a survey (n=737) and qualitative data from focused group discussion (n=14). The participants were recruited using a non-probability Peer Esteem Snowballing technique. Quantitative data were analyzed using descriptive and inferential statistics, whereas qualitative data was examined using a narrative thematic analytic approach.
Results: Mean age of participants was 22±2.01 with (81%) female participation. The quantitative findings revealed that the “synchrony” domain had the highest mean score (4.10±0.47) and “course interaction” had the lowest mean score (2.93±0.81) amongst the four domains. The domains were significantly correlated to each other (P=0.01) and (P=0.05). Results from focus group discussion indicated that interactions were lower in the virtual classes and there was a great variation between the learners’ perception and their experiences of virtual classrooms. Students preferred blended classes to be implemented in future sessions.
Conclusion: In spite of various challenges, the students perceived the transition from traditional to virtual classrooms in a positive and enthusiastic way. An effective virtual learning experience requires a modified instructional approach on the part of educators and a consistent attitude from learners.

Does Advanced Trauma Life Support Training work? 10-Year Follow Up of Advanced Trauma Life Support India Program

Background
Studies evaluating the efficacy of ATLS in Low & Middle-income countries (LMICs) are limited. We followed up ATLS providers certified by ATLS India program over a decade (2008-2018), aiming at measuring the benefits, if any, in knowledge, skills & attitude (KSA) from ATLS, and attrition over time.

Methods
Survey instrument was developed taking a cue from published literature on ATLS and improvised using the Delphi method. Randomly selected ATLS providers were sent the survey instrument via email, as a Google form along with a statement of purpose. Results are presented descriptively.

Results
1030 (41.2%) doctors responded. Improvement in knowledge (n=1013; 98.3%), psychomotor skills (n=986; 95.7%), organizational skills (n=998; 96.9%), overall trauma management (n=1013; 98.7%), self-confidence (n= 939; 91%) and ATLS promulgation at workplace in personal capacity (904; 87.8%) were reported. More than 60% opined benefits lasting beyond two years; more than 40% opined cognitive (492; 47.8%), psychomotor (433; 42%), and organizational benefits (499; 48.4%) lasting beyond three years. The Faculty-ATLS subgroup reported significantly more improvement in confidence, tendency to teach ATLS at the workplace, and retention of organizational skills than the providers’ subgroup. Lack of trained manpower (660; 64.1%) & attitude issues (n-495; 48.1%) were the major impediments at workplace. One third (n=373; 36.2%) recalled & enumerated life/ limb saving incidents applying ATLS principles.

Conclusion
Cognitive, psychomotor, organizational, and affective impact of ATLS is overwhelmingly positive in the Indian scenario. Till establishing formal trauma systems, ATLS remains the best hope for critically injured patients in LMICs.

Predictors of iron consumption for at least 90 days during pregnancy: Findings from National Demographic Health Survey, Pakistan (2017–2018)

Background
Iron supplementation is considered an imperative strategy for anemia prevention and control during pregnancy in Pakistan. Although there is some evidence on the predictors of iron deficiency anemia among Pakistani women, there is a very limited understanding of factors associated with iron consumption among Pakistani pregnant women. Thus, this study aimed to investigate the predictors of iron consumption for at least ≥90 days during pregnancy in Pakistan.

Methods
We analyzed dataset from the nationally representative Pakistan Demographic Health Survey 2017–2018. The primary outcome of the current study was the consumption of iron supplementation for ≥90 days during the pregnancy of the last birth. Women who had last childbirth 5 years before the survey and who responded to the question of iron intake were included in the final analysis (n = 6370). We analyzed the data that accounted for complex sampling design by including clusters, strata, and sampling weights.

Results
Around 30% of the women reported consumed iron tablets for ≥90 days during their last pregnancy. In the multivariable logistic regression analysis, we found that factors such as women’s age (≥ 25 years) (adjusted prevalence ratio (aPR) = 1.52; 95% CI: 1.42–1.62)], wealth index (rich/richest) (aPR = 1.25; [95% CI: 1.18–1.33]), primary education (aPR = 1.33; [95% CI: 1.24–1.43), secondary education (aPR = 1.34; [95% CI: 1.26–1.43), higher education (aPR = 2.13; [95% CI: 1.97–2.30), women’s say in choosing husband (aPR = 1.68; [95% CI: 1.57–1.80]), ≥ five antenatal care visits (aPR =2.65; [95% CI (2.43–2.89]), history of the last Caesarian-section (aPR = 1.29; [95% CI: 1.23–1.36]) were significantly associated with iron consumption for ≥90 days.

Conclusion
These findings demonstrate complex predictors of iron consumption during pregnancy in Pakistan. There is a need to increase the number of ANC visits and the government should take necessary steps to improve access to iron supplements by targeting disadvantaged and vulnerable women who are younger, less educated, poor, and living in rural areas.

Global Neurosurgery – The Problem and Solution -The Asian Perspective

The world of Neurosurgery has witnessed a quantum jump in the last few decades. However, this progress has reaped benefits for patients’ income countries; the preventable deaths due to surgical deficit are as high as 47 million annually (1). Given this uneven balance of facilities in the health sector, the WHO has agreed to resolve the issues by participating in worldwide governing bodies of neurosurgery faculties in the individual country. The former president of the world bank was quoted that “surgery is an indivisible, indispensable part of health care and progress towards universal health coverag