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Background: Cause-of-death (CoD) information is crucial for health policy formulation, planning, and program implementation. Verbal Autopsy (VA) is an approach employed for the collection and analysis of CoD estimates at the population level where medical certification of cause of death is low and, secondly, for integrating it with the existing public health system by utilizing the grassroots level workforce. Objective: The study aims to understand the field perspectives on implementing the 2022 WHO VA instrument in rural India through the existing public health system. Methods: This article is derived from a qualitative arm of study that was conducted in one of the blocks of Kanpur district, Uttar Pradesh. Frontline health workers (FHWs), as well as Medical Officers (MOs) serving in the Community Health Centre (CHC) area, were selected as study participants. A 5-day training and orientation workshop was conducted to train the FHWs to conduct computer-assisted personal interview VA using the 2022 WHO VA instrument. MOs have been trained to assign the CoD via Physician-Certified VA (PCVA). In-depth interviews (IDIs) were conducted with FHWs involved in conducting VA and physicians involved in conducting PCVA within the field practice area. Results: A total of 13 IDIs were conducted, consisting of 10 FHWs and 3 MOs, within the selected CHC area of Ghatampur. Based on the responses received, five major themes were identified. Although VA is being used to collect CoD information from the community in India through a Sample Registration Survey (SRS), the key findings suggest that this activity could be scaled up by utilizing the existing public health system. However, additional manpower may be required for constant monitoring and evaluation of the program. Incentivization of FHWs would aid in the timely completion of VAs and coordination with local and higher health authorities. Conclusion: The perception of healthcare workers about the feasibility and acceptability of VA in this study highlighted some of the challenges and possible solutions that could aid in developing a comprehensive model to improve CoD information at the population level through the existing public health system.

Background: This study aims to address the lack of substantial evidence regarding the effect of COVID-19 on maternal and child health (MCH) services in India and also highlight the role of primary care physicians in maintaining essential services during a pandemic. While studies conducted worldwide and in India have examined the effects of COVID-19 on these services, a significant gap in robust evidence remains. Methods: Forty-two districts were selected randomly from seven regional states of India. Data on five selected MCH indicators were extracted from HMIS for the months from March to June 2019 and 2020. Relative changes in service utilization for each month from March to June over the two years were compared. Comparisons were also made between the selected districts based on the COVID-19 categorization into red and green zones. Results: COVID-19 and its associated restrictive measures created significant disruption to essential MCH service utilization in India across all states reviewed. Both institutional, and outreach services were impacted; however, hospital-based services were more impacted. Institutional deliveries and emergency obstetric services saw a decline in March and April 2020 which gradually improved between May and June in some states. Immunization sessions held in 2020 observed a decrease in April. Conclusions: The analysis indicates a disruption in service delivery during the initial phase of the lockdown. However, the services resumed gradually as national and state-specific operational guidelines were implemented to maintain a continuum of care.

Abstract BackgroundVerbal autopsy (VA) has been a crucial tool in ascertaining population-level cause of death (COD) estimates, specifically in countries where medical certification of COD is relatively limited. The World Health Organization has released an updated instrument (Verbal Autopsy Instrument 2022) that supports electronic data collection methods along with analytical software for assigning COD. This questionnaire encompasses the primary signs and symptoms associated with prevalent diseases across all age groups. Traditional methods have primarily involved paper-based questionnaires and physician-coded approaches for COD assignment, which is time-consuming and resource-intensive. Although computer-coded algorithms have advanced the COD assignment process, data collection in densely populated countries like India remains a logistical challenge. ObjectiveThis study aimed to develop an Android-based mobile app specifically tailored for streamlining VA data collection by leveraging the existing Indian public health workforce. The app has been designed to integrate real-time data collection by frontline health workers and seamless data transmission and digital reporting of COD by physicians. This process aimed to enhance the efficiency and accuracy of COD assignment through VA. MethodsThe app was developed using Android Studio, the primary integrated development environment for developing Android apps using Java. The front-end interface was developed using XML, while SQLite and MySQL were employed to streamline complete data storage on the local and server databases, respectively. The communication between the app and the server was facilitated through a PHP application programming interface to synchronize data from the local to the server database. The complete prototype was specifically built to reduce manual intervention and automate VA data collection. ResultsThe app was developed to align with the current Indian public health system for district-level COD estimation. By leveraging this mobile app, the average duration required for VA data collection to ascertainment of COD, which typically ranges from 6 to 8 months, is expected to decrease by approximately 80%, reducing it to about 1‐2 months. Based on annual caseload projections, the smallest administrative public health unit, health and wellness centers, is anticipated to handle 35‐40 VA cases annually, while medical officers at primary health centers are projected to manage 150‐200 physician-certified VAs each year. The app’s data collection and transmission efficiency were further improved based on feedback from user and subject area experts. ConclusionsThe development of a unified mobile app could streamline the VA process, enabling the generation of accurate national and subnational COD estimates. This mobile app can be further piloted and scaled to different regions to integrate the automated VA model into the existing public health system for generating comprehensive mortality statistics in India.

BackgroundMortality statistics are vital for health policy development, epidemiological research, and health care service planning. A robust surveillance system is essential for obtaining vital information such as cause of death (CoD) information. ObjectiveThis study aims to develop a comprehensive model to strengthen the CoD information in the selected study sites. The specific objectives are (1) to identify the best practices and challenges in the functioning of the Civil Registration and Vital Statistics (CRVS) system with respect to mortality statistics and CoD information; (2) to develop and implement interventions to strengthen the CoD information; (3) to evaluate the quality improvement of the Medical Certification of Cause of Death (MCCD); and (4) to improve the CoD information at the population level through verbal autopsy for noninstitutional deaths in the selected study sites. MethodsAn uncontrolled, before-after, mixed method study will be conducted in 3 blocks located in the districts of 3 states (Madhya Pradesh, Uttar Pradesh, and Odisha) in India. A baseline assessment to identify the best practices and challenges in the functioning of the CRVS system, along with a quality assessment of the MCCD, will be conducted. An intervention informed by existing literature and the baseline assessment will be developed and implemented in the study sites. The major components of intervention will include a Training of Trainers workshop, orientation of stakeholders in the functioning of the CRVS system, training of physicians and medical officers in the MCCD, and training of community health workers in World Health Organization Verbal Autopsy 2022 instrument. Postintervention evaluation will be carried out to assess the impact made by the intervention on the availability and quality improvement of CoD information in the selected study sites. The outcome will be measured in terms of the quality improvement of the MCCD and the availability of CoD information at population level through verbal autopsy in the selected study sites. ResultsThe project has been funded, and regulatory approval has been obtained from the Institutional Ethics Committee. The data collection process began in May 2023. The duration of the study will be for 24 months. ConclusionsOur study is expected to provide a valuable contribution toward strengthening CoD information, which could be helpful for policy making and further research. The intervention model will be developed in collaboration with the existing functionaries of the health and CRVS systems in the selected study sites that are engaged in reporting and recording CoD information; this will ensure sustainability and provide lessons for upscaling, with the aim to improve the reporting of CoD information in the country. International Registered Report Identifier (IRRID)DERR1-10.2196/51493

Background: Hypertension significantly contributes to avoidable morbidity and mortality. The literature indicates an increased risk of hypertension among tobacco users. This study examines the determinants of undetected hypertension among women in India and infers its relationship with smokeless tobacco (SLT) use. Materials and Methods: A nationally representative sample of 699,686 women (aged 15–49 years) in the National Family Health Survey-4 (2015–2016) was utilized. Women participants who did not self-report hypertension but their mean blood pressure measured during the interview were above 140/90 mmHg were considered as having undetected hypertension. Multivariate logistic regression was used to examine the association between hypertension and predictor variables including the use of SLT. Results: The prevalence of undetected hypertension was found to be 9.1% among women in India, and in comparison to non-SLT users, a higher prevalence of hypertension was observed among current SLT users. Age, illiteracy, obesity, use of SLT, alcohol consumption, and residing in Northeast India were found to be significant determinants of hypertension. Conclusion: Preventing the use of SLT through socioculturally tailored tobacco control interventions, raising awareness for behavior and lifestyle changes, and regular screening for hypertension in communities may have the potential to reduce the increasing burden of hypertension among women in India.

BackgroundPhysician-coded verbal autopsy (PCVA) is the most widely used method to determine causes of death (COD) in countries where medical certification of death is low. Computer-coded verbal autopsy (CCVA), an alternative method to PCVA for assigning the COD is considered to be efficient and cost-effective. However, the performance of CCVA as compared to PCVA is yet to be established in the Indian context.MethodsWe evaluated the performance of PCVA and three CCVA methods i.e., InterVA 5, InSilico, and Tariff 2.0 on verbal autopsies done using the WHO 2016 VA tool on 2,120 reference standard cases developed from five tertiary care hospitals of Delhi. PCVA methodology involved dual independent review with adjudication, where required. Metrics to assess performance were Cause Specific Mortality Fraction (CSMF), sensitivity, positive predictive value (PPV), CSMF Accuracy, and Kappa statistic.ResultsIn terms of the measures of the overall performance of COD assignment methods, for CSMF Accuracy, the PCVA method achieved the highest score of 0.79, followed by 0.67 for Tariff_2.0, 0.66 for Inter-VA and 0.62 for InSilicoVA. The PCVA method also achieved the highest agreement (57%) and Kappa scores (0.54). The PCVA method showed the highest sensitivity for 15 out of 20 causes of death.ConclusionOur study found that the PCVA method had the best performance out of all the four COD assignment methods that were tested in our study sample. In order to improve the performance of CCVA methods, multicentric studies with larger sample sizes need to be conducted using the WHO VA tool.

Objectives: To highlight and assess the impact of intervention tools used by Indian Council of Medical Research (ICMR) against COVID19 associated infodemic in the world's largest democratic country, India. Study design: It is a retrospective cross sectional study. The impact of ICMR's multi-pronged strategy to address the infodemic during pandemic has been assessed through analysis of print media reportage and social media engagements. Methods: The impact of the interventions was assessed using cloud media mappers like MediaCloud and Meltwater using keywords. The data was analysed in terms of reportage, theme of reportage. A sub-section of media reportage (Feb 2020–June 2020) was analysed in details from 4 major dailies to understand the coverage and tonality of media reports. The data on COVID 19 related tweets, posts and uploads were taken from social media platforms of Indian Council of Medical Research (ICMR) particularly twitter, instagram, facebook and youtube and estimate of pre and post pandemic changes in followers or users were collected for analysis. The data was curated and analysed using MS excel. Results: There was a surge of 3800% reportage in media during pandemic as compared to same time frame in pre-pandemic times. A surge of followers on twitter from 26,823 on Feb 2020 (before pandemic) to 3,36,098 at March 2022 (after pandemic) was observed. A drastic increase in monthly followers was observed after start of Pandemic (after Feb 2020) in comparison to before pandemic (Before Feb 2020). Similar trends were observed on other social media platforms of ICMR. Conclusions: The Communications Unit at ICMR geared up with more robust plans and designed several interventions to mitigate the infodemic which helped in evidence based decision making towards outbreak response and action. This highlights the importance of evidence based, crisp, timely and effective communication during the epidemics/pandemics to buid trust and confidence in the community.

Objectives This study provides insights on the impact of a targeted intervention (TI) programme on behaviour change among injecting drug users (IDUs) in India. Methods This paper examined the data from the Integrated Biological and Behavioural Surveillance 2014–2015 for IDUs in India. Logistic regression was performed to understand the factors (TI programme services) that affected injecting risk behaviours by adjusting for covariates. Propensity score matching was conducted to understand the impact of the TI programme on using new needles/syringes and sharing needles/syringes in the most recent injecting episode by accounting for the covariates that predicted receiving the intervention. Results Participants who received new needles and syringes from peer educators or outreach workers were 1.3 times (adjusted odds ratio, 1.29; 95% confidence interval [CI], 1.09 to 1.53) more likely to use new needles/syringes during most recent injecting episode than participants who did not receive needles/syringes. The matched-samples estimate (i.e., average treatment effect on treated) of using new needles in the most recent injecting episode showed a 2.8% (95% CI, 0.0 to 5.6) increase in the use of new needles and a 6.5% (95% CI, −9.7 to −3.3) decrease in needle sharing in the most recent injecting episode in participants who received new needles/syringes. There was a 2.2% (95% CI, −3.8 to −0.6) decrease in needle sharing in the most recent injecting episode among participants who were referred to other services (integrated counselling and testing centre, detox centres, etc.). Conclusions The TI programme proved to be effective for behaviour change among IDUs, as substantiated by the use of new needles/syringes and sharing of needles/syringes.

BackgroundPeople with disabilities are vulnerable because of the many challenges they face attitudinal, physical, and financial. The National Policy for Persons with Disabilities (2006) recognizes that Persons with Disabilities are valuable human resources for the country and seeks to create an environment that provides equal opportunities, and protection of their rights, and full. There are limited studies on health care burden due to disabilities of various types.AimThe present study examines the socioeconomic and state-wise differences in the prevalence of disabilities and related household financial burden in India.MethodsData for this study was obtained from the National Sample Survey (NSS), 76th round Persons with Disabilities in India Survey 2018. The survey covered a sample of 1,18,152 households, 5,76,569 individuals, of which 1,06,894 of had any disability. This study performed descriptive statistics, and bivariate estimates.ResultsThe finding of the analysis showed that prevalence of disability of any kind was 22 persons per 1000. Around, one-fifth (20.32%) of the household's monthly consumption expenditure was spent on out-of-pocket expenditure for disability. More than half (57.1%) of the households were pushed to catastrophic health expenditure due to one of the members being disabled. Almost one-fifth (19.1%) of the households who were above the poverty line before one of members was treated for disability were pushed below the poverty line after the expenditure of the treatment and average percentage shortfall in income from the poverty line was 11.0 percent due to disability treatment care expenditure.ConclusionThe study provides an insight on the socioeconomic differentials in out-of-pocket expenditure, catastrophic expenditure for treatment of any kind of disability. To attain SDG goal 3 that advocates healthy life and promote well-being for all at all ages, there is a need to recognize the disadvantaged and due to disability.

ObjectiveTo assess factors associated with COVID-19 stigmatizing attitudes in the community and stigma experiences of COVID-19 recovered individuals during first wave of COVID-19 pandemic in India.MethodsA cross-sectional study was conducted in 18 districts located in 7 States in India during September 2020 to January 2021 among adults > 18 years of age selected through systematic random sampling. Data on socio demographic and COVID-19 knowledge were collected from 303 COVID-19 recovered and 1,976 non-COVID-19 infected individuals from community using a survey questionnaire. Stigma was assessed using COVID-19 Stigma Scale and Community COVID-19 Stigma Scale developed for the study. Informed consent was sought from the participants. Univariate and multivariate binary logistic regression analysis were conducted.ResultsHalf of the participants (51.3%) from the community reported prevalence of severe stigmatizing attitudes toward COVID-19 infected while 38.6% of COVID-19 recovered participants reported experiencing severe stigma. Participants from the community were more likely to report stigmatizing attitudes toward COVID-19 infected if they were residents of high prevalent COVID-19 zone (AOR: 1.5; CI: 1.2–1.9), staying in rural areas (AOR: 1.5; CI:1.1–1.9), belonged to the age group of 18–30 years (AOR: 1.6; CI 1.2–2.0), were male (AOR: 1.6; CI: 1.3–1.9), illiterate (AOR: 2.7; CI: 1.8–4.2), or living in Maharashtra (AOR: 7.4; CI: 4.8–11.3). COVID-19 recovered participants had higher odds of experiencing stigma if they had poor knowledge about COVID-19 transmission (AOR: 2.8; CI: 1.3–6.3), were staying for 6–15 years (AOR: 3.24; CI: 1.1–9.4) in the current place of residence or belonged to Delhi (AOR: 5.3; CI: 1.04–26.7).ConclusionFindings indicated presence of stigmatizing attitudes in the community as well as experienced stigma among COVID-19 recovered across selected study sites in India during the first wave of COVID-19 pandemic. Study recommends timely dissemination of factual information to populations vulnerable to misinformation and psychosocial interventions for individuals affected by stigma.

COVID-19 pandemic has caused disruptions in carrying out research activities in the field. The established methods of data collection for both qualitative and quantitative research could not be implemented. Researchers worldwide adopted contactless data collection methods, including the use of mobile phones for research purposes. This paper presents the experiences of conducting interviews among tribal population using mobile phones in three villages of Manipur during the pandemic. The interviews proved to be successful and effective. Minor technical glitches were a challenge but were not significant to affect the quality of the data. During unprecedented times such as the current pandemic, conducting interviews via mobile phones could be a viable alternative to face-to-face interviews for collecting qualitative data from the communities.

Background: Abundant research studies has recorded availability, accessibility and quality of antenatal care and safe delivery in India but comparatively less information is known for postnatal care and furthermore limited attempts at capturing the whole spectrum of obstetric and newborn health services. Assessing discontinuity in maternal and child health service utilization provides us holistic information about existing health inequities and barriers in service provision. Objective: Current study evaluated the coverage of quality antenatal care (QANC), delivery care (QDC) and postnatal care (QPNC) in India as a part of a single continuum accounting for significant regional and sub-regional disparities. Methods: This study analyzed nationally representative data obtained from NFHS-4 (2015–16). Included in the data, were 190 898 Indian women who had a recent birth in last five years. Coverage of QANC, QDC and QPNC was examined at the national, state and district level. Bivariate association of key sociodemographic variables with coverage of services was assessed during chi-squared analysis. Multilevel logistic regression analysis examined correlates associated with coverage of services. The output was presented using odds ratios (OR) with 95% CI. Findings: About 23.5% women utilized QANC out of which 92.9% opted for QDC and 35.1% of newborns received QPNC. About 400 and 471 districts out of 640 had less than 30% coverage of QANC and QPNC, respectively. Women residing in rural regions of Bihar and Northeastern states were found with less than 10% coverage of QANC. Regression analysis shows that women with more than 12 years of education and belonging to richest households had increased odds of availing QANC (OR 1.95; 95%CI: 1.84–2.06) and QDC (OR: 2.86; 95%CI: 2.27–3.60), respectively. Conclusion: Focused interventions targeting the delivery of quality services especially ANC and PNC among newborns are imperative to achieve SDG-3 goals to achieve improvement in maternal and newborn health.

ObjectivesThis study examines the association between quality Postnatal Care (PNC) considering timing and providers' type on neonatal mortality. The aim extends to account for regional disparities in service delivery and mortality including high and non-high focus states.MethodsEver-married women aged 15-49 years (1,87,702) who had delivered at least one child in five years preceding the survey date surveyed in National Family Health Survey (2015-16) were included in the study. Neonatal deaths between day two and seven and neonatal deaths between day two and twenty-eight were considered dependent variables. Descriptive statistics and multivariate regression analysis were conducted.ResultsChances of early neonatal mortality were 29% (OR = 0.71; 95%CI: 0.59-0.84) among newborns receiving PNC within a day compared to ones devoid of it while 40% (OR: 0.60; 95%CI: 0.51-0.71) likelihood for the same was noted if PNC was delivered within a week. Likelihood of neonatal mortality decreased by 24% (OR: 0.76; 95%CI: 0.65-0.88) when skilled PNC was delivered within 24 hours. Receiving quality PNC by skilled providers within a day in a non-high focus state decreased the chances of neonatal mortality by 26% (OR: 0.74; 95%CI: 0.59-0.92) compared to ones who did not receive any PNC.ConclusionsNeonatal deaths were significantly associated with socioeconomic and contextual characteristics including age, education, household wealth, social group and region. Timing of PNC delivered and by a skilled healthcare provider was found significant in reducing neonatal mortality.

Background: Use of tobacco, especially smokeless tobacco have characterised as highly prevalent among women, and also the mode of using smokeless tobacco varies based on geographic location, ingredient availability, cultural/societal norms, and personal preferences. Therefore, this study examines the prevalence and social determinants of use of smokeless tobacco among women in NE India. Further, it also identifies the cluster and district hotspots of smokeless tobacco prevalence. Methods: We analysed a nationally representative data of NFHS-4, covering 93,409 eligible women aged 15–49 years from a survey of representative households from NE states, India. Descriptive statistics, chi-square, binary logistic and log-binomial regression were employed to analyse the data by using STATA software 13.1. Spatial clustering analysis and hotspot analysis were carried out using R-library. Findings: The prevalence of SLT use among women in NE states, India is 23%. Mizoram (47.8 ± 1.2) shows the highest prevalence of SLT use, followed by Manipur (46.1 ± 0.7). It increases concomitantly with age among women. Social determinants like marital status (divorced/widowed), low educational level and residence (urban) were observed to be associated with smokeless tobacco use. Out of the 4032 clusters used in the analysis, 949 clusters were showed as hotspots. Conclusion: The existing implementation of tobacco control programs and policies in the NE states needs to be evaluated. Owing to the geographical barriers and cultural differences, there is a need to explore the influences unique to these regions, which can further strengthen tobacco control measures. Targeted and tailored intervention within the identified hotspots can be beneficial.

Abstract Background Persistent low rates of spacing contraceptive use among young wives in rural India have been implicated in ongoing negative maternal, infant and child health outcomes throughout the country. Gender inequity has been found to consistently predict low rates of contraception. An issue around contraceptive reporting however is that when reporting on contraceptive use, spouses in rural India often provide discordant reports. While discordant reports of contraceptive use potentially impede promotion of contraceptive use, little research has investigated the predictors of discordant reporting. Methods Using data we collected from 867 couples in rural Maharashtra India as part of a men-focused family planning randomized controlled trial. We categorized couples on discordance of men’s and women’s reports of current contraceptive use, communication with their spouse regarding contraception, and ideal family size, and assessed the levels of discordance for each category. We then ran multinomial regression analyses to determine predictors of discordance categories with a focus on women’s empowerment (household and fertility decision-making, women’s education, and women’s knowledge of contraception). Results When individuals reported communicating about contraception and their spouses did not, those individuals were also more likely to report using contraception when their spouses did not. Women’s empowerment was higher in couples in which both couples reported contraception communication or use or in couples in which only wives reported contraception communication or use. There were couple-level characteristics that predicted husbands reporting either contraception use or contraception communication when their wives did not: husband’s education, husband’s familiarity with contraception, and number of children. Conclusions Overall there were clear patterns to differential reporting. Associations with women’s empowerment and contraceptive communication and use suggest a strategy of women’s empowerment to improve reproductive health. Discordant women-only reports suggest that even when programs interact with empowered women, the inclusion of husbands is essential. Husband-only discordant reports highlight the characteristics of men who may be more receptive to family planning messages than are their wives. Family planning programs may be most effective when working with couples rather than just with women, and should focus on improving communication between couples, and supporting them in achieving concordance in their reproductive preferences. Trial registration Clinical Trials Number: NCT01593943, registered May 4, 2012 at clinicaltrials.gov.

Background: There is increasing programming and research on male engagement and gender-equity (GE) counselling in family planning (FP) services. However, there is a lack of data on healthcare provider’s perspectives on delivering these interventions. The objective of the paper is to present providers’ perspectives on delivering a GE-focused FP intervention, CHARM, to married couples in rural India. Methods: In-depth interviews were carried out with 22 male village health care providers who were delivering a GE-focused FP intervention, CHARM, to 428 husbands (247 couples) rural Maharashtra, India. Providers were interviewed on their experiences and perspectives during delivery of CHARM. Major domains were identified during a thematic analysis. Results: Local male health providers are interested and can be engaged in delivering a GE-focused FP intervention. Providers believed that the CHARM intervention improves couples’ communication, contraceptive use and strengthened their own capacity to provide FP services in accordance with national FP programmatic efforts. Providers found the low-tech flipchart including pictures and information helpful in supporting their service provision. Providers reported some challenges including lack of privacy and space for counselling, limited access to contraceptive options beyond pill and condom, numerous myths and misconceptions about contraceptives. Providers also reported persistent social norms related to expectancy of pregnancy early in marriage, and son preference. Conclusions: Providers in rural areas with high fertility and related maternal health complications are interested in and can successfully implement a GE-focused FP intervention. Future efforts using this approach may benefit from greater focus to support broader array of spacing contraceptives particularly among first time parents, none or one child parents. There is a need to better support engagement of wives possibly through female provider led sessions parallel to male programs, i.e. gender synchronized rather than couples’ sessions. Trial registration: ClinicalTrials.gov NCT01593943, May 8, 2012.

Summary: Introduction: India accounts for about a fifth of cardiovascular deaths globally, but nationally representative data on mortality trends are not yet available. In this nationwide mortality study, we aimed to assess the trends in ischaemic heart disease and stroke mortality over 15 years using the Million Death Study. Methods: We determined national and subnational cardiovascular mortality rates and trends by sex and birth cohort using cause of death ascertained by verbal autopsy from 2001 to 2013 among 2·4 million households. We derived mortality rates for ischaemic heart disease and stroke by applying mortality proportions to UN mortality estimates for India and projected the rates from 2000 to 2015. Findings: Cardiovascular disease caused more than 2·1 million deaths in India in 2015 at all ages, or more than a quarter of all deaths. At ages 30–69 years, of 1·3 million cardiovascular deaths, 0·9 million (68·4%) were caused by ischaemic heart disease and 0·4 million (28·0%) by stroke. At these ages, the probability of dying from ischaemic heart disease increased during 2000–15, from 10·4% to 13·1% in men and 4·8% to 6·6% in women. Ischaemic heart disease mortality rates in rural areas increased rapidly and surpassed those in urban areas. By contrast, the probability of dying from stroke decreased from 5·7% to 5·0% in men and 5·0% to 3·9% in women. A third of premature stroke deaths occurred in the northeastern states, inhabited by a sixth of India's population, where rates increased significantly and were three times higher than the national average. The increased mortality rates of ischaemic heart disease nationally and stroke in the northeastern states were higher in the cohorts of adults born in the 1970s onwards, than in earlier decades. A large and growing proportion of the ischaemic heart disease nationally and stroke deaths in high-burden states reported earlier diagnosis of cardiovascular disease, but low medication use. Interpretation: The unexpectedly diverse patterns of cardiovascular mortality require investigation to identify the role of established and new cardiovascular risk factors. Secondary prevention with effective and inexpensive long-term treatment and adult smoking cessation could prevent substantial numbers of premature deaths. Without progress against the control of cardiovascular disease in India, global goals to reduce non-communicable diseases by 2030 will be difficult to achieve. Funding: Fogarty International Center of the US National Institutes of Health, Dalla Lana School of Public Health, University of Toronto, Indian Council of Medical Research, and the Disease Control Priorities.

Qualitative evidence suggests that husbands’ inequitable gender equity (GE) ideologies may influence associations between husbands’ alcohol use and intimate partner violence (IPV) against wives. However, little quantitative research exists on the subject. To address this gap in the literature, associations of husbands’ elevated alcohol use and GE ideologies with wives’ reports of IPV victimization among a sample of married couples in Maharashtra, India, were examined. Cross-sectional analyses were conducted using data from the baseline sample of the C ounseling H usbands to A chieve R eproductive Health and M arital Equity (CHARM) study. Participants included couples aged 18 to 30 years ( N = 1081). Regression models assessed the relationship between husbands’ elevated alcohol use and GE ideologies (using the Gender-Equitable Men [GEM] Scale) and wives’ history of physical and/or sexual IPV victimization ever in marriage. Husbands and wives were 18 to 30 years of age, and married on average of 3.9 years ( SD ± 2.7). Few husbands (4.6%) reported elevated alcohol use. Husbands had mean GEM scores of 47.3 ( SD ± 5.4, range: 35–67 out of possible range of 24–72; least equitable to most equitable). Approximately one fifth (22.3%) of wives reported a history of physical and/or sexual IPV. Wives were less likely to report IPV if husbands reported greater GE ideologies (adjusted odds ratio [AOR]: 0.97, 95% CI [0.95, 0.99]), and husband’s elevated alcohol use was associated with increased risk of IPV in the final adjusted model (AOR: 1.89, 95% CI [1.01, 3.40]). Findings from this study indicate the need for male participation in violence intervention and prevention services and, specifically, the need to integrate counseling on alcohol use and GE into such programming.

BACKGROUND:Despite ongoing recommendations to increase male engagement and gender-equity (GE) counseling in family planning (FP) services, few such programs have been implemented and rigorously evaluated. This study evaluates the impact of CHARM, a three-session GE+FP counseling intervention delivered by male health care providers to married men, alone (sessions 1&2) and with their wives (session 3) in India. METHODS AND FINDINGS:A two-armed cluster randomized controlled trial was conducted with young married couples (N = 1081 couples) recruited from 50 geographic clusters (25 clusters randomized to CHARM and a control condition, respectively) in rural Maharashtra, India. Couples were surveyed on demographics, contraceptive behaviors, and intimate partner violence (IPV) attitudes and behaviors at baseline and 9 &18-month follow-ups, with pregnancy testing at baseline and 18-month follow-up. Outcome effects on contraceptive use and incident pregnancy, and secondarily, on contraceptive communication and men's IPV attitudes and behaviors, were assessed using logistic generalized linear mixed models. Most men recruited from CHARM communities (91.3%) received at least one CHARM intervention session; 52.5% received the couple's session with their wife. Findings document that women from the CHARM condition, relative to controls, were more likely to report contraceptive communication at 9-month follow-up (AOR = 1.77, p = 0.04) and modern contraceptive use at 9 and 18-month follow-ups (AORs = 1.57-1.58, p = 0.05), and they were less likely to report sexual IPV at 18-month follow-up (AOR = 0.48, p = 0.01). Men in the CHARM condition were less likely than those in the control clusters to report attitudes accepting of sexual IPV at 9-month (AOR = 0.64, p = 0.03) and 18-month (AOR = 0.51, p = 0.004) follow-up, and attitudes accepting of physical IPV at 18-month follow-up (AOR = 0.64, p = 0.02). No significant effect on pregnancy was seen. CONCLUSIONS:Findings demonstrate that men can be engaged in FP programming in rural India, and that such an approach inclusive of GE counseling can improve contraceptive practices and reduce sexual IPV in married couples. TRIAL REGISTRATION:ClinicalTrials.gov NCT01593943.

ObjectivesThis paper discusses patterns of daily smokeless tobacco (SLT) use and correlates of poly SLT use among married women aged 18-40 years in a Mumbai slum community with implications for tobacco control.MethodsUsing a mixed methods approach, the study included a structured survey with 409 daily SLT users and in-depth interviews with 42 women. Participants for the survey were selected using a systematic sampling procedure (one woman in every fourth eligible household). Univariate and bivariate analysis, and multiple logistic regressions were conducted to identify demographic and social factors associated with women's use of poly SLT products. To illustrate survey results, in-depth interviews were analyzed using Atlas ti software.ResultsSixty-four percent of the women surveyed used only one type of SLT; of these, 30% used mishri, 32% used pan with tobacco and the rest used chewed tobacco (11%), gul (17%) or gutkha (10%). Thirty-six percent used more than one type of SLT. Poly SLT users chewed or rubbed 50% more tobacco as compared to single users (mean consumption of tobacco per day: 9.54 vs. 6.49 grams; pConclusionsTobacco control policies and programs must focus specifically on both social context and use patterns to address SLT use among women of reproductive age with special attention to poly SLT users, an understudied and vulnerable population.