The post-natal period is a critical phase in the lives of mothers and new-borns. Most maternal and infant deaths occur during this time. Yet, this is the most neglected period in the provision of quality care and maintenance of healthy practices. The District Medical Officer (DMO) in Malappuram, Kerala with support from an action group of obstetricians in the district, proposes to train Post-Natal Care (PNC) attendants. The DMO intends to design training modules, particularly in relation to post-natal nutrition and breastfeeding.

She requested our RES team to conduct a rapid review that could support her in this policy endeavour. The team together with the DMO concurred on summarising evidence on three relevant components:  recommendation from relevant guidelines on best practices for postnatal care, harmful postpartum beliefs and practices of mothers in India, and training of post-natal care attendants for post-natal care, nutrition and breastfeeding. This would provide the DMO with an evidence base to develop the training modules.

The team, with concurrence of the DMO, felt that evidence related to Traditional Birth Attendants (TBAs) may be relevant for their training, which was the focus of this rapid review.

Policy Options

Policy makers might consider engaging PNC attendants to improve post-natal care nutrition and breastfeeding even as direct evidence is lacking on their impact or training needs. Based on evidence from trained TBAs, training might be of 2-8 days in duration may be suitable, depending on domains being covered (No direct evidence was found related to maternal nutrition). Evidence suggests that training programs which focus on limited basic content accompanied by supportive supervision (by lady health workers or trained nurses or community midwives) and follow-up training may lead to better outcomes. An overall training plan should be developed which would include components related to “Training of the trainers”
and evaluation.

In different cultures and regions across India, specific traditional beliefs and practices are observed during the postpartum period to ensure recovery and avoid ill health of mothers in later years. However, some of these beliefs and practices may prove to be harmful and impact maternal and newborn health outcomes negatively.

The District Medical Officer (DMO), Malappuram, Kerala identified some undesirable and/or harmful postnatal care (PNC) practices being encouraged by post-natal care attendants supporting women for 40 days post-delivery. The DMO, with support from an action group of obstetricians in the district, intends to design and develop training modules to address the harmful practices, particularly in relation to nutrition and breastfeeding.

She requested our RES team to conduct a rapid review that could support her in this policy endeavour. The team together with the DMO concurred on summarising evidence on three relevant components:  recommendation from relevant guidelines on best practices for postnatal care, harmful postpartum beliefs and practices of mothers in India, and training of post-natal care attendants for post-natal care, nutrition and breastfeeding. This would provide the DMO with an evidence base to develop the training modules.

This rapid review identified and summarised some of the commonalities in harmful postpartum cultural practices across different regions and settings in India.

Policy options:

• Health education and promotion programmes should identify and discourage mothers and their family members from resorting to locally prevalent harmful postpartum practices.
• A checklist of healthy postpartum practices may be developed for postpartum mothers, their families and for newborn care.
• It is important that community level health workers such as the ANMs, Anganwadi, and ASHAs in rural India are supported to develop locally tailored behaviour change communication strategies related to postpartum care.

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease witnessing an increase in its burden worldwide, particularly in low-and-middle-income countries (LMICs). The State Health Resource Centre (SHRC), Chhattisgarh identified a high burden of COPD in the State. The decision makers perceived a lack of evidence-informed interventions to improve quality of care (QoC) among COPD patients at the primary healthcare (PHC) level. The Centre requested our RES team to review the existing evidence on such interventions.

The rapid review we conducted offers an overview of evidence on the interventions to improve QoC for patients with COPD in PHC settings. This would enable decision makers to better manage COPD and improve quality of care among the patients in Chhattisgarh.

Key policy considerations:

1. Smoking cessation is a key measure in improving health outcomes for smokers with COPD. Primary health care centres and professionals should be engaged for providing anti-tobacco initiatives.
2. Patients who smoke should be assisted with smoking-cessation through counselling (behavioural) and pharmacological support to enhance the success of smoking quit rates.
3. Support for smoking cessation for all types of tobacco products including but not limited to cigarettes, cigars, bidi, hookah, chillum etc. should be provided in primary health centres.
4. Primary healthcare professionals may deliver smoking cessation counselling via oral, written instructions or through audio-visual media.
5. Patients should be provided structured education and support on self-management of COPD with written action plans, including signs of worsening symptoms and what to do in that case, medications and doses, and instructions on smoking cessation.
6. Long-acting bronchodilators’ (long-acting beta2-agonist (LABA) or long-acting muscarinic antagonist (LAMA)) fixed dose combinations (according to local guidelines), in a single inhaler are effective for patients with persisting symptoms and/or exacerbations, as a follow-up treatment to bronchodilator monotherapy. 
7. Future studies including cost analyses are required for definitive conclusions on the health care costs of various strategies in primary health care settings.
8. Trials with a larger sample size, longer follow ups, and tailored interventions should be conducted to address the knowledge gaps relevant to primary health care settings.

The full policy brief and technical supplement document are available below:

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Download supplement document (PDF 935 KB)

Breast cancer is the most commonly reported cancer among women in India with an incidence rate of 25.8 percent per 100,000 women in 2012. A key strategy of India’s National Programme for the Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) has been to carry out effective primary breast cancer screening among women. The Atal Bihari Vajpayee Institute of Good Governance and Policy Analysis (AIGGPA), an autonomous policy think-tank under the Government of Madhya Pradesh, requested our RES team to review the existing evidence on the usability of palmer ATD-angle measurement to accurately screen women at-risk of breast cancer. The method was perceived as cost-effective, non-invasive and accessible.

The rapid evidence synthesis thus conducted provided AIGGPA with evidence-informed policy options on the use of ATD-angle measurement as an alternative to standard breast cancer screening methods.

Key policy options are:

1. Research done so far on ATD-angle measurement for breast cancer did not use appropriate and rigorous study designs. Further, the studies did not measure the required parameters (sensitivity and specificity) to understand if ATD-angle measurement could be used instead of CBE (alone or in conjunction with USG/mammography) for community screening.
2. Decision-makers may consider prioritising funding for a pilot study to assess the diagnostic accuracy of ATD-angle measurement for breast cancer screening in women using an appropriate study design.

The full policy brief and technical supplement documents are available below:

• Download Policy brief (PDF 741 KB)
• Download Supplement document (PDF 1.1 MB)

The pandemic is putting an unprecedented demand on health systems and the health workforce in India and across countries. Emergency hospital admissions for chronic conditions can further stretch an already strained public health system. There are medications which can affect hospital admissions for patients with such conditions like chronic obstructive pulmonary disease (COPD) and asthma.

This policy brief summarises evidence on such medications from a single high-quality overview of systematic reviews. Recommendations on the medicines based on available evidence are:

1. Long-acting muscarinic antagonists like tiotropium bromide (moderate quality evidence) and long-acting beta 2 agonists like formoterol and salmeterol (moderate quality evidence) can reduce odds of hospital stay of stable COPD patients by 44% and decrease risk of hospital admission by 27% respectively.
2. Inhaled corticosteroids like beclomethasone and short acting antimuscarinic agent such as ipratropium bromide (moderate quality evidence) may be used early in patients with acute asthma exacerbation to reduce the risk of emergency admissions by 58% and 32% respectively.
3. Fluticasone (high quality evidence) increases the risk of pneumonia led hospitalization in patients with moderate to severe stable COPD by 81%

Download policy brief (PDF 221 KB)

This report is a part of the Ensuring Health Systems Capacity for COVID-19 and Beyond: Evidence Series. The series aims to provide high quality and contextualised evidence from systematic reviews or rapid evidence synthesis to work on the opportunity the COVID-19 scenario offers i.e., to build a strong, resilient and equitable health system in India and other low-and-middle income countries (LMICs).

A collective of public health and consumer advocates make the following statement in response to this review.

 
In Australia, almost one quarter of children aged 5-17 years are overweight or obese. We do not agree with the use of an industry self-regulated code on such an important public health issue. Consequently, we do not believe any current or previous AANA Review of Food and Beverage Advertising, or any resultant changes to the Code, will provide an adequate response to reducing children’s exposure to unhealthy food and drink advertising. We affirm our position that any action to address the persistently high levels of marketing of unhealthy products to children in Australia must come in the form of legislation supported by the Government. 

For our full statement please download the attached submission.

The Ministry of Health and Family Welfare (MoHFW), Government of India had released a guidance note which identified the use of telehealth platforms to deliver essential medical services for non-COVID health conditions. The WHO guideline on digital interventions for health system strengthening recognises Mobile Health (mHealth) as an effective means to support such service delivery. It minimises patient-provider contact, thus ensuring physical distancing. mHealth involves the use of mobile devices such as smartphones, patient-monitoring devices, personal digital assistants, and tablets to support public healthcare practices. It could be used effectively by healthcare workers to deliver health services to patients remotely and improve overall communication with co-workers, patients and decision makers. It is important to also outline challenges and enabling factors to adoption of mHealth for delivering healthcare services from health workers’ perspective.

This policy brief summarises evidence on barriers and enablers to the use of mHealth for delivering primary healthcare services by health workers.

Key policy considerations are:

1. Health workers should be encouraged to use mobile devices to initiate remote consultation calls to their patients. To facilitate this, policies and protocols should be in place to explain what can and cannot be done in the remote consultations (i.e.  determine what type of cases warrant face-to-face contact), and to clarify the liability issues of health workers using mobile devices. (high confidence in the evidence).
2. A standardised mHealth training package that covers the generic aspects of use of mobile devices and good data practices should be developed to appropriately train and mentor health workers on the correct use of mobile devices. The package should include the provision of learning and training content via mobile devices to complement traditional methods of delivering continued health education and post-certification training.  
3. Using  mobile devices should lead to reduced travel time to remote/distant places and settings of health workers. Guidelines in collaboration with health workers should be developed to protect them from patients contacting them outside of normal working hours, such as in the context of emergencies or other considerations. (high confidence in the evidence)
4. Health workers need to be aware of the importance of confidentiality of patient information when using mobile devices. mHealth applications for use by health workers to incorporate privacy and confidentiality preserving technologies by design. (high confidence in the evidence).
5. Health workers should use mobile devices to counsel and influence patients' health behaviours in a positive way through health promotion and educational messages. (moderate confidence in the evidence)
6. Health workers need better integration of mHealth interventions with other existing electronic health information systems and to consolidate data dashboard between different vertical programmes. This will improve the usability of their mobile devices and replace the need for physical reporting tools to avoid duplication of data recording and reporting systems. (moderate confidence in the evidence)
7. The use of mobile devices to record routine patient or surveillance data is helpful for decision making. Ensure mechanisms for documenting and tracing past exchanges and decisions made during consultations.

The report provides a summary of evidence from two systematic reviews and a WHO guideline on digital health interventions.

Download full report (PDF 303 KB)

This report is a part of the Ensuring Health Systems Capacity for COVID-19 and Beyond: Evidence Series. The series aims to provide high quality and contextualised evidence from systematic reviews or rapid evidence synthesis to work on the opportunity the COVID-19 scenario offers i.e., to build a strong, resilient and equitable health system in India and other low-and-middle income countries (LMICs).

The George Institute’s food policy team work in Australia and overseas to reduce death and disease caused by diets high in salt, harmful fats, added sugars and excess energy. The team does multi-disciplinary research with a focus on outputs that will help government and industry deliver a healthier food environment for all. 

The George Institute strongly supports HSR as an important step forward in improving nutrition labelling for consumers and supporting healthier diets. Our research suggests HSR is performing well overall, while also highlighting areas where the system must be strengthened to retain consumer trust and maximise public health impact. As a public health organization, we are best able to support and promote a revised HSR that addresses the legitimate public health and consumer concerns raised in the Review.
 
In these final stages, our support relies upon attention being directed to the following:

• Strengthening HSR’s algorithm by adopting Calculator 2. 
• Avoiding further delay in delivering an improved HSR to consumers. While acknowledging the impact of COVID-19 on all system stakeholders, we believe the proposed start date and two-year implementation period is more than sufficient to take possible disruptions into account.
• Taking concrete action now to make HSR mandatory. 
• Implementing improvements to HSR’s governance. 

 
The George Institute welcomes this opportunity to engage on implementation of changes resulting from Health Star Rating’s Five Year Review (HSR Review). 

For our full comments and additional modelling, please download the attached submission.

Chronic obstructive pulmonary disease (COPD) is preventable and often remains undetected in its mild and moderate forms. The State Health Resource Centre (SHRC), Chhattisgarh identified a high burden of the condition in the State particularly in areas of high industrial pollution. The Centre requested our RES team to review the existing evidence on effectiveness of different case-finding approaches and the accuracy of screening tests for detecting COPD. The evidence was to be relevant to a primary health care setting and from a low-and-middle income (LMIC) perspective.

The rapid review thus conducted provided the SHRC with a summary of evidence-based policy considerations. This would enable decision makers in improving detection of COPD at the primary health care level in Chhattisgarh.

Key policy considerations:

1. Screening for COPD in primary healthcare should be promoted and appropriate training provided.
2. The COPD Diagnostic Questionnaire (CDQ) might be considered as a screening tool for detecting air flow limitation in general population and facilitate early diagnosis. Those with a high score (>16.5 or 17) should undergo confirmatory test.
3. Use of handheld flow meters under the supervision of trained health professionals in addition to COPD questionnaire is likely to improve accuracy in detection of undiagnosed COPD but leads to additional resource investment
4. Provision for pre and post bronchodilator spirometry as a confirmation test for all the suspected cases of COPD in a Primary Healthcare centre is essential

The full policy brief and technical supplement document are available below:

Download policy brief (PDF 284 KB)

Download supplement document (PDF 463 KB)

Asthma is a common chronic respiratory disease with an increasing incidence reported in low-and-middle-income (LMIC) countries. The State Health Resource Centre (SHRC), Chhattisgarh identified a high burden of the condition in the State particularly in areas of high industrial pollution. The Centre requested our RES team to review the existing evidence on interventions to improve quality of care among children and adolescents with asthma. The evidence was to be contextualised for primary health care settings and from an LMIC perspective.

The rapid review thus conducted provided the SHRC with a summary of evidence-based policy considerations. This would enable decision makers in better managing and improving the quality of care among children and adolescents with asthma at the primary health care level in Chhattisgarh.

Key policy considerations:

1. Children and their parents/caregivers should be provided education and support on self-management of asthma including signs of worsening symptoms and what to do in that case. Primary care providers should be provided education on self-management support for asthma patients.
2. Self-management support and education (frequency of inhaler use and proper inhaler technique) should be provided by primary health care staff to improve adherence. Multimedia training (for example, through online video training) should be considered for improving inhaler technique.
3. Medication technique and adherence should be reviewed at each follow-up visit (supported by spirometry results).
4. Peer support might improve quality of life in adolescents. This might be facilitated through the National Adolescent Health Program.
5. Telehealth interventions that are mobile app-based may be considered for consultations and monitoring; however, the additional costs of telemonitoring should be taken into consideration.
6. Prevention of acute exacerbations for asthma is the key to improving quality of care. Considerations for that are covered in a separate policy brief.

The full policy brief and technical supplement document are available below:

Download policy brief (PDF 222 KB)

Download supplement document (PDF 785 KB)