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Estimates of out-of-pocket (OOP) payment on health care are increasingly used in research and policy. In India, estimates of OOP payment are usually derived from health surveys carried out by the National Sample Survey (NSS). The questions on OOP payment on delivery care have recently integrated in the last two rounds of India’s National Family and Health Survey (NFHS-4 & NFHS-5). There are several issues relating to design of questions, reporting and recording of responses that have bearing on reliability of OOP estimates. This paper compares the OOP estimates from latest rounds of two of the large-scale population-based surveys; NFHS-5, 2019-21 and the National Sample Survey (NSS), 2018. We also highlight the type of question canvassed and its implications on OOP estimates of NFHS-5 survey. We used 155,624 births that were reported between in NFHS-5 and a total of 27,664 hospitalised cases for delivery care that were recorded in 75thround of NSS health survey, 2018. We have used descriptive statistics and two-part regression model to examine variations of OOP across surveys. We found large variations in distribution of OOP payment in NFHS-5 and NSS survey. Based on births during the five years preceding the survey, the OOP payment on institutional birth from public health centres in India from NFHS-5 was INR 2,894 (95% CI:2843-2945) compared to INR 2,738 (95% CI: 2644-2832) from NSS. Variations are similar for those availing services from private health centres. Controlling for socio-economic and demographic characteristics, the OOP payment from NFHS was lower among poorest and higher among richest compared to NSS. The variations in OOP across two surveys were larger across states of India. The variations in OOP payment across surveys were possibly due to structure of questions, recall bias, and variations in price level. We suggest to canvass standardised questions across surveys to obtain reliable OOP estimates across surveys.

Utilization of maternal health care services by tribal population could be detrimental in reducing high maternal mortality in Madhya Pradesh, India. A growing body of evidence indicates the positive association between male involvement and increased use of antenatal care services. Further research is required to understand barriers and possible solutions to develop culturally appropriate interventions to engage men to promote the utilization of maternal health care services. The study used qualitative data collected through 8 focus group discussions with men and women and 8 key informant interviews with either a community representative or health worker in two blocks dominated by Saharia tribes in Gwalior district, Madhya Pradesh, India in 2018. Information on the perception of utilization of maternal and child health services, male involvement, challenges and opportunities were elicited using a structured guide. Framework analysis was used to analyse the data. Findings document barriers at the individual (poor knowledge, fear of loss of wage, choice of home as a place of delivery), community (practices that reinforced the prevailing gender norms) and health care facility level (quality and attitude of health care providers) to male engagement in utilization of maternal health services. Community perceptions on possible solutions to address these were more likely to be gender exploitative interventions. To promote utilization of maternal health care services among Saharia tribes, this study highlights the importance of developing gender sensitive interventions that addresses the individual, community and health care facility level barriers of male involvement and do not reinforce existing gender norms.

Background/Objectives: Globally, the COVID-19 pandemic and its prevention and control policies have impacted maternal and child health (MCH) services. This study documents the challenges faced by patients in accessing MCH services, and the experiences of health care providers in delivering those services during the COVID-19 outbreak, explicitly focusing on the lockdown period in India. Methods: A cross-sectional study (rapid survey) was conducted in 18 districts from 6 states of India during March to June, 2020. The sample size included 540 MCH patients, 18 gynaecologists, 18 paediatricians, 18 district immunisation officers and 108 frontline health workers. Bivariate analysis and multivariable analysis were used to assess the association between sociodemographic characteristics, and challenges faced by the patients. Results: More than one-third of patients (n = 212; 39%) reported that accessing MCH services was a challenge during the lockdown period, with major challenges being transportation-related difficulties (n = 99; 46%) unavailability of hospital-based services (n = 54; 23%) and interrupted outreach health services (n = 39; 18.4%). The supply-side challenges mainly included lack of infrastructural preparedness for outbreak situations, and a shortage of human resources. Conclusions/Recommendations: A holistic approach is required that focuses on both preparedness and response to the outbreak, as well reassignment and reinforcement of health care professionals to continue catering to and maintaining essential MCH services during the pandemic.

Despite great progress in recent years in improving access to formal financial services in developing countries, there is still significant access and usage disparity between men and women. We use individual-level data from the World Bank’s Global Findex 2017 database to investigate the differences in the use of accounts by men and women who are account holders and who save and borrow money formally to provide a comprehensive picture of individuals’ financial behaviour in India. Employing treatment effects estimations through the use of propensity scores, we find that although there is improvement in saving behaviour, borrowing behaviour as well as financial resilience among men and women who save and borrow formally as compared to those who do not, women lag significantly behind men in terms of the same. Thus, expanding women’s access to economic opportunity is critical to achieving gender equality in financial inclusion and unlocking the potential for economic empowerment and development. Our findings can aid in the formulation of policies that consider the unique requirements of women in order to increase financial inclusion and close the gender gap in India.

OBJECTIVE To assess the coverage and adequacy of antenatal care services (ANC) available to women and examine the socio-economic determinants affecting service utilisation. DESIGN Secondary data analysis of a population-based national survey. SETTING India, 2015/16. SAMPLE In all, 190 898 women between 15 and 49 years of age who had a live birth during the 5 years preceding the survey. METHODS Ordinal logistic regression. MAIN OUTCOME VARIABLE Adequacy of ANC services received was measured under four categories - delivery of services by skilled personnel, timely provision of services, sufficiency and appropriateness of content. Quality of care was categorised as adequate ANC, inadequate ANC and no ANC. RESULTS Only 23.5% (95% CI 23.1-23.9%) of all women received adequate ANC, while 58.8% (95% CI 58.4-59.2%) received inadequate and 17.7% (95% CI 17.4-18.0%) received no ANC services. Regression analysis revealed that women belonging to the adolescent age group, illiterate women, and those in the poorest wealth quintile and in rural areas were less likely to receive any ANC. CONCLUSION There is a need to improve the quality of ANC services. Currently

Objectives This article explores the consequences of hospitalization expenditure on noncommunicable diseases (NCD) and its impact on out-of-pocket expenditure (OOPE), catastrophic health expenditure, impoverishment, and hardship financing of households in India. Methods Data on hospitalized cases of NCDs from the 3 rounds of National Sample Surveys (NSS) (2004, 2014, 2018) were used. Bivariate and multivariate analyses were conducted to investigate the socioeconomic differentials of the impact of OOPE on catastrophic health expenditure, impoverishment, and exposure to hardship financing. Results Rural households had greater exposure to catastrophic health expenditure but urban households had higher risk of impoverishment due to OOPE. Older patients (aged ≥60 years) had the highest hospitalization rate per 100 000, including increase in average healthcare expenditure from 2004 to 2018. At 10% and 30% thresholds, 50% and 25% of the households, respectively, faced catastrophic health expenditure across all the 3 rounds. Due to OOPE on hospitaliation treatment for NCDs, about 3.8%, 7.4% and 4.8% of households fell below poverty line, and percentage shortfall in income for the population from the poverty line was 3%, 4.9% and 3%, in 2004, 2014 and 2018 respectively. Percentage of households facing hardship financing reduced from 49.2% in 2004 to 24.4% 2014 and 12.7% in 2018. Conclusion OOPE by households are still very high and hence the higher effects of CHE, impoverishment and exposure to hardship financing due to health expenditure in India. This study proposes that along with increase in budgetary allocations for healthcare, the government should develop suitable policies to expand the effectiveness of government-sponsored health insurance, such as developing a specific NCD service package to be included in the health insurance program.

BackgroundIndia contends with a high rate of intimate partner violence (IPV), which is associated with unintended pregnancy and reflects low levels of women’s decision-making control in relation to their reproductive health. Few studies from South Asia have examined the relationship between pregnancy decision-making, IPV and unintended pregnancy.AimThis study examined associations between unintended (mistimed and unwanted) pregnancy, women’s reports of pregnancy decided externally by husband or in-laws, and IPV, among a sample of married, postpartum women.MethodsData from the ‘Mechanisms for Relations of Domestic Violence to Poor Maternal and Infant Health in India’ study were analysed. Descriptive comparisons between levels of unintended pregnancy were run on all major variables. Unadjusted and adjusted multinomial logistic regression analyses assessed women’s reports of having externally-decided pregnancies and IPV victimisation in the year prior to pregnancy as factors in mistimed and unwanted pregnancies.ResultsMistimed and unwanted pregnancies were reported by 12.2% and 7.2% of women, respectively. Externally-decided pregnancies were reported by 8.8% of women. Some 29.4% of women reported experiencing physical and/or sexual IPV in the year prior to pregnancy. Women reporting externally-decided pregnancies were significantly more likely to have had mistimed pregnancies than intended pregnancies, as were women reporting IPV. Neither external pregnancy control nor IPV were associated with unwanted pregnancy.ConclusionsWomen’s exclusion from pregnancy decision-making and violence from husbands relate to their ability to time their pregnancies as they wish. The lack of significant association between external decision-making and IPV with unwanted pregnancy may be due to low reporting of unwanted pregnancy. The overall findings highlight the importance of integrating women’s involvement in reproductive health decision-making and IPV reduction messaging in programming for the women’s health sector.

Contrary to overall declining trend in smokeless tobacco (SLT) use in India, an increase is observed in north-east (NE) India. This study examined the predictors of daily SLT use by gender and assessed the demographic and socio-economic characteristics that contribute to gender differences in SLT use in NE India.Data collected from 15,259 and 13,574 adults in the two rounds of Global Tobacco Adult Survey 1 and 2 for NE India during 2009-2010 and 2016-2017 were analyzed. Relative change, multivariable binary logistic regression and Blinder-Oaxaca decomposition analysis were used for analysis.The findings suggest that among women in NE India, the daily SLT use significantly increased by 58 per cent between 2009-2010 to 2016-2017. Women residing in Nagaland, Manipur, Mizoram and Tripura were 3.5 and 2.5 times, respectively more likely to be daily SLT users compared to those in Assam. While age, education and wealth were the significant predictors of SLT use in both women and men, increased odds of SLT use were observed with women's type of occupation and the State of residence. The majority of the gender differences in daily SLT use was explained by differences in work status (44%), age (26%), education (14%) and wealth status (9%) between men and women.Increasing prevalence of SLT use amongst women in the NE States necessitates integration of gender-specific messages on harmful effects of SLT in the ongoing tobacco control programmes and development of culturally appropriate community-based interventions for cessation of SLT use.

COVID-19 pandemic has triggered social stigma towards individuals affected and their families. This study describes the process undertaken for the development and validation of scales to assess stigmatizing attitudes and experiences among COVID-19 and non-COVID-19 participants from the community.COVID-19 Stigma Scale and Community COVID-19 Stigma Scale constituting 13 and six items, respectively, were developed based on review of literature and news reports, expert committee evaluation and participants' interviews through telephone for a multicentric study in India. For content validity, 61 (30 COVID-19-recovered and 31 non-COVID-19 participants from the community) were recruited. Test-retest reliability of the scales was assessed among 99 participants (41 COVID-19 recovered and 58 non-COVID-19). Participants were administered the scale at two-time points after a gap of 7-12 days. Cronbach's alpha, overall percentage agreement and kappa statistics were used to assess internal consistency and test-retest reliability.Items in the scales were relevant and comprehensible. Both the scales had Cronbach's α above 0.6 indicating moderate-to-good internal consistency. Test-retest reliability assessed using kappa statistics indicated that for the COVID-19 Stigma Scale, seven items had a moderate agreement (0.4-0.6). For the Community COVID-19 Stigma Scale, four items had a moderate agreement.Validity and reliability of the two stigma scales indicated that the scales were comprehensible and had moderate internal consistency. These scales could be used to assess COVID-19 stigma and help in the development of appropriate stigma reduction interventions for COVID-19 infected, and mitigation of stigmatizing attitudes in the community.

We assess the effect of CHARM, a gender equity and family planning counseling intervention for husbands in rural India, on men's gender ideology. We used a two-armed cluster randomized control trial design and collected survey data from husbands (n=1081) at baseline, 9 months, and 18 months. We used a continuous measure of support for gender equity and a dichotomous measure of equitable attitudes toward women's role in household decision-making. To assess differences on these outcomes, we used generalized linear mixed models. After controlling for socio-demographic factors, men who received the CHARM intervention were significantly more likely than men in the control group to have equitable attitudes toward household decision-making at 9-months follow-up; there was a non-significant difference between the groups for the measure of support for gender equity. For household decision-making, differences were not sustained at 18-months follow-up. Given the role of husbands' gender ideology in women's contraceptive use, the CHARM intervention represents a promising approach for challenging root causes of women's unmet need for contraception.

Summary Background Documentation of the demographic and geographical details of changes in cause-specific neonatal (younger than 1 month) and 1–59-month mortality in India can guide further progress in reduction of child mortality. In this study we report the changes in cause-specific child mortality between 2000 and 2015 in India. Methods Since 2001, the Registrar General of India has implemented the Million Death Study (MDS) in 1·3 million homes in more than 7000 randomly selected areas of India. About 900 non-medical surveyors do structured verbal autopsies for deaths recorded in these homes. Each field report is assigned randomly to two of 404 trained physicians to classify the cause of death, with a standard process for resolution of disagreements. We combined the proportions of child deaths according to the MDS for 2001–13 with annual UN estimates of national births and deaths (partitioned across India's states and rural or urban areas) for 2000–15. We calculated the annual percentage change in sex-specific and cause-specific mortality between 2000 and 2015 for neonates and 1–59-month-old children. Findings The MDS captured 52 252 deaths in neonates and 42 057 deaths at 1–59 months. Examining specific causes, the neonatal mortality rate from infection fell by 66% from 11·9 per 1000 livebirths in 2000 to 4·0 per 1000 livebirths in 2015 and the rate from birth asphyxia or trauma fell by 76% from 9·0 per 1000 livebirths in 2000 to 2·2 per 1000 livebirths in 2015. At 1–59 months, the mortality rate from pneumonia fell by 63% from 11·2 per 1000 livebirths in 2000 to 4·2 per 1000 livebirths in 2015 and the rate from diarrhoea fell by 66% from 9·4 per 1000 livebirths in 2000 to 3·2 per 1000 livebirths in 2015 (with narrowing girl–boy gaps). The neonatal tetanus mortality rate fell from 1·6 per 1000 livebirths in 2000 to less than 0·1 per 1000 livebirths in 2015 and the 1–59-month measles mortality rate fell from 3·3 per 1000 livebirths in 2000 to 0·3 per 1000 livebirths in 2015. By contrast, mortality rates for prematurity or low birthweight rose from 12·3 per 1000 livebirths in 2000 to 14·3 per 1000 livebirths in 2015, driven mostly by increases in term births with low birthweight in poorer states and rural areas. 29 million cumulative child deaths occurred from 2000 to 2015. The average annual decline in mortality rates from 2000 to 2015 was 3·3% for neonates and 5·4% for children aged 1–59 months. Annual declines from 2005 to 2015 (3·4% decline for neonatal mortality and 5·9% decline in 1–59-month mortality) were faster than were annual declines from 2000 to 2005 (3·2% decline for neonatal mortality and 4·5% decline in 1–59-month mortality). These faster declines indicate that India avoided about 1 million child deaths compared with continuation of the 2000–05 declines. Interpretation To meet the 2030 Sustainable Development Goals for child mortality, India will need to maintain the current trajectory of 1–59-month mortality and accelerate declines in neonatal mortality (to >5% annually) from 2015 onwards. Continued progress in reduction of child mortality due to pneumonia, diarrhoea, malaria, and measles at 1–59 months is feasible. Additional attention to low birthweight is required. Funding National Institutes of Health, Disease Control Priorities Network, Maternal and Child Epidemiology Estimation Group, and University of Toronto.

Masculine gender ideologies are thought to underlie alcohol use, intimate partner violence (IPV) perpetration, and sexual risk of HIV and other sexually transmitted infections (STIs). We extend on studies in the Indian context by examining the roles of masculine gender ideologies, alcohol use, and IPV on three outcomes of HIV risk (condom use, genital tract infection [GTI] symptoms, and GTI diagnosis). We applied logistic regression models to cross-sectional data of men and their wives in rural Maharashtra, India ( n = 1,080 couples). We found that men with less masculine gender ideologies demonstrated greater odds of condom use (i.e., lower odds no condom use, odds ratio [OR] = 0.96, 95% confidence interval [CI] = [0.93, 0.98]). IPV perpetration was associated with increased odds of reporting ≥1 GTI symptom (adjusted OR [AOR] = 1.56, 95% CI = [1.07, 2.26]) and decreased GTI diagnosis (AOR = 0.28, 95% CI = [0.08, 0.97]). Moderate alcohol consumption was associated with increased odds of reporting ≥1 GTI symptom (AOR = 1.51, 95% CI = [1.01, 2.25]). Our findings have direct implications for men’s and women’s health in rural India, including targeted GTI diagnosis and treatment, integrated violence prevention in STI clinics, and targeted intervention on masculine gender ideologies.

Emerging research has documented non-violent forms of abuse against wives in India. Gender-based household maltreatment (GBHM) has been linked to poor maternal and child health outcomes, but the measurement of GBHM requires statistical validation. The objective of this study is to evaluate a new measure of GBHM of women by husbands and in-laws during the perinatal period for validity and internal reliability (before, during, and post pregnancy). This study utilized cross-sectional quantitative data collected from women ( n = 1,049) seeking immunizations for their infants

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

Background: Behaviour of men, their beliefs and attitudes affect the maternal health outcomes of women and their babies. The exclusion of men from maternal health care services could lead to few women seeking maternal health services. A study was conducted for development of a Behaviour change communication (BCC) model for improving the male participation in utilization of maternal and child health services among Saharia tribes of Gwalior district of Madhya Pradesh and to assess its feasibility.Methods: Mixed method approach, both quantitative and qualitative, were used in the study. Couple interviews were conducted to assess the level of maternity care services utilization and level of male participation in maternity care. Focused Group Discussions (FGDs) and Key informants’ Interviews (KIIs) were conducted to assess the community perspective and barriers of male participation. In the exploratory phase, there were couple interviews, key informant interviews and focus group discussions and data analysis, followed by development of a Behavior Change Communication (BCC). Feasibility of the model was assessed through three principles, i.e., acceptance, integration with the current programme and short term impact of BCC.Results: Based on the findings of couple interviews, FGDs and KIIs, a BCC model was developed to improve the male involvement in maternal and child health and its feasibility was assessed.Conclusions: The developed BCC model went successfully through the three principles of the feasibility and therefore it can be implemented in Saharias for improving the male participation in maternity care and for improving the utilization of maternity care services.

The socio-demographic, sex work characteristics and the factors affecting HIV prevalence among female sex workers (FSWs) are not well known in low prevalence states showing rising trends within the HIV epidemic. This paper studies these attributes among FSWs in three north (Punjab, Rajasthan and Uttar Pradesh) and one east Indian states (Jharkhand). Integrated Biological and Behavioural Surveillance (IBBS) data, collected from 4491 FSWs in the study states, were analysed, with HIV status as the dependent variable and several socio-demographic, sex work, knowledge and agency characteristics as independent variables. Multivariate analysis found a number of factors such as age above 25 years (adjusted odds ratio [AOR] 5.0, 95% confidence interval [CI] 1.4–18.1), client solicitation in rented rooms (AOR 2.8, 95% CI 1.2–6.4) and the use of mobile phones for client solicitation (AOR 5.1, 95% CI 1.6–16.0) to be significantly associated with HIV risk. The study found low levels of HIV programme services uptake and HIV/AIDS knowledge among FSWs in the study states. There is an urgent need to focus on these risk factors for improving the effectiveness of the ongoing HIV prevention efforts and attaining the ‘Sustainable Development Goals’ goal of ‘Ending the AIDS epidemic’ by 2030.

Husbands’ alcohol use has been associated with family-level stress and intimate partner violence (IPV) against women in India. Joint family systems are common in India and IPV often co-occurs with non-violent family maltreatment of wives (e.g., nutritional deprivation, deprivation of sleep, blocking access to health care). Alcohol use increases for some parents following the birth of a child. This study examined 1,038 postpartum women’s reports of their husbands’ alcohol use and their own experiences of IPV (by husband) and non-violent maltreatment from husbands and/or in-laws. We analyzed cross-sectional, quantitative data collected in 2008, from women (ages 15-35) seeking immunizations for their infants

Introduction: In India, there are few cessation programs for women smokeless tobacco (SLT) users who want to quit. This paper uses Fishbein’s IM model to identify women SLT users’ challenges to quitting and multilevel correlates of “readiness to quit”. Methods: A survey of SLT use among women of reproductive age was conducted in 2010-13 in an urban slum community of Mumbai with a representative sample of 409 married women aged 18 to 40 years using at least one type of SLT daily. Data were analyzed using frequencies, bivariate statistics and logistic regression. Results: Social influences to continue SLT use included husband’s use (71%), family influence and positive beliefs and norms about use. Pressure to quit from significant others influenced past quit attempts but media had no effect on reported behavior. Four groups represented different readiness to quit statues based on intention to quit and past quit/reduce attempts. Seventeen percent had no intention of quitting or reducing; their husbands were more likely to be tobacco users. Half of (52%) the sample had attempted to quit/reduce tobacco and intended to do so in the future. These women were depressed. Fifteen percent had tried to quit but did not intend to again. Correlates were positive beliefs and norms about SLT and withdrawal symptoms. Conclusions: Cessation programs should be made available to women, addressing correlates of women’s readiness to quit statuses. Results suggest the need for more complex social/contextual approaches to sustained cessation of SLT use including addressing depression and withdrawal, improved media messages and campaigns tailored to women, and support from family members.

To assess whether intimate partner violence (IPV) is associated with discordant reports of contraceptive use (whereby wives but not husbands report such use) among married couples in Maharashtra, India.The present cross-sectional study in rural Maharashtra, India, analyzed survey data collected in 2012 among husbands and wives aged 18-30 years, fluent in Marathi, with no prior sterilization, and with no current pregnancy or plans to conceive. Crude and adjusted logistic regression models assessed husbands' perpetration of IPV in relation to discordant reports of contraceptive use.Among 577 couples meeting the eligibility criteria, 207 (35.9%) women reported ever experiencing physical IPV from their husbands, and 183 (31.7%) reported ever experiencing sexual IPV from their husbands. In adjusted logistic regression models, discordant contraceptive use was significantly associated with wives' experiences of physical IPV (adjusted odds ratio [AOR] 1.81, 95% confidence interval [CI] 1.15-4.42) and sexual IPV (AOR 1.95, 95% CI 1.08-4.82).Women who reported IPV from their husbands might be more likely to use contraceptives without informing their husbands, possibly to redress the reproductive control often exerted by abusive male partners.

Background The use of smokeless tobacco (SLT) among women is increasing in India, especially among those with limited education and resources. Preventing the initiation of SLT among women is critical since it has known negative consequences for oral and reproductive health. Most research on tobacco initiation in India focuses on adolescents. This paper addresses the unrecognized issues of post marital initiation among women of reproductive age, highlighting the importance of reproductive stages in women's tobacco initiation. The objective is to examine the correlates of SLT initiation among low income women in Mumbai from pre-marriage through early marriage, first pregnancy and beyond, using case examples to illustrate initiation during each of these stages. Materials and methods In 2011-2012, cross-sectional community level survey data were collected from a representative sample of 409 daily SLT-using married women aged 18-40 years in a low income community in Mumbai. Information on socio-demographics, initiation by reproductive stage, types of tobacco use, childhood exposure to tobacco, learning to use, and initiation influences and reasons were collected through a researcher-administered survey. Univariate and bivariate analysis assessed factors influencing initiation of SLT use by reproductive stage. In addition 42 narratives of tobacco use were collected from a purposive sample of pregnant and non-pregnant married women addressing the same questions in detail. Narratives were transcribed, translated, and coded for key concepts including initiation of tobacco use. Results Thirty-two percent of women initiated SLT use before marriage, 44% initiated after marriage but before pregnancy, 18.1% initiated during their first pregnancy and the remainder started after their first pregnancy. Mean age of marriage among women in this study was 16 years. Younger women (i.e. age at time of the interview of less than 30 years) were 0.47 [95% CI (0.32, 0.87)] percent less likely to initiate after marriage than women aged more than 30 years. Women who got married before 18 years of age were 2.34 [95% CI (1.40, 3.93)] times more likely to initiate after marriage than their counterparts. Childhood exposure was a predictor for initiating SLT use prior to marriage but not after. Women reporting tooth and gum pain were 1.85 times more likely to initiate after marriage than their counterparts. Husband and neighbours were the most significant influences on post-marital initiation. Narratives highlighted differences in processes of initiation pre and post marriage and during pregnancy. Conclusions Most tobacco prevention interventions are directed to adolescents in school. This study suggests that especially for low literate or illiterate women, school based interventions are ineffective. To be effective strategies to prevent SLT initiation must reach women in urban areas at or immediately after marriage and during their first pregnancy. Messages must negate culturally rooted beliefs about the health benefits of SLT in order to prevent initiation and onset of daily use.

Objective. Evidence has linked economic hardship with increased intimate partner violence (IPV) perpetration among males. However, less is known about how economic debt or gender norms related to men's roles in relationships or the household, which often underlie IPV perpetration, intersect in or may explain these associations. We assessed the intersection of economic debt, attitudes toward gender norms, and IPV perpetration among married men in India. Methods. Data were from the evaluation of a family planning intervention among young married couples ( n=1,081) in rural Maharashtra, India. Crude and adjusted logistic regression models for dichotomous outcome variables and linear regression models for continuous outcomes were used to examine debt in relation to husbands' attitudes toward gender-based norms (i.e., beliefs supporting IPV and beliefs regarding male dominance in relationships and the household), as well as sexual and physical IPV perpetration. Results. Twenty percent of husbands reported debt. In adjusted linear regression models, debt was associated with husbands' attitudes supportive of IPV (β=0.015, p=0.004) and norms supporting male dominance in relationships and the household (β=0.006, p=0.003). In logistic regression models adjusted for relevant demographics, debt was associated with perpetration of physical IPV (adjusted odds ratio [AOR] = 1.4, 95% confidence interval [CI] 1.1, 1.9) and sexual IPV (AOR=1.6, 95% CI 1.1, 2.1) from husbands. These findings related to debt and relation to IPV were slightly attenuated when further adjusted for men's attitudes toward gender norms. Conclusion. Findings suggest the need for combined gender equity and economic promotion interventions to address high levels of debt and related IPV reported among married couples in rural India.

In this paper, we aim to assess the effect of the CHARM, a gender equity and family planning counseling intervention for husbands in rural India, on men’s gender ideology. We used a two-armed cluster randomized control trial design and collected survey data from husbands (n=1081) at baseline, 9-months, and 18-months. We used a continuous measure of support for gender equity (i.e. Gender Equitable Men Scale) and a dichotomous measure of equitable attitudes towards women’s role in household decision-making. To assess differences on these outcomes, we used generalized linear mixed models. After controlling for socio-demographic factors, men who received the CHARM intervention were significantly more likely than men in the control condition to have equitable attitudes towards household decision-making at 9-month follow-up (AOR 1.83, 95% CI 1.29–2.60); there was a non-significant difference between the groups for the measure of support for gender equity (23.2 vs. 22.0; p=0.08). For household decision-making, differences were not sustained at 18-month follow-up. Given the role of husbands’ gender ideology on women’s contraceptive use, the CHARM intervention represents a promising approach for tackling root causes of women’s unmet contraceptive needs.

Violence against women by their husband is a pervasive public health and human rights problem1. In India, 34 per cent of women of reproductive age group have ever experienced physical domestic violence2. Women in slum areas (22.9%) in Pune were more likely to have experienced domestic violence than women in non-slum area (14%)3. Globally, the negative impact of violence on health of women has been recognized. Domestic violence increases the incidence of unintended pregnancies4,5,6,7 and abortions4, and reduces the contraceptive use8,9. Domestic violence during pregnancy increases the risk of infant and child mortality10,11,12,13. Women experiencing domestic violence during pregnancy are less likely to get antenatal care14,15. Sexual violence associated with vaginal, anal or urethral trauma leads to risk of infection and sexual health problems16,17. Not only physical but mental health of the women is also affected due to domestic violence18,19. Various studies have identified factors associated with the likelihood of domestic violence among women. Underlying factors of domestic violence are the failure to perform duties and responsibilities20, economic stress, hierarchical gender relations21, lower household income, illiteracy, belonging to lower caste22, not having male child23, age at marriage, number of living children, women employment23 and dowry21,23,24. Studies also showed a link between husband's alcohol consumption and domestic violence21,22,23,24. A few studies have also explored the relationship between domestic violence and contraceptive use in India25,26. However, the social determinants of domestic violence in urban slum community in India remain limited. Hence, the objective of this study was to know the prevalence of domestic violence and to understand the socio-demographic factors associated with it in urban slums of Mumbai, Maharashtra, India.

In order to design appropriate HIV prevention programs, it is important to examine the perception and knowledge of HIV/AIDS and methods of preventive. This article explores comprehensive knowledge of HIV/AIDS prevention methods among women and men in slum and non-slum areas in the National Capital Territory of Delhi, India. Data were drawn from the National Family Health Survey, 2005-06 (NFHS-3). The sample included 3096 women aged 15 - 49 years and 1321 men aged 15 - 54 years. Pearson Chi-square test and logistic regression analyses were conducted to examine the association between the study variables and the background characteristics of the slum and non-slum populations. Comprehensive knowledge of HIV/AIDS prevention methods was significantly lower among women and men in slum areas as compared with non-slum areas. Compared to men, women had less comprehensive knowledge of HIV/AIDS prevention methods in slum and non-slum areas, even after controlling for various demographic and socio-economic and exposure variables. Findings indicate that comprehensive knowledge of HIV prevention methods is low among women in slum areas. Interventions are needed to build knowledge of HIV transmission and prevention methods in this vulnerable group. Strategies to build awareness of HIV/AIDS could include mass media campaigns HIV/AIDS, and information, education and communication programs (IEC) on HIV/AIDS in slum areas.

Integrated analysis of data together with fit-for-purpose modelling can help in fast track maturation of opportunities. In 2012, an opportunity to increase oil by implementing waterflood was identified, and last year was further reviewed by Shell. An integrated approach helped the team to mature ten development wells within three months which were subsequently drilled and helped the operator to surpass their production targets. The field located in Western Desert, Egypt comprises of an Upper Cretaceous tidal channel system across four key reservoirs where sand thickness ranges between 2-15 m. Large uncertainties in reservoir extent, architecture and properties required the integration of data across multiple disciplines for identifying new development wells. It was recognized early on that the construction of full-field fine-scale static models would be time-consuming and hence a simplified fast-track approach was used for maturing the opportunity. Conceptual depositional models were built by integrating dipmeter data, image logs and core facies descriptions to understand the direction of continuity of tidal channels, tidal bars and mud flats. Net sand thickness maps were then constructed to represent the conceptual depositional model and integrated with the production behaviour of the wells. Production from historical wells drilled up to 2012 caused non-uniform pressure depletion across reservoirs. The pressure data from Modular Dynamic Tester (MDT), along with the production-injection history, was reviewed to identity both areal and vertical stratigraphically connected areas which were incorporated in the net sand maps. The constructed maps were quality checked with pressure and production data so as to validate the range of in-place volumes. Net sand maps, porosity maps and saturation models were combined to generate Hydrocarbon Pore Volume (HCPV) maps used to identify new well opportunities. Separate sector models were also constructed to evaluate the waterflood and to optimise the decision parameters like injector-producer spacing, injection rates, voidage replacement ratio and target reservoir pressure. A range of type curves were generated from Monte Carlo simulation runs for all key sub-surface uncertainties then was used to estimate the low, base and high case recoverable volumes for the identified well locations and patterns. The identified wells were drilled between February and August 2015 and helped increase production rates of the field by over 5,000 stb/d.A fit-for-purpose modelling using sand maps and connectivity maps can often greatly help in fast-tracking opportunity maturation and fine-scale detailed simulation modelling may not provide additional value.

A new seismic and quantitative reinterpretation was carried out for a brownfield in Western Desert, Egypt to improve depth predictability, de-risk appraisal well locations and to better understand producer-injector connectivity. The study field is located in the Western Desert, Onshore Egypt and comprises of Upper Cretaceous tidal channel systems across four key reservoir levels where sand thicknesses range from 2 to 15 m. The field was discovered in 1993 but development drilling only commenced in 2008. The last integrated field study was performed in 2012. The analysis of wells drilled post-2012 indicated that there is a considerable depth difference along the flanks of the structure between seismic predicted depths and actual well tops (>50 m). The fault interpretation also required a re-look so as to reduce the lateral uncertainty of the main boundary fault and explain the lack of injection response in some areas of the field. This necessitated an update of seismic interpretation, static and dynamic models. A new interpretation could help identify attic volume upsides and help mature new appraisal and producer-injector locations. Further work was also proposed to test the feasibility of using seismic inversion for facies discrimination. The available Pre-Stack Depth Migration (PreSDM) data was re-interpreted as part of the project. The fault interpretations were quality checked using Semblance/Dip maps, sand box models and wherever possible, were tied to the fault cuts seen in previously drilled wells. The time horizon correlation and seismic polarity were verified and were also cross-checked with the P-Impedance volume before being used in the static modelling workflow. The PreSDM Interval velocity model was used for depth conversion, where an anisotropy correction was applied to tie the wells. Vok and Polynomial methods were also applied, which in turn were used to derive depth uncertainty estimates. The update in the main bounding fault interpretation generated new appraisal locations in the deeper levels. The new interpretation was tested against the results from the latest drilling campaign in the field, and nine out of ten wells were within the one standard deviation uncertainty range. Simultaneous inversion of the seismic data was also carried out as part of the project using the acoustic, shear and density data from 6 wells over the field. The inverted P-Impedance and S-Impedance were converted to Net to Gross (NtG), and were checked against the remaining 24 wells, which helped in validating the property cubes. Forward wedge modelling suggested that individual sands of less than 15 m thickness would not be resolved from seismic due to seismic bandwidth limitations. Still, a review of inversion data together with geological insights and dynamic data helped to identify the high NtG areas across the reservoirs. The integrated interpretation of inverted volumes with well and production data resulted in new insights into the field and helped to mature new appraisal and development well locations.