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PurposeThis study aims to assess the associations of early marriage and spousal age difference (independent of early marriage) with reproductive and sexual health and autonomy in decision-making among married women before conception.Design/methodology/approachThe present study was a part of a three-year community intervention to improve the preconception health of young married women (20–35 years) in the West Delhi district of India. The six key outcomes assessed were: knowledge of reproductive health, discussions related to sexual health, history of anemia, use of contraceptives by women, frequency of consumption of meals per day and the autonomy in decision-making for household expenditures. Unadjusted and adjusted logistic regression models were used to explore the associations between the two key predictors (early marriage or spousal age difference), sociodemographic variables and six outcomes. The results were expressed as odds ratio (OR) and 95% confidence interval (CI). A total of 2,324 women, enrolled from four wards in the district using cluster-based sampling, were interviewed.FindingsAround 17% of women were married by the exact age of 18, and 20% were elder or just one year younger than their husbands. Women who were married early had low reproductive health knowledge (OR (95% CI): 0.48 (0.38–0.60)) and a lower probability of expressing autonomy (OR (95% CI): 0.78 (0.62–0.97)). However, women older than men or younger by just one year in the married relationship had higher reproductive health knowledge (OR (95% CI): 1.25 (1.01–1.54)) than women younger than men more than two years.Originality/valueUnder the umbrella of the preconception care domain, frontline workers should emphasize counseling girls and young women to marry late and delay the first pregnancy.

Background Accredited Social Health Activists (ASHA) are community health workers responsible for improving the health status of people by facilitating their access to healthcare services. The life skills of ASHA are known to be effective in negotiating behaviour change in the community; however, there has been a meagre focus towards improving them. Considering this gap, we adopted a comprehensive training program, known as Personal Advancement and Career Enhancement (P.A.C.E.), to empower ASHAs on life skills and financial literacy. The present study intends to assess the training program in two districts of Uttar Pradesh, India, by examining changes in knowledge, perceptions, and practices of ASHAs about life skills and financial literacy. Methods We conducted a quasi-experimental, non-randomized, controlled study with pre-and post-test assessments. Data were collected on socio-demographic characteristics, knowledge, and practices related to life skills (communication skills, self-confidence, problem–solving and decision-making skills, time and stress management skills) and financial literacy. Additionally, change perceptions on gender-, life skills-, and savings-related practices at the personal, community, and workplace levels were assessed in the intervention group. Factor analysis was performed to obtain the change patterns by assessing the degree to which the four life skills, financial literacy, and change perceptions on practices were correlated. A general linear regression model was performed to assess associations among change pattern scores and socio-demographic variables. Results We analyzed the data of 171 ASHAs (intervention group:86 and control group:85). There was a significant improvement in the average post-test scores of all the life skills and financial literacy in the intervention group (p Conclusions The P.A.C.E training program was found effective in improving the life skills and financial literacy of ASHAs in India.

Background A considerable proportion of the population remain unvaccinated due to multiple reasons including vaccine hesitancy. To study the factors responsible for the incomplete immunization of under-5 children from the perspectives of the communities, a vaccine hesitancy survey was done in two districts of Odisha. In addition, the survey aimed to elucidate the reasons for differential vaccine hesitancy. Methods This community-based cross-sectional study was conducted in the rural areas of Balangir and Nuapada districts in Odisha. We adapted the vaccine hesitancy survey questionnaire (core closed questions) developed by SAGE working group. We used this questionnaire in a sample of 260 households, selected from 30 clusters. The questions were categorized into three main dimensions, namely, awareness about vaccine efficacy, accessibility to obtain vaccine, and acceptability of the vaccines at the individual and community level. We used bivariate and multivariate regression analysis to determine the predictors for refusal or hesitancy of the vaccine. Results Long distances and time are the two prime factors of accessibility linked with the refusal or hesitancy of the vaccine. We found that there is a high level of acceptance of vaccines at the level of parents and more than three-fourths took their children for vaccination despite hearing negative information about them. Pentavalent and measles were more commonly refused or hesitated vaccines by the parents compared to BCG or polio. Conclusion In the current scenario of increasing immunization coverage in India, vaccine hesitancy acts as a missing link in action for the policymakers to achieve cent percent target.

Adolescence (10–19 years) is marked by many physiological changes and is vulnerable to health and nutritional problems. Adolescence, particularly, early adolescence is inadequately addressed in our national surveys. The present study aimed to assess the reproductive health awareness, nutrition, and hygiene of marginalized adolescent girls and boys and compare them among early and late adolescents. Our cross-sectional study was a part of a community-based project across India’s five zones, namely North, East, West, Central, and South. Unadjusted and adjusted logistic regression was performed to compare awareness about HIV/AIDS, or Sexually Transmitted Infections (STI), consumption of Iron Folic Acid (IFA) tablets and three meals in a day, safe menstrual hygiene practices, history of anemia, and open defecation practice among early and late adolescents. Data were reported as unadjusted and adjusted odds ratio (aOR) with a 95% confidence interval (95% CI). Among early adolescents, around 58% of girls and boys did not consume IFA tablets, and 28% of girls and 24% of boys defecated in the open. Compared to late adolescents, early adolescent girls had lower odds of awareness about HIV/AIDS (aOR (95% CI): 0.50 (0.47–0.54)) and open defecation (aOR (95% CI): 0.90 (0.83–0.98)) and higher odds of hand hygiene after defecation (aOR (95% CI): 1.52 (1.37–1.68)) and safe menstrual practices (aOR (95% CI): 1.42 (1.23–1.64)). There is a dire need to start public health interventions from early adolescence for long-term benefits throughout adolescence.

Background: A community-based intervention was implemented to improve maternal, child, and adolescent health practices, promote financial literacy and enhance livelihood opportunities for young people in marginalized communities. A hypothesis related to our intervention was that peer-led education sessions on health and nutrition in conjunction with community mobilization would change communities’ perceptions towards maternal and child health. Design and methods: This three-year intervention was done in the two districts of Rajasthan, India, namely Nagaur and Pali. The paper explored the changes in perceptions and practices that resulted from this intervention among women and adolescents. We performed a retrospective, qualitative effect evaluation of the project. Focus group discussions with married women (15-49 years) and adolescents (10-19 years), and in-depth interviews with frontline workers and village health committees were done. The qualitative data were translated, coded, and analyzed thematically using an inductive approach. Results: Overall, 4853 women and 8158 adolescents were engaged in the intervention. The study seemed to have brought a change in some of the practices like postnatal care uptake, breastfeeding, and uptake of antenatal care among women, and enhanced awareness about sexual and reproductive health and harms of substance abuse among adolescents was noted. Around 23% and 67% of the young people from Nagaur and Pali, respectively, were linked with jobs in computer training centres, tailoring centres, and beauty parlours. Conclusions: The intervention was perceived successful in improving many health and nutrition practices and livelihood opportunities among project beneficiaries, calling for a comprehensive and multi-dimensional intervention to target social determinants of health. Significance for public health This paper adds evidence on a community-based intervention using peer-led approach to improve maternal, child, and adolescent health and nutrition. This study provides valuable qualitative research to evaluate a community intervention in India. Our article highlights the key maternal and child health issues that can be addressed easily and the issues that are more challenging to achieve. Furthermore, the study sheds light on the need and importance of fostering financial security through empowering youth with skills and financial literacy and help them secure a livelihood.

IntroductionIndia has an overall neonatal mortality rate of 28/1000 live births, with higher rates in rural India. Approximately 3.5 million pregnancies in India are affected by preterm birth (PTB) annually and contribute to approximately a quarter of PTBs globally. Embedded within the PROMISES study (which aims to validate a low-cost salivary progesterone test for early detection of PTB risk), we present a mixed methods explanatory sequential feasibility substudy of the salivary progesterone test.MethodsA pretraining and post-training questionnaire to assess Accredited Social Health Activists (ASHAs) (n=201) knowledge and experience of PTB and salivary progesterone sampling was analysed using the McNemar test. Descriptive statistics for a cross-sectional survey of pregnant women (n=400) are presented in which the acceptability of this test for pregnant women is assessed. Structured interviews were undertaken with ASHAs (n=10) and pregnant women (n=9), and were analysed using thematic framework analysis to explore the barriers and facilitators influencing the use of this test in rural India.ResultsBefore training, ASHAs’ knowledge of PTB (including risk factors, causes, postnatal support and testing) was very limited. After the training programme, there was a significant improvement in the ASHAs’ knowledge of PTB. All 400 women reported the salivary test was acceptable with the majority finding it easy but not quick or better than drawing blood. For the qualitative aspects of the study, analysis of interview data with ASHAs and women, our thematic framework comprised of three main areas: implementation of intervention; networks of influence and access to healthcare. Qualitative data were stratified and presented as barriers and facilitators.ConclusionThis study suggests support for ongoing investigations validating PTB testing using salivary progesterone in rural settings.

Common mental health disorders are studied extensively among adult women globally. However, they remain under-researched among young women. This study aims to determine whether gender disadvantage factors are associated with psychological distress among young women in rural India, where the child sex ratio is lower than the national average. A cross-sectional survey was conducted in rural Pune, India. A total of 229 young married women who had a live birth in the last 12 months were screened for psychological distress. The predictors of psychological distress were estimated using multivariable logistic regression analyses. Psychological distress was found among 50 respondents (21.9%). Young women who were married before 18 years had 2.19 times higher odds of distress than women who were married after 18 years. Young women who gave birth to a female infant had 2.43 times higher odds of distress than those who gave birth to a male infant. Lack of partner support and experience of postnatal health complications were other predictors. Study findings ascertain the role of gender disadvantage factors in causing psychological distress. From a public health perspective, early identification and treatment of psychological distress, is imperative, along with addressing gender inequitable practices.

Background Indonesia is the only country in the Asia Pacific region where the incidence of HIV is still on the rise, and its prevalence is extremely high among the key populations such as men who have sex with men, transgender women, and people who inject/use drugs. Mobile health (mHealth) apps provide an innovative platform for delivering tailored HIV prevention and care among these populations more efficiently than possible through the direct face-to-face approach. Objective The aim of this study was to assess the role of a peer-customized mobile app based on the principle of self-learning for improving HIV prevention knowledge and access to health services among men who have sex with men, transgender women (known as Waria in Indonesia), and people who use drugs in Indonesia. Methods A prospective intervention cohort study was conducted among the key populations in five provinces of Indonesia (Jakarata, West Java, East Java, Special Region of Yogyakarta, and Bali). The data were evaluated using a pre-post assessment survey conducted on a sample of 200 unique users, including 50 men who have sex with men and transgender women each, and 100 people who use drugs, with a follow-up response rate of 98% and 70%, respectively. An mHealth app named RUMAH SELA was developed and implemented among the key populations. Results From baseline to the endpoint of the study, there was a significant increase in comprehensive HIV-related knowledge from 20% (10/49) to 60% (29/49), 22% (11/49) to 57% (28/49), and 49% (34/70) to 74% (52/70) among men who have sex with men (P=.004), transgender women (P Conclusions This one-of-a-kind mHealth intervention with an mHealth app as a self-learning tool is effective in increasing HIV-related knowledge and behavior, and access to services with strong acceptability by the community. There is a need to scale up such interventions for efficacy testing in a larger population to provide evidence for national-level mHealth programs addressing HIV.

Pre-school age (3–5 years) children are vulnerable to malnutrition due to poor dietary intake, dietary habits, and socio-economic conditions. Children from marginalized families are more vulnerable than non-marginalized families due to limited access to health- and nutrition-related services, besides other socio-economic factors. This study was done to assess the dietary intakes, patterns, and determinants of pre-school age (3–5 years) children from marginalized populations in two districts of Odisha. We used three different questionnaires, namely general demographic information, single 24-h recall dietary survey, and food frequency questionnaire, to collect data. Dietary patterns were obtained using principal component analysis, and the recommended dietary allowance (RDA) method was applied to estimate the prevalence of inadequate intake. A general linear model of regression was used to investigate the relationship of dietary patterns scores with independent variables. A total of 86 boys (57.3%) and 64 girls (42.7%) were recruited for the study. The majority (more than two-third) of the children had

The dearth of trained mental health care professionals to deliver specialized and complex models of interventions is one of the biggest barriers to accessing mental health care services particularly in less resourced settings. Perinatal mental health issues continue to contribute significantly to the global mental health burden. According to WHO (2015), 20 % of mothers in low and middle income countries suffer from a mental disorder after childbirth. There is robust research evidence particularly from LMICs to state that interventions delivered by non-specialist lay counsellors at the grass root level is emerging as an effective alternative to address the large treatment gaps.MAMTA Health Institute for mother and child(HIMC) is a pioneer organization in the field of RMNCH+A. Against this background, MAMTA HIMC explored the feasibility of remote training level health workers in the delivery of simple psycho social interventions for women in the perinatal period. Philips PAN India is a project at MAMTAHIMC which attempts to task shift expert mental health services to front line workers by interspersing simple psycho services into the framework of routine RMCH+A services. The paper aims to (1) Describe the experience of remote training of persons with no previous knowledge or experience of mental health to recognize mental health problems and deliver psychosocial services at the grassroot level 2) Discuss the impact and acceptability of the training.The paper recommends using non- specialized strategies, digital platforms, engaging community level human resources and low cost resources as opposed to complex conventional psychotherapies.

Background: India contributes high broaden of maternal and child death globally. Over the past decade, there has been considerably improvement in maternal and child health indicator in India with intervention of national health mission. However, inequalities in basic health outcomes, lack of access and poor quality of medical care still exists. Marginalized, poor, and rural populations have noticeable low health indicators. Aim: The aim of this study isto describe the design, implementation, and baseline findings of “family centric safe motherhood approach among marginalized young married couples in rural India. Settings and Design: To establish a baseline, we completed 1347 interviews in 100 villages from two rural blocks (Balotra and Siwana) of Rajasthan, India. Methods: The progress of health outcomes is to be measured by set of indicators. Based on results, intervention package was developed. Statistical Analysis Used: The data were entered in SPSS 22 version. Bivariate analysis was performed. Results: Around two-fifth of couples (42.9%) used any temporary contraceptive method. Although the percentage of antenatal care (ANC) in the first trimester (77%) was high, but only 10% of them received three or more ANC check-up. Institutional delivery was reported to be 64.5%. Less than 10% of the women reported that they received quality of ANC (7.1%) and 32.7% was tetanus vaccination coverage in the study area. Aware of any contraceptive method was above 92.7% and 64.3% of respondents have an intention to use any family planning method in the next 12 months. Conclusions: These data provide a baseline of crucial information for evidence-based action on maternal and child health at rural inaccessible villages. Our baseline estimates will facilitate the evaluation of interventions and feasibility of scaling up of intervention.

Introduction Emerging evidence suggests a difference in access to facilities for medical termination of pregnancy (MTP) and delivery among women in different regions of the country. However, we lack assessments at a large scale across all geographies. Our study aims to describe the percent contribution of private and public sectors in institutional deliveries and MTP in India. Methods A secondary data analysis using the Health Management Information System statistics was performed. We obtained selective data regarding the total number of MTP and deliveries conducted at public and private institutions. The standard reports of the period between April 2018 and March 2019 were analyzed. The states (n = 29) and union territories (n = 7) were dichotomized into regions, namely north, south, east, west, north-east, and central. Results A large part of women underwent deliveries and abortions in the private sector in the southern and western states of India like Kerala, Tamil Nadu, Andhra Pradesh, Goa, and Maharashtra. Women in most of the northern states opted for public facilities for deliveries as well as abortions, except Punjab and Haryana. On the contrary, states like Bihar, Nagaland, and Union territories like Delhi and Dadra and Nager Haveli had a high percentage of abortions in the private sector and deliveries in public health facilities. Conclusion This differential access highlights the need to assess the underlying factors for immediate actions by the policy-makers. Ensuring safe and good quality delivery and abortion services is the means to assure the sexual and reproductive health rights of women by the government.

Background Non-communicable diseases (NCDs) represent the largest, and fastest growing, burden of disease in India. This study aimed to quantify levels of diagnosis, treatment, and control among hypertensive and diabetic patients, and to describe demand- and supply-side barriers to hypertension and diabetes diagnosis and care in two Indian districts, Shimla and Udaipur. Methods We conducted household and health facility surveys, as well as qualitative focus group discussions and interviews. The household survey randomly sampled individuals aged 15 and above in rural and urban areas in both districts. The survey included questions on NCD knowledge, history, and risk factors. Blood pressure, weight, height, and blood glucose measurements were obtained. The health facility survey was administered in 48 health care facilities, focusing on NCD diagnosis and treatment capacity, including staffing, equipment, and pharmaceuticals. Qualitative data was collected through semi-structured key informant interviews with health professionals and public health officials, as well as focus groups with patients and community members. Results Among 7181 individuals, 32% either reported a history of hypertension or were found to have a systolic blood pressure ≥ 140 mmHg and/or diastolic ≥90 mmHg. Only 26% of those found to have elevated blood pressure reported a prior diagnosis, and just 42% of individuals with a prior diagnosis of hypertension were found to be normotensive. A history of diabetes or an elevated blood sugar (Random blood glucose (RBG) ≥200 mg/dl or fasting blood glucose (FBG) ≥126 mg/dl) was noted in 7% of the population. Among those with an elevated RBG/FBG, 59% had previously received a diagnosis of diabetes. Only 60% of diabetics on treatment were measured with a RBG

Young people with disabilities face numerous challenges, including poorer access to education, health services, employment opportunities, etc., than their peers without disabilities. Besides, they tend to face discrimination, stigma, social exclusion, and violence. There is a lack of efficient, accountable, and coordinated policy-level actions for these people in low- and middle-income countries. On the contrary, Swedish welfare policies toward ensuring social security benefits and services for people with disabilities promote their effective integration and equal participation in society. There is a pressing need for political commitment and actions to make our systems inclusive and sensitive for people with disabilities, especially in low- and middle-income countries.

Health education materials such as flipbooks enhance learning and deliver key messages in a captivating mode. Validation of such materials is crucial to ensuring implementation fidelity. We conducted a study to achieve two objectives: (a) to develop two flipbooks, one each for adolescents and young married women (YMW), (b) to validate the flipbooks using five parameters, namely, content validity, construct validity, concurrent validity, relevance, and face validity. The study was a part of a community-based peer-led intervention on health, nutrition, and hygiene. The content validity and relevance were assessed by interviewing outreach workers (ORWs, n = 42) using self-administered five-point Likert scale-based tools. A pre- and post-intervention assessment of knowledge among adolescents (n = 100) and YMW (n = 50) across six out of 13 intervention sites was done to evaluate the construct validity. The two flipbooks contained 12 structured sessions with five key messages per session, in addition to illustrations, discussion points, and theme-based stories at the end of each session. The content and relevancy indices were ranked above 80% by ORW. There was a statistically significant increase in the knowledge scores of adolescents (p &lt, 0.001) and YMW (p &lt, 0.001) post intervention. The validation process helps in assessing the relevance and appropriateness of the education content for greater acceptance and responsiveness by the users.

Introduction: Millions of adolescents are facing the burden of malnutrition in India, and the sociocultural context of nutrition poses challenges while addressing this burden. This study aimed to assess: (a) the determinants of knowledge, attitude, and self-efficacy scores and (b) the relationships between nutrition-related knowledge, attitude, and self-efficacy scores among adolescents in India. Methods: The community-based study was conducted among adolescents across three rural and three urban districts in India. This observational study employed a self-administered structured questionnaire containing information on demography, nutrition-related knowledge, attitude, and dietary self-efficacy. Differences in knowledge, attitude, and self-efficacy scores between sociodemographic variables were assessed using the t-test. Regression analysis was used to determine relationships between knowledge, attitude, and self-efficacy scores. Results: A total of 985 adolescents (44.5%) from rural areas and 1225 (55.5%) from urban slums participated. There were significant differences in knowledge, and self-efficacy scores between rural, urban inhabitants (P < 0.001), and adolescents with different grades of education (P < 0.001 for knowledge and P = 0.01 for self-efficacy). There were significant differences in knowledge and attitude scores among adolescents from non-backward and backward classes (P < 0.001 for knowledge and P = 0.02 for attitude) and those who were vegetarians and non-vegetarians (P = 0.002 for knowledge and P < 0.001 for attitude). The study demonstrated significant relationships between knowledge, attitude, and self-efficacy scores (P < 0.001). Conclusion: Nutrition-related knowledge, attitude, and self-efficacy scores are determinants of dietary behavior and are inter-related. Community-based interventions targeting to improve the nutritional status of adolescents should focus on improving self-efficacy besides the other two determinants.

Introduction Notably, less than two-thirds of under-5 children received full immunization in 2016 in India. It is critical to understand the inequalities in access to immunization for determining an effective health policy agenda to ensure universal health coverage. Hence, we performed a study to assess the determinants of income-based inequality in the full immunization of children aged 12–23 using Fairlie decomposition analysis. Methods This cross-sectional study was a part of a community-based project that aimed to improve maternal and child health in the backward states of India, namely Bihar and Assam. The study was conducted in the rural and urban areas of Munger and Darrang districts of Bihar and Assam, respectively. The degree of income-related inequality in full immunization coverage was obtained through the concentration index. The Fairlie decomposition was employed to quantify the absolute contribution of socio-demographic factors explaining the group differences (higher or lower income) in the probability of having full immunization. Results There were 73 fully and 82 non-fully immunized children. The concentration curve was lying above the line of equality, which implied that full immunization coverage was concentrated towards the lower-income group. Maternal education (7.5%) and place of residence (5.1%) widened the inequality gap, and caste (−13.5%) and age of the child (−2.5%) narrowed down the inequality gap for full immunization among lower and higher-income groups. Conclusions The socio-economic inequalities in access to full immunization can be mitigated by multi-sectoral interventions with a focus on children with less-educated mothers and living in urban slums.

Background Children born to high-risk pregnancies are more likely to experience adverse health outcomes later in life. As estimated, 15% of all pregnancies are at risk of various life-threatening conditions leading to adverse maternal and foetal outcomes. Millennium Development Goal resulted in the global reduction of maternal death from 390,000 to 275000 in 1990–2015). Similarly, to keep this momentum, the current United Nations Sustainable Development Goal (SDG: 3.1) aims at reducing the global maternal mortality ratio to less than 70 per 100,000 live births by 2030, and this can be achieved by addressing high-risk pregnancy contributing to significant mortality and morbidity. In India, gestational diabetes, gestational hypertension, and gestational hypothyroidism were identified as factors contributing to the high-risk pregnancy. This review summarises the commonly used approach for screening, diagnosis, and management of these conditions in the Asian population. It draws a comparison with the current protocols and guidelines in the Indian setting. Methods Electronic search in PubMed and Google Scholar, reference snowballing, and review of current guidelines and protocols were done between January 2010 to October 2019. Published studies reporting Screening, diagnosis, and management of these conditions were included. Articles selected were then screened, appraised for quality, extract relevant data, and synthesised. Results Screening, diagnosis, and management of these three conditions vary and no single universally accepted criteria for diagnosis and management exist to date. In India, national guidelines available have not been evaluated for feasibility of implementation at the community level. There are no national guidelines for PIH diagnosis and management despite the increasing burden and contribution to maternal and perinatal morbidity and mortality. Criteria for diagnosis and management of gestational diabetes, gestational hypertension, and gestational hypothyroidism varies but overall early screening for predicting risk, as reported from majority of the articles, were effective in minimizing maternal and foetal outcome. Conclusion Existing National guidelines for Screening, Diagnosis, and Management of Gestational Diabetes Mellitus (2018) and Gestational Hypothyroidism (2014) need to be contextualized and modified based on the need of the local population for effective treatment. Findings from this review show that early screening for predicting risk to be an effective preventive strategy. However, reports related to a definitive diagnosis and medical management were heterogeneous.

Among the ground-breaking achievements of the International Conference on Population and Development (ICPD) was its call to place adolescent sexual and reproductive health (ASRH) on global health and development agendas. This article reviews progress made in low- and middle-income countries in the 25 years since the ICPD in six areas central to ASRH—adolescent pregnancy, HIV, child marriage, violence against women and girls, female genital mutilation, and menstrual hygiene and health. It also examines the ICPD's contribution to the progress made. The article presents epidemiologic levels and trends; political, research, programmatic and social responses; and factors that helped or hindered progress. To do so, it draws on research evidence and programmatic experience and the expertise and experiences of a wide number of individuals, including youth leaders, in numerous countries and organizations. Overall, looking across the six health topics over a 25-year trajectory, there has been great progress at the global and regional levels in putting adolescent health, and especially adolescent sexual and reproductive health and rights, higher on the agenda, raising investment in this area, building the epidemiologic and evidence-base, and setting norms to guide investment and action. At the national level, too, there has been progress in formulating laws and policies, developing strategies and programs and executing them, and engaging communities and societies in moving the agenda forward. Still, progress has been uneven across issues and geography. Furthermore, it has raced ahead sometimes and has stalled at others. The ICPD's Plan of Action contributed to the progress made in ASRH not just because of its bold call in 1994 but also because it provided a springboard for advocacy, investment, action, and research that remains important to this day.

Background Although the need for multi-faceted and multi-sectoral approaches to address the multidimensional issue of child marriage is well-acknowledged, there is a dearth of documented experience on the process of implementing and managing such programmes. Methods WHO evaluated a district-level, government-led multi-sectoral intervention to address child marriage in Jamui, Bihar and Sawai Madhopur, Rajasthan, implemented by MAMTA Health Institute for Mother and Child (MAMTA). We evaluated the intervention’s design, implementation, monitoring, and outputs and identified key challenges and successes. Results Through actions at the state and district levels, the intervention succeeded in creating a cascade effect to stimulate more concerted action at block and village levels, with tangible intersectoral convergence occurring at the village level. The success factors we identified included an experienced partner NGO that was committed to supporting this effort, context-specific design and implementation, and a flexible and responsive approach. However, despite contributing to informal coordination between various stakeholders, the intervention did not succeed in developing a sustained joint-working mechanism at the district level. Shared ownership for prioritization of child marriage across national- and state-level sectors was not established, due in part to lack of directives transcending ministerial/departmental boundaries. Nevertheless, due to its efforts at the district-level, the intervention was able to enlist leadership from the District Magistrates and Child Marriage Prohibition Officers, in line with their duties outlined in the 2006 Prohibition of Child Marriage Act. The challenges we identified included lack of clear directives and institutional support for collaboration, obstacles to monitoring, administrative challenges, differing perspectives on strategy among district leaders, community resistance, and intervention over-commitment. Conclusions The findings of this evaluation reveal the potential of multi-sectoral approaches to prevent and respond to child marriage and provide insight into obstacles that affect multi-sectoral coordination. We point to actions that MAMTA could take to strengthen collaboration on this and other initiatives. We also recommend further documentation and evaluation of projects and programmes in this area.

Background Social inequities in early child bearing persist among young married people, especially among tribal populations in India. Rural women belonging to tribal groups and those coming from poor households are more likely to give birth before age 18. This paper explores the connection between ethnicity, gender and early fertility intention among young married people in rural India. Methods The data is drawn from a cross sectional baseline evaluation of an intervention programme in rural India. A sample of 273 married young people was taken. Respondents were selected using systematic random sampling. Logistic Regression was used to assess the effect of being a tribal on early fertility intention and also to determine if covariates associated with early fertility intention differed by tribal status. Qualitative data was analysed using deductive content analysis approach. Results Bivariate and logistic regression results indicated that young married people from tribal communities had higher odds of planning a child within one year of marriage than non-tribals (OR = 1.47, p-value-0.079). Findings further suggest that early fertility intention among tribals is driven by gender factors and higher education and among non-tribals, higher education and awareness on contraception are key predictors. Among tribals, the odds of planning a child within one year of marriage was strongly associated with inequitable gender norms (OR = 1.94, p-value-0.002). Higher education showed significant positive association with non-tribals (OR = 0.19, p-value-0.014) and positive association with tribals (OR = 0.56, p-value-0.416). Qualitative investigation confirms that fertility desires of young married people are strongly influenced by gender norms especially among tribal populations. Conclusion Early child bearing was underpinned by complex ethnic factors and gender norms. Preference for early child bearing was seen most among tribal communities. Gender attitudes were a cause of concern especially among tribal groups. These results suggest that efforts to improve early child birth will require changing gender norms related to fertility among tribals as well as social equity issues including higher education among non-tribals and tribals.

Background: The uptake of maternal healthcare services by young women in rural India is limited. This study aims to assess the effectiveness of community intervention model to improve the maternal healthcare service uptake of young married couples (15-24 years) in rural India. A three year project was carried out to reach young married women through a multi-pronged community intervention involving sensitizing family members, community mobilization, and capacity building of frontline health functionaries. Methods: The study was conducted among the young married couples aged 15-25 years in states of Uttar Pradesh and Rajasthan of India. A quasi-experimental evaluation design was adopted for this study. Two rounds of cross-sectional surveys at baseline and end line were carried out at both intervention and control sites. Net impact of intervention (Difference-in-Difference and multivariate regression) on key outcomes was assessed adjusting for control variables. Composite maternal healthcare uptake score significantly increased in intervention area compared to control area. Results: Women who were able to discuss about delivery care with family, were five times more likely to go for institutional delivery, also the utilization of maternal health care services was higher among these women (β=1.58). Likelihood of uptake for more than three visits for antenatal care (3+ANC) service indicated three times (OR=3.14, p

Background Child marriage is being increasingly recognized globally as a fundamental violation of human rights. Child marriages occur globally in varying degrees across countries and regions. South Asia alone accounted for almost half of the total number of child marriages that have occurred globally. Early marriage can lead to serious ramifications such as school drop-out, early pregnancy, maternal morbidity and mortality. The aim of this study was to assess impact of a multi-pronged community based intervention on early marriage, early pregnancy and school retention among young people in two states of India. Method Cross-sectional (post-test) was adopted to assess the effect of the intervention. Multi-stage sampling was adopted for the selection of a sample group of young people aged 10–24 years. A total of 1770 respondents participated in the survey, out of which 826 were males, and 944 were females. The assessment was conducted in eight districts in each of the two states. Descriptive statistics, cross-tabulation, chi square and logistic regression methods were used to analyse the data. Results Youth information centres (YIC) as an intervention strategy showed a significant effect towards decrease in the number of early marriages (Adjusted Odd Ratios [Adj] 2.25, CI 1.28–3.94), of early pregnancies (Adj 3.00, CI 1.06–8.43) and increase in the number of school retentions (Adj 2.96, CI 2.02–4.34). Access to mass media was also associated with reduction in likelihood of early marriages (Adj 1.79, CI 1.15–2.78), and increase in the number of school retentions (Adj 1.49, CI 1.12–1.97). We also found that there was an increase in mean age of marriage (1.2 years), of conception (.85 years) and in the mean years of schooling (1.54 years) among youth surveyed compared to their older siblings. Conclusion Intervention strategies such as YIC and exposure to mass media, showed an effect in reducing early marriage, early pregnancy and improved school retention. Peer education conducted through the YIC proved to be an effective model. Therefore, this multi-component community based intervention can be a potential model for reducing the number of early marriages and its related consequences in other districts of India with similar socio-economic and cultural settings.

With increasing girls’ enrolment in schools, school preparedness to ensure a menstrual friendly environment is crucial. The study aimed to conduct a systematic review regarding the existing evidence on menstrual hygiene management (MHM) across schools in India. It further aimed to highlight the actions that have been taken by the government to improve the MHM situation in India. We conducted the systematic literature search using PubMed, EMBASE, and Web of Science for searching the peer-reviewed articles and Google Scholar for anecdotal reports published from inception until 30 October 2019. Of 1125 publications retrieved through the search, 183 papers were included in this review, using a priori created data-extraction form. Meta-analysis was used to estimate the pooled prevalence (PP) of MHM practices in schools. Less than half of the girls were aware of menstruation before menarche (PP 0.45, 0.39 to 0.51, I2 = 100.0%, n = 122). Teachers were a less common source of information about menstruation to girls (PP 0.07, 0.05 to 0.08, I2 = 100.0%, n = 86). Separate toilets for girls were present in around half of the schools (PP 0.56, 0.42 to 0.75, I2 100.0%, n = 11). MHM in schools should be strengthened with convergence between various departments for explicit implementation of guidelines.

Introduction : HIV self-testing can increase coverage of essential HIV services. This study aimed to establish the acceptability, concordance and feasibility of supervised HIV self-testing among pregnant women in rural India. Methods : A cross-sectional, mixed methods study was conducted among 202 consenting pregnant women in a rural Indian hospital between August 2014 and January 2015. Participants were provided with instructions on how to self-test using OraQuick ® HIV antibody test, and subsequently asked to self-test under supervision of a community health worker. Test results were confirmed at a government-run integrated counselling and testing centre. A questionnaire was used to obtain information on patient demographics and the ease, acceptability and difficulties of self-testing. In-depth interviews were conducted with a sub-sample of 35 participants to understand their experiences. Results : In total, 202 participants performed the non-invasive, oral fluid-based, rapid test under supervision for HIV screening. Acceptance rate was 100%. Motivators for self-testing included: ease of testing (43.4%), quick results (27.3%) and non-invasive procedure (23.2%). Sensitivity and specificity were 100% for 201 tests, and one test was invalid. Concordance of test result interpretation between community health workers and participants was 98.5% with a Cohen’s Kappa (k) value of k =0.566 with p< 0.001 for inter-rater agreement. Although 92.6% participants reported that the instructions for the test were easy to understand, 18.7% required the assistance of a supervisor to self-test. Major themes that emerged from the qualitative interviews indicated the importance of the following factors in influencing acceptability of self-testing: clarity and accessibility of test instructions; time-efficiency and convenience of testing; non-invasiveness of the test; and fear of incorrect results. Overall, 96.5% of the participants recommended that the OraQuick ® test kits should become publicly available. Conclusions : Self-testing for HIV status using an oral fluid-based rapid test under the supervision of a community health worker was acceptable and feasible among pregnant women in rural India. Participants were supportive of making self-testing publicly available. Policy guidelines and implementation research are required to advance HIV self-testing for larger populations at scale. Keywords: supervised HIV self-testing; pregnant women; India; acceptability; feasibility. To access the supplementary material to this article please see Supplementary Files in the column to the right (under Article Tools). (Published: 12 September 2016) Citation: Sarkar A et al. Journal of the International AIDS Society 2016, 19 :20993 http://www.jiasociety.org/index.php/jias/article/view/20993 | http://dx.doi.org/10.7448/IAS.19.1.20993

In recent decades, low– and middle–income countries (LMICs) have achieved decreased morbidity and mortality associated with infectious diseases and poor maternal– and child–health (MCH). However, despite these advances, LMICs now face an additional burden with the inexorable rise of non–communicable diseases (NCDs). Deaths due to NCDs in LMICs are expected to increase from 30.8 million in 2015 to 41.8 million by 2030 [1]. While improvements in life expectancy, lifestyle and urbanisation go some way to explaining why more people in LMICs are affected by NCDs, it is less clear why these populations are contracting NCDs at a younger age and with worse outcomes than in high–income countries (HICs) [2]. Despite having a lower cardiovascular disease risk factor burden, LMIC populations have a four–fold higher mortality rate from cardiovascular events than HIC populations [3] in part due to a lack of access to quality, integrated health services and the poor availability of early interventions and effective NCD prevention programmes. The HIV/AIDS epidemic was the last time the world confronted a global health challenge that so disproportionately caused premature adult deaths in LMICs. The conclusion is unavoidable: the time to act is now. Prevention of NCDs at a population and an individual level is key and requires policy and structural changes. We have a unique opportunity to learn from the successes of infectious disease control programmes in LMICs and leverage these to address the growing NCD burden. Translatable learnings include: 1) emphasizing primary prevention, particularly in those at highest risk; 2) targeting service delivery to high–risk populations; 3) enabling access to adequate, affordable care at community level; 4) engendering patient empowerment and involving people affected by chronic conditions; 5) enabling access to quality drugs and adherence programmes; 6) regularly measuring the effectiveness and impact of programmes to ensure their appropriateness and improvement; and 7) creating an environment of health financing for universal coverage. Innovations to counter the emerging NCD epidemic must encompass both prevention and the delivery of care. Infectious disease programmes have used task–shifting, where less skilled health workers and community members are involved in delivery of health services. In India, we have seen this used for NCDs in the Arogya Kiran model where the existing health workforce was overstretched. Volunteers and teachers successfully delivered diabetes and hypertension screening and management to over 600 000 people [4]. Patient empowerment, and community involvement in health care delivery and governance, will be critical in tackling NCDs, since most are chronic conditions, which initially present silently and require long–term management [5]. In Malawi, recognizing the close relationship of HIV infection and cardiovascular diseases has led to screening for hypertension being integrated into HIV care [6]. In Ghana, decentralised community–based hypertension care, using digital technology, is helping to empower patients to manage their own disease: a model that is again adapted from HIV management [7]. We are also starting to see examples in India of MCH care coupled with life–long NCD screening and awareness programmes [8]. While these examples of managing the dual burden of infectious diseases and NCDs are encouraging, more needs to be done. The largest gap is in NCD prevention. Tackling the obesity epidemic and wrestling with the issues around curbing tobacco sales and smoking are rightly high on the NCD prevention agenda. The greatest opportunity is preventing a tobacco–related epidemic in sub–Saharan Africa where smoking levels are still low. Health budgets and development assistance for health must allocate resources commensurate with the dual disease burden. Health spending of governments in LMICs has tripled over the past 20 years, but remains low [9]. In addition, more health care models should consider diversified revenue streams or hybrid financing (eg, tiered payment schemes) to ensure sustainability. If equity is to be improved, patients need access to quality health care, through sustainable health–financing systems for universal health coverage, while reducing out–of–pocket expenditure for the under–served population. Photo: © Nana Kofi Acquah/Novartis Foundation Implementing such models will require strong government leadership and interventions, and partnerships across the public and private sectors. Some public–private partnerships (PPPs) in infectious diseases have demonstrated their potential to catalyze the delivery of, and access to, prevention and care through providing complementary strengths [10]. The private sector draws on its business and scientific expertise, focusing on strong results–based operations, whereas the public sector brings a wealth of expertise in implementation with equity, management and documentation. The end–users of the services, including patients and health care providers, also need to be included from the outset to ensure that the models are people–centered, co–created, adapted to prevailing contextual nuances, and sustainable. If we build on what we have learnt from infectious disease management, we could have a transformational impact on the growing NCD burden.

Bariatric surgery is well established in reducing weight and improving the obesity-associated morbidity and mortality. Hyperammonemic encephalopathy following bariatric surgery is rare but highly fatal if not diagnosed in time and managed aggressively. Both macro- and micronutrients deficiencies play a role. A 42-year-old Hispanic female with a history of Roux-en-Y Gastric Bypass Procedure was brought to ED for progressive altered mental status. Physical exam was remarkable for drowsiness with Glasgow Coma Scale 11, ascites, and bilateral pedal edema. Labs showed elevated ammonia, low hemoglobin, low serum prealbumin, albumin, HDL, and positive toxicology. She remained obtunded despite the treatment with Narcan and flumazenil and the serum ammonia level fluctuated despite standard treatment with lactulose and rifaximin. Laboratory investigations helped to elucidate the etiology of the hyperammonemia most likely secondary to unmasking the functional deficiency of the urea cycle enzymes. Hyperammonemia in the context of normal liver function tests becomes diagnostically challenging for physicians. Severe hyperammonemia is highly fatal. Early diagnosis and aggressive treatment can alter the prognosis favorably.