Background. Inappropriate footwear may be a major cause of foot ulceration among patients with diabetic neuropathy in India. No study has specifically examined the types of footwear or its components in patients with diabetes mellitus and their role in causing foot ulcers. We analysed the role of commonly used footwear in India in inducing first foot ulcers (FFU) in people with diabetes. Methods. Of 4800 patients with diabetes attending our centre over 1 year, 301 had FFU from different causes. Sixty-six patients with diabetic neuro-/vasculopathy presenting with ulcers due to footwear were included as cases. An equal number of patients with diabetes but without foot ulcers were enrolled as controls. Cases and controls were matched demographically and clinically for type of diabetes, metabolic control, duration of diabetes, comorbid conditions and foot neurovascular status. We did a detailed foot examination for neurological, vascular and wound status. We also evaluated the footwear in both groups. Results. In one-fifth of 335 limbs (301 patients), the primary cause for the FFU was use of inappropriate footwear. The patients used seven different models of footwear, six of which were found to be inappropriate. The straps of footwear caused over 50% of ulcers. Another one-third were due to penetration of sharp objects through the outer sole of footwear; among these cases, 1 3.6% of ulcers were caused by not using soft inner soles. Conclusions. The use of softer insole is least effective in preventing foot ulcers. Similarly, straps contribute to a higher percentage of foot ulcers. Foot ulcers can be prevented by a combination of soft insole, with midsole and hard outsole with proper back counter and adjustable front and back straps.

ObjectiveThe objective of this study is to evaluate the effects of a community-based effort in a rural area of central India to decrease the prevalence of hypertension among the middle-aged and older population by using multiple blood pressure measurements.MethodsWith a prevalence of 16.8% (error of 3.36, and 95% confidence interval) from a recent study in a nearby district, the sample size required for this study was 495 subjects. A proportionally stratified random sample design was used. With maps of ten villages, where in a community-based health project had been in place for many years, 20 households and 20 backups were randomly selected from a list of all households. Multiple BP measurements were obtained and categorized and one-month period prevalence was calculated. Statistical analyses of frequency and percentage were performed.ResultsApproximately one-fifth of the population above 40 years of age in central India where a community-based approach is in place was hypertensive. This is significantly lower than the previously documented prevalence rate of one-third or even more prevalence rate in India. The attribute of caste and religion, a specific rural Indian characteristic did not have any significant bearing on the above results. The prevalence tended to increase progressively with age until 70 years, after which it declined. Multiple blood pressure measurements may yield an accurate prevalence of hypertension.ConclusionWith the documented evidences from India, the current reduced prevalence of hypertension could have been influenced by the community-based interventions in this population.

Village health worker (VHW) programs are known to be effective means of promoting health of communities. Comprehensive rural health project in India recently trained VHWs to identify, refer, and help people with mental health issues. This study evaluated knowledge, attitude, and behavior of VHWs regarding depression. Cluster sampling was used including all 36 VHWs trained in mental health. Among these, 24 were available and willing to participate in the study. Five FGDs were conducted among 24 VHWs, and the results were analyzed qualitatively. Four out of five groups were able to diagnose the presented case correctly as depression. VHWs were able to identify many symptoms and to suggest management options for depression. They showed supportive and empathetic attitudes towards depressed patients. VHWs are likely to be useful at identifying and assisting people with depression in the communities with lack of adequate resources provided they receive ongoing training and supervision.

BACKGROUND:By analyzing the perspectives of village health worker/trainers with the Comprehensive Rural Health Project (CRHP), this study aimed to investigate their level of knowledge of treatment, risks, and prevention of complications of labor and delivery and to evaluate current teaching methods.METHODS:Three focus groups of six village health workers/trainers were conducted and divided according to level of experience. The resulting semistructured discussion was analyzed according to grounded theory.RESULTS:Participants displayed strong content retention with respect to clinically relevant knowledge. Village health workers experienced barriers, including lack of education and casteism, which affected their ability to establish trust in the community. Clinical observation was perceived to be the most effective learning method and is recommended for teaching village health workers about the treatment and prevention of the complications of labor and delivery.CONCLUSION:When implementing this training model in comparable global communities, local culture and its impact on establishing trust is an important factor to consider.

Many sub-Saharan African countries are confronted by the HIV/AIDS epidemic. This article reviews academic literature in the social sciences and health to discover why HIV/AIDS has become an epidemic in sub-Saharan Africa and not in other parts of the world. This was studied by examining the social determinants of diminishment of tradition and social cohesion in terms of political, social and economic problems. Four countries in this region were selected for this case study, namely South Africa, Botswana, Uganda and Zimbabwe. The findings showed that instability in socio-economic and political aspects in these nations was responsible for creating a suitable environment for the spread of HIV/AIDS infection. This paper concludes by using the theories of collective action/responsibility and social cohesion to hypothesise that the breakdown of social ties due to various kinds of conflicts and unrest is one of the main contributors to the HIV/AIDS epidemic.

BACKGROUND AND AIMThe aim is to measure and to compare the level of social participation experienced by vitiligo and psoriasis patients in their domestic and social life in an Indian context.METHODSA cross-sectional comparative study with a sample of 150 cases each of psoriasis and vitiligo, a total of 300 subjects. A detailed clinical assessment of these two conditions, including the extent of lesions on the affected body parts, socioeconomic status and participation levels in social and domestic lives, was done.RESULTSThe result showed that, 17.3% of vitiligo patients participated minimally in domestic and social life, whereas 28% of psoriasis patients had this problem (P=0.027). Extreme participation restriction was observed only among psoriasis patients (2.7%). Psoriasis patients also faced significantly more restrictions in a number of day-to-day life situations such as, less confidence in learning and applying knowledge, difficulties in meaningfully participating in major life areas like, work, education and employment, and also in community, social and civic life (all three domains P<0.0001), to vitiligo patients.CONCLUSIONBoth psoriasis and vitiligo patients suffered moderate to severe restriction while participating in their domestic and social life. Of these two groups, psoriasis patients faced significantly more restrictions in a number of day-to-day life situations. The Indian population of this study was predominantly dark-skinned and hypo-pigmentation as seen in vitiligo is much more noticeable than psoriatic red patches. However, the results showed that the component of hypo or hyperpigmentation of the skin is not the only factor leading to participation restrictions.

OBJECTIVE Karigiri was set up initially to be a sanatorium with a difference, and the objective of this review is to study whether this had been achieved. METHODS A broad search of 43 various publications from Karigiri. RESULTS Stigma towards leprosy lead to the creation of this sanatorium, and within 20 years of its existence it made a significant contribution to the knowledge and treatment of this disease through research, and provided skilled manpower for both India and other developing countries.

Introduction The Bellagio Child Survival Study Group brought the issue of child survival to the forefront of the global health care agenda in 2003 when it reported that 10 million children were dying every year. (1) Reducing child mortality by two-thirds before 2015 is one of the United Nations Millennium Development Goals. (2) As the Bellagio series and the Lancet neonatal survival series (3) and Alma-Ata series (4) all point out, most of these deaths are preventable. In India, as in many developing countries, providing even basic health care in rural areas is a major challenge for the government. Analyses of India's health system have suggested that rural health care has been neglected by the government and that increasing privatization may further reduce health care in remote areas. (5,6) Community-based primary health care provided by trained community residents has been shown to improve child survival in areas with high child mortality. The Warmi project in Bolivia and the Society for Education, Action and Research in Community Health (SEARCH) in Maharashtra, India, have demonstrated significant reductions in perinatal and neonatal mortality. (7,8) Recent trials in Nepal and in Uttar Pradesh, India, have reported reductions in neonatal mortality of 30% and 52%, respectively. (9,10) Many aid agencies strive to address the lack of health care and improve child survival in developing countries, but they rarely conduct rigorous independent evaluations of their work. Such evaluations are expensive, carry the risk of showing negative results and are under-appreciated by donors. Consequently, there are few credible data on the impact of ongoing aid work. (11-15) Though randomized controlled interventions can generate such data, (15) a study with prospectively assigned controls is seldom an option and retrospective approaches must therefore be used to assess the impact of aid efforts. The Comprehensive Rural Health Project The Comprehensive Rural Health Project (CRHP), one of the inspirations for the 1978 International Conference on Primary Health Care at Alma-Ata, has been working for the past 40 years to address the issues highlighted in the aforementioned Lancet series. (1,3,4) It has had a major influence in health policy circles, including the World Health Organization (WHO) and schools of public health, (16) and is a rare example of a long-term community-based primary health care project. The project was highlighted in the Alma-Ata Rebirth and Revival series as a model for delivering primary health care to poor rural regions, (4) and--if found to be effective upon rigorous evaluation--could prove important for achieving the Millennium Development Goals on child mortality reduction elsewhere in India and in other vulnerable areas. CRHP was founded in 1970 by physicians Mabelle and Rajnikant Arole, who envisioned a system that delivered both curative and preventative care to India's most vulnerable people. Based in the town of Jamkhed, CRHP also serves surrounding areas in the central part of Maharashtra state. The area is predominantly rural, poor and drought-prone. Public health care and education are notoriously poor. CRHP has gradually expanded from a single hospital in Jamkhed and currently covers approximately 300 communities with a total population of over 500 000 people. (17) Activities in project villages The CRHP model, which focuses on community-centred primary health care, is described in detail elsewhere. (17,18) Activities in the project villages are carried out at three levels: village health workers, mobile health teams and the secondary-care hospital in Jamkhed. Village health workers, who are the cornerstone of the model, are local women selected by their communities, often from the lowest caste. They receive intensive training from CRHP trainers in primary health care and health promotion, including family planning, women's and children's health and home birth delivery. …

OBJECTIVE:To conduct the first rigorous evaluation of the long-term effect of the Comprehensive Rural Health Project on childhood mortality in rural Maharashtra.METHODS:Background information and full birth histories were collected by conducting household surveys and interviewing women. Control villages resembling project villages in terms of population size were randomly selected from an area enclosed by two ellipses centred around, but not including, the project area. An equal number of villages and approximately equal numbers of households and women were randomly sampled from both areas. Cox models with robust standard errors were used to compare the hazard of death among children under 5 years of age in project and control villages.FINDINGS:The hazard of death was reduced by 30% (95% confidence interval, CI: 6% to 48%) after the neonatal period in the project villages compared with control villages after adjustment for caste and religion of subjects and for availability of irrigation in the villages. During the neonatal period there was an increase of 3% in the hazard of death, but it was not statistically significant (95% CI: -18% to 29%).CONCLUSION:Our methods provide useful tools for evaluating long-running community-based primary health care programmes. Our findings add to the growing debate on the long-term sustainability of community-based interventions designed to reduce child mortality.

Background: The global burden of mental illness is high and opportunities for promoting mental health are neglected in most parts of the world. Many people affected by mental illness live in developing countries, where treatment and care options are limited. In this context, primary health care (PHC) programs can indirectly promote mental health by addressing its determinants i. e. by enhancing social unity, minimising discrimination and generating income opportunities. The objectives of this study were to: 1. Describe concepts of mental health and beliefs about determinants of mental health and illness among women involved with a PHC project in rural Maharashtra, India; 2. Identify perceived mental health problems in this community, specifically depression, suicide and violence, their perceived causes, and existing and potential community strategies to respond to them and; 3. Investigate the impact of the PHC program on individual and community factors associated with mental health.Method: We undertook qualitative in-depth interviews with 32 women associated with the PHC project regarding: their concepts of mental health and its determinants; suicide, depression and violence; and the perceived impact of the PHC project on the determinants of mental health. The interviews were taped, transcribed, translated and thematically analysed.Results: Mental health and illness were understood by these women to be the product of cultural and socio-economic factors. Mental health was commonly conceptualised as an absence of stress and the commonest stressors were conflict with husbands and mother-in-laws, domestic violence and poverty. Links between empowerment of women through income generation and education, reduction of discrimination based on caste and sex, and promotion of individual and community mental health were recognised. However, mental health problems such as suicide and violence were well-described by participants.Conclusion: While it is essential that affordable, accessible, appropriate treatments and systems of referral and care are available for people with mental illness in developing country settings, the promotion of mental health by addressing its determinants is another potential strategy for reducing the burden of mental illness for individuals and communities in these settings.

In a study of 304 pregnant women, the prevalence of HIV infection in remote rural areas of western India was 0.7% (confidence interval 0.08-2.3%). It is nearly 2½ times higher than the presumed prevalence for this part of the country.