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Background: Low-density malaria infections (LDMI) are defined as infections that are missed by the rapid diagnostic test (RDT) and/or microscopy which can lead to continued transmission and poses a challenge in malaria elimination efforts. This study was conducted to investigate the prevalence of LDMI in febrile cases using species-specific nested Polymerase Chain Reaction (PCR) tests in the Malaria Elimination Demonstration Project, where routine diagnosis was conducted using RDT. Methods: Every 10th fever case from a cross-sectional community based fever surveillance was tested with RDT, microscopy and nested PCR. Parasite DNA was isolated from the filter paper using Chelex based method. Molecular diagnosis by nested PCR was performed targeting 18SrRNA gene for Plasmodium species. Results: The prevalence of malaria was 2.50% (436/17405) diagnosed by PCR, 1.13% (196/17405) by RDT, and 0.68% (118/ 17,405) by microscopy. Amongst 17,405 febrile samples, the prevalence of LDMI was 1.51% (263/17405) (95% CI 1.33–1.70), which were missed by conventional methods. Logistic regression analysis revealed that illness during summer season [OR = 1.90 (p < 0.05)] and cases screened within three days of febrile illness [OR = 5.27 (p < 0.001)] were the statistically significant predictors of LDMI. Conclusion: The prevalence of malaria among febrile cases using PCR was 2.50% (436/17405) as compared to 1.13% (196/17405) by RDT. Higher number of the LDMI cases were found in subjects with ≤ 3 days mean duration of reported fever, which was statistically significant (p < 0.001). This observation suggests that an early detection of malaria with a more sensitive diagnostic method or repeat testing of the all negative cases may be useful for curtailing malaria transmission. Therefore, malaria elimination programme would benefit from using more sensitive and specific diagnostic methods, such as PCR. [ABSTRACT FROM AUTHOR]

Background: Rural Indians have higher mortality rates than urban Indians. However, the rural-urban gap in under-five mortality has changed is less researched. This paper aims to assess 1) whether the rural-urban gap in under-five mortality has reduced over time 2) Whether rural children are still experiencing a higher likelihood of death after eliminating the role of other socioeconomic factors 3) What factors are responsible for India's rural-urban gap in under-five mortality.Methods: We used all rounds for National Family Health Survey data for understanding the trend of rural-urban gap in under-five mortality. Using NFHS-2019-21 data, we carried out a binary logistic regression analysis to examine the factors associated with under-five mortality. Fairlie's decomposition technique was applied to understand the relative contribution of different covariates to the rural-urban gap in under-five mortality.Results: India has witnessed a more than 50% reduction in under-five mortality rate between 1992 and 93 and 2019-21. From 1992 to 93 to 2019-21, the annual decrease in rural and urban under-five mortality is 1.6% and 2.7%, respectively. Yet, rural population still contributes a higher proportion of the under-five deaths. The rural-urban gap in under-five mortality has reduced from 44 per thousand live births in 1992-1993 to 30 per thousand in 2004-2005 which further decreased to 14 per thousand in 2019-2021. There is no disadvantage for the rural children due to their place of residence if they belong to economically well-off household or their mothers are educated. It is wealth index rather than place of residence which determines the under-five mortality. Economic (50.82% contribution) and educational differential (28.57% contribution) are the main reasons for rural-urban under-five mortality gaps.Conclusion: The existing rural-urban gap in under-five mortality suggests that the social and health policies need to be need to reach rural children from poor families and uneducated mothers. This call for attention to ensure that the future programme must emphasize mothers from economically and educationally disadvantaged sections. While there should be more emphasis on equal access to health care facilities by the rural population, there should also be an effort to strengthen the rural economy and quality of education. [ABSTRACT FROM AUTHOR]

The 'Cost of Health Services in India (CHSI)' is the first large scale multi-site facility costing study to incorporate evidence from a national sample of both private and public sectors at different levels of the health system in India. This paper provides an overview of the extent of heterogeneity in costs caused by various supply-side factors.A total of 38 public (11 tertiary care and 27 secondary care) and 16 private hospitals were sampled from 11 states of India. From the sampled facilities, a total of 327 specialties were included, with 48, 79 and 200 specialties covered in tertiary, private and district hospitals respectively. A mixed methodology consisting of both bottom-up and top-down costing was used for data collection. Unit costs per service output were calculated at the cost centre level (outpatient, inpatient, operating theatre, and ICU) and compared across provider type and geographical location.The unadjusted cost per admission was highest for tertiary facilities (₹ 5690, 75 USD) followed by private facilities (₹ 4839, 64 USD) and district hospitals (₹ 3447, 45 USD). Differences in unit costs were found across types of providers, resulting from both variations in capacity utilisation, length of stay and the scale of activity. In addition, significant differences in costs were found associated with geographical location (city classification).The reliance on cost information from single sites or small samples ignores the issue of heterogeneity driven by both demand and supply-side factors. The CHSI cost data set provides a unique insight into cost variability across different types of providers in India. The present analysis shows that both geographical location and the scale of activity are important determinants for deriving the cost of a health service and should be accounted for in healthcare decision making from budgeting to economic evaluation and price-setting. [ABSTRACT FROM AUTHOR]

Background: Based on an increased prevalence of diabetes, asthma and hypertension among women in reproductive age, understanding the risk factors of non-communicable diseases (NCDs) is crucial to inform policy and program interventions to address the problem. In this study, we empirically assessed the associations of behavioural factors such as alcohol consumption and tobacco use and a variety of socioeconomic characteristics with prevalence of NCDs in adult women. Methods: The data were derived from the National Family Health Survey conducted in 2015–16. The effective sample size for the present paper was 699,686 women aged 15–49 years in India. Descriptive statistics along with bivariate analysis were conducted to find the preliminary results. Additionally, multivariable logistic regression analysis was conducted to find the relationship between NCDs and behavioural factors such as alcohol consumption and tobacco use. Moreover, population attributable risk was estimated in the present study. Results: It was revealed that 15.9% of women had any of the NCDs. A proportion of 0.8% of women smoked tobacco whereas 5.5% of women consumed smokeless tobacco. Also, a proportion of 1.2% of women consumed alcohol in the current study. The odds of having NCDs among women who smoked tobacco, consumed smokeless tobacco and consume alcohol were 16, 8 and 20% significantly higher than the odds of having NCDs among women who did not smoke tobacco, consume smokeless tobacco and consume alcohol respectively. The population attributable risk of having NCDs was 1.8% (p < 0.001) for women who smoked, 0.8% (p < 0.001) for women who consumed smokeless tobacco and 2.2% (p < 0.001) for women who consumed alcohol. Besides, the odds of having NCDs among overweight and obese women were 2.25 and 3.60 times greater than the odds of having NCDs among women who were underweight. Conclusion: The findings revealed that smoking and using smokeless tobacco and alcohol consumption were risk factors of NCDs in women. The findings also alarm the focus of maternal and child health programs on NCDs' risk factors like maternal obesity, due to their adverse health consequences on their children too. Also, the coexistence of higher levels of tobacco use and alcohol consumption requires different strategies to address the vulnerability of women towards NCDs, including screening and early detection of NCDs especially among those who smoke or chew tobacco and consume alcohol. [ABSTRACT FROM AUTHOR]

Background: This paper investigates trends in rape-related crimes against women and girls reported in the Indian administrative data from 2001 to 2018 to assess the burden of crime, describe sub-national variations, and highlight data gaps to address sexual violence effectively in India. Methods: Data on five rape-related crimes were extracted from the annual reports of National Crimes Record Bureau (NCRB), and included assault with the intent to outrage modesty of woman, rape, insult to the modesty of women, attempt to commit rape, and murder with rape/gang-rape. Rates for all categories combined, and for each crime were estimated for women and girls for India and its states. Trends for type of offender for rape, mean number of people arrested, and legal status of the cases was also assessed. Results: The rate of all rape-related crime increased from 11.6 in 2001 to 19.8 in 2018 per 100,000 women and girls. Most of the 70.7% increase in rate between 2001 and 2018 was post 2012 following a gang-rape and murder case in India's capital. The largest proportion of crimes was recorded as assault with the intent to outrage modesty of the woman, followed by rape. The cited offender in rape cases was for the majority a close known person (44·3%) or other known person (43·1%). By the end of 2018, only 9·6% of the cases had completed trials, with acquittals in 73% cases. Conclusions: The wide variations in the yearly crime rates at state-level highlighted significant issues in data quality including under-reporting, non-comparability, possible bias in data reporting in NCRB, definition of rape-related crime in India, and access in reporting of crimes. Addressing barriers to reporting, improving quality and scope of administrative data recorded on sexual violence is urgently needed for India to meet SDG targets of eliminating all forms of violence against women and girls. [ABSTRACT FROM AUTHOR]

Background: In India, the prevalence of overweight among adolescents is on the rise, setting the stage for an increase in metabolic syndrome (MS). This paper presents the national prevalence of MS in adolescents in India. Methods: A nationally representative data of adolescents (10–19 years) from the Comprehensive National Nutrition Survey was used. MS was defined based on the NCEP–ATP III criteria for adolescents. Bivariate analysis was used to report socio-demographic differentials in prevalence and to assess interstate variability. Multivariate logistic regression model was constructed to measure the association between socio-demographic characteristics and prevalence of MS. Census data from 2011 was projected to 2017 to calculate burden. Results: The prevalence of MS was 5.2% among adolescents. 11.9%, 15.4%, 26.0%, 31.9% and 3.7% had central obesity, high blood pressure, hypertriglyceridemia, low HDL-cholesterol and high fasting glucose, respectively. The prevalence was higher among males (5.7% vs. 4.7%, adjusted odds ratio (AOR): 1.3, 95% confidence interval [CI]: 1.0, 1.6), those residing in urban areas (7.9% vs 4.2%, AOR: 1.4, 95% CI: 1.1, 1.8), and from wealthier households as compared to their counterparts (8.3% vs. 2.4%, AOR: 3.4, 95% CI: 2.1, 5.5). There was wide interstate variability in the prevalence of MS (0.5% – 16.5%). In 2017, 14.2 million adolescents had MS in India. Conclusions: The prevalence of MS among adolescents in India is low and clustered in urban areas and richer households. Early prevention interventions promoting a healthy lifestyle, especially in high prevalence areas, are needed to keep MS from becoming a public health issue. [ABSTRACT FROM AUTHOR]

Self-rated health (SRH) is a well-established measure in public health to administer the general health of an individual. It can also be used to assess overall health status' relationship with the social, physical, and mental health of a person. In this study, we examine the association of SRH and various socio-economic & health-related factors such as multi-morbidity status, mental health, functional health, and social participation. Data used in this paper is collated from the first wave of Longitudinal Ageing Study in India (LASI) 2017-18. A total of 65,562 older adults aged 45 or above are considered in our study. Various indices (multimorbidity, social participation, functional and mental health) have been created to measure factors influencing the SRH of an individual. Overall, in the study population, around 18.4% of people reported poor SRH. Dominance Analysis results show that the contribution of multimorbidity in predicting poor SRH is highest, followed by functional health, mental health, and social participation. In a developing country like India, there is a dire need for policies having a holistic approach regarding the health and well-being of the older population. [ABSTRACT FROM AUTHOR]

Background: Diet diversity signifies the nutrient adequacy of an individual and thus has gained widespread significance in recent times. In developing countries achieving maximum diet diversity, especially among pregnant women from rural areas is challenging although of great importance. However, to do so understanding the primary factors associated with diet diversity is important. This paper, therefore, assessed the socio-demographic and socio-economic determinants of diet diversity among rural pregnant women in India. Methods: The study consisted of a community-based prospective cohort of n = 204 pregnant women attending primary healthcare centers (PHC) across 14 villages in Mulshi Taluka, Pune, Maharashtra, India. The data was collected using a structured questionnaire through a one-to-one interview method. Results: The prevalence of low, medium and high diet diversity was 56.4%, 33.3%, and 10.3% respectively. Minimum diversity in the diet was achieved among 73.5% of pregnant women. The mean diet diversity score (DDS) was 3.6 ± 1.3 with starchy staples being (100%) of commonly consumed foods. Young (< 20 years) women (OR = 5.2; CI:1.9- 13.8), housewives (OR = 3; CI:1.4–6.7), husbands working as skilled laborers (OR = 2.5; CI:1.2–5.5) were at significant risk of having low diet diversity scores. Whereas, those living in a joint family (OR = 0.3; CI:0.1–0.6), not owning a house (OR = 0.5; CI:0.2–0.9), and having a poor income (OR = 1.9; CI: 0.9- 3.7) were less likely to have low diet diversity. Conclusion: Socio-economic and demographic factors (maternal age, mother's occupation, and husband's occupation) influenced the diet diversity among pregnant women. Monotonous diets are commonly seen in developing countries, especially in rural areas which can be a risk factor for poor nutrient adequacy and health of pregnant women. Policies and programs about these determinants of diet diversity should be enacted to replace the poor quality diets to ensure improved diet diversity and nutrient adequacy. [ABSTRACT FROM AUTHOR]

Introduction: There is a significant lack of palliative care access and service delivery in the Indian cancer institutes. In this paper, we describe the development, implementation, and evaluation of a palliative care capacity-building program in Indian cancer institutes. Methods: Participatory action research method was used to develop, implement and evaluate the outcomes of the palliative care capacity-building program. Participants were healthcare practitioners from various cancer institutes in India. Training and education in palliative care, infrastructure for palliative care provision, and opioid availability were identified as key requisites for capacity-building. Researchers developed interventions towards capacity building, which were modified and further developed after each cycle of the capacity-building program. Qualitative content analysis was used to develop an action plan to build capacity. Descriptive statistics were used to measure the outcomes of the action plan. Results: Seventy-three healthcare practitioners from 31 cancer treatment centres in India were purposively recruited between 2016 and 2020. The outcome indicators of the project were defined a priori, and were audited by an independent auditor. The three cycles of the program resulted in the development of palliative care services in 23 of the 31 institutes enrolled in the program. Stand-alone palliative care outpatient services were established in all the 23 centres, with the required infrastructure and manpower being provided by the organization. Morphine availability improved and use increased in these centres, which was an indication of improved pain management skills among the participants. The initiation and continuation of education, training, and advocacy activities in 20 centres suggested that healthcare providers continued to remain engaged with the program even after the cessation of their training cycle. Conclusion: This program illustrates how a transformational change at the organizational and individual level can lead to the development of sustained provision of palliative care services in cancer institutes. [ABSTRACT FROM AUTHOR]

Background: Despite recent achievement in economic progress in India, the fruit of development has failed to secure a better nutritional status among all children of the country. Growing evidence suggest there exists a socioeconomic gradient of childhood malnutrition in India. The present paper is an attempt to measure the extent of socio-economic inequality in chronic childhood malnutrition across major states of India and to realize the role of household socio-economic status (SES) as the contextual determinant of nutritional status of children. Methods: Using National Family Health Survey-3 data, an attempt is made to estimate socio-economic inequality in childhood stunting at the state level through Concentration Index (CI). Multi-level models; random-coefficient and random-slope are employed to study the impact of SES on long-term nutritional status among children, keeping in view the hierarchical nature of data. Main findings: Across the states, a disproportionate burden of stunting is observed among the children from poor SES, more so in urban areas. The state having lower prevalence of chronic childhood malnutrition shows much higher burden among the poor. Though a negative correlation (r = -0.603, p < .001) is established between Net State Domestic Product (NSDP) and CI values for stunting; the development indicator is not always linearly correlated with intra-state inequality in malnutrition prevalence. Results from multi-level models however show children from highest SES quintile posses 50 percent better nutritional status than those from the poorest quintile. Conclusion: In spite of the declining trend of chronic childhood malnutrition in India, the concerns remain for its disproportionate burden on the poor. The socio-economic gradient of long-term nutritional status among children needs special focus, more so in the states where chronic malnutrition among children apparently demonstrates a lower prevalence. The paper calls for state specific policies which are designed and implemented on a priority basis, keeping in view the nature of inequality in childhood malnutrition in the country and its differential characteristics across the states. [ABSTRACT FROM AUTHOR]

Introduction: Pseudomyxoma peritonei (PMP) is a generalized term, usually known as "jelly belly" since 1884. Incidence is very low, 1–3 per million people per year. Because of its indolent nature, it is usually diagnosed at an advanced stage, thereby impacting the quality of life. The 5-year survival rate varies from 23 to 86% in world literature. Even 10 years and 20 years of survival have been described. With our experience, we like to propose rename of PMP as abdomino-peritoneal mucinous carcinoma (APM) as we strongly feel the time has come to specify the term and standardize the management strategy. Methodology: In the premier institute of India and as a tertiary referral center, we experienced the maximum number of advanced cases of APM. From 2012 to 2021, we analyzed all the APM patients based on a prospectively maintained computerized database in the department of surgical oncology and found the reasons for renaming from this traditional one. Results: We included a total of 87 patients who underwent surgical intervention. Thirty-five patients underwent cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC), and 52 patients underwent debulking. In CRS-HIPEC patients, CC-0 was achieved in 28 patients (80%), CC-1 in 4 patients (11.4%), and CC-2 in 3 patients (8.6%). Palliative intent HIPEC was done in 3 patients (8.6%). Clavien-Dindo grade III and IV morbidity was observed in 18.8% of patients with 90 days mortality of 5.7%. Conclusion: With our long-term experience and advancement of scientific evidence, we like to propose a new name for PMP as APM. We strongly believe this paper will give a clear picture of this rare disease and standard management outlines. [ABSTRACT FROM AUTHOR]

Background: In the last two decades, cesarean section (CS) deliveries in India have increased by six-fold and created economic hardship for families and households. Although several schemes and policies under the National Health Mission (NHM) have reduced the inequality in the use of maternal care services in India, the distributive effect of public health subsidies on CS deliveries remains unclear. In this context, this paper examines the usage patterns of CS delivery and estimates the share of public health subsidies on CS deliveries among mothers by different background characteristics in India.Data: Data from the fourth round of the National Family Health Survey (NFHS-4) was used for the study. Out-of-pocket (OOP) payment for CS delivery was used as a dependent variable and was analyzed by level of care that is, primary (PHC, UHC, other) and secondary (government/municipal, rural hospital). Descriptive statistics, binary logistic regression, benefit incidence analysis, concentration curve and concentration index were used for the analysis.Results: A strong economic gradient was observed in the utilization of CS delivery from public health facilities. Among mothers using any public health facility, 23% from the richest quintile did not pay for CS delivery compared to 13% from the poorest quintile. The use of the public subsidy among mothers using any type of public health facility for CS delivery was pro-rich in nature; 9% in the poorest quintile, 16.1% in the poorer, 24.5% in the middle, 27.5% among richer and 23% in the richest quintile. The pattern of utilization and distribution of public subsidy was similar across the primary and secondary health facilities but the magnitude varied. The findings from the benefit-incidence analysis are supported by those obtained from the inequality analysis. The concentration index of CS was 0.124 for public health centers and 0.291 for private health centers. The extent of inequality in the use of CS delivery in public health centers was highest in the state of Mizoram (0.436), followed by Assam (0.336), and the lowest in Tamil Nadu (0.060), followed by Kerala (0.066).Conclusion: The utilization of CS services from public health centers in India is pro-rich. Periodically monitoring and evaluating of the cash incentive schemes for CS delivery and generating awareness among the poor would increase the use of CS delivery services in public health centers and reduce the inequality in CS delivery in India. [ABSTRACT FROM AUTHOR]

Insects are important bioresources as they supply numerous tangible and intangible benefits to humans. Day-to-day livings of many communities in the world are associated with insects as food, medicine, social beliefs, livelihood and other aspects. Many communities from immemorial time traditionally practice insects as food (entomophagy). People consumed insects for delicacy and nutritional purposes. However, some entomophagy species have medicinal value and many traditional healers used them for the treatment of various health ailments like sore throat, mouth ulcers, jaundice, body ache, wound healing, etc. In India, such traditions are widely practised in Northeast India more than other states of India. The focus of this research is on the traditional knowledge of entomophagy species having medicinal properties and social beliefs that are practised by the Tangkhul, Mao and Poumai ethnic community of Manipur, northeast region of India. Review literature was conducted through published journal paper, books and other electronic resources along with questioner's survey. The present study recorded nine entomophagy species and four species having social beliefs according to the local people. This traditional knowledge is inherent from generation to generation, and to conserve such precious indigenous knowledge, proper documentation is necessary. The documented information on the ethnic therapeutic knowledge of the important entomo-therapeutics species of the local community can be transferred to modern pharmacology. [ABSTRACT FROM AUTHOR]

Background: Declining functionality affects an individual's musculoskeletal integrity increasing the risk of fall and disability. Individuals with severe functional limitations are 5 times more likely to experience a fall. Thus, this paper investigated the association between functional decline and falls in older adults.Methods: This study uses secondary data from the Longitudinal Aging Study in India (2017-18). A total of 31,477 people over the age of 60 are included in the study. Descriptive statistics and bivariate analysis were performed to determine the association between activities of daily living (ADL), instrumental activities of daily living (IADL) and fall. Adjusted odds ratio was used to determine the association of ADL and IADL with fall while controlling for age, gender, balance and gait impairments.Results: The study reported 6352 fall episodes in 3270 participants aged 60 and above, over a period of 2 years. More than 30% of participants reported difficulty in ADL and IADL. Age and gender adjusted odds of fall were higher in participants with difficulty in more than 4 ADLs (AOR:1.32; CI:1.08 - 1.67) and in more than 2 IADL (AOR: 1.39; CI:1.02 - 1.89). Similarly, the odds of fall were higher for difficulty in ADL (AOR:1.31; CI:1.11 - 1.73) and IADL (AOR of 1.18; CI:1.07 - 1.29) controlling for gait and balance impairment. Difficulty in pushing-pulling objects (AOR: 1.30; CI: 1.15 - 1.46 & AOR: 1.40; CI: 1.21-1.61) and getting up from the chair (AOR: 1.12; CI:1.01-1.26 & AOR: 1.27; CI: 0.99 - 1.26) was significantly associated with fall when adjusted for age, gender and balance and gait parameters.Conclusions: This study provides the new insights into the association of fall and risk of functional decline, especially difficulty in pushing and pulling objects and getting up from a chair, can be incorporated in the primary screening of fall risk assessment. [ABSTRACT FROM AUTHOR]

Background: Bluetongue virus (BTV) is transmitted by Culicoides biting midges and causes bluetongue (BT), a clinical disease observed primarily in sheep. BT has a detrimental effect on subsistence farmers in India, where hyperendemic outbreaks impact on smallholdings in the southern states of the country. In this study, we establish a reliable method for testing the toxic effects of deltamethrin on Culicoides and then compare deltamethrin with traditional control methods used by farmers in India. Results: Effects of deltamethrin were initially tested using a colonised strain of Culicoides nubeculosus Meigen and a modified World Health Organisation exposure assay. This method was then applied to field populations of Culicoides spp. in India. The field population of C. oxystoma in India had a greater LC50 (0.012 ± 0.009%) for deltamethrin than laboratory-reared C.nubeculosus (0.0013 ± 0.0002%). Exposure of C. nubeculosus to deltamethrin at higher ambient temperatures resulted in greater rates of knockdown but a lower mortality rate at 24 h post-exposure. Behavioural assays with C. nubeculosus in WHO tubes provided evidence for contact irritancy and spatial repellence caused by deltamethrin. The field experiments in India, however, provided no evidence for repellent or toxic effects of deltamethrin. Traditional methods such as the application of neem oil and burning of neem leaves also provided no protection. Conclusions: Our study demonstrates that field-collected Culicoides in India are less susceptible to deltamethrin exposure than laboratory-bred C. nubeculosus and traditional methods of insect control do not provide protection to sheep. These low levels of susceptibility to deltamethrin have not been recorded before in field populations of Culicoides and suggest resistance to synthetic pyrethrioids. Alternative insect control methods, in addition to vaccination, may be needed to protect Indian livestock from BTV transmission. [ABSTRACT FROM AUTHOR]

Background: Developing public health educational programs that provide workers prepared to adequately respond to health system challenges is an historical dilemma. In India, the focus on public health education has been mounting in recent years. The COVID-19 pandemic is a harbinger of the increasing complexities surrounding public health challenges and the overdue need to progress public health education around the world. This paper aims to explore strengths and challenges of public health educational institutions in India, and elucidate unique opportunities to emerge as a global leader in reform.Methods: To capture the landscape of public health training in India, we initiated a web-based desk review of available offerings and categorized by key descriptors and program qualities. We then undertook a series of in-depth interviews with representatives from a purposively sample of institutions and performed a qualitative SWOT analysis.Results: We found that public health education exists in many formats in India. Although Master of Public Health (MPH) and similar programs are still the most common type of public health training outside of community medicine programs, other postgraduate pathways exist including diplomas, PhDs, certificates and executive trainings. The strengths of public health education institutions include research capacities, financial accessibility, and innovation, yet there is a need to improve collaborations and harmonize training with well-defined career pathways. Growing attention to the sector, improved technologies and community engagement all hold exciting potential for public health education, while externally held misconceptions can threaten institutional efficacy and potential.Conclusions: The timely need for and attention to public health education in India present a critical juncture for meaningful reform. India may also be well-situated to contextualize and scale the types of trainings needed to address complex challenges and serve as a model for other countries and the world. [ABSTRACT FROM AUTHOR]

Background: The interdisciplinary Participatory Approach for Nutrition in Children: Strengthening Health, Education, Engineering and Environment Linkages (PANChSHEEEL) study used a participatory approach to develop locally-feasible and tailored solutions to optimise Infant and Young Child Feeding (IYCF) practices at an individual, household, community, and environmental level. This paper aims to evaluate the influence of gender; migration; and Health, Education, Engineering and Environmental (HEEE) factors on IYCF practices, with the primary outcomes being three key complementary-feeding practices of Minimum Dietary Diversity (MDD), Minimum Meal Frequency (MMF) and Minimum Acceptable Diet (MAD). Methods: A cross-sectional survey of 325 households with children aged 6–23 months was conducted in nine purposively selected villages in two blocks of Banswara district, Rajasthan, India. A survey tool was developed, translated into the local language, pre-tested, and administered in a gender-sensitive manner. Data-collection processes were standardized to ensure quality measures. Association of the primary outcome with 27 variables was tested using a Chi-square test (Mantel-Haenszel method); backward stepwise regression analysis was conducted to assess the impact of effect modifiers (gender, parental migration). Results: Half of the surveyed children were of each gender, and fathers from half of the households were found to have migrated within the previous year to search for additional income. Parental literacy ranged from 60 to 70%. More than half of the households had access to milk-producing animals. Consumption of each of the seven food groups, eggs (4.7% vs 0.7%; p < 0.02), MDD (10.5% vs 3.2%; p < 0.02) and MAD (9.4% vs 2.6%; p < 0.02) were higher for boys than for girls. After controlling for contextual factors, a male child was 4.1 times more likely to get a diet with MDD and 3.8 times more likely to get a diet with MAD. A child from a non-migrant household was 2.0–2.1 times more likely to get a diet with MDD and MAD as compared to a child from a migrant household. However, this association was not found to be statistically significant after regression. Presence of milk-producing animals in households and consumption of milk/milk products by children in the previous 24 h were the other two strong predictors of MDD and MAD, although access to animal milk in the house did not translate to an increase in consumption of milk/milk products by a child. Conclusion: Gender discrimination in diet diversity and complementary-feeding practices starts early in childhood with boys having a distinct advantage over girls. In the case of parental migration, further research is required to establish if it has an adverse impact on feeding practices. Emphasis needs to be given to gender issues and other contextual factors when developing strategies to optimise complementary feeding practices. Trial registration: With UCL ethics [Ethics ID 4032/002] in United Kingdom and with Sigma IRB [10,025/IRB/D/17–18] in India. [ABSTRACT FROM AUTHOR]

Background: Government-sponsored health insurance schemes (GSHIS) aim to improve access to and utilization of healthcare services and offer financial protection to the population. India's Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) is one such GSHIS. This paper aims to understand how the processes put in place to manage hospital-based transactions, from the time a beneficiary arrives at the hospital to discharge are being implemented in PM-JAY and how to improve them to strengthen the scheme's operation.Methods: Guidelines were reviewed for the processes associated with hospital-based transactions, namely, beneficiary authentication, treatment package selection, preauthorization, discharge, and claims payments. Across 14 hospitals in Gujarat and Madhya Pradesh states, the above-mentioned processes were observed, and using a semi-structured interview guide fifty-three respondents were interviewed. The study was carried out from March 2019 to August 2019.Results: Average turn-around time for claim reimbursement is two to six times higher than that proposed in guidelines and tender. As opposed to the guidelines, beneficiaries are incurring out-of-pocket expenditure while availing healthcare services. The training provided to the front-line workers is software-centric. Hospital-based processes are relatively more efficient in hospitals where frontline workers have a medical/paramedical/managerial background.Conclusions: There is a need to broaden capacity-building efforts from enabling frontline staff to operate the scheme's IT platform to developing the technical, managerial, and leadership skills required for them. At the hospital level, an empowered frontline worker is the key to efficient hospital-based processes. There is a need to streamline back-end processes to eliminate the causes for delay in the processing of claim payment requests. For policymakers, the most important and urgent need is to reduce out-of-pocket expenses. To that end, there is a need to both revisit and streamline the existing guidelines and ensure adherence to the guidelines. [ABSTRACT FROM AUTHOR]

Background: Intra-regional cultural and linguistic differences are common in low- and middle-income countries. To sensitise undergraduate medical students to the social and contextual determinants of health to achieve the 'health for all' goal, these countries must focus on innovative teaching methods. The early introduction of a Community Orientation Program (COP) as a Community-based Medical Education (CBME) method could be a game changing strategy. In this paper the methods, evaluation, and implication of the COP in an Indian setting are described. Methods: The curriculum of the COP was developed based on the analysis, design, development, implementation, and evaluation (ADDIE) model for educational intervention. In this learner-centric and supervised educational program, the key aim was to focus on developing students' communication skills, observation power and enhancing their motivation for learning through collaborative learning. To meet the objectives of the COP, a situated learning model under the constructivism theory was adopted. Results: Between 2016 and 2019, 557 students were trained through the COP by visiting more than 1300 households in ten villages. To supplement the students' observations in the community, more than 150 small group discussions, a health education programme for the community and summary presentations were conducted. The students' feedback indicated the need to improve the clinical examinations demonstration quality and increase the number of instruments for clinical examinations. More than 80% of students felt that the program would assist them to improve their communication skills, their understanding of the various socio-demographic factors associated with the common diseases, and it will enable them to respect the local culture during their clinical practice. Conclusions: Early initiation of the COP as a CBME method in the undergraduate medical curriculum in an Indian setting has shown promising results. Further evidence is required to adopt such a program routinely for under-graduate medical teaching in the low- and middle- income settings. [ABSTRACT FROM AUTHOR]

Background: Although existing research supports the correlation of hereditary and psychological factors with an adolescent's deliberate self-harm, there is a dearth of research that focus on their socio-economic characteristics. This paper intends to identity the potential risk factors that influence an adolescent's deliberate self-harm. Methods: Data for this study was obtained from Understanding the Lives of Adolescents and Young Adults (UDAYA) study conducted in 2015–16 with sample of 5,969 adolescent boys and 9,419 girls aged 10–19 years. The outcome variable was deliberate self-harm among adolescents. The explanatory variables added in the study were age, current schooling status, working status, media exposure, access to internet, parental abuse, involvement in fights, substance use, depressive symptoms, caste, religion, wealth index, residence and states. Bivariate analysis along with binary logistic regression analysis was done to fulfill the study objectives. Results: About 4.5% and 3.2% of adolescent boys and girls, respectively had deliberate self-harm. The odds of deliberate self-harm were 50 per cent more likely among adolescent girls who had internet access [OR 1.50; CI 1.05–2.16]. The likelihood of deliberate self-harm was 49 per cent and 61 per cent significantly more likely among adolescent boys [OR 1.49; CI 1.11–2.0] and girls [OR 1.61; CI 1.27–2.04] who experienced parental physical abuse respectively. With reference to minimal/mild depressive symptoms, adolescents who had moderate [boys-OR 2.10; CI 1.29–3.4 and girls-OR 2.50; CI 1.774–3.59] or moderately high/severe [boys-OR 4.58; CI 2.88–7.29 and girls-OR 4.18; CI 3.1–5.63] depressive symptoms had significantly higher odds of deliberate self-harm. Conclusions: Internet access, parental abuse, involvement in fights, and depressive symptoms emerged as significant predictors of deliberate self-harm among adolescent boys and girls. Results suggest that an early identification of the predictors and intervention might prevent deliberate self-harm among adolescents. Since parents play a major role in the lives and development of adolescents, it is highly recommended that they initiate open and supportive communication with their children. [ABSTRACT FROM AUTHOR]

Background: The geographical differences that cause anaemia can be partially explained by the variability in environmental factors, particularly nutrition and infections. The studies failed to explain the non-linear effect of the continuous covariates on childhood anaemia. The present paper aims to investigate the risk factors of childhood anaemia in India with focus on geographical spatial effect.Methods: Geo-additive logistic regression models were fitted to the data to understand fixed as well as spatial effects of childhood anaemia. Logistic regression was fitted for the categorical variable with outcomes (anaemia (Hb < 11) and no anaemia (Hb ≥ 11)). Continuous covariates were modelled by the penalized spline and spatial effects were smoothed by the two-dimensional spline.Results: At 95% posterior credible interval, the influence of unobserved factors on childhood anaemia is very strong in the Northern and Central part of India. However, most of the states in North Eastern part of India showed negative spatial effects. A U-shape non-linear relationship was observed between childhood anaemia and mother's age. This indicates that mothers of young and old ages are more likely to have anaemic children; in particular mothers aged 15 years to about 25 years. Then the risk of childhood anaemia starts declining after the age of 25 years and it continues till the age of around 37 years, thereafter again starts increasing. Further, the non-linear effects of duration of breastfeeding on childhood anaemia show that the risk of childhood anaemia decreases till 29 months thereafter increases.Conclusion: Strong evidence of residual spatial effect to childhood anaemia in India is observed. Government child health programme should gear up in treating childhood anaemia by focusing on known measurable factors such as mother's education, mother's anaemia status, family wealth status, child health (fever), stunting, underweight, and wasting which have been found to be significant in this study. Attention should also be given to effects of unknown or unmeasured factors to childhood anaemia at the community level. Special attention to unmeasurable factors should be focused in the states of central and northern India which have shown significant positive spatial effects. [ABSTRACT FROM AUTHOR]

Background: Reduction of multidimensional poverty and tuberculosis are priority development agenda worldwide. The SDGs aims to eradicate poverty in all forms (SDG 1.2) and to end tuberculosis (SDG 3.3.2) by 2030. While poverty is increasingly being measured across multiple domains, reduction of tuberculosis has been an integral part of public health programmes. Though literature suggests a higher prevalence of tuberculosis among the economically poor, no attempt has been made to understand the association between multidimensional poverty and tuberculosis in India. The objective of this paper is to examine the association of multidimensional poverty and tuberculosis in India.Methods: The unit data from the National Family Health Survey-4, conducted in 2015-16 covering 628,900 households and 2,869,043 individuals across 36 states and union territories of India was used in the analysis. The survey collected information on the self-reported tuberculosis infection of each member of a sample household at the time of the survey. Multidimensional poverty was measured in the domains of education, health, and standard of living, with a set of 10 indicators. The prevalence of tuberculosis was estimated among the multidimensional poor and non-poor populations across the states of India. A binary logistic regression model was used to understand the association of tuberculosis and multidimensional poverty.Results: Results suggest that about 29.3% population of India was multidimensional poor and that the multidimensional poverty index was 0.128. The prevalence of tuberculosis among the multidimensional poor was 480 (95% CI: 464-496) per 100,000 population compared to 250 (95% CI: 238-262) among the multidimensional non-poor. The prevalence of tuberculosis among the multidimensional poor was the highest in the state of Kerala (1590) and the lowest in the state of Himachal Pradesh (220). Our findings suggest a significantly higher prevalence of tuberculosis among the multidimensional poor compared to the multidimensional non-poor in most of the states in India. The odds of having tuberculosis among the multidimensional poor were 1.82 times higher (95% CI, 1.73-1.90) compared to the non-poor. Age, sex, smoking, crowded living conditions, caste, religion, and place of residence are significant socio-demographic risk factors of tuberculosis.Conclusion: The prevalence of tuberculosis is significantly higher among the multidimensional poor compared to the multidimensional non-poor in India. [ABSTRACT FROM AUTHOR]

Background: Timely and skilled care is key to reducing maternal and neonatal mortality. Birth preparedness involves preparation for safe childbirth during the antenatal period to reach the appropriate health facility for ensuring safe delivery. Hence, understanding the factors associated with birth preparedness and its significance for safe delivery is essential. This paper aims to assess the levels of birth preparedness, its determinants and association with institutional deliveries in High Priority Districts of Uttar Pradesh, India.Methods: A community-based cross-sectional survey was conducted between June-October 2018 in the rural areas of 25 high priority districts of Uttar Pradesh, India. Simple random sampling was used to select 40 blocks among 294 blocks in 25 districts and 2646 primary sampling units within the selected blocks. The survey interviewed 9458 women who had a delivery 2 months prior to the survey. Descriptive statistics were included to characterize the study population. Multivariable logistic regression analyses were performed to identify the determinants of birth preparedness and to examine the association of birth preparedness with institutional delivery.Results: Among the 9458 respondents, 61.8% had birth preparedness (both facility and transportation identified) and 79.1% delivered in a health facility. Women in other caste category (aOR = 1.24, CI 1.06-1.45) and those with 10 or more years of education (aOR = 1.68, CI 1.46-1.92) were more likely to have birth preparedness. Antenatal care (ANC) service uptake related factors like early registration for ANC (aOR = 1.14, CI 1.04-1.25) and three or more front line worker contacts (aOR = 1.61, CI 1.46-1.79) were also found to be significantly associated with birth preparedness. The adjusted multivariate model showed that those who identified both facility and transport were seven times more likely to undergo delivery in a health facility (aOR = 7.00, CI 6.07-8.08).Conclusion: The results indicate the need for focussing on marginalized groups for improving birth preparedness. Increasing ANC registration in the first trimester of pregnancy, improving frontline worker contact, and optimum utilization of antenatal care check-ups for effective counselling on birth preparedness along with system level improvements could improve birth preparedness and consequently institutional delivery rates in Uttar Pradesh, India. [ABSTRACT FROM AUTHOR]

The Garo community living in Meghalaya has always relied on fermented rice liquor known as Chubitchi as a main beverage in their everyday life. Chubitchi is celebrated by the Garos during feasts and ceremonies. The indigenous populations of North-East India prepare alcoholic beverage in their traditional ways, almost always using rice as the base for those drinks. Chubitchi is a popular traditional alcoholic beverage prepared by the Garo tribe of Meghalaya, India. It is consumed during festive occasions such as Wangala (harvest festival), Do.si Do.doka (wedding festivities) and religious rituals, and also served as refreshments for weary field labourers and guests. It has a great significance in the social and cultural life of the Garos. This paper deals with the traditional preparation of Chubitchi by the Garo tribe, which is a vital part of their culture, and also examines the sociocultural significance of the beverage. [ABSTRACT FROM AUTHOR]

Background: Caesarean section delivery is a major life-saving obstetric surgical intervention for mothers and babies from pregnancy and childbirth related complications. This paper attempts to investigate the geographical variations and correlating factors of caesarean section delivery in India, particularly focusing on the states of Bihar and Tamil Nadu, accounting for one of the lowest and highest prevalence states of caesarean section delivery respectively.Methods: This study is based on secondary data, collected from the fourth round of the National Family Health Survey (NFHS-4), 2015-16. We utilized 190,898 women aged 15-49 years who had a living child during the past 5 years preceding the survey. In this study, caesarean section delivery was the outcome variable. A variety of demographic, socio-economic, and pregnancy- and delivery-related variables were considered as explanatory variables. Descriptive statistics, bivariate percentage distribution, Pearson's Chi-square test, and multivariate binary logistic regression models were employed to draw the inferences from data.Results: Of participants, about 19% of women had undergone caesarean section delivery in the country. The state-wise distribution shows that Telangana (60%) followed by Andhra Pradesh (42%) and Tamil Nadu (36%) represented the topmost states in caesarean delivery, while Bihar (7%), Madhya Pradesh (10%), and Jharkhand (11%) placed at the bottom end. Multivariate logistic models show that the likelihood of caesarean delivery was higher among older women (35-49 years), women with higher levels of education, Muslims, women belonging to the upper quintiles of the household wealth, and those who received antenatal care (ANC), experienced pregnancy loss and delivery complications. Moreover, the odds of caesarean section delivery were remarkably greater for the private health sector than the public health sector in both focused states: Bihar (odds ratio [OR] = 12.84; 95% confidence interval [CI]: 10.90, 15.13) and Tamil Nadu (OR = 2.90; 95% CI: 2.54, 3.31).Conclusion: Findings of this study suggest that improvement in female education, providing economic incentives, and spreading awareness through mass media could raise the caesarean section delivery among women whose vaginal delivery could be unsafe for them as well as for their babies. Moreover, providing adequate ANC and well-equipped public healthcare services would facilitate caesarean delivery among needy women. [ABSTRACT FROM AUTHOR]

Introduction: Reduction in health inequalities and providing universal access to health care have been identified as two important global milestones by the World Health Organization for countries to achieve by 2030. Therefore, recognizing the magnitude of oral health inequalities in India has become a pressing priority to improve access to dental care within the country. This scoping review was conducted with the aim of reviewing, collating and analysing the current knowledge base on oral health inequalities in India. Methodology: The scoping review followed Arksey and O'Malley's approach, and reporting was performed in accordance with the PRISMA-ScR guidelines. A systematic search was conducted on Scopus, PubMed, Web of Science, and EMBASE to identify literature addressing one or more dimensions of oral health inequalities in India, published in English between January 2002 and April 2022. The data were charted, and qualitative analysis was performed to derive themes, highlighting the key concepts emerging from this review. Results: In accordance with the eligibility criteria, a total of 71 articles retrieved through database search and backward citation search were included in this scoping review. The major themes ranged from individual to diverse sociodemographic factors acting as barriers to and facilitators of access to dental care. Deficiencies in human resources for oral health, along with a wide diversity in dental service provision and dental education were other major themes contributing to inequality. Subsequently, this has resulted in recommendations on restructuring the dental workforce and their development and modifications in oral health care policies and practices. The qualitative synthesis demonstrates the intertwined nature of the multiple factors that influence the goal of achieving an affordable, accessible, extensive and inclusive oral healthcare system in India. Conclusions: This comprehensive review provides a broad perspective on oral health inequalities in India, providing valuable insights for both researchers and policymakers in this area and guiding their efforts towards achieving universal oral health coverage in the Indian context. [ABSTRACT FROM AUTHOR]

Introduction: It is well acknowledged that India's community health workers known as Accredited Social Health Activists (ASHA) are the bedrock of its health system. Many ASHAs are currently working in fragile and conflict-affected settings. No efforts have yet been made to understand the challenges and vulnerabilities of these female workers. This paper seeks to address this gap by bringing attention to the situation of ASHAs working in the fragile and conflict settings and how conflict impacts them and their work.Methods: Qualitative fieldwork was undertaken in four conflict-affected villages in two conflict-affected districts -Kokrajhar and Karbi Anglong of Assam state situated in the North-East region of India. Detailed account of four ASHAs serving roughly 4000 people is presented. Data transliterated into English were analysed by authors by developing a codebook using grounded theory and thematic organisation of codes.Results: ASHAs reported facing challenges in ensuring access to health services during and immediately after outbreaks of conflict. They experienced difficulty in arranging transport and breakdown of services at remote health facilities. Their physical safety and security were at risk during episodes of conflict. ASHAs reported hostile attitudes of the communities they served due to the breakdown of social relations, trauma due to displacement, and loss of family members, particularly their husbands.Conclusions: Conflict must be recognised as an important context within which community health workers operate, with greater policy focus and research devoted to understanding and addressing the barriers they face as workers and as persons affected by conflict. [ABSTRACT FROM AUTHOR]

Background: Osteomyelitis variolosa is a self-limiting disease triggered by variola virus that cannot be prevented or repaired. Smallpox has been eradicated for 40 years, and complications that remain after smallpox has been cured have become a remarkable diagnostic challenge for contemporary physicians. In this systematic review, we searched PubMed (MEDLINE), Web of Science, and Google Scholar for cases on complications, diagnosis, and treatment for osteomyelitis variolosa between January 1980 and February 2021.Results: Ten papers and eleven finished cases, all patients from India, were included for comparison with the present case. In total, 100% of patients presented with bilateral elbow deformities, the ankle was the second most common site of lesion in 50%, and knee lesions accounted for 25% in this study. Flexion contracture, joint instability, secondary arthritis, and fracture are common complications of osteomyelitis variolosa, and most patients receive conservative treatment, while internal fixation has good results for combined fractures.Conclusions: Although osteomyelitis variolosa is not a direct threat to the safety of patients, severe skeletal deformities can have a significant impact on quality of life. With advances in surgical techniques, clinicians are offering an increasing number of treatment options for patients with osteomyelitis variolosa. However, most importantly, smallpox has basically been removed from the historical arena, and for areas where smallpox was once endemic, physicians need to deepen the understanding of this disease again. [ABSTRACT FROM AUTHOR]

Background: In medical diagnosis and clinical practice, diagnosing a disease early is crucial for accurate treatment, lessening the stress on the healthcare system. In medical imaging research, image processing techniques tend to be vital in analyzing and resolving diseases with a high degree of accuracy. This paper establishes a new image classification and segmentation method through simulation techniques, conducted over images of COVID-19 patients in India, introducing the use of Quantum Machine Learning (QML) in medical practice.Methods: This study establishes a prototype model for classifying COVID-19, comparing it with non-COVID pneumonia signals in Computed tomography (CT) images. The simulation work evaluates the usage of quantum machine learning algorithms, while assessing the efficacy for deep learning models for image classification problems, and thereby establishes performance quality that is required for improved prediction rate when dealing with complex clinical image data exhibiting high biases.Results: The study considers a novel algorithmic implementation leveraging quantum neural network (QNN). The proposed model outperformed the conventional deep learning models for specific classification task. The performance was evident because of the efficiency of quantum simulation and faster convergence property solving for an optimization problem for network training particularly for large-scale biased image classification task. The model run-time observed on quantum optimized hardware was 52 min, while on K80 GPU hardware it was 1 h 30 min for similar sample size. The simulation shows that QNN outperforms DNN, CNN, 2D CNN by more than 2.92% in gain in accuracy measure with an average recall of around 97.7%.Conclusion: The results suggest that quantum neural networks outperform in COVID-19 traits' classification task, comparing to deep learning w.r.t model efficacy and training time. However, a further study needs to be conducted to evaluate implementation scenarios by integrating the model within medical devices. [ABSTRACT FROM AUTHOR]

Background: With 8,82,000 deaths in the under-five period, India observed varied intra-state and inter-regional differences across infant and child mortality in 2018. However, scarce literature is present to capture this unusual concentration of mortality in certain families by examining the association of the mortality risks among the siblings of those families along with various unobserved characteristics of the mother. Looking towards the regional and age differential in mortality, this paper attempts to provide evidence for the differential in mortality clustering among infants (aged 0-11 months), children (12-59 months) and under-five (0-59 months) period among mothers from the Empowered Action Group (EAG) and non-EAG regions of India.Methods: The study used data from the National Family Health Survey (2015-16) which includes all the birth histories of 475,457 women aged 15-49 years. Bivariate and multivariate analyses were used to fulfil the objectives of the study. A two-level random intercept Weibull regression model was used to account for the unexplained mother (family) level heterogeneity.Results: About 3.3% and 5.9% of infant deaths and 0.8% and 1.6% of childhood deaths were observed in non-EAG and EAG regions respectively. Among them, a higher percentage of infant and child death was observed due to the death of a previous sibling. There were 1.67 times [95% CI: 1.55-1.80] and 1.46 times [CI: 1.37-1.56] higher odds of infant and under-five mortality of index child respectively when the previous sibling at the time of conception of the index child was dead in the non-EAG regions. In contrast, the odds of death scarring (death of previous sibling scars the survival of index child) were 1.38 times [CI: 1.32-1.44] and 1.24 times [CI: 1.20-1.29] higher for infant and under-five mortality respectively in the EAG regions.Conclusion: The extent of infant and child mortality clustering and unobserved heterogeneity was higher among mothers in the non-EAG regions in comparison to their EAG region counterparts. With the growing situation of under-five mortality clustering in non-EAG states, region-wise interventions are recommended. Additionally, proper care is needed to ameliorate the inter-family variation in mortality risk among the children of both EAG and non-EAG regions throughout their childhood. [ABSTRACT FROM AUTHOR]

Background: Health policy interventions were expected to improve access to health care delivery, provide financial risk protection, besides reducing inequities that underlie geographic and socio-economic variation in population access to health care. This article examines whether health policy interventions and accelerated health investments in India during 2004–2018 could close the gap in inequity in health care utilization and access to public subsidy by different population groups. Did the poor and socio-economically vulnerable population gain from such government initiatives, compared to the rich and affluent sections of society? And whether the intended objective of improving equity between different regions of the country been achieved during the policy initiatives? This article attempts to assess and provide robust evidence in the Indian context. Methods: Employing Benefit-Incidence Analysis (BIA) framework, this paper advances earlier evidence by highlighting estimates of health care utilization, concentration and government subsidy by broader provider categories (public versus private) and across service levels (outpatient, inpatient, maternal, pre-and post-natal services). We used 2 waves of household surveys conducted by the National Sample Survey Organisation (NSSO) on health and morbidity. The period of analysis was chosen to represent policy interventions spanning 2004 (pre-policy) and 2018 (post-policy era). We present this evidence across three categories of Indian states, namely, high-focus states, high-focus north eastern states and non-focus states. Such categorization facilitates quantification of reform impact of policy level interventions across the three groups. Results: Utilisation of healthcare services, except outpatient care visits, accelerated significantly in 2018 from 2004. The difference in utilisation rates between poor and rich (between poorest 20% and richest 20%) had significantly declined during the same period. As far as concentration of healthcare is concerned, the Concentrate Index (CI) underlying inpatient care in public sector fell from 0.07 in 2004 to 0.05 in 2018, implying less pro-rich distribution. The CI in relation to pre-natal, institutional delivery and postnatal services in government facilities were pro-poor both in 2004 and 2018 in all 3 groups of states. The distribution of public subsidy underscoring curative services (inpatient and outpatient) remained pro-rich in 2004 but turned less pro-rich in 2018, measured by CIs which declined sharply across all groups of states for both outpatient (from 0.21 in 2004 to 0.16 in 2018) and inpatient (from 0.24 in 2004 to 0.14 in 2018) respectively. The CI for subsidy on prenatal services declined from approximately 0.01 in 2004 to 0.12 in 2018. In respect to post-natal care, similar results were observed, implying the subsidy on prenatal and post-natal services was overwhelmingly received by poor. The CI underscoring subsidy for institutional delivery although remained positive both in 2018 and 2004, but slightly increased from 0.17 in 2004 to 0.28 in 2018. Conclusions: Improvement in infrastructure and service provisioning through NHM route in the public facilities appears to have relatively benefited the poor. Yet they received a relatively smaller health subsidy than the rich when utilising inpatient and outpatient health services. Inequality continues to persist across all healthcare services in private health sector. Although the NHM remained committed to broader expansion of health care services, a singular focus on maternal and child health conditions especially in backward regions of the country has yielded desired results. [ABSTRACT FROM AUTHOR]

Background: A social mobilization (SM) initiative contributed to India's success in polio elimination. This was the CORE Group Polio Project (CGPP) India, a partner of the Uttar Pradesh (UP) SM Network and which continued its SM activities, even during the polio-free period through a network of multi-level social mobilizers. This paper assesses the effects of this community-level SM (CLSM) intervention on the extent of community engagement and performance of polio Supplementary Immunization Activity campaigns (SIAs) during the post-polio-endemic period (i.e., from March 2012 to September 2017).Methods: This study followed a quasi-experimental design. We used secondary, cluster-level data from CGPP India's Management Information System, including 52 SIAs held from January 2008 to September 2017, covering 56 blocks from 12 districts of UP. We computed various indicators and performed Generalized Estimating Equations based analysis to assess the statistical significance of differences between the outcomes of intervention and non-intervention areas. We then estimated the effects of the SM intervention using Interrupted time-series, Difference-in-Differences and Synthetic Control Methods. Finally, we estimated the population influenced by the intervention.Results: The performance of polio SIAs changed over time, with the intervention areas having better outcomes than non-intervention areas. The absence of CLSM intervention during the post-polio-endemic period would have negatively impacted the outcomes of polio SIAs. The percentage of children vaccinated at polio SIA booths, percentage of 'X' houses (i.e., households with unvaccinated children or households with out-of-home/out-of-village children or locked households) converted to 'P' (i.e., households with all vaccinated children or households without children eligible for vaccination), and percentage of resistant houses converted to polio acceptors would have gone down by 14.1 (Range: 12.7 to 15.5), 6.3 (Range: 5.2 to 7.3) and 7.4 percentage points, respectively. Community engagement would have reduced by 7.2 (Range: 6.6 to 7.7) percentage points.Conclusions: The absence of CLSM intervention would have significantly decreased the level of community engagement and negatively impacted the performance of polio SIAs of the post-polio-endemic period. The study provides evidence of an added value of deploying additional human resource dedicated to social mobilization to achieve desired vaccination outcomes in hard-to-reach or programmatically challenging areas. [ABSTRACT FROM AUTHOR]

Background: Many popular disease transmission models have helped nations respond to the COVID-19 pandemic by informing decisions about pandemic planning, resource allocation, implementation of social distancing measures, lockdowns, and other non-pharmaceutical interventions. We study how five epidemiological models forecast and assess the course of the pandemic in India: a baseline curve-fitting model, an extended SIR (eSIR) model, two extended SEIR (SAPHIRE and SEIR-fansy) models, and a semi-mechanistic Bayesian hierarchical model (ICM).Methods: Using COVID-19 case-recovery-death count data reported in India from March 15 to October 15 to train the models, we generate predictions from each of the five models from October 16 to December 31. To compare prediction accuracy with respect to reported cumulative and active case counts and reported cumulative death counts, we compute the symmetric mean absolute prediction error (SMAPE) for each of the five models. For reported cumulative cases and deaths, we compute Pearson's and Lin's correlation coefficients to investigate how well the projected and observed reported counts agree. We also present underreporting factors when available, and comment on uncertainty of projections from each model.Results: For active case counts, SMAPE values are 35.14% (SEIR-fansy) and 37.96% (eSIR). For cumulative case counts, SMAPE values are 6.89% (baseline), 6.59% (eSIR), 2.25% (SAPHIRE) and 2.29% (SEIR-fansy). For cumulative death counts, the SMAPE values are 4.74% (SEIR-fansy), 8.94% (eSIR) and 0.77% (ICM). Three models (SAPHIRE, SEIR-fansy and ICM) return total (sum of reported and unreported) cumulative case counts as well. We compute underreporting factors as of October 31 and note that for cumulative cases, the SEIR-fansy model yields an underreporting factor of 7.25 and ICM model yields 4.54 for the same quantity. For total (sum of reported and unreported) cumulative deaths the SEIR-fansy model reports an underreporting factor of 2.97. On October 31, we observe 8.18 million cumulative reported cases, while the projections (in millions) from the baseline model are 8.71 (95% credible interval: 8.63-8.80), while eSIR yields 8.35 (7.19-9.60), SAPHIRE returns 8.17 (7.90-8.52) and SEIR-fansy projects 8.51 (8.18-8.85) million cases. Cumulative case projections from the eSIR model have the highest uncertainty in terms of width of 95% credible intervals, followed by those from SAPHIRE, the baseline model and finally SEIR-fansy.Conclusions: In this comparative paper, we describe five different models used to study the transmission dynamics of the SARS-Cov-2 virus in India. While simulation studies are the only gold standard way to compare the accuracy of the models, here we were uniquely poised to compare the projected case-counts against observed data on a test period. The largest variability across models is observed in predicting the "total" number of infections including reported and unreported cases (on which we have no validation data). The degree of under-reporting has been a major concern in India and is characterized in this report. Overall, the SEIR-fansy model appeared to be a good choice with publicly available R-package and desired flexibility plus accuracy. [ABSTRACT FROM AUTHOR]

Background: Health service and health outcome data collection across many low- and middle-income countries (LMICs) is, to date largely paper-based. With the development and increased availability of reliable technology, electronic tablets could be used for electronic data collection in such settings. This paper describes our experiences with implementing electronic data collection methods, using electronic tablets, across different settings in four LMICs.Methods: Within our research centre, the use of electronic data collection using electronic tablets was piloted during a healthcare facility assessment study in Ghana. After further development, we then used electronic data collection in a multi-country, cross-sectional study to measure ill-health in women during and after pregnancy, in India, Kenya and Pakistan. All data was transferred electronically to a central research team in the UK where it was processed, cleaned, analysed and stored.Results: The healthcare facility assessment study in Ghana demonstrated the feasibility and acceptability to healthcare providers of using electronic tablets to collect data from seven healthcare facilities. In the maternal morbidity study, electronic data collection proved to be an effective way for healthcare providers to document over 400 maternal health variables, in 8530 women during and after pregnancy in India, Kenya and Pakistan.Conclusions: Electronic data collection provides an effective platform which can be used successfully to collect data from healthcare facility registers and from patients during health consultations; and to transfer large quantities of data. To ensure successful electronic data collection and transfer between settings, we recommend that close attention is paid to study design, data collection, tool design, local internet access and device security. [ABSTRACT FROM AUTHOR]

Background: Health outcomes in India are characterized by pervasive inequities due to deeply entrenched socio-economic gradients amongst the population. Therefore, it is imperative to investigate these systematic disparities in health, however, evidence of inequities does not commensurate with its policy objectives in India. Thus, our paper aims to examine the magnitude of and trends in horizontal inequities in self-reported morbidity and untreated morbidity in India over the period of 2004 to 2017–18. Methods: The study used cross-sectional data from nationwide healthcare surveys conducted in 2004, 2014 and 2017–18 encompassing sample size of 3,85,055; 3,35,499 and 5,57,887 individuals respectively. Erreygers concentration indices were employed to discern the magnitude and trend in horizontal inequities in self-reported morbidity and untreated morbidity. Need standardized concentration indices were further used to unravel the inter-regional and intra-regional income related inequities in outcomes of interest. Additionally, regression based decomposition approach was applied to ascertain the contributions of both legitimate and illegitimate factors in the measured inequalities. Results: Estimates were indicative of profound inequities in self-reported morbidity as inequity indices were positive and significant for all study years, connoting better-off reporting more morbidity, given their needs. These inequities however, declined marginally from 2004(HI: 0.049, p< 0.01) to 2017–18(HI: 0.045, P< 0.01). Untreated morbidity exhibited pro-poor inequities with negative concentration indices. Albeit, significant reduction in horizontal inequity was found from 2004(HI= − 0.103, p< 0.01) to 2017–18(HI = − 0.048, p< 0.01) in treatment seeking over the years. The largest contribution of inequality for both outcomes stemmed from illegitimate variables in all the study years. Our findings also elucidated inter-state heterogeneities in inequities with high-income states like Andhra Pradesh, Kerala and West Bengal evincing inequities greater than all India estimates and Northeastern states divulged equity in reporting morbidity. Inequities in untreated morbidity converged for most states except in Punjab, Chhattisgarh and Himachal Pradesh where widening of inequities were observed from 2004 to 2017–18. Conclusions: Pro-rich and pro-poor inequities in reported and untreated morbidities respectively persisted from 2004 to 2017–18 despite reforms in Indian healthcare. Magnitude of these inequities declined marginally over the years. Health policy in India should strive for targeted interventions closing inequity gap. [ABSTRACT FROM AUTHOR]

Background: Violence against older adults is a well-recognised socio-psychological and public health problem. It is uncared-for, undiagnosed, and an untreated problem that is widespread across both developed and developing countries. The present paper aims to understand the extent of the socio-economic status related inequality in violence against older adults in India.Methods: The study uses data from Building a Knowledge Base on Population Aging in India (BKPAI). Violence against older adults is the outcome variable for the study and is defined as older adults who faced any abuse or violence or neglect or disrespect by any person. Bivariate analysis and regression-based decomposition technique is used to understand the relative contribution of various socio-economic factors to violence against older adults (N = 9541).Results: The prevalence of violence faced by older adults was 11.2%. Older adults aged 80+ years [OR: 1.49; CI: 1.14-1.93] and working [OR: 1.26; CI: 1.02-1.56] had higher likelihood to face violence than their counterparts. On the other hand, older adults who were currently in union [OR: 0.79; CI: 0.65-0.95], lived with children [OR: 0.53; CI: 0.40-0.72] and who belonged to richer wealth quintile [OR: 0.35; CI:0.24-0.51] had lower likelihood to suffer from violence than their counterparts. The decomposition results revealed that poor older adults were more prone to violence (Concentration index: - 0.20). Household's wealth status was responsible for explaining 93.7% of the socio-economic status related inequality whereas living arrangement of older adults explained 13.7% of the socio-economic related inequality. Education and working status of older adults made a substantial contribution to the inequalities in reported violence, explaining 3.7% and 3.3% of the total inequality, respectively.Conclusion: Though interpretation of the results requires a cautious understanding of the data used, the present study highlights some of the relevant issues faced by the country's older adults. With no or meagre income of their own, older adults belonging to the poorest wealth quintile have little or no bargaining power to secure a violent free environment for themselves. Therefore, special attention in terms of social and economic support should be given to the economically vulnerable older population. [ABSTRACT FROM AUTHOR]

Background: Financing for NCDs is encumbered by out-of-pocket expenditure (OOPE) assuming catastrophic proportions. Therefore, it is imperative to investigate the extent of catastrophic health expenditure (CHE) on NCDs, which are burgeoning in India. Thus, our paper aims to examine the extent of CHE and impoverishment in India, in conjunction with socio-economic determinants impacting the CHE.Methods: We used cross-sectional data from nationwide healthcare surveys conducted in 2014 and 2017-18. OOPE on both outpatient and inpatient treatment was coalesced to estimate CHE on NCDs. Incidence of CHE was defined as proportion of households with OOPE exceeding 10% of household expenditure. Intensity of catastrophe was ascertained by the measure of Overshoot and Mean Positive Overshoot Indices. Further, impoverishing effects of OOPE were assessed by computing Poverty Headcount Ratio and Poverty Gap Index using India's official poverty line. Concomitantly, we estimated the inequality in incidence and intensity of catastrophic payments using Concentration Indices. Additionally, we delineated the factors associated with catastrophic expenditure using Multinomial Logistic Regression.Results: Results indicated enormous incidence of CHE with around two-third households with NCDs facing CHE. Incidence of CHE was concentrated amongst poor that further extended from 2014(CI = - 0.027) to 2017-18(CI = - 0.065). Intensity of CHE was colossal as households spent 42.8 and 34.9% beyond threshold in 2014 and 2017-18 respectively with poor enduring greater overshoot vis-à-vis rich (CI = - 0.18 in 2014 and CI = - 0.23 in 2017-18). Significant immiserating impact of NCDs was unraveled as one-twelfth in 2014 and one-eighth households in 2017-18 with NCD burden were pushed to poverty with poverty deepening effect to the magnitude of 27.7 and 30.1% among those already below poverty on account of NCDs in 2014 and 2017-18 respectively. Further, large inter-state heterogeneities in extent of CHE and impoverishment were found and multivariate analysis indicated absence of insurance cover, visiting private providers, residing in rural areas and belonging to poorest expenditure quintile were associated with increased likelihood of incurring CHE.Conclusion: Substantial proportion of households face CHE and subsequent impoverishment due to NCD related expenses. Concerted efforts are required to augment the financial risk protection to the households, especially in regions with higher burden of NCDs. [ABSTRACT FROM AUTHOR]

Background: Disability in India is associated with increasing non-communicable diseases, rising longevity, and increasing accidents and injuries. Though studies have examined prevalence, patterns, and socioeconomic correlates of disability, no attempt has been made in estimating age of onset of disability in India.Objective: This paper investigates the economic gradient of age of onset of locomotor, visual, hearing, speech, mental retardation, mental illness, and other disabilities in India.Method: We use nationally representative data of 106,894 disabled individuals from the 76th round of National Sample Survey (NSS), 2018. Descriptive statistics, kernel density, Kaplan-Meier survival curves, and linear regression models are used in the analysis.Result: The disability rate in India was 2184 per 100,000 persons. The disability rate was highest for locomotor (1353) followed by hearing (296), visual (234), speech (228), mental retardation (158), and mental illness (131). Over 85% of mental retardation and 80% of speech disabilities occur at birth, while 82% of locomotor and 81% of visual disabilities occur after birth. Among those who had disability after birth, the median age for mental retardation was 2 years followed by mental illness (28 years), speech (29 years), locomotor (42 years), visual (55 years), and 56 years for hearing disability. Adjusting for socioeconomic covariates, the age of onset of locomotor and speech disabilities among the poorest individuals were 7 and 11 years earlier than the richest, respectively.Conclusion: The economic gradient of onset of locomotive and speech disabilities are strong. The age of onset of disability was earliest for mental retardation followed by mental illness and speech disability. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 infections and deaths have largely been uneven within and between countries. With 17% of the world's population, India has so far had 13% of global COVID-19 infections and 8.5% of deaths. Maharashtra accounting for 9% of India's population, is the worst affected state, with 19% of infections and 33% of total deaths in the country until 23rd December 2020. Though a number of studies have examined the vulnerability to and spread of COVID-19 and its effect on mortality, no attempt has been made to understand its impact on mortality in the states of India.Method: Using data from multiple sources and under the assumption that COVID-19 deaths are additional deaths in the population, this paper examined the impact of the disease on premature mortality, loss of life expectancy, years of potential life lost (YPLL), and disability-adjusted life years (DALY) in Maharashtra. Descriptive statistics, a set of abridged life tables, YPLL, and DALY were used in the analysis. Estimates of mortality indices were compared pre- and during COVID-19.Result: COVID-19 attributable deaths account for 5.3% of total deaths in the state and have reduced the life expectancy at birth by 0.8 years, from 73.2 years in the pre-COVID-19 period to 72.4 years by the end of 2020. If COVID-19 attributable deaths increase to 10% of total deaths, life expectancy at birth will likely reduce by 1.4 years. The probability of death in 20-64 years of age (the prime working-age group) has increased from 0.15 to 0.16 due to COVID-19. There has been 1.06 million additional loss of years (YPLL) in the state, and DALY due to COVID-19 has been estimated to be 6 per thousand.Conclusion: COVID-19 has increased premature mortality, YPLL, and DALY and has reduced life expectancy at every age in Maharashtra. [ABSTRACT FROM AUTHOR]

Background: Segregation of household waste at the source is an effective and sustainable strategy for management of municipal waste. However, household segregation levels remain insufficient as waste management approaches are mostly top down and lack local support. The realisation and recognition of effective, improved and adequate waste management may be one of the vital drivers for attaining environmental protection and improved health and well-being. The presence of a local level motivator may promote household waste segregation and ultimately pro-environmental behaviour. The present cluster randomized control trial aims to understand if volunteer based information on waste segregation (I-MISS) can effectively promote increased waste segregation practices at the household level when compared with existing routine waste segregation information in an urban Indian setting.Methods: This paper describes the protocol of an 18 month two-group parallel,cluster randomised controlled trialin the urban setting of Ujjain, Madhya Pradesh, India. Randomization will be conducted at ward level, which is the last administrative unit of the municipality. The study will recruit 425 households in intervention and control groups. Assessments will be performed at baseline (0 months), midline (6 months), end line (12 months) and post intervention (18 months). The primary outcome will be the comparison of change in proportion of households practicing waste segregation and change in proportion of mis-sorted waste across the study period between the intervention and control groups as assessed by pick analysis. Intention to treat analysis will be conducted. Written informed consent will be obtained from all participants.Discussion: The present study is designed to study whether an external motivator, a volunteer selected from the participating community and empowered with adequate training, could disseminate waste segregation information to their community, thus promoting household waste segregation and ultimately pro-environmental behaviour. The study envisages that the volunteers could link waste management service providers and the community, give a local perspective to waste management, and help to change community habits through information, constant communication and feedback.Trial Registration: The study is registered prospectively with Indian Council of Medical Research- Clinical Trial Registry of India ( CTRI/2020/03/024278 ). [ABSTRACT FROM AUTHOR]

Background: Uncontrolled hypertension and tobacco use are two major public health issues that have implications for reproductive outcomes. This paper examines the association between tobacco-use status and uncontrolled hypertension among prime childbearing age (20-35) women in India.Methods: We used the India National Family Health Survey (NFHS-4) 2015-2016 to obtain data on hypertension status and tobacco use for 356,853 women aged 20-35. We estimated multivariate logistic regressions to obtain the adjusted odds ratio for tobacco users in favor of having uncontrolled hypertension. We examined the adjusted odds at different wealth index quintiles, at different educational attainment, and at different level of nutritional status measured by body mass index.Results: We found that the odds of having uncontrolled hypertension for the tobacco user women in India was 1.1 (95% CI: 1.01-1.19) times that of tobacco non-users at prime childbearing age. The odds were higher for tobacco-users at the poorest quintile (1.27, 95% CI: 1.14-1.42) and with no education (1.22, 95% CI: 1.10-1.34). The odds were also higher for tobacco-users who were overweight (1.88, 95% CI: 1.57-2.29) or obese (2.82, 95% CI: 1.88-4.24).Conclusions: Our findings highlight the disproportionate dual risk of uncontrolled hypertension and tobacco use among lower-income women of prime childbearing age, identifying an opportunity for coordinated tobacco control and hypertension prevention initiatives to ensure better health of reproductive-age women in India. [ABSTRACT FROM AUTHOR]

Background: Poor Maternal and Child Health (MCH) outcomes pose challenges to India's ability to attain Goal-3 of the Sustainable Development Goals (SDGs). The government of India strengthened the existing network of frontline health workers (FHWs), under its National Rural Health Mission in 2005 and subsequent National Urban Health Mission in 2013 as a strategy to mitigate the shortage of skilled health workers and to provide affordable healthcare services. However, there is a lack of robust national-level empirical analysis on the role of maternal engagement with FHWs in influencing the level of maternal and child health care utilisation and child health outcomes in India.Methods: Using data from the nationally representative Indian National Family Health Survey (NFHS) 2015-2016, this paper aims to investigate the intensity of engagement of FHWs with married women of child-bearing age (15-49 years), its influence on utilisation of maternal and child healthcare services, and child health outcomes. Our empirical analyses use multivariate regression analyses, focusing on five maternal and child health indicators: antenatal care visits (ANC) (4 or > 4 times), institutional delivery, full-immunisation of children, postnatal care (PNC) (within 2 days of delivery), and child survival.Results: Our analysis finds that maternal engagement with FHWs is statistically significant and a positive predictor of maternal and child health care utilisation, and child survival. Further, the level of engagement with FHWs is particularly important for women from economically poor households. Our robustness checks across sub-samples of women who delivered only in public health institutions and those from rural areas provides an additional confidence in our main results.Conclusions: From a policy perspective, our findings highlight that strengthening the network of FHWs in the areas where they are in shortage which can help in further improving the utilisation of maternal and child healthcare services, and health outcomes. Also, the role of FHWs in the government health system needs to be enhanced by improving skills, working environment, and greater financial incentives. [ABSTRACT FROM AUTHOR]

Background: Menstrual hygiene products used by women have evolved in the past several decades with comfort, ease of use and cost driving women's choices. In a country like India, where women form nearly 50% of the population, the sheer volume of periodic menstrual non-biodegradable waste generated has significant environmental implications. With majority of the country hailing from low-middle class backgrounds, observing healthy menstrual hygiene practices with environmentally friendly products necessitates the consideration of affordable and highly sustainable alternatives. Further, during the COVID-19 pandemic, period poverty is higher than ever, causing women to turn to the reusable product market for affordable and long lasting alternatives. Hence, we studied the Feasibility and Acceptability (FA) of a novel banana fiber based menstrual pad (BFP) amongst women living in rural and urban environments.Methods: The quantitative study of FA of the BFP was conducted amongst 155 rural and 216 urban participants in India. For greater authenticity of the FA study, we considered participants who used BFP for more than 4 months (Rural = 111 and Urban = 186) in the study. The survey data included responses from participants from Bihar, Delhi, Karnataka, Kerala, Maharashtra, Tamil Nadu and West Bengal. A 22-item survey instrument was developed and validated using Exploratory Factor Analysis (EFA) and reliability test (Cronback's [Formula: see text]). Binomial logistic regression analysis was used to analyse the factors that affect the FA of BFP based on the survey responses. In addition to survey analysis, environmental sustainability through [Formula: see text] footprint analysis, microbial load, pH and the ability of the BFP to withstand pressure after absorption were also studied.Results: The results indicated high levels of feasibility (rural [Formula: see text], urban [Formula: see text] and acceptability (rural [Formula: see text], urban [Formula: see text]) of BFPs across both participant groups. Comparing key BFP characteristics such as leakage and comfort to participants' prior practices revealed general satisfaction on the performance of BFP, leading to them recommending BFPs to others. User perception on the reasons for their preference of BFP highlighted their concern for environment, health and cost as decisive factors. The microbial load on a 3 year reused BFP was found to be similar to an unused BFP. Regression analysis showed cost as an important indicator for feasibility ([Formula: see text]; 95% CI = 1.083-3.248) and acceptability ([Formula: see text]; 95% CI = 1.203-3.748) amongst rural participants.Conclusion: Based on feasibility and acceptability results, BFP is a promising consideration as an environmentally sound, non-invasive; yet reusable alternative to fulfil MHM needs in populous countries such as India. Longer term studies in larger samples are necessary to validate these findings. [ABSTRACT FROM AUTHOR]

Background: Hydroxyurea and blood transfusion therapies remain the main therapeutic strategies for Sickle cell disease. Preliminary data suggest substantial variation and inconsistencies in practice of these two therapeutic modalities in South Asia. In this systematic review we searched Medline, Cochrane library and Scopus for articles on usage of hydroxyurea and blood transfusion therapies for sickle cell disease in South Asia published in English between October 2005 and October 2020.Results: We selected 41 papers: 33 from India, 3 from Sri Lanka, 2 each from Pakistan and Bangladesh and one from Nepal. Only 14 prospective trials focused on hydroxyurea therapy from which majority (n = 10; 71.4%) adopted fixed low dose (10 mg/kg/day) regimen. With hydroxyurea therapy, 12 and 9 studies reported significant reductions in vaso-occlusive crises and transfusion requirement respectively. Severe anaemia (haemoglobin level < 6-7 g/dl) was the commonest indicator (n = 8) for transfusion therapy followed by vaso-occlusive crisis.Conclusions: Published data on the hydroxyurea and transfusion therapies in South Asia are limited and heterogeneous. A clear gap of knowledge exists about the nature of the sickle cell disease in the Indian subcontinent particularly from countries outside India necessitating further evidence-based assessments and interventions. [ABSTRACT FROM AUTHOR]

Background: Efforts are underway to develop an easy-to-use contraceptive microarray patch (MAP) that could expand the range of self-administrable methods. This paper presents results from a discrete choice experiment (DCE) designed to support optimal product design. Methods: We conducted a DCE survey of users and non-users of contraception in New Delhi, India (496 women) and Ibadan, Nigeria (two versions with 530 and 416 women, respectively) to assess stated preferences for up to six potential product attributes: effect on menstruation, duration of effectiveness, application pain, location, rash after application, and patch size. We estimated Hierarchical Bayes coefficients (utilities) for each attribute level and ran simulations comparing women's preferences for hypothetical MAPs with varying attribute combinations. Results: The most important attributes of the MAP were potential for menstrual side effects (55% of preferences in India and 42% in Nigeria) and duration (13% of preferences in India and 24% in Nigeria). Women preferred a regular period over an irregular or no period, and a six-month duration to three or one month. Simulations show that the most ideal design would be a small patch, providing 6 months of protection, that would involve no pain on administration, result in a one-day rash, and be applied to the foot. Conclusions: To the extent possible, MAP developers should consider method designs and formulations that limit menstrual side effects and provide more than one month of protection. [ABSTRACT FROM AUTHOR]

Background: Timely initiation of breastfeeding, also known as early initiation of breastfeeding, is a well-recognized life-saving intervention to reduce neonatal mortality. However, only one quarter of newborns in Uttar Pradesh, India were breastfed in the first hour of life. This paper aims to understand the association of community-based prenatal counselling and postnatal support at place of delivery with early initiation of breastfeeding in Uttar Pradesh, India. Methods: Data from a cross-sectional survey of 9124 eligible women (who had a live birth in 59 days preceding the survey) conducted in 25 districts of Uttar Pradesh, India, in 2018, were used. Simple random sampling was used to randomly select 40 Community Development Blocks (sub district administrative units) in 25 districts. The Primary Sampling Units (PSUs), health service delivery unit for frontline workers, were selected randomly from a linelisting of PSUs in each selected Community Development Block. Bivariate and multivariate logistic regression analyses were performed to assess the association of prenatal counselling and postnatal support on early initiation of breastfeeding in public, private and home deliveries. Results: Overall 48.1% of mothers initiated breastfeeding within an hour, with major variation by place of delivery (61.2% public, 23.6% private and 32.6% home). The adjusted odds ratio (aOR) of early initiation of breastfeeding was highest among mothers who received both counselling and support (aOR 2.67; 95% CI 2.30, 3.11), followed by those who received only support (aOR 1.99; 95% CI 1.73, 2.28), and only counselling (aOR 1.40; 95% CI 1.18, 1.67) compared to mothers who received none. The odds of early initiation of breastfeeding was highest among mothers who received both prenatal counselling and postnatal support irrespective of delivery at public health facilities (aOR 2.49; 95% CI 2.07, 3.01), private health facilities (aOR 3.50; 95% CI 2.25, 5.44), or home (aOR 2.84; 95% CI 2.02, 3.98). Conclusions: A significant association of prenatal counselling and postnatal support immediately after birth on improving early initiation of breastfeeding, irrespective of place of delivery, indicates the importance of enhancing coverage of both the interventions through community and facility-based programs in Uttar Pradesh. [ABSTRACT FROM AUTHOR]

Background: Malaria control system (MCS), an Information technology (IT)-driven surveillance and monitoring intervention is being adopted for elimination of malaria in Mangaluru city, Karnataka, India since October 2015. This has facilitated 'smart surveillance' followed by required field response within a timeline. The system facilitated data collection of individual case, data driven mapping and strategies for malaria elimination programme. This paper aims to present the analysis of post-digitization data of 5 years, discuss the current operational functionalities of MCS and its impact on the malaria incidence. Methods: IT system developed for robust malaria surveillance and field response is being continued in the sixth year. Protocol for surveillance control was followed as per the national programme guidelines mentioned in an earlier publication. Secondary data from the malaria control system was collated and analysed. Incidence of malaria, active surveillance, malariogenic conditions and its management, malariometric indices, shrinking malaria maps were also analysed. Results: Smart surveillance and subsequent response for control was sustained and performance improved in five years with participation of all stakeholders. Overall malaria incidence significantly reduced by 83% at the end of 5 years when compared with year of digitization (DY) (p < 0.001). Early reporting of new cases (within 48 h) was near total followed by complete treatment and vector control. Slide positivity rate (SPR) decreased from 10.36 (DY) to 6.5 (PDY 5). Annual parasite incidence (API) decreased from 16.17 (DY) to 2.64 (PDY 5). There was a negative correlation between contact smears and incidence of malaria. Five-year data analyses indicated declining trends in overall malaria incidence and correlation between closures by 14 days. The best impact on reduction in incidence of malaria was recorded in the pre-monsoon months (~ 85%) compared to lower impact in July–August months (~ 40%). Conclusion: MCS helped to micromanage control activities, such as robust reporting, incidence-centric active surveillance, early and complete treatment, documentation of full treatment of each malaria patient, targeted mosquito control measures in houses surrounding reported cases. The learnings and analytical output from the data helped to modify strategies for control of both disease and the vector, heralding the city into the elimination stage. [ABSTRACT FROM AUTHOR]

Background: The Theory of Change (ToC) is a management and evaluation tool supporting critical thinking in the design, implementation and evaluation of development programmes. We document the experience of Future Health Systems (FHS) Consortium research teams in Bangladesh, India and Uganda with using ToC. We seek to understand how and why ToCs were applied and to clarify how they facilitate the implementation of iterative intervention designs and stakeholder engagement in health systems research and strengthening.Methods: This paper combines literature on ToC, with a summary of reflections by FHS research members on the motivation, development, revision and use of the ToC, as well as on the benefits and challenges of the process. We describe three FHS teams' experiences along four potential uses of ToCs, namely planning, communication, learning and accountability.Results: The three teams developed ToCs for planning and evaluation purposes as required for their initial plans for FHS in 2011 and revised them half-way through the project, based on assumptions informed by and adjusted through the teams' experiences during the previous 2 years of implementation. All teams found that the revised ToCs and their accompanying narratives recognised greater feedback among intervention components and among key stakeholders. The ToC development and revision fostered channels for both internal and external communication, among research team members and with key stakeholders, respectively. The process of revising the ToCs challenged the teams' initial assumptions based on new evidence and experience. In contrast, the ToCs were only minimally used for accountability purposes.Conclusions: The ToC development and revision process helped FHS research teams, and occasionally key local stakeholders, to reflect on and make their assumptions and mental models about their respective interventions explicit. Other projects using the ToC should allow time for revising and reflecting upon the ToCs, to recognise and document the adaptive nature of health systems, and to foster the time, space and flexibility that health systems strengthening programmes must have to learn from implementation and stakeholder engagement. [ABSTRACT FROM AUTHOR]

Background: Implementation Research (IR) in and around health systems comes with unique challenges for researchers including implementation, multi-layer governance, and ethical issues. Partnerships between researchers, implementers, policy makers and community members are central to IR and come with additional challenges. In this paper, we elaborate on the challenges faced by frontline field researchers, drawing from experience with an IR study on Village Health Sanitation and Nutrition Committees (VHSNCs). Methods: The IR on VHSNC took place in one state/province in India over an 18-month research period. The IR study had twin components; intervention and in-depth research. The intervention sought to strengthen the VHSNC functioning, and concurrently the research arm sought to understand the contextual factors, pathways and mechanism affecting VHSNC functions. Frontline researchers were employed for data collection and a research assistant was living in the study sites. The frontline research assistant experienced a range of challenges, while collecting data from the study sites, which were documented as field memos and analysed using inductive content analysis approach. Results: Due to the relational nature of IR, the challenges coalesced around two sets of relationships (a) between the community and frontline researchers and (b) between implementers and frontline researchers. In the community, the frontline researcher was viewed as the supervisor of the intervention and was perceived by the community to have power to bring about beneficial changes with public services and facilities. Implementers expected help from the frontline researcher in problem-solving in VHSNCs, and feedback on community mobilization to improve their approaches. A concerted effort was undertaken by the whole research team to clarify and dispel concerns among the community and implementers through careful and constant communication. The strategies employed were both managerial, relational and reflexive in nature. Conclusion: Frontline researchers through their experiences shape the research process and its outcome and they play a central role in the research. It demonstrates that frontline researcher resilience is very crucial when conducting health policy and systems research. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 pandemic further propelled the recent growth of telemedicine in low-resource countries, with new models of telemedicine emerging, including volunteer-based telemedicine networks. By leveraging existing infrastructure and resources to allocate health personnel more efficiently, these volunteer networks eased some of the pandemic burden placed on health systems. However, there is insufficient understanding of volunteer-based telemedicine models, especially on the human resources engagement on such networks. This study aims to understand the motivations and barriers to health practitioner engagement on a volunteer telemedicine network during COVID-19, and the mechanisms that can potentially sustain volunteer engagement to address healthcare demands beyond the pandemic., Methods: In-depth qualitative interviews were conducted with health practitioners volunteering on an Indian, multi-state telemedicine network during the COVID-19 pandemic. Data were analyzed using thematic content analysis methods., Results: Most practitioners reported being motivated to volunteer by a sense of duty to serve during the pandemic. Practitioners suggested organizational-level measures to make the process more efficient and facilitate a more rewarding provider-patient interaction. These included screening calls, gathering patient information prior to consultations, and allowing for follow-up calls with patients to close the loop on consultations. Many practitioners stated that non-financial incentives are enough to maintain volunteer engagement. However, practitioners expressed mixed feelings about financial incentives. Some stated that financial incentives are needed to maintain long-term provider engagement, while others stated that financial incentives would devalue the volunteer experience. Most practitioners highlighted that telemedicine could increase access to healthcare, especially to the rural and underserved, even after the pandemic. Practitioners also expressed an interest in continuing to volunteer with the network if the need arose again., Conclusion: Our study findings suggest that practitioners are highly intrinsically motivated to volunteer during large healthcare emergencies and beyond to address the healthcare needs of the underserved. Following the recommendations presented in the study, telemedicine networks can more successfully engage and maintain volunteer practitioners. Volunteer-based telemedicine networks have the potential to bridge shortages of health personnel in resource-constrained settings both in times of crises and beyond., (© 2024. The Author(s).)