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OBJECTIVES: To determine the proportion of deaths attributable to suicides in rural Andhra Pradesh, India over a 4-year period using a verbal autopsy method. METHODS: Deaths occurring in 45 villages (population 185,629) were documented over a 4-year period from 2003-2007 by non-physician healthcare workers (NPHWs) trained in the use of a verbal autopsy tool. Causes of death were assigned by physicians trained in the International Classification of Diseases, version 10. All data were entered and processed electronically using a secure study website. RESULTS: Verbal autopsies were completed for 98.2% (5786) of the deaths (5895) recorded. The crude death rate was 8.0/1000. 4.8% (95% CI 4.3-5.4) of all deaths were suicides, giving a suicide rate of 37.5/100,000 population. 43% of suicides occurred in the age group 15-29 years, and 62% were in men. In the younger age groups (10-29 years), suicides by women (56%), were more common than by men (44%). Poisoning (40%) was the most common method of self-harm followed by hanging (12%). CONCLUSION: The suicide rate in this part of rural Andhra Pradesh is three times higher than the national average of 11.2/100,000, but is in line with those reported in the Million Death Study. There is an urgent need to develop strategies targeted at young individuals to prevent deaths by suicide in India. This article is protected by copyright. All rights reserved. Language: en

BackgroundCardiovascular disease (CVD) is the major cause of premature death and disability in India and yet few people at risk of CVD are able to access best practice health care. Mobile health (mHealth) is a promising solution, but very few mHealth interventions have been subjected to robust evaluation in India. ObjectiveThe objectives were to develop a multifaceted, mobile clinical decision support system (CDSS) for CVD management and evaluate it for use by public nonphysician health care workers (NPHWs) and physicians in a rural Indian setting. MethodsPlain language clinical rules were developed based on standard guidelines and programmed into a computer tablet app. The algorithm was validated and field-tested in 11 villages in Andhra Pradesh, involving 11 NPHWs and 3 primary health center (PHC) physicians. A mixed method evaluation was conducted comprising clinical and survey data and in-depth patient and staff interviews to understand barriers and enablers to the use of the system. Then this was thematically analyzed using NVivo 10. ResultsDuring validation of the algorithm, there was an initial agreement for 70% of the 42 calculated variables between the CDSS and SPSS software outputs. Discrepancies were identified and amendments were made until perfect agreement was achieved. During field testing, NPHWs and PHC physicians used the CDSS to screen 227 and 65 adults, respectively. The NPHWs identified 39% (88/227) of patients for referral with 78% (69/88) of these having a definite indication for blood pressure (BP)-lowering medication. However, only 35% (24/69) attended a clinic within 1 month of referral, with 42% (10/24) of these reporting continuing medications at 3-month follow-up. Physicians identified and recommended 17% (11/65) of patients for BP-lowering medications. Qualitative interviews identified 3 interrelated interview themes: (1) the CDSS had potential to change prevailing health care models, (2) task-shifting to NPHWs was the central driver of change, and (3) despite high acceptability by end users, actual transformation was substantially limited by system-level barriers such as patient access to doctors and medicines. ConclusionsA tablet-based CDSS implemented within primary health care systems has the potential to help improve CVD outcomes in India. However, system-level barriers to accessing medical care limit its full impact. These barriers need to be actively addressed for clinical innovations to be successful. Trial RegistrationClinical Trials Registry of India: CTRI/2013/06/003753; http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=6259&EncHid=51761.70513&userName=CTRI/2013/06/003753 (Archived by WebCite at http://www.webcitation.org/6UBDlrEuq).

Background Levels of haemoglobin A1c (HbA1c) and blood lipids are important determinants of risk in patients with diabetes. Standard analysis methods based upon venous blood samples can be logistically challenging in resource-poor settings where much of the diabetes epidemic is occurring. Dried blood spots (DBS) provide a simple alternative method for sample collection but the comparability of data from analyses based on DBS is not well established. Methods We conducted a systematic review and meta-analysis to define the association of findings for HbA1c and blood lipids for analyses based upon standard methods compared to DBS. The Cochrane, Embase and Medline databases were searched for relevant reports and summary regression lines were estimated. Results 705 abstracts were found by the initial electronic search with 6 further reports identified by manual review of the full papers. 16 studies provided data for one or more outcomes of interest. There was a close agreement between the results for HbA1c assays based on venous and DBS samples (DBS = 0.9858venous + 0.3809), except for assays based upon affinity chromatography. Significant adjustment was required for assays of total cholesterol (DBS = 0.6807venous + 1.151) but results for triglycerides (DBS = 0.9557venous + 0.1427) were directly comparable. Conclusions For HbA1c and selected blood lipids, assays based on DBS samples are clearly associated with assays based on standard venous samples. There are, however, significant uncertainties about the nature of these associations and there is a need for standardisation of the sample collection, transportation, storage and analysis methods before the technique can be considered mainstream. This should be a research priority because better elucidation of metabolic risks in resource poor settings, where venous sampling is infeasible, will be key to addressing the global epidemic of cardiovascular diseases.

Objective: The gold standard method for measuring population sodium intake is based on a 24 h urine collection carried out in a random population sample. However, because participant burden is high, response rates are typically low with less than one in four agreeing to provide specimens. At this low level of response it is possible that simply asking for volunteers would produce the same results. Conclusions: The estimated salt consumption derived from the two samples was comparable and was not substantively different to estimates obtained from other surveys. In countries where salt is pervasive and cannot easily be avoided, estimates of consumption obtained from volunteer samples may be valid and less costly. Participants: We randomly selected 2152 adults and obtained usable 24 h urine samples from 306 (response rate 16%). Specimens were also collected from a further 113 volunteers. Estimated salt consumption and the costs for each strategy were compared. Results: The characteristics of the 'random' and 'volunteer' samples were moderately different in mean age 58 (SD 14.6 vs 49(17.7) years, respectively; p

Background Setting priorities for the prevention and management of heart failure requires an empirical understanding of the pattern of disease burden. We aim to describe the methods for a systematic review of the literature on burden of heart failure in low- and middle-income countries (LMIC) and how this information will be synthesized to produce useful estimates that can inform policy and practice. Methods We will conduct a comprehensive search strategy for articles published between 1995 and April 2012 related to incidence, prevalence and treatment of heart failure in LMIC. Populations will be coded as urban, rural, or combined and studies classified as national, sub-national, healthcare system-based, or community level. Details from eligible studies will be extracted independently by two reviewers using a pre-designed data extraction form that will cover information on demographics, diagnostic criteria including disease incidence and prevalence, medical history, medication history, and hospital- or community-based management and outcomes. We will assess the reporting and methodological quality of the included studies and conduct a quantitative summary of reported outcomes where appropriate. Discussion Currently, there are important gaps in our knowledge on the burden of heart failure in LMIC and this systematic review aims to provide useful information that improves our knowledge in this field. Results are expected to be publicly available in early 2013.

Background The process of data collection and the methods used to assign the cause of death vary significantly among different verbal autopsy protocols, but there are few data to describe the consequences of the choices made. The aim of this study was to objectively define the impact of the format of data presented to physician reviewers on the cause-specific mortality fractions defined by a verbal autopsy-based mortality-surveillance system. Methods Verbal autopsies were done by primary health care workers for all deaths between October 2006 and September 2007 in a community in rural Andhra Pradesh, India (total population about 180,162). Each questionnaire had a structured section, composed of a series of check boxes, and a free-text section, in which a narrative description of the events leading to death was recorded. For each death, a physician coder was presented first with one section and then the other in random order with a 20- to 40-day interval between. A cause of death was recorded for each data format at the level of ICD 10 chapter headings or else the death was documented as unclassified. After another 20- to 40-day interval, both the structured and free-text sections of the questionnaire were presented together and an index cause of death was assigned. Results In all, 1,407 verbal autopsies were available for analysis, representing 94% of all deaths recorded in the population that year. An index cause of death was assigned using the combined data for 1,190 with the other 217 remaining unclassified. The observed cause-specific mortality fractions were the same regardless of whether the structured, free-text or combined data sources were used. At the individual level, the assignments made using the structured format matched the index in 1,012 (72%) of cases with a kappa statistic of 0.66. For the free-text format, the corresponding figures were 989 (70%) and 0.64. Conclusions The format of the verbal autopsy data used to assign a cause of death did not substantively influence the pattern of mortality estimated. Substantially abbreviated and simplified verbal autopsy questionnaires might provide robust information about high-level mortality patterns.

IntroductionThe scientific evidence base in support of salt reduction is strong but the data required to translate these insights into reduced population salt intake are mostly absent. The aim of this research project is to develop the evidence base required to formulate and implement a national salt reduction programme for India.Methods and analysisThe research will comprise three components: a stakeholder analysis involving government, industry, consumers and civil society organisations; a population survey using an age-stratified and sex-stratified random samples drawn from urban (slum and non-slum) and rural areas of North and South India; and a systematic quantitative evaluation of the nutritional components of processed and restaurant foods. The stakeholder interviews will be analysed using qualitative methods to summarise the main themes and define the broad range of factors influencing the food environment in India. The population survey will estimate the mean daily salt consumption through the collection of 24 h urine samples with concurrent dietary surveys identifying the main sources of dietary sodium/salt. The survey of foods will record the nutritional composition of the chief elements of food supply. The findings from this research will be synthesised and proposals for a national salt reduction strategy for India will be developed in collaboration with key stakeholders.Ethics and disseminationThis study has been approved by the Human Research Ethics Committees of the University of Sydney and the Centre for Chronic Disease Control in New Delhi, and also by the Indian Health Ministry's Screening Committee. The project began fieldwork in February 2014 and will report the main results in 2016. The findings will be targeted primarily at public health policymakers and advocates, but will be disseminated widely through other mechanisms including conference presentations and peer-reviewed publications, as well as to the participating communities.

Background Monitoring progress with disease and injury reduction in many populations will require widespread use of verbal autopsy (VA). Multiple methods have been developed for assigning cause of death from a VA but their application is restricted by uncertainty about their reliability. Methods We investigated the validity of five automated VA methods for assigning cause of death: InterVA-4, Random Forest (RF), Simplified Symptom Pattern (SSP), Tariff method (Tariff), and King-Lu (KL), in addition to physician review of VA forms (PCVA), based on 12,535 cases from diverse populations for which the true cause of death had been reliably established. For adults, children, neonates and stillbirths, performance was assessed separately for individuals using sensitivity, specificity, Kappa, and chance-corrected concordance (CCC) and for populations using cause specific mortality fraction (CSMF) accuracy, with and without additional diagnostic information from prior contact with health services. A total of 500 train-test splits were used to ensure that results are robust to variation in the underlying cause of death distribution. Results Three automated diagnostic methods, Tariff, SSP, and RF, but not InterVA-4, performed better than physician review in all age groups, study sites, and for the majority of causes of death studied. For adults, CSMF accuracy ranged from 0.764 to 0.770, compared with 0.680 for PCVA and 0.625 for InterVA; CCC varied from 49.2% to 54.1%, compared with 42.2% for PCVA, and 23.8% for InterVA. For children, CSMF accuracy was 0.783 for Tariff, 0.678 for PCVA, and 0.520 for InterVA; CCC was 52.5% for Tariff, 44.5% for PCVA, and 30.3% for InterVA. For neonates, CSMF accuracy was 0.817 for Tariff, 0.719 for PCVA, and 0.629 for InterVA; CCC varied from 47.3% to 50.3% for the three automated methods, 29.3% for PCVA, and 19.4% for InterVA. The method with the highest sensitivity for a specific cause varied by cause. Conclusions Physician review of verbal autopsy questionnaires is less accurate than automated methods in determining both individual and population causes of death. Overall, Tariff performs as well or better than other methods and should be widely applied in routine mortality surveillance systems with poor cause of death certification practices.

Background Verbal autopsy methods are critically important for evaluating the leading causes of death in populations without adequate vital registration systems. With a myriad of analytical and data collection approaches, it is essential to create a high quality validation dataset from different populations to evaluate comparative method performance and make recommendations for future verbal autopsy implementation. This study was undertaken to compile a set of strictly defined gold standard deaths for which verbal autopsies were collected to validate the accuracy of different methods of verbal autopsy cause of death assignment. Methods Data collection was implemented in six sites in four countries: Andhra Pradesh, India; Bohol, Philippines; Dar es Salaam, Tanzania; Mexico City, Mexico; Pemba Island, Tanzania; and Uttar Pradesh, India. The Population Health Metrics Research Consortium (PHMRC) developed stringent diagnostic criteria including laboratory, pathology, and medical imaging findings to identify gold standard deaths in health facilities as well as an enhanced verbal autopsy instrument based on World Health Organization (WHO) standards. A cause list was constructed based on the WHO Global Burden of Disease estimates of the leading causes of death, potential to identify unique signs and symptoms, and the likely existence of sufficient medical technology to ascertain gold standard cases. Blinded verbal autopsies were collected on all gold standard deaths. Results Over 12,000 verbal autopsies on deaths with gold standard diagnoses were collected (7,836 adults, 2,075 children, 1,629 neonates, and 1,002 stillbirths). Difficulties in finding sufficient cases to meet gold standard criteria as well as problems with misclassification for certain causes meant that the target list of causes for analysis was reduced to 34 for adults, 21 for children, and 10 for neonates, excluding stillbirths. To ensure strict independence for the validation of methods and assessment of comparative performance, 500 test-train datasets were created from the universe of cases, covering a range of cause-specific compositions. Conclusions This unique, robust validation dataset will allow scholars to evaluate the performance of different verbal autopsy analytic methods as well as instrument design. This dataset can be used to inform the implementation of verbal autopsies to more reliably ascertain cause of death in national health information systems.

Mean and confidence interval measures of reliability for question responses and COD predictions including and excluding text in the short and long forms of the Verbal Autopsy Instrument. (DOCX 18Â kb)

UGA 1 Assessment. Utilizing HIV/AIDS Infrastructure as a Gateway to Chronic Care of Hypertension in Africa - Uganda (UGA 1).

PER 11 Assessment. Launching a Salt Substitute to Reduce Blood Pressure at the Population Level (PER 11).

IND 6 Assessment. Improving the Control of Hypertension in Rural India: Overcoming the Barriers to Diagnosis and Effective Treatment (IND 6).

TZA 3 Assessment. DREAM-GLOBAL: Diagnosing hypeRtension - Engaging Action and Management in Getting LOwer Bp in Aboriginal and LMIC - Tanzania (TZA 3).

NGA 15 Assessment. Tailored Hospital-based Risk Reduction to Impede Vascular Events after Stroke (THRIVES) (NGA 15).

Tables S1-S6. We have made several assumptions in describing the effects of different treatment paradigms, based on meta-analyses of relevant clinical trials. The additional file 1 consists results of sensitivity analyses conducted to indicate our conclusions remain robust to varying assumptions. (DOCX 34 kb)

Background: Blood Pressure related disease affected 118 million people in India in the year 2000; this figure will double by 2025. Around one in four adults in rural India have hypertension, and of those, only a minority are accessing appropriate care. Health systems in India face substantial challenges to meet these gaps in care, and innovative solutions are needed. Methods: We hypothesise that a multifaceted intervention involving capacity strengthening of primary healthcare doctors and non-physician healthcare workers through use of a mobile device-based clinical decision support system will result in improved blood pressure control for individuals at high risk of a cardiovascular disease event when compared with usual healthcare. This intervention will be implemented as a stepped wedge, cluster randomised controlled trial in 18 primary health centres and 54 villages in rural Andhra Pradesh involving adults aged ≥40 years at high cardiovascular disease event risk (approximately 15,000 people). Cardiovascular disease event risk will be calculated based on World Health Organisation/International Society of Hypertension’s region-specific risk charts. Cluster randomisation will occur at the level of the primary health centres. Outcome analyses will be conducted blinded to intervention allocation. Expected outcomes: The primary study outcome is the difference in the proportion of people meeting guideline-recommended blood pressure targets in the intervention period vs. the control period. Secondary outcomes include mean reduction in blood pressure levels; change in other cardiovascular disease risk factors, including body mass index, current smoking, reported healthy eating habits, and reported physical activity levels; self-reported use of blood pressure and other cardiovascular medicines; quality of life (using the EQ-5D); and cardiovascular disease events (using hospitalisation data). Trial outcomes will be accompanied by detailed process and economic evaluations. Significance: The findings are likely to inform policy on a scalable strategy to overcome entrenched inequities in access to effective healthcare for under-served populations in low and middle income country settings. Trial registration: Clinical Trial Registry India CTRI/2013/06/003753.

COL/MYS 2 Assessment. Developing an Innovative Strategy for Hypertension Detection, Treatment and Control in Two MiddleIncome Countries (Hypertension Outcomes Prevention and Evaluation: HOPE -4) (COL/MYS 2).

Mean and confidence interval measures of reliability for question responses and COD predictions including and excluding text in the short and long forms of the Verbal Autopsy Instrument. (DOCX 18Â kb)

Tables S1-S6. We have made several assumptions in describing the effects of different treatment paradigms, based on meta-analyses of relevant clinical trials. The additional file 1 consists results of sensitivity analyses conducted to indicate our conclusions remain robust to varying assumptions. (DOCX 34 kb)

ZAF 1 Assessment. Utilizing HIV/AIDS Infrastructure as a Gateway to Chronic Care of Hypertension in Africa - South Africa (ZAF1).

NGA 15 Assessment. Tailored Hospital-based Risk Reduction to Impede Vascular Events after Stroke (THRIVES) (NGA 15).

CAN 3 Assessment. DREAM-GLOBAL: Diagnosing hypeRtension - Engaging Action and Management in Getting LOwer Bp in Aboriginal and LMIC - Canada (CAN 3).

GACD hypertension consensus variables, suggested collection methods and number of teams using variable.(DOCX 36Â kb)

PER 11 Assessment. Launching a Salt Substitute to Reduce Blood Pressure at the Population Level (PER 11).

IND 8 Assessment. Randomised Controlled Trial of Early Use of a Simplified Treatment Regimen Incorporating a Half-Dose, Three-in-One Blood Pressure Lowering Pill vs. Usual Care for Improving Hypertension Control in India (IND8).

ARG 14 Assessment. Comprehensive Approach for Hypertension Prevention and Control in Argentina (ARG 14).

ZAF 1 Assessment. Utilizing HIV/AIDS Infrastructure as a Gateway to Chronic Care of Hypertension in Africa - South Africa (ZAF1).

ZAF 5 Assessment. Treating Hypertension in Rural South Africa: Strengthening Community- Based Outreach Services for Integrated Chronic Care (ZAF 5).

CHN 4 Assessment. A School-Based Education Programme to Reduce Salt Intake in Children and their Families (CHN 4).

UGA 1 Assessment. Utilizing HIV/AIDS Infrastructure as a Gateway to Chronic Care of Hypertension in Africa - Uganda (UGA 1).

ZAF 5 Assessment. Treating Hypertension in Rural South Africa: Strengthening Community- Based Outreach Services for Integrated Chronic Care (ZAF 5).

TZA 3 Assessment. DREAM-GLOBAL: Diagnosing hypeRtension - Engaging Action and Management in Getting LOwer Bp in Aboriginal and LMIC - Tanzania (TZA 3).

IND 6 Assessment. Improving the Control of Hypertension in Rural India: Overcoming the Barriers to Diagnosis and Effective Treatment (IND 6).

IND 7 Assessment. A Smartphone-Based Clinical Decision Support System for Primary Health care Workers in Rural India (IND7).

CAN 3 Assessment. DREAM-GLOBAL: Diagnosing hypeRtension - Engaging Action and Management in Getting LOwer Bp in Aboriginal and LMIC - Canada (CAN 3).

IND 7 Assessment. A Smartphone-Based Clinical Decision Support System for Primary Health care Workers in Rural India (IND7).

ARG 14 Assessment. Comprehensive Approach for Hypertension Prevention and Control in Argentina (ARG 14).

IND 8 Assessment. Randomised Controlled Trial of Early Use of a Simplified Treatment Regimen Incorporating a Half-Dose, Three-in-One Blood Pressure Lowering Pill vs. Usual Care for Improving Hypertension Control in India (IND8).

COL/MYS 2 Assessment. Developing an Innovative Strategy for Hypertension Detection, Treatment and Control in Two MiddleIncome Countries (Hypertension Outcomes Prevention and Evaluation: HOPE -4) (COL/MYS 2).

GACD hypertension consensus variables, suggested collection methods and number of teams using variable.(DOCX 36Â kb)

Gold standard clinical diagnosis criteria. (DOCX 117 kb)