Study Design and Settings
In the present paper, we present a secondary analysis of routinely collected STFC-MMU program data. The program currently operates in 22 cities (program locations) across 12 states of India. In each city, a particular MMU covers specific program service sites (average 11 per site). The program service sites are selected based on truck driver’s density, closeness to major national highways, and after discussion with truck union leaders and the respective state governments. Figure 1 gives an overview of the program locations in different states. For analysis purpose, we divide program locations into three regions namely East (Odisha, Bihar, Assam, Jharkhand & West Bengal), West (Maharashtra, Gujarat & Rajasthan), and South (Karnataka, Tamil Nadu, Andhra Pradesh & Telangana).
STFC-MMU Program Description
The scope of STFC-MMU program is to provide beneficiaries preventive (screening for diabetes and hypertension through random blood glucose and blood pressure monitoring, and oral precancerous conditions), promotive (counseling on life-style related, and locally prevalent diseases including sexually transmitted diseases chiefly HIV & AIDS), diagnostic (urine albumin, haemoglobin and malaria testing), curative (treatment for minor ailments, injuries, including illnesses such as diarrhoea and acute respiratory infections) and referral services (for complicated and high risk cases). PSMRI manages the design and implementation of the program while the STFCL provides funds to deliver the health care services to truck drivers. The program has two essential elements: physical and operational.
Manpower: Each MMU has four staff members (Medical doctor, nurse, pharmacist, and driver). The role of the doctor is to provide preventive, promotive, curative care and referral services; nurse takes care of registration, captures the anthropometrics, basic lab testing, and assists doctor; pharmacist maintains the drug inventory, dispenses medicine, and responsible for data entry and management. The driver takes care of the vehicle and accompanies other staff members.
Equipment: Every vehicle is equipped with essential medicines and medical equipment such as digital blood pressure machine, glucometer, thermometer, weighing and height meter scale and torchlights to perform simple clinical investigations. Also, each MMU has an internet-enabled tablet and a preloaded software application for data collection and documentation purpose.
Field Operations: All MMUs operate 24 days (Monday to Saturday; 10.00 AM to 5:00 PM) in a month. Every day, each MMU visit two program service sites (morning and evening) as per fixed-day service delivery schedule and pre-defined route maps. On a routine day, MMU nurse registers the beneficiary using software application and records their basic demographics, vitals, anthropometrics, biochemical, and clinical parameters. Next, the doctor performs the routine physical examination, prescribe laboratory tests as needed, and diagnose the health problems. The doctor then either prescribe the required medicine or refer the beneficiary to the next level of the healthcare facility as per assessed need. The doctor also counsels the beneficiary to maintain a healthy lifestyle.
In the next counter, a pharmacist dispenses the prescribed medicines free of cost based on the doctor’s prescription. The pharmacist also manages the drug and data inventory of his MMU. Finally, nurse and pharmacist enter the beneficiary data using software application, synced daily on to centrally placed data servers. Figure 2 describes the services flow on any day.
Analytical Frame for Analysis
We accessed and analyzed routinely collected health records of truck drivers who availed STFC-MMU program services between July 2018 to February 2019. Variable filters such as age range (15 to 75 years), body mass index range (10 to 75 kg/square meter) random blood sugar ranges (40 to 600 mg/dl) were applied considering possible theoretical values of medical metrics (14–16). Figure 3 explains the procedure for calculating the final analytical frame.
The analysis was restricted to routinely collected health records of truck drivers, defined as “someone who drives the heavy/medium/small truck” and is utilizing STFC-MMU program services. The data include variables and information of the truck driver captured on their first visit to MMU.
Health records of helpers, support staff, or family member of the truck drivers.
Variables, Definitions, and Measures
From the final set of routine health records, we extracted the data on demographics (age, sex, marital status, and occupation), habits (tobacco and alcohol consumption), anthropometric measures (height, weight), clinical parameters (blood pressure and random blood sugar) and types of health problems. Health problems among truck drivers were either self-reported or diagnosed on-site by MMU doctor during their first consultation visit.
We used “Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT)" for consultation classification (17). We classified consultations further into six problem categories:
- The non-communicable disease includes diabetes mellitus, hypertension, asthma, cataract, chronic obstructive pulmonary disease (COPD), and acid peptic disease
- Musculoskeletal problems include arthralgia, arthritis, injury/trauma, myalgia, and osteoarthritis
- Communicable diseases include acute bronchitis, acute diarrhea, acute rhinitis, amebiasis, conjunctivitis, dengue fever, dysentery, gastroenteritis, giardiasis, influenza (flu), lower respiratory tract infection, malaria, otitis media, pharyngotonsillitis, sinusitis, typhoid fever, urinary tract infection, viral fever, viral hepatitis and worm infestation
- Skin problems include allergic rash, boils, fungal infections, impetigo, pyoderma, scabies, and wounds
- Problems related to the oral cavity include aphthous ulcers, dental caries, dental fluorosis, febrile blisters, gingivitis, glossitis, gum abscess, oral ulcers, and stomatitis & cheilitis
- Other category includes anything not specified as above
We used standard definitions of body mass index for Asian Indians for risk profiling (14). Random blood sugar (RBS) values were categorized into “Normal” (RBS < 140 mg/dl); “Impaired glucose level”( RBS between 140—199 mg/dl) and “Diabetic” (RBS ≥200 mg/dl) with classic symptoms of hyperglycemia” (18). National Family Health Survey–4 definitions for “Normal” (Systolic <140 mm Hg and/or Diastolic <90 mm Hg); “Slightly above normal” (Systolic 140–159 mm Hg and/or Diastolic 90–99 mm Hg); “Moderately high” (Systolic 160–179 mm Hg and/or Diastolic 100–109 mm Hg) and “Very high” (Systolic ≥180 mm Hg and/or Diastolic ≥110 mm Hg) were used for blood pressure categorization (19).