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Scholarly Works (92 results)

  • Article
  • Peer Reviewed
UC San Francisco Previously Published Works (2019)

Introduction

Palliative care coverage and opioid consumption in India are relatively low compared with global data. The literature suggests commonplace concealment and collusion in withholding information, but these hypotheses lack evidence.

Objectives

This study aimed to develop an explanatory evidence-based model of stigma, communication and access to cancer palliative care in India that can be used to develop, test and implement future interventions.

Design

This cross-sectional qualitative study sampled advanced cancer patients (n=10), their family caregivers (n=10) and oncologists (n=10). Grounded theory procedures were utilised to analyse transcripts, and a theoretical model generated.

Setting

A tertiary teaching hospital in South India.

Results

The model explains how stigma associated with communicating a diagnosis of advanced cancer is enacted by treating oncologists, family members and community. This leads to patient expectations of cure and futile treatment uptake. Patients commonly only present needs with respect to pain, not within psychological, social or spiritual domains, likely due to the lack of patients' insight into their diagnosis and prognosis. As a result of oncologists' and families' unwillingness to disclose the prognosis, and patient focus on pain due to their lack of insight, palliative care clinicians view their services as under-utilised, and patients perceive palliative care as a pain management service that is not 'different' from other clinical services. Advanced care needs and purchase of futile treatments lead to lost employment among families, increased family debt and high care costs, which are rarely disclosed due to their unwillingness to discuss their needs.

Conclusion

Our novel theoretical model is an essential first step to ensure that complex interventions are plausible, with mechanisms of action that address the needs of relevant stakeholders. A family-centred approach with an oncology workforce skilled in communication and an enabled patient population could increase access to palliative care, and improved outcomes may be attainable.
    Cover page: Multilevel model of stigma and barriers to cancer palliative care in India: a qualitative study
    • Article
    • Peer Reviewed
    UC San Francisco Previously Published Works (2021)

    Objective

    The main objective of this exploratory study was to investigate the overlooked perspectives and beliefs of Accredited Social Health Activists (ASHA workers) regarding a collaborative care mental health intervention (HOPE: Healthier Options through Empowerment), mental illness and the health of their rural communities.

    Design

    Semi-structured, one-on-one, qualitative interviews.

    Setting

    Seven primary health centres (PHCs) in rural Karnataka, India. All PHCs had previously completed the HOPE study.

    Participants

    15 ASHA workers, selected via purposive sampling. ASHAs are high school-educated village women trained as community health workers. ASHAs were included if they had previously participated in the HOPE intervention, a collaborative-care randomised controlled trial that aimed to integrate mental healthcare into existing primary care systems in rural Karnataka.

    Interventions

    No interventions were introduced.

    Results

    ASHA workers mostly had positive interactions with patients, including encouraging them to attend sessions, helping to explain the topics and techniques, and checking on the patients frequently. ASHA workers were able to identify key barriers to treatment and facilitators to treatment. ASHAs claimed that their knowledge about mental illness improved because of the HOPE study, though gaps remained in their understanding of aetiology and treatment. Several expressed interest in receiving additional mental health training. Overall, ASHAs viewed the HOPE study as a necessary and effective intervention, and requested that it expand.

    Conclusions

    This paper discusses the perspectives of ASHAs who participated in a novel effort to extend the collaborative care model to their own communities. ASHA workers help maintain relationships with patients that encourage participation, and the efforts of ASHAs often aid in mitigating common barriers to treatment. ASHA workers' beliefs and knowledge regarding mental illness can be changed, and ASHAs can become effective advocates for patients. Future collaborative care interventions would likely benefit from involving ASHA workers in community outreach efforts.
      Cover page: Perceptions of ASHA workers in the HOPE collaborative care mental health intervention in rural South India: a qualitative analysis
      • Thesis
      • Peer Reviewed
      UC Berkeley Electronic Theses and Dissertations (2014)

      New technologies, such as mobile phones and the Internet, have created digital environments that may alter the social and environmental factors that contribute to sexual behavior. To date, sexual health research has largely focused on participation in digital environments as risk factors for sexual behavior, with relatively little exploration of their possible contribution to protective sexual behavior. This research explores the possibility of a more fluid association of digital environments with sexual behavior, with the capacity to contribute to either risky or protective sexual behavior. We present three analyses to make connections between digital environments and sexual behavior more explicit among populations who are traditionally sexually stigmatized, hidden, and at high risk for adverse sexual health outcomes in resource-limited settings. The populations studied included female sex workers (FSWs), men who have sex with men (MSM), and adolescents.

      The first analysis examined the use of mobile phones as a platform to solicit clients among FSWs, and the association between this behavior and inconsistent condom use with clients in two diverse areas in South India. The second analysis tested the extent to which sex work income moderates the relationship between mobile phone solicitation and condom use with clients among South Indian FSWs. Finally, a systematic review of sexual health studies in naturalistic situations, i.e., in the absence of technology-based sexual health interventions, among three hidden populations (e.g., FSWs, MSM, and adolescents) was conducted. Existing evidence was examined to identify patterns linking findings of risk versus protective factors that may inform the relationship between sexual behavior and the digital environment.

      These findings demonstrated--for the first time in the literature on Indian FSWs-a protective association between client solicitation via mobile phone and condom use with clients as well as evidence that sex work income moderates this association. Both findings were dependent on the type of mobile phone method applied. These empirical findings and existing evidence from adolescent and MSM populations suggest utilization strategies, the way in which digital environments are employed for sexual interactions, may provide a concrete approach to help clarify differential risk/ protective effects between digital environments and sexual behavior. These findings offer new insights to help inform a next generation of technology-based sexual health interventions targeting hidden populations in resource-limited settings.

        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2023)
        INTRODUCTION: Common mental disorders (CMD) and cardiovascular diseases (CVD), common health problems among patients seeking primary healthcare, contribute to high economic productivity losses. Collaborative care programs for CMDs and CVDs have shown improvement in clinical outcomes for both conditions; however, data on productivity outcomes are scarce. Objective: Effect of integrated collaborative care on productivity among people with comorbid CMD and CVD in rural Karnataka primary health clinics. METHODS: Participants were recruited within a randomized trial in rural South India, where patients received either collaborative or enhanced standard care. In this substudy, 303 participants were followed for 3 months and assessed with the iMTA Productivity Cost Questionnaire (iPCQ). RESULTS: We found a reduction in the proportion of individuals reporting productivity loss at 3 months (66%) compared to baseline (76%; P = 0.002). Productivity losses decreased from INR 30.3 per person per day at baseline to 17.7 at 3 months. Reductions were similar in the two treatment conditions. CONCLUSION: Medical intervention may foster reduced productivity losses among patients with CMD and CVD. Collaborative care did not translate into higher reductions in productivity losses than enhanced standard care.
          Cover page: Effect of collaborative care intervention on productivity losses among people with comorbid common mental disorders and cardiovascular disease in rural Karnataka.
          • Article
          • Peer Reviewed
          UC San Francisco Previously Published Works (2022)

          Introduction

          Half of all mental disorders start during adolescence, before 14 years. In India, the current prevalence of mental disorders in 13-17 years age group was 7.3%. Many gaps persist in the mental healthcare delivery through the national mental health program, the low psychiatrist population ratio being one of them. Community health workers can play an essential role in providing mental healthcare in such resource-constrained settings. The World Health Organization mental health gap action program (WHO mhGAP) is a widely studied mental health tool that health workers can use to identify mental disorders. The study's aim was to test the preliminary efficacy of training healthcare workers (HCWs) in identifying mental health conditions among adolescents using modified WHO mhGAP modules.

          Methods

          The feasibility study was carried out in two Primary Health Centers (PHCs) in rural Bengaluru. Study had two components: (1) training of HCWs on adolescent mental health and (2) detection of selected priority mental health conditions among adolescents by trained HCWs. HCWs were trained in five adolescent mental health conditions using a training manual and modified WHO mhGAP modules that excluded emergency presentations and management sections. Pre- and post-training assessments were carried out. A sample of 272 adolescents attending PHCs were assessed for any mental health condition by HCWs using mhGAP modules. A sub-sample of adolescents and all adolescents identified by HCWs with a mental health condition was interviewed by the investigator to validate the diagnosis. Qualitative interviews were carried out with participating HCWs to understand the acceptability of the intervention, acceptability, and barriers to training in identifying mental health conditions among adolescents RESULTS: A total of 23 HCWs underwent training. There was a significant increase in the mental health knowledge scores of HCWs post-training compared to baseline (p value <0.001). Out of 272 adolescents, 18 (6.8%) were detected to have any mental health condition by HCWs as per the modified WHO mhGAP modules. A sample of 72 adolescents consisting of all adolescents identified with a mental health condition by HCWs and a random sample of adolescents without any diagnosis were validated by the research investigator (AS). There was a good agreement between diagnosis by health workers and the research investigator with a Cohen's Kappa of 0.88. Four themes emerged from the qualitative analysis.

          Conclusions

          Training was effective in improving the knowledge of HCWs. There was a good agreement between trained HCWs and the investigator in detecting adolescent mental health conditions using modified mhGAP modules. The modified WHO mhGAP can thus be used by trained non-specialist HCWs to screen for adolescent mental health conditions in primary health centers.
            Cover page: Feasibility and preliminary efficacy of training health workers in detecting Priority Mental Health Conditions among adolescents in rural South India
            • Article
            • Peer Reviewed
            UC San Francisco Previously Published Works (2019)

            Context

            Common mental disorders (CMD) and cardiovascular diseases (CVDs) frequently co-occur. Productivity losses due to these diseases are substantial in high-income countries. Similar data from the developing world are lacking.

            Aims

            This study aims to quantify productivity losses among individuals with comorbid CMD and CVD in rural Karnataka, India.

            Settings and design

            A cross-sectional study was done among patients with a dual diagnosis of a comorbid CMD and CVD in a district in Karnataka, India.

            Subjects and methods

            Three hundred and three patients were administered the iMTA Productivity Cost Questionnaire to measure losses of productivity at paid work (absenteeism and presenteeism) and unpaid work.

            Statistical analysis used

            Valuation of productivity losses was done by multiplying the number of days of lost productivity by the standard value of productivity based on the minimum wage for agricultural work.

            Results

            Among individuals with dual CMD and CVD, 76% had productivity losses. These losses were higher at unpaid (62%) than at paid work (32%). At paid work, losses due to presenteeism were greater than those due to absenteeism. The total days of productivity loss were 1204, amounting to 14.2% of the available person-days. The total productivity loss among 303 individuals with mental illness and comorbid CVD over a 4-week period amounted to 30.3 INR (0.47 USD) per person per day, representing 9.9% of total potential productivity.

            Conclusions

            Productivity losses due to common mental illnesses and CVDs are high. There is a need to conduct more studies in this field.
              Cover page: Productivity losses among individuals with common mental illness and comorbid cardiovascular disease in rural Karnataka, India
              • Article
              • Peer Reviewed
              UC San Francisco Previously Published Works (2022)
              OBJECTIVE: Cancer patients in India prefer full information regarding diagnosis and prognosis, but evidence suggests poor insight. This study aimed to identify the role of health literacy among adult patients living with cancer, their families and health professionals in decision-making and treatment outcomes in India. METHODS: This cross-sectional in-depth study recruited patients, families and clinicians from three centers. Inductive thematic analysis informed a novel conceptual model. RESULTS: We recruited n = 34 cancer patients, n = 33 family members, n = 11 doctors and n = 14 nurses (N = 92). Principle emergent themes were the following: (1) Preferences and dynamics of diagnosis and prognosis disclosure, for example, the dominant preference was for families who held hope for cure to discourage disclosure; clinicians sometimes disclosed in line with perceived ability to pay for treatment. (2) Understanding of disease and its treatment options (etiology, potential trajectory, treatment options), for example, lay understandings of cancer etiology as contamination from outside the home, and reluctance of patients to ask questions of clinicians. (3) Priorities in decision-making, for example, not engaging patients due to fear of patient distress, patients initiated on anticancer treatments without knowledge or consent, pursuing futile treatments. (4) Anxieties over finances and outcomes (disclosure, decision-making, care pathways), for example, clinicians attempting to reduce families pursuing expensive and inappropriate treatment options with patients who have poor insight, catastrophic spending based on poor decisions. CONCLUSION: The novel evidence-based health literacy model offers potential for feasible and acceptable intervention to support families in communication, disclosure and decision-making. This may improve patients access to informed, appropriate care pathways.
                Cover page: Health literacy in communication, decision-making and outcomes among cancer patients, their families and clinicians in India: A multicentre cross-sectional qualitative study.
                • Article
                • Peer Reviewed
                UC San Francisco Previously Published Works (2013)

                Introduction

                Routine HIV viral load (VL) testing is not available in India. We compared test performance characteristics of immunologic failure (IF) against the gold standard of virologic failure (VF), examined evolution of drug resistance among those who stayed on a failing regimen because they did not meet criteria for IF and assessed implications for second-line therapy.

                Methods

                Participants on first-line highly active antiretroviral therapy (HAART) in Bangalore, India, were monitored for 24 months at six-month intervals, with CD4 count, VL and genotype, if VL>1000 copies/ml. Standard WHO criteria were used to define IF; VF was defined as having two consecutive VL>1000 copies/ml or one VL>10,000 copies/ml. Resistance was assessed using standard International AIDS Society-USA (IAS-USA) recommendations.

                Results

                Of 522 participants (67.6% male, mean age of 37.5; 85.1% on nevirapine-based and 40.4% on d4T-containing regimens), 57 (10.9%) had VF, 38 (7.3%) had IF and 13 (2.5%) had both VF and IF. The sensitivity of immunologic criteria to detect VF was 22.8%, specificity was 94.6% and positive predictive value was 34.2%. Forty-four participants with VF only continued on their failing first-line regimen; by the end of the study period, 90.9% had M184V, 63.6% had thymidine analogue mutations (TAMs), 34.1% had resistance to tenofovir, and 63.6% had resistance to etravirine.

                Conclusions

                WHO IF criteria have low sensitivity for detecting VF, and the presence of IF poorly predicts VF. Relying on CD4 counts leads to unnecessary switches to second-line HAART and continuation of failing regimens, jeopardizing future therapeutic options. Universal access to VL monitoring would avoid costly switches to second-line HAART and preserve future treatment options.
                  Cover page: Evaluation of WHO immunologic criteria for treatment failure: implications for detection of virologic failure, evolution of drug resistance and choice of second‐line therapy in India
                  • Article
                  • Peer Reviewed
                  UC San Francisco Previously Published Works (2023)
                  BACKGROUND: Only a few studies have explored the relationship between psychosocial factors and medication adherence in Indian patients with noncommunicable diseases (NCDs). We aimed to examine the association of psychosocial variables with medication adherence in people with NCDs and comorbid common mental disorders (CMDs) from primary care in rural southern India. METHODS: We performed a secondary analysis using baseline data from a randomized controlled trial in 49 primary care health centers in rural southern India (HOPE study). Participants were adults (≥30 years) with NCDs that included hypertension, diabetes, and/or ischemic heart disease, and comorbid depression or anxiety disorders. Medication adherence was assessed by asking participants if they had missed any prescribed NCD medication in the past month. Data were collected between May 2015 and November 2018. The association between psychosocial and demographic variables and medication nonadherence were assessed via logistic regression analyses. RESULTS: Of the 2486 participants enrolled, almost one-fifth (18.06%) reported missing medication. Male sex (OR = 1.74, 95% CI 1.37-2.22) and higher internalized mental illness stigma (OR = 1.46, 95% CI 1.07-2.00) were associated with higher odds of missing medication. Older age (OR = 0.40, 95% CI 0.26-0.60, for participants aged 64-75 years vs 30-44 years), reporting more social support (OR = 0.65, 95% CI 0.49-0.86), and higher satisfaction with health (OR = 0.74, 95% CI 0.61-0.89) were associated with lower odds of missing medication. CONCLUSIONS: Greater internalized mental illness stigma and less social support are significantly associated with lower rates of medication adherence in patients with NCDs and comorbid CMDs in rural India.
                    Cover page: Medication Adherence among Primary Care Patients with Common Mental Disorders and Chronic Medical Conditions in Rural India.
                    • Article
                    • Peer Reviewed
                    UC San Francisco Previously Published Works (2021)

                    Purpose

                    The purpose of the study was to examine the association between socio-demographic and clinical characteristics and perceived social support among patients with a diagnosis of depression and/or anxiety and co-morbid medical conditions from rural south India.

                    Methods

                    The study was conducted in 49 PHCs in Ramanagara district, Karnataka, and included 2481 participants, who were 30 years or older with co-morbid CMD (Common Mental Disorder) and hypertension, diabetes or ischemic heart disease. Socio-demographic characteristics of the participants were collected, and instrumental, emotional and total social support, quality of life, severity of disability, depression and anxiety were measured via face-to-face interviews using structured questionnaires.

                    Results

                    The sample predominantly consisted of Hindu (98.5%) females (75%) in their middle to late adulthood. In multivariate models, age showed a significant curvilinear relation with all forms of social support (B = 0.001 and p < 0.05), and emotional social support (B = - 0.056, p = 0.004) was lower in employed than non-working participants. Household size was positively related to all forms of social support (B = 0.029 for instrumental, B = 0.022 for emotional, B = 0.025 for total social support, all p < 0.001). Quality of life was positively associated with all forms of social support (B = 0.019 for instrumental, B = 0.016 for emotional, B = 0.018 for total social support, all p < 0.001).

                    Conclusions

                    For this sample of outpatients diagnosed with both CMD and at least one comorbid medical condition in rural south India, greater household size was associated with better social support. The role of family in providing support can be utilized while designing interventions.

                    Trial registration number

                    http://Clinicaltrials.gov : NCT02310932 registered December 8, 2014 URL: https://clinicaltrials.gov/ct2/show/record/NCT02310932 ; Clinical Trials Registry India: CTRI/2018/04/013001 retrospectively registered on April 4, 2018.
                      Cover page: Correlates of social support in individuals with a diagnosis of common mental disorders and non communicable medical diseases in rural South India.
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