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Objective: To explore intersections of social determinants of maternal healthcare utilization using the Classification and Regression Trees (CART) algorithm which is a machine-learning method used to construct prediction models. Methods: Institutional review board approval for this study was granted from Public Health Service—Ethical Review Board (PHS-ERB) and from the Health Ministry Screening Committee (HMSC) facilitated by Indian Council for Medical Research (ICMR). IRB review and approval for the current analyses was obtained from University of California, San Diego. Cross-sectional data were collected from women with children aged 0–11 months (n = 5,565) from rural households in 25 districts of Uttar Pradesh, India. Participants were surveyed on maternal healthcare utilization including registration of pregnancy (model-1), receipt of antenatal care (ANC) during pregnancy (model-2), and delivery at health facilities (model -3). Social determinants of health including wealth, social group, literacy, religion, and early age at marriage were captured during the survey. The Classification and Regression Tree (CART) algorithm was used to explore intersections of social determinants of healthcare utilization. Results: CART analyses highlight the intersections, particularly of wealth and literacy, in maternal healthcare utilization in Uttar Pradesh. Model-1 documents that women who are poorer, illiterate and Muslim are less likely to have their pregnancies registered (71.4% vs. 86.0% in the overall sample). Model-2 documents that poorer, illiterate women had the lowest ANC coverage (37.7% vs 45% in the overall sample). Model-3, developed for deliveries at health facilities, highlighted that illiterate and poor women have the lowest representation among facility deliveries (59.6% vs. 69% in the overall sample). Conclusion: This paper explores the interactions between determinants of maternal healthcare utilization indicators. The findings in this paper highlights that the interaction of wealth and literacy can play a very strong role in accentuating or diminishing healthcare utilization among women. The study also reveals that religion and women’s age at marriage also interact with wealth and literacy to create substantial disparities in utilization. The study provides insights into the effect of intersections of determinants, and highlights the importance of using a more nuanced understanding of the impact of co-occurring forms of marginalization to effectively tackle inequities in healthcare utilization. [ABSTRACT FROM AUTHOR]

Despite various efforts for enhancing women’s autonomy in developing countries, many women are deprived of their capacity in decision-making on their household affairs as well as social issues. This paper aimed to examine women’s autonomy and its associated factors in the Kapilvastu district of Nepal. We measured women’s autonomy using a recently developed women’s autonomy measurement scale from June to October 2014. Descriptive statistics, chi-square test and logistic multivariate modeling technique were applied for assessing the association of demographic and socio-economic characteristics of women and their autonomy. Mean score for women’s autonomy was 23.34± 8.06 out of the possible maximum 48. It was found to be positively associated with higher age difference at marriage, advantaged caste/ethnicity, better employment for the husband, couple’s education more than 10 years schooling, and higher economic status of the household. We found strong direct effect of women’s education (OR = 8.14, CI = 3.77–17.57), husband’s education (OR = 2.63, CI = 1.69–4.10) and economic status of household (OR = 1.42, CI = 1.01–2.03) on women’s autonomy. When we adjusted women’s education for husband’s education, the odds ratio decreased by around 22% {from (OR = 8.14, CI = 3.77–17.57) to (OR = 6.32, CI = 2.77–14.46)} and was a mediator effect. The economic status of household also had mediator effect on women’s autonomy through their education. Education status of women is a key predictor of women’s autonomy in Kapilvastu district. Husband’s education and economic status of the household are other important predictors of women’s autonomy which have a mediator effect on women’s autonomy. Improving educational status and economic conditions of both women and their husbands may be the best solution to promote women’s autonomy. [ABSTRACT FROM AUTHOR]

Recent study shows that 617 million children and adolescents–or six out of 10 globally- are not acquiring minimum levels in literacy and mathematics, indicating the magnitude of the learning acquisition problem. For children with disabilities in context of conflict, the situation is arguably even worse: the literature shows that they face difficulties to access the education system due to multiple barriers, and when they do access, they are not learning. Our paper examines if an active education policy promoting inclusion since 2005 in Afghanistan, a protracted crisis context, has been effective. Using two cross sectional household surveys carried out eight years apart (2005–2013), our study shows that access to school and literacy did not improve between 2005 and 2013 for children and youth with disabilities. Both access and literacy outcomes were worse for girls with disabilities, those with a mental, learning or associated disability and those living in household where the head was uneducated. Finally, odds of being mentally distressed significantly declined between 2005 and 2013 indicating that schools might play a protective role for children with disabilities in Afghanistan. Our findings suggest that a multilevel multi-pronged adaptation of the existing system to improve the learning experience and promote children’s resilience, particularly for children with disabilities, in conflict context such as Afghanistan, is required. [ABSTRACT FROM AUTHOR]

The demand for district level statistics has increased tremendously in Bangladesh due to existence of decentralised approach to governance and service provision. The Bangladesh Demographic Health Surveys (BDHS) provide a wide range of invaluable data at the national and divisional level but they cannot be used directly to produce reliable district-level estimates due to insufficient sample sizes. The small area estimation (SAE) technique overcomes the sample size challenges and can produce reliable estimates at the district level. This paper uses SAE approach to generate model-based district-level estimates of diarrhoea prevalence among under-5 children in Bangladesh by linking data from the 2014 BDHS and the 2011 Population Census. The diagnostics measures show that the model-based estimates are precise and representative when compared to the direct survey estimates. Spatial distribution of the precise estimates of diarrhoea prevalence reveals significant inequality at district-level (ranged 1.1–13.4%) with particular emphasis in the coastal and north-eastern districts. Findings of the study might be useful for designing effective policies, interventions and strengthening local-level governance. [ABSTRACT FROM AUTHOR]

Background: Violence against women by an intimate partner (DV) is a serious public health and human rights issue. Attitudes justifying DV strongly predict its perpetration and victimisation. This paper presents gendered ecological analyses of the societal acceptance of DV in 49 low- and middle-income countries (LMICs) across geographical regions. Methods and findings: We utilised data from 49 Demographic and Health Surveys conducted between 2005 and 2017, United Nations Statistics and topic-specific meta-databases. DV acceptance was measured as the justification of ‘wife-beating’ in at least one of five circumstances, and by the summative scale. Stepwise multiple linear regression examined country-level social, economic and political empowerment predictors of societal acceptance of DV amongst women, men, and the aggregate gender difference. Women were more likely than men to justify DV in Sub-Saharan Africa and South (east) Asia with societal acceptance of DV being more widespread in these regions compared with Latin America, the Caribbean, Central/West Asia and Europe. Political conflict and limited economic rights for women were associated with higher levels of DV acceptance amongst women and men. Men in more democratic countries were less likely to justify DV. Amongst women, higher national female literacy rates predicted lower levels of justification. There were higher levels of DV acceptance amongst women and a wider aggregate gender difference in countries with a larger representation of women in national parliament. Conclusion: Justification of DV is widespread amongst women and men in LMICs with acceptance rates varying across countries and regions. Gender differences in the impact of contextual factors on DV acceptance supports a gendered approach to national-level interventions. Our findings highlight the need for tailored interventions targeting DV acceptance in conflict-impacted societies. The emphasis of inter(national) policies on the ‘empowerment’ domains of widely-used gender (in)equality indices need to be coupled with strategies tackling discriminatory gender norms. [ABSTRACT FROM AUTHOR]

Background: Child peer violence is a global problem and seriously impacts children’s physical and psychological health, and their education outcomes. There are few research studies on children’s peer violence available in South Asian countries, particularly in Afghanistan. This paper describes the prevalence of children’s peer violence perpetration and victimization and associated factors among school children in Afghanistan. Methods: A total of 770 children were recruited into a baseline study conducted as part of an intervention evaluation in 11 schools (seven girls’ and four boys’ schools). All children were interviewed with a questionnaire developed for the study. The main outcome is a three-level peer violence variable consisting of (a) no violence, (b) victimization only, or (c) perpetration (with or without victimization). Peer violence victimization was measured through the Multidimensional Peer-Victimization Scale, and peer violence perpetration was measured through an adjusted version of the same scale with wording changed to measure perpetration. Results: 49.7% of boys and 43.3% of girls reported having experienced more than one instance of violence victimization in the past month, and 31.7% of boys and 17.6% of girls disclosed perpetration of more than one instance of violence in the past month, with considerable overlap found between experience of victimization and perpetration, particularly among boys. Multinomial models of factors associated with peer violence show that for boys, food insecurity was associated with perpetration of peer violence but not with victimization, and experiencing corporal punishment at school in the last month was significantly associated with both peer victimization and perpetration. For girls, food insecurity, more depressive symptoms and experiencing any beating at home were associated with both violence victimization and perpetration. Having a disability was associated with victimization only, and having witnessed their father fighting and experiencing any kind of corporal punishment were associated with peer violence perpetration only. Discussion: Peer violence in Afghanistan is linked to food insecurity, exposure of children to witnessing family violence, and children’s experience of physical violence at home and corporal punishment at school. School-based settings provide an important platform for interventions to reduce and prevent peer violence; however, such interventions may benefit from broader violence-prevention initiatives conducted at the community level. [ABSTRACT FROM AUTHOR]

Bangladesh is a culturally conservative nation with limited freedom for women. A number of studies have evaluated intimate partner violence (IPV) and spousal physical violence in Bangladesh; however, the views of women have been rarely discussed in a quantitative manner. Three nationwide surveys in Bangladesh (2007, 2011, and 2014) were analyzed in this study to characterize the most vulnerable households, where women themselves accepted spousal physical violence as a general norm. 31.3%, 31.9% and 28.7% women in the surveys found justification for physical violence in household in 2007, 2011 and 2014 respectively. The binary logistic model showed wealth index, education of both women and their partner, religion, geographical division, decision making freedom and marital age as significant household contributors for women’s perspective in all the three years. Women in rich households and the highly educated were found to be 40% and 50% less likely to accept domestic physical violence compared to the poorest and illiterate women. Similarly, women who got married before 18 years were 20% more likely accept physical violence in the family as a norm. Apart from these particular groups (richest, highly educated and married after 18 years), other groups had around 30% acceptance rate of household violence. For any successful attempt to reduce spousal physical violence in the traditional patriarchal society of Bangladesh, interventions must target the most vulnerable households and the geographical areas where women experience spousal violence. Although this paper focuses on women’s attitudes, it is important that any intervention scheme should be devised to target both men and women. [ABSTRACT FROM AUTHOR]

This paper aimed to investigate the role of parental education in child disability in China. We used nationally representative data from China’s National Sample Survey on Disability, iterated twice, in 1987 and 2006, with data of 764,718 children aged 0–14 years. Logit models were used for statistical analysis. Results showed that the prevalence of child disability was significantly associated with each parent’s education. Maternal education was more important than paternal education in child disability in both surveys. The analysis of marginal effect indicated a one-year increase in maternal and paternal schooling led to an average decrease of 0.121% and 0.091% in the probability of child disability in 1987, and 19 years later, these figures had dwindled to 0.091% and 0.072%, respectively. [ABSTRACT FROM AUTHOR]

Background: While women and girls face special risks from lack of access to sanitation facilities, their ability to participate and influence household-level sanitation is not well understood. This paper examines the association between women's decision-making autonomy and latrine construction in rural areas of Odisha, India. Methods: We conducted a mixed-method study among rural households in Puri district. This included a cross sectional survey among 475 randomly selected households. These were classified as either having a functional latrine, a non-functional latrine or no latrine at all. We also conducted 17 in-depth interviews and 9 focus group discussions among household members of these three categories of households. Results: Decisions on the construction of household level sanitation facilities were made exclusively by the male head in 80% of households; in 11% the decision was made by men who consulted or otherwise involved women. In only 9% of households the decision was made by women. Households where women were more involved in general decision making processes were no more likely to build a latrine, compared to households where they were excluded from decisions. Qualitative research revealed that women’s non-involvement in sanitation decision making is attributed to their low socio-economic status and inability to influence the household’s financial decisions. Female heads lacked confidence to take decisions independently, and were dependent on their spouse or other male family members for most decisions. The study revealed the existence of power hierarchies and dynamics within households, which constrained female’s participation in decision-making processes regarding sanitation. Conclusions: Though governments and implementers emphasize women’s involvement in sanitation programmes, socio-cultural factors and community and household level dynamics often prevent women from participating in sanitation-related decisions. Measures are needed for strengthening sanitation policies and effective implementation of programmes to address gender power relations and familial relationships that influence latrine adoption and use. [ABSTRACT FROM AUTHOR]

Out-of-pocket spending at out-patient departments (OPD) by households is relatively less analyzed compared to hospitalization expenses in India. This paper provides new evidence on the levels and drivers of expenditure on out-patient care, as well as choice of providers, using household survey data from 8 districts in 3 states of India. Results indicate that the economically vulnerable spend more on OPD as a proportion of per capita consumption expenditure, out-patient care remains overwhelmingly private and switches of providers—while not very prevalent—is mostly towards private providers. A key result is that choice of public providers tend to lower OPD spending significantly. It indicates that an improvement in the overall quality and accessibility of government facilities still remain an important tool that should be considered in the context of financial protection. [ABSTRACT FROM AUTHOR]

Disability prevents an individual from performing to the fullest potential. It is multidimensional. Disability may be physical, mental, social, personal, and environmental or a combination of these. The elderly experience an increased burden of disability, especially in areas where there are limited resources and rapid urbanization. Comparison of reported disability is difficult because several definitions and scales are in use. We used the World Health Organization Disability Assessment Schedule version 2.0 (WHODAS 2.0) to study the prevalence of disability, and its association with sociodemographic factors among elderly persons residing in an urban resettlement colony, New Delhi, India. The WHODAS 2.0 provides continuous summary scores, where higher scores indicate higher disability, and vice versa. Elderly persons aged 60 years and above were selected by simple random sampling in this community-based cross-sectional study. Trained interviewers administered the semi-structured interview schedule and WHODAS 2.0. The prevalence of disability was 7.4% (5.8% - 9.3%) among the 931 participants. The prevalence was higher among females than males. Female sex, elderly aged 70 years and above, and those who were illiterate had increased risk of higher disability scores. Participants who were in government or private service had 50% decreased risk of having higher disability scores. The burden of disability was high among elderly persons residing in this resettlement colony. Community-based holistic interventions are required to mitigate the disability, and to improve the functioning of elderly persons. [ABSTRACT FROM AUTHOR]

Background: The prevalence of overweightness in Bangladesh is increasing, while underweightness also continues to persist. A better understanding of the patterns and socioeconomic risk factors of both conditions, particularly among women, is critical in order to promote the development of interventions to improve maternal health in Bangladesh. This study therefore sought to assess the patterns of under- and overweightness between 2004 and 2014 and to examine the predictors of individual and community-level inequalities of under- and overnutrition in Bangladesh. Methods: Cross-sectional data of 10, 431, and 16,478 ever-married nonpregnant women aged between 15 and 49 years who did not give birth in the two months preceding the survey were extracted from the 2004 and 2014 Bangladesh Demographic and Health Surveys, respectively. Body mass index was used to measure weight status, and underweightness, at-risk for overweightness, overweightness, and obesity were the main outcome variables. Patterns of nutritional change over time was examined by considering the annual average rate of change. Multilevel multinomial logistic regression and quantile regression were used to identify the inequalities. Results: In 2014, the age-adjusted prevalence values of underweightness, at-risk for overweightness, overweightness, and obesity were 19.7%, 14.9%, 18.1% and 4.0%, respectively. A higher average annual rate of reduction of underweightness was found among wealthier, highly educated, and wealthier community–living women, while a rate of increase of overweightness was found among poorer, uneducated, and poor community–living women. Individual and community-level inequalities of malnutrition were observed among these populations. In comparison with women living in low wealth communities, women from wealthier communities were at an increased risk of being at-risk for overweightness [adjusted odds ratio (AOR): 1.53, 95% confidence interval (CI): 1.23–1.91], overweight (AOR: 1.60, 95% CI: 1.27–2.00), and obese (AOR: 2.12, 95% CI: 1.42–3.18). Conclusions: This study suggests the coexistence of a double burden of under- and overnutrition in Bangladesh and that the prevalence of overweightness surpasses that of underweightness. The burdens of under- and overnutrition are strongly associated with women’s individual socioeconomic positions and the nature of the community in which they live. [ABSTRACT FROM AUTHOR]

The Global Gender Gap Index is one of the best-known measures of national gender inequality, used by both academics and policy makers. We argue that that this measure has a number of problems and introduce a simpler measure of national levels of gender inequality. Our proposed measure is based on sex differences in the opportunity to lead a long healthy and satisfied life that is grounded on educational opportunities. The measure better captures variation in gender inequality than other measures, with inclusion of outcomes that can be favorable or unfavorable to either sex, not simply unfavorable to women. We focus on some of the most basic measures available for 134 countries from 2012–2016 (i.e., disadvantages in children’s basic education, life satisfaction, and healthy life span) and we relate these to various measures, including the United Nations' Human Development Index. We found that low levels of human development are typically associated with disadvantages for girls and women, while medium and high levels of development are typically associated with disadvantages for boys and men. Countries with the highest levels of human development are closest to gender parity, albeit typically with a slight advantage for women. We argue that the disparities, when they are found, are related to the sexual division of labor (i.e., traditional gender roles) in poorly developed countries as well as the underinvestment in preventative health care in more developed nations. [ABSTRACT FROM AUTHOR]

Background: Menstrual exile, also known as Chhaupadi, is a tradition of “untouchability” in far-western Nepal. Forbidden from touching other people and objects, women and girls are required to live away from the community, typically in a livestock shed, during menstruation. We assessed the lived experiences of Chhaupadi among Nepalese adolescent girls in the far-western Achham district of Nepal, observed the safety and sanitation of their living spaces during Chhaupadi, and assessed the perceptions of local adult stakeholders towards the practice of Chhaupadi. Methods: We collected data from 107 adolescent girls using a self-administered survey in two local schools in Achham. We also conducted a focus group discussion with seven girls, held key informant interviews, and observed the girls’ living spaces during Chhaupadi, using a checklist. Descriptive statistics of the quantitative survey and thematic analyses of qualitative interviews are presented. Results: The majority of the girls (n = 77, 72%) practiced exile, or Chhaupadi, during their menstruation, including 3 (4%) exiled to traditional Chhau sheds, 63 (82%) to livestock sheds, and 11 (14%) to courtyards outside their home. The remaining girls (n = 30, 28%) stayed inside the house, yet practiced some form of menstrual taboos. Of the 77 observed living spaces where the girls stayed during exile, only 30% (n = 23) had a toilet facility. Most exiled girls (97.4%) were restricted from eating dairy products. Participants reported having various psychological problems, including lonliness and difficulty sleeping while practicing Chhaupadi. Three of the girls were physically abused; nine were bitten by a snake. Notably high proportions of the living spaces lacked ventilation/windows (n = 20, 26%), electricity (n = 29, 38%), toilets (n = 54, 70%) and a warm blanket and mattress for sleeping (n = 29, 38%). Our qualitative findings supported our quantitative results. Conclusions: Chhaupadi has been condemned by human rights organizations. While the government has banned the practice, implementation on the ban is proceeding slowly, especially in far-western Nepal. Thus, as a temporary measure, public health professionals must work towards promoting the health and safety of Nepalese women and girls still practicing Chhaupadi. [ABSTRACT FROM AUTHOR]

Setting: Myanmar National AIDS Program has had significant scale-up of services and changes in CD4 eligibility criterion for ART initiation from 2013 to 2016. This study assessed early death within 6 months and attrition (death and loss to follow-up, LTFU) after ART initiation and their associated factors. Design: A retrospective cohort study on people living with HIV (PLHIV >15 year of age) enrolled at three specialist hospitals in Yangon from 1st June 2013 to 30th June 2016. Cox regression was used to calculate hazard ratios (HRs) of early death and attrition. Results: Of 11,727 adults enrolled, 11,186 (95%) were initiated on ART, providing 15,964 person-years of follow-up. At baseline, median age was 36 years [IQR: 30–43], 58% were men and median CD4 count was 151 cells/mm3 (IQR: 54–310). There were 733(6%) early deaths, 961(9%) total deaths and 1371 (12%) LTFU during the study period. Independent risk factors for early death were older age (41–50 and ≥51 years) [aHR 1.38, 1.07–1.78 and 1.68, 1.21–2.34], male (1.84, 1.44–2.35), low weight (2.06, 1.64–2.59), bedridden, (3.81, 2.57–5.66) and CD4 count ≤ 50 cells/mm3 (6.83, 2.52–18.57). In addition to above factors, high attrition was associated with an abacavir-based regimen. Conclusion: Although there was a low rate of early deaths, patients were being diagnosed late and there was a high attrition rate from specialist hospitals. Concerted effort is required to increase early diagnosis and ART initiation, and strengthen community systems for HIV care to achieve ambitious goal of ending AIDS epidemic by 2030. [ABSTRACT FROM AUTHOR]

Objective: To determine if pregnant, literate women and female community health volunteers (FCHVs) in Nepal can accurately determine a woman’s eligibility for medical abortion (MA) using a toolkit, compared to comprehensive abortion care (CAC) trained providers. Study design: We conducted a prospective diagnostic accuracy study in which women presenting for first trimester abortion, and FCHVs, independently assessed each woman’s eligibility for MA using a modified gestational dating wheel to determine gestational age and a nine-point checklist of MA contraindications or cautions. Ability to determine MA eligibility was compared to experienced CAC-providers using Nepali standard of care. Results: Both women (n = 3131) and FCHVs (n = 165) accurately interpreted the wheel 96% of the time, and the eligibility checklist 72% and 95% of the time, respectively. Of the 649 women who reported potential contraindications or cautions on the checklist, 88% misidentified as eligible. Positive predictive value (PPV) of women’s assessment of eligibility based on gestational age was 93% (95% CI 92, 94) compared to CAC-providers’ (n = 47); PPV of the medical contraindications checklist and overall (90% [95% CI 88, 91] and 93% [95% CI 92, 94] respectively) must be interpreted with caution given women’s difficulty using the checklist. PPV of FCHVs’ determinations were 93% (95% CI 92, 94), 90% (95% CI 89,91), and 93% (95% CI 91, 94) respectively. Conclusion: Although a promising strategy to assist women and FCHVs to assess MA eligibility, further refinement of the eligibility tools, particularly the checklist, is needed before their widespread use. [ABSTRACT FROM AUTHOR]

Health literacy (HL) has become an important public health issue and is receiving growing attention. However, the HL levels of military college students in China have never been analyzed. This study aimed to investigate the HL and related associate factors in military college students in Chongqing, China. Data was obtained with the “Chinese Citizen Health Literacy Questionnaire (2012 edition)” from 3183 military college students aged 16–28 years at Chongqing in December 2015. A total score of ≥80 points determined adequate HL, and HL level was defined as the proportion of students who had adequate HL out of the total number of participants. Multiple logistic regression analysis with a stepwise forward likelihood ratio (LR) method was used to determine the effects of sociodemographic characteristics, health-related behaviors, and family-related factors on HL level. The mean score of HL was 68.56, and the HL level of military college students was 21.05%; the overall knowledge rate was 71.33%. The independent factors that were associated with HL level were years in college, educational system, time playing online games, annual household income and father's education level. Senior (odds ratio [OR] = 1.229, 95% confidence interval [CI] 1.018∼1.484), undergraduate (OR = 1.509, 95% CI 1.151∼1.978), time played games more than 5 hours each week (OR = 0.638, 95% CI 0.486∼0.837), annual household incomes more than 50,000 yuan (OR = 1.231, 95% CI 1.027∼1.476) and father's education level (high school: OR = 2.327, 95% CI 1.186∼4.565; university: OR = 2.450, 95% CI 1.244∼4.825), were independently associated with higher HL level. HL levels of military college students in Chongqing need to be improved across the board. Our data suggests that special emphasis should be placed on students in junior and those in the specialist educational system. School departments may also benefit from incorporating health literacy into their curricula and helping students manage the time they spend playing online games. [ABSTRACT FROM AUTHOR]

Introduction: The need for efficient retention in HIV care is more evident than ever because of the expansion of earlier ART initiation and the shift towards ‘Test and Treat’. This study assesses factors affecting participation in the HIV care cascade among people living with HIV (PLHIV) in the Asia-Pacific Region. Methods: A total of 7843 PLHIV aged 18–50 years were recruited using targeted and venue-based sampling between October 1, 2012, and May 31, 2013, across 59 sites in 7 countries (Bangladesh, Indonesia, Lao People's Democratic Republic (Lao PDR), Nepal, Pakistan, Philippines and Vietnam). Statistically significant associations between demographic and health system determinants, and various steps in the HIV care cascade were computed using a generalized structural equation model. Results: A high proportion of PLHIV (40–51%) presented late for HIV care and delayed linkage to care in all seven countries. However, once PLHIV enrolled in care, retention in the various steps of the care cascade including adherence to antiretroviral treatment (ART) was satisfactory. The proportion still engaged in HIV care at 36 months post HIV diagnosis, varied from 78% in Nepal to >90% in Lao PDR. Similarly, the proportion of ART initiation who also were adherent to ART ranged from 91% in Bangladesh to >95% in Philippines/ Vietnam and from 70% in Lao PDR to 89% in the Philippines respectively. The following factors enhanced the likelihood of ART initiation and high adherence to HIV care and ART: good client-provider communication, high HIV treatment literacy, a referral from a health worker and TB/HIV co-infection. The following barriers were identified: young age, sex work, imprisonment, transgender identity, illiteracy, rural residence, alcohol/ injecting drug use, perceived poor health status, lack of health insurance, fear of confidentiality breach, self-referral for HIV testing, and public hospital as the place of HIV diagnosis. Conclusions: HIV programme planners should ensure easy access to HIV testing and earlier linkage to HIV care among PLHIV. In addition, multiple socio-economic and health systems barriers need to be addressed along the HIV care cascade to reach the UNAIDS 90-90-90 target in the Asia-Pacific region. [ABSTRACT FROM AUTHOR]

Background: Understanding the socioeconomic and regional divides in disability prevalence in India has considerable relevance for designing public health policies and programs. Objectives: The aim of the present study is to quantify the prevalence of disability by gender, region (rural and urban; states and districts), and caste. We also examine the association between disability prevalence and the major socio-demographic and socioeconomic characteristics of the districts in India. Methods: Age-standardized disability prevalence (ASDP) was calculated using 2011 census data and applying the WHO World Standard Population. A regression analysis was carried out to examine the association between disability prevalence and demographic and socioeconomic characteristics across districts of India. Results: The study found that ASDP varies substantially across districts and is higher among women, rural dwellers, and members of scheduled tribes (STs) and scheduled castes (SCs). The regression model showed that the disability rate in districts rises with increasing proportions of the population who are urban dwellers, aged 65 or older, members of STs, and living in dilapidated housing; and that the disability prevalence decreases with increasing proportions of the female population who are literate, and of the general population who are working and have access to safe drinking water. Conclusion: As the burden of disability falls disproportionately across geographic regions and socioeconomic groups, public health policies in India should take this variation into account. The definition of disability used in the census should be modified to generate internationally comparable estimates of disability prevalence. [ABSTRACT FROM AUTHOR]

Introduction: HIV-positive people’s clinic attendance for medication pick-up is critical for successful HIV treatment. However, limited evidence exists on it especially in low-income settings such as Nepal. Moreover, the role of family support in clinic attendance remains under-explored. Therefore, this study was conducted to examine the association between perceived family support and regular clinic attendance and to assess factors associated with regular clinic attendance for antiretroviral pills pick-up among HIV-positive individuals in Nepal. Methods: A cross-sectional study was conducted among 423 HIV-positive people in three districts of Nepal. Clinic attendance was assessed retrospectively for the period of 12 months. To assess the factors associated, an interview survey was conducted using a semi-structured questionnaire from July to August, 2015. Multiple logistic regression models were used to assess the factors associated with regular clinic attendance. Results: Of 423 HIV-positive people, only 32.6% attended the clinics regularly. They were more likely to attend them regularly when they received high family support (AOR = 3.98, 95% CI = 2.29, 6.92), participated in support programs (AOR = 1.68, 95% CI = 1.00, 2.82), and had knowledge on the benefits of antiretroviral therapy (AOR = 2.62, 95% CI = 1.15, 5.99). In contrast, they were less likely to attend them regularly when they commuted more than 60 minutes to the clinics (AOR = 0.53, 95% CI = 0.30, 0.93), when they self-rated their health status as being very good (AOR = 0.13, 95% CI = 0.04, 0.44), good (AOR = 0.14, 95% CI = 0.04, 0.46), and fair (AOR = 0.21, 95% CI = 0.06, 0.70). Conclusion: HIV-positive individuals are more likely to attend the clinics regularly when they receive high family support, know the benefits of antiretroviral therapy, and participate in support programs. To improve clinic attendance, family support should be incorporated with HIV care programs in resource limited settings. Service providers should also consider educating them about the benefits of antiretroviral therapy. [ABSTRACT FROM AUTHOR]

Background: While the gender disparity in health and mortality in various stages of life in India is well documented, there is limited evidence on female disadvantage in health-care expenditure (HCE). Aims: Examine the gender difference in HCE in short-term and major morbidity in India, and understand the role of factors underlying the difference. Data and Methods: Using two rounds of nationally representative panel data—the India Human Development Survey (IHDS) 2004–2005 and 2011–2012 (IHDS I & II)—we calculate morbidity prevalence rate and mean HCE by gender, and examine the adjusted effect of gender on major morbidity-related HCE by using a two-part regression model. Further, we performed Oaxaca-Blinder decomposition of the gender gap in HCE in major morbidity to understand the contribution of demographic and socio-economic factors. Results: Health-care expenditure on females was systematically lower than on males across all demographic and socio-economic groups. Multivariate analysis confirms that female HCE is significantly lower than male HCE even after controlling demographic and socio-economic factors (β = -0.148, p = 0.000, CI:-0.206–0.091). For both short-term and major morbidity, a female disadvantage on HCE increased from IHDS I to IHDS II. For instance, the male–female gap in major morbidity related expenditure increased from INR 1298 to INR 4172. A decomposition analysis of gender gap in HCE demonstrates that about 48% of the gap is attributable to differences in demographic and socio-economic factors (endowment effect), whereas 50% of the gap is due to the differential effect of the determinants (coefficient effect). Interpretation: Indians spend less on female health care than on male health care. Most of the gender gap in HCE is not due to differential distribution of factors affecting HCE. [ABSTRACT FROM AUTHOR]

Background: Several developing countries like Pakistan step into Sustainable Development Goals period with crucial maternal and child health needs that need to be addressed for improving health outcomes among people. We aim to explore existent socio-economic disparities in use of family planning methods (FPM) among Pakistani women, and compare any such inequalities between the years 2006 and 2013. Setting: Pakistan Demographic and Health Surveys (PDHS) 2006–7 (n = 9177) and the most recent 2012–13(n = 13558) data were used to conduct secondary analysis. Participants were ever married women aged between 15 and 49 years. Socio-economic status was assessed by the education level and wealth index. Inequalities were measured through Odds Ratio (OR), Relative Index of inequality (RII), and Slope index of inequality (SII) on non-use of FPM. Results: Although the prevalence of FPM use has increased over time (28% in 2006 versus 54% in 2013), the socio-economic inequalities persistently exist. Comparing results of PDHS 2006 with PDHS 2013, education related absolute inequalities among urban dwellers increased from -0.41 (95% CI -0.67, -0.13, p-value < 0.01) to -0.83 (95% CI -1.02, -0.63, p-value < 0.01); and increased from -0.93 (95% CI -1.21, -0.64, p-value < 0.01) to -0.98 (95% CI -1.20, -0.76, p-value < 0.01) among rural dwellers. Similarly wealth related absolute inequalities are also existent. Conclusions: Although the FPM use has increased over time, but it is important to note that socio-economic gap in use of FPM persists. Such differences have disadvantaged the poor and the illiterate. Family planning programs may target the disadvantaged subgroups for ensuring well-being of women and children in Pakistan. [ABSTRACT FROM AUTHOR]

Background: Stigmatising and discriminating attitudes may discourage tuberculosis (TB) patients from actively seeking medical care, hide their disease status, and discontinue treatment. It is expected that appropriate knowledge regarding TB should remove stigmatising and discriminating attitudes. In this study we assessed the prevalence of stigmatising and discriminating attitudes towards TB patients among general population and their association with knowledge regarding TB. Method: A cross-sectional knowledge, attitude and practice survey was conducted in 30 districts of India in January-March 2011. A total of 4562 respondents from general population were interviewed using semi-structured questionnaires which contained items to measure stigma, discrimination and knowledge on TB. Result: Of the 4562 interviewed, 3823 were eligible for the current analysis. Of these, 73% (95% CI 71.4–74.2) had stigmatising and 98% (95% CI 97.4–98.3) had discriminating attitude towards TB patients. Only 17% (95% CI 15.6–18.0) of the respondents had appropriate knowledge regarding TB with even lower levels observed amongst females, rural areas and respondents from low income groups. Surprisingly stigmatising (adjusted OR 1.31 (0.78–2.18) and discriminating (adjusted OR 0.79 (0.43–1.44) attitudes were independent of knowledge regarding TB. Conclusion: Stigmatising and discriminating attitudes towards TB patients remain high among the general population in India. Since these attitudes were independent of the knowledge regarding TB, it is possible that the current disseminated knowledge regarding TB which is mainly from a medical perspective may not be adequately addressing the factors that lead to stigma and discrimination towards TB patients. Therefore, there is an urgent need to review the messages and strategies currently used for disseminating knowledge regarding TB among general population and revise them appropriately. The disseminated knowledge should include medical, psycho-social and economic aspects of TB that not only informs people about medical aspects of TB disease, but also removes stigma and discrimination. [ABSTRACT FROM AUTHOR]