Resources & Protocols for Primary Care

Please be aware that I am not a medical doctor, and none of these protocols or guidelines have been formulated by me. This note is simply an attempt to bring them together in one place for easy accessibility by primary care providers. These protocols are not meant for direct personal use by readers without medical training.

Primary is often thought of as being simple. However, while it is indeed the case that for each condition, the primary care level treatment to be offered is straightforward, making it eminently suitable for non-physicians like Ashiya (in the blue uniform in the picture; see here for the full graphical narrative) to provide it to patients, the sheer range of conditions that one encounters is very high and picking the proper treatment often becomes an enormous challenge. Fortunately, this is where protocols, workflows, and decision support systems come in.

Some of the best tools that offer this support are fully automated and also use natural language processing and other techniques to help the clinician with differential diagnoses, treatment strategies, and even note-taking and automated ordering of the required medicines. Some examples are Babylon and Ada Health . In India, these tools are not available, but fortunately, there are several resources that we can turn to for guidance:

Comprehensive Screening Protocols

I could not find a good resource for this, so I assembled them into a discussion paper with complete citations for where I found them. These protocols have been drawn from a combination of Indian and international sources, with some, like the US Preventive Services Task Force, also available on a free app .

Comprehensive Treatment Protocols for Primary Care

• Basic Healthcare Services Protocols: If you don’t want to refer to multiple sites and want something that your non-physician staff can quickly begin to use, Basic Healthcare Services offers primary care protocols that have been in active use in remote-rural primary care settings. They are available in English and Hindi . For clarifications on these protocols, please contact Dr Amruth Jacob ([email protected] ) at Basic Healthcare Services.
• Alaska Community Health Aide Manual (CHAM): One of the most successful models that I have come across, which uses protocols as an integral part of their work, is the Alaska Community Health Aide Program (CHAP) . Young people from remote Alaskan tribal communities (for the most part, high school graduates), chosen by the community for this purpose, are trained over a four-to-six-week period (see here and here ) ?and rely entirely on the Community Health Aide Manual for all their tasks (a really old version of the CHAM can be found here -- there is a settings icon on the right of the screen -- it will allow you to download the book -- it is a 211 MB file).
• South African Ideal Clinic Program: This is the best comprehensive primary care design effort I have seen. If interested, you can learn more about it from their beautifully designed website . They have a wealth of high-quality resources available for free download from their site. You can, for example, download their marvellously illustrated “Symptom-based integrated approach to the adult in primary care” from this link and their “Integrated Management of Childhood Illness” from this link .
• SughaVazhvu Treatment Protocols: These protocols were developed around 2010-11 when the SughaVazhvu effort was active in Thanjavur (Tamil Nadu). They were actively used in the SughaVazhvu clinics.
• Treatment Protocols from ICMR: The Indian Council of Medical Research has published a collection of treatment protocols in beautifully designed workflows that are very easy to use. They are downloadable as PDF files, accessible from the web, and also have a free app associated with them. They can all be accessed here .

Specialised Treatment Protocols

Malnutrition

• Intervention Protocols: This is very much a primary care condition and, like most other such conditions, requires a deep engagement with the community, which cannot be just confined to the clinic. This is a complex area, and there is no better partner to guide you in your efforts than SNEHA .?Their implementation study provides all the details necessary to make a program similar to theirs operational. More information can be obtained directly from them by contacting Dr Rijuta Sawant ([email protected] ) at SNEHA. This note lists two interventions for mothers and four for children under the age of two years.
• Breastfeeding and Complementary Feeding: The Spoken Tutorial project of IIT Bombay has produced a series of YouTube videos on the correct breastfeeding and complementary feeding techniques?for the first 1000 days of life. The entire series has been created using graphics and animation with simultaneous narration in simple words to help illustrate the respective topics with maximum clarity. These videos are available in 22 Indian languages.
• Iron Deficiency Anaemia: The WHO guideline on this for children (published on March 11th, 2016) and the Government of India's Ministry of Health and Family Welfare guideline (published on January 15th, 2013 -- see table 6.1 on page 17) both suggest that where the prevalence of anaemia is more than 40%, women and children can be offered regular deworming and iron supplementation "irrespective of their iron/Hb status". The status of iron deficiency anaemia in your district can be obtained through this very easy-to-use visualisation tool for the data generated by the National Family Health Survey.
• Severe Acute Malnutrition (SAM): Basic Healthcare Services (BHS) uses a clearly defined set of protocols for the treatment of SAM children (page 1.14 here in English and Hindi ). The BHS protocol requires that the SAM child be regularly given Ready-to-Use Therapeutic Food (RUTF) to make up for the extreme nutritional deficiencies quickly. The product they use in the BHS clinics is called eeZeePoshan and is made by a company called Compact India. The person to contact there is Naman Jain (+91 97176 91114, [email protected] ). If more information is needed at the BHS end, the person to contact is Preeti Bhatnagar at [email protected] .

Urinary Tract Infection (UTI)

While NICE (UK) has perhaps the most comprehensive guidelines that I've seen, in a developing country context, the best are in the South African "Symptom-based integrated approach to the adult in primary care” (see the section on South Africa in the list for the link to it) on page 51 ("Urinary Symptoms"). An important, surprising distinction between the South African guideline and the UK guideline is that while the former requires the use of a dipstick urine test for leukocytes and nitrites, the UK guideline permits proceeding to treatment (even with a phone consult ) if two or more of the following symptoms are present:

1. burning pain while passing urine (dysuria);
2. passing urine more than usual at night (new nocturia);
3. urine cloudy to the naked eye.

The guidelines on UTI issued by Basic Healthcare Services (included in this article -- pages 4.31-4.33) are also consistent with the South African ones. However, on the issue of dipstick usage, in a low-resource setting, the UK guideline may well be an adequate one to consider.

Fever in Adults

This component is missing from the ICMR workflows, and the best document is Chapter 2 of ICMR’s?Treatment Guidelines for Antimicrobial Use in Common Syndromes .?These are somewhat harder to grasp than the workflows, but the chart on page 9 is easy enough to follow.

Pain Management

This is another area in which there is much need (and much malpractice, unfortunately, both in terms of “too much too soon” as well as “too little too late”). The WHO has guidelines which are relatively easy to use and are best described in this 6-minute YouTube video . There are also simple Yoga exercises that the primary care provider can show the patient and offer some physiotherapy. While there are several sources one could refer to for these exercises, the one I found most comprehensive is the Swasth Yog Institute . Their back pain exercise videos and their joint pain exercise videos are comprehensive and easy to use. For more information as well as to request training support for your health workers, you could reach out to them directly by email/phone using [email protected] or +91 77770 92540.

Along with other forms of therapy, medicines are often required to be used to manage pain. The best-written guidance I have seen on the use of medicines for pain management is in the South African "Symptom-based integrated approach to the adult in primary care” (see the section on South Africa in the list for the link to it) -- in order to formulate your own protocol, the best place to start would be on page 52 ("Body/General Pain).

If you're interested in a deeper understanding of both opioid and non-opioid therapies in the use of pain management, I would recommend this (free) course titled "Best Practices in the Use of Opioids" developed by Dr Nandini Vallath for the National Cancer Grid's online learning portal .

Preventing and Managing Hyperthermia and Heat Stroke

As the summer months start, managing complications related to heat becomes an urgent priority. Basic Healthcare Services recently posted complete guidance on this topic, which could prove useful in most Indian settings.

Management of Diabetes and Hypertension

In its effort to provide definitive value to its clients, Dvara Health has moved away from the traditional clinic walk-in model and, instead, working with its "Sakhis" and "Digital Doctors," developed a carefully structured and outcome-focused approach to improving the health of its clients. Since the Dvara model calls for a high degree of precision and consistency, Dvara has developed very detailed protocols to guide its work. Dvara has recently posted its protocols for Hypertension and Diabetes . For clarifications on these protocols, please get in touch with Dr Lavanya Kallakuri ([email protected] ) at Dvara Health.

Mental Health

I could not find a comprehensive set of evidence-based primary care protocols for mental health from an Indian source.

1. The World Health Organization has a free tool called the mhGAP Intervention Guide, which can be accessed through their mhGAP app and website from here .
2. The Johns Hopkins School of Public Health has protocols for use in primary care settings (for mental health as well as a few other conditions) and makes them available in the form of apps which can be downloaded from here (unfortunately, the Johns Hopkins protocols are not free but are kept updated, are very easy to use, and can significantly strengthen your clinical practice).
3. For first-level counselling support, a ChatBot like Wysa could also prove to be quite a useful resource for primary care providers to recommend to their patients.
4. If you're looking for high-quality content on mental health that you can review and share, this set of 11 introductory videos from Oxford Health NHS Trust may be a good place to start.
5. If your interest is more in the preventive and community-wide aspects of mental health, I offer a course in Public Mental Health in which I discuss a wide range of evidence-based programs that focus on stress Reduction, building up Resilience, early Recognition of at-risk individuals, families, and communities, and Recovery of patients.

Cognitive Impairment / Dementia

Dr Vinay Bhardwaj , a Bengaluru-based board-certified Neurologist, has developed a protocol for addressing cognitive impairment/dementia in primary care settings.

Child Sexual Abuse

While this is not a condition that the primary care provider is often called in for a consultation, it is entirely possible that during a routine visit, the provider notices evidence of abuse either from the child's behaviour or during a physical examination. The best set of resources to turn to in such a situation is from Arpan . The primary care provider can share the material meant for parents with the parent accompanying the child. More information can be obtained from Arpan by contacting them at [email protected] or +91 22 2686 2444.

Silicosis

If in the communities you serve, there are young men who work in industries such as stone-carving, mining, or even construction work, you are likely to see this serious lung disease caused by "inhaling large amounts of crystalline silica dust, usually over many years" (see the description provided by the UK National Health Service here ). Working with Dr Ramani Atkuri , Basic HealthCare Services has prepared this resource that can be used by primary care providers for preventing, diagnosing, and treating this condition. More information on this can be obtained directly from Dr Atkuri by contacting her at [email protected] .

I will keep updating this document as I learn more, but if you spot errors or have additional guidelines I could include in this piece, please let me know.