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Background: Adivasi communities in Kerala continue to bear a disproportionately high burden of child undernutrition compared with other communities in Kerala. Furthermore, different ethnic groups within the Adivasi communities have different patterns of nutritional inequality that require understanding the historical and contextual pathways of nutritional inequity. This paper examines the historical and contextual pathways of inequity in child nutritional outcomes between the Paniyaand Kurichiya Adivasi communities in the Wayanad district of Kerala. Methods:This study used a mixed-method approach with quantitative cross-sectional and qualitative case study components. The Diderichsen framework was used as the conceptual framework of the study. The quantitative cross-sectional component was done using a survey involving 314 children aged 2–5 years and their mothers as participants chosen using a multi-stage cluster sampling that was conducted using a structured interview schedule. Qualitative data were collected using in-depth interviews, observation diary notes, and document reviews and analysed using inductive and deductive approaches. Results:The Paniya and Kurichiya Adivasi children reported stark disparities in the prevalence of stunting, underweight, and wasting; the prevalence of these conditions among the Paniya was 52.3%, 58.9%, and 25.2%, respectively, whereas the prevalence among the Kurichiya was 28.2%, 31.1%, and 12.3%, respectively. Historical accumulation of poverty through land alienation and overall social exclusion from developmental reforms among the Paniya contributed to their lower socio-economic position, which in turn explains the higher prevalence of child undernutrition among Paniya compared to that of Kurichiya. These historical pathways continue to drive an experience of stigma and discrimination while using health and nutritional services, thus intergenerationally contributing to their inequalities in the social determinants of child nutrition. Conclusions:The tribal health and nutritional policies and programmes that are currently targeted at Adivasi communities need to integrate particular Adivasi identities into their strategies and implementations.

While the United Nations has long implemented strategies to tackle deep-rooted gender-based inequalities and discrimination in its programmes and policies, there is limited evidence on successful strategies to foster institutional structures and practices that promote gender equality or institutional gender mainstreaming. This paper explores and analyses the experience of institutional gender mainstreaming within UN Agencies working on global health, highlighting potential areas for learning. Overall, progress on institutional gender mainstreaming has been modest, with slow increases (if any) in investments in financial and human resources. The findings highlight the importance of well-established strategies, such as enforcing accountability, a robust gender architecture, and a cohesive capacity-building policy. Drawing on the experiences of gender experts, the paper shows that equally or more critical to the success of institutional gender mainstreaming were approaches such as leveraging strategic internal and external support and identifying strategic entry points for gender mainstreaming. There is considerable scope for strengthening gender mainstreaming within UN Agencies by reviewing and learning from UN system successes. In addition to learning from practice, the way forward lies in making visible and developing strategies to challenge embedded patriarchal organisational norms and systems.

The decision to terminate a pregnancy is not one that is taken lightly. The need for an abortion reflects limited sexual autonomy, ineffective or lack of access to contraceptive options, or a health indication. Abortion is protected under human rights law. That notwithstanding, access to abortions continues to be contested in many parts of the world, with vested interests from politically and religiously conservative states, patriarchal societies, and cultural mores, not just within local contexts but also within a broader geopolitical context. Criminalization of a women's choice not to carry a pregnancy is a significant driver of unsafe procedures, and even where abortions are provided legally, the policies remain constrained by the practice or by a lack of coherence. This review outlines the trends in abortion policy in low- and middle-income countries and highlights priority areas to ensure that women are safe and able to exercise their reproductive rights.

Objectives: Consequent to the drastic growth that has occurred over the past few decades in the dental education sector, dental profession in India, has also undergone changes. Hence, it is critical to inquire whether the current training that is being offered to dental students is successful in preparing them adequately to meet the challenges of the changing dental profession. We have aimed to assess the level of preparedness for independent dental practice among newly graduated dentists of Kerala and to explore the factors associated with their preparedness. Materials and Methods: This cross-sectional survey was conducted among a random sample of 400 recently graduated dentists from Kerala. We developed and validated a self-administered scale named Preparedness for Practice among Dental Graduates-Scale, PPDG-S, to assess the level of preparedness. The overall preparedness scores were categorized based on the median value of the total score (87) – score less than or equal to the median was considered “low preparedness” (0–87) and score greater than the median (>87) was considered “high preparedness.” The difference in proportion between high and low prepared participants across socio- demographic background, training characteristics, and employment characteristics was assessed and the significance was tested using the Chi-square test. A binary logistic regression analysis was conducted to identify the predictors of preparedness among recent dental graduates. Results: The majority of the participants reported themselves to be in the “low preparedness” category (209, 52.3%) as compared to the “high preparedness” category (191, 47.8%). In the bivariate analysis, five variables were found to have significant differences in their proportions between the high and low preparedness categories – gender, caste, type of training institution, work experience, and frequent job changes. According to multivariate analysis, being trained in a private/cooperative college (as opposed to a public institution) and not possessing continuous work experience of even 1 year in a single job (as opposed to having a continuous work experience) were found to pose significant adjusted risk for the lower preparedness among graduates. Conclusion: The high proportion of our study participants reporting lower preparedness for independent practice, reflect poor self-rating of their employability. This is critical, when we consider the competitive, saturated private practice sector, and unemployment among young dentists. The relatively higher proportion of poor preparedness among the private sector trained graduates when compared to the government college trained graduates is another matter that raises concern.

As part of the 2030 Agenda for Sustainable Development, all countries, including India, have committed to trying to achieve univeral health coverage (UHC) by 2030. There are three dimensions to UHC: population coverage, services coverage, and financial risk protection. The goal is to make available to 100% of the population a broad-enough range of essential health services that cover 100% of their healthcare needs and ensure that 100% of the population can receive these services without incurring health expenditure that is more than 10% of the monthly household expenditure. While UHC is a desirable goal, it poses significant challenges for low- and middle-income countries on many fronts. Over the past two decades, India has implemented a wide range of reforms in the health sector ostensibly towards making healthcare services accessible to all. This paper discusses major health financing reforms and private sector engagement in health in India from the perspective of their contribution to UHC. Based on the existing evidence, the paper argues that recent health reforms in India have made limited contributions to access with financial risk protection for socially and economically marginalised groups. Inequalities in coverage by health services have been accentuated and the less privileged bear a disproportionate burden of catastrophic health expenditures. Drawing on the experiences of LMICs in Asia, such as Thailand and Vietnam that have achieved near-universal health coverage, the paper concludes with listing much-needed reforms that are urgently needed for India to move anywhere close to UHC.

More comprehensive understanding of gender inequality is required, particularly the broader structural drivers that underpin the political economy of gender power relations, say Asha George and colleagues

The legacy of male bias within pharmaceutical research, regulation, and commercialisation needs to be rectified, argue Sundari Ravindran and colleagues

Trial design With the rise in prevalence of non-communicable diseases in India and Kerala in particular, efforts to develop lifestyle interventions have increased. However, contextualised interventions are limited. We developed and implemented contextualised behavioural intervention strategies focusing on household dietary behaviours in selected rural areas in Kerala and conducted a community-based pragmatic cluster randomized controlled trial to assess its effectiveness to increase the intake of fruits and vegetables at individual level, and the procurement of fruits and vegetables at the household level and reduce the consumption of salt, sugar and oil at the household level. Methods Six out of 22 administrative units in the northern part of Thiruvananthapuram district of Kerala state were selected as geographic boundaries and randomized to either intervention or control arms. Stratified sampling was carried out and 30 clusters comprising 6–11 households were selected in each arm. A cluster was defined as a neighbourhood group functioning in rural areas under a state-sponsored community-based network (Kudumbasree). We screened 1237 households and recruited 479 (intervention: 240; control: 239) households and individuals (male or female aged 25–45 years) across the 60 clusters. 471 households and individuals completed the intervention and end-line survey and one was excluded due to pregnancy. Interventions were delivered for a period of one-year at household level at 0, 6, and 12 months, including counselling sessions, telephonic reminders, home visits and general awareness sessions through the respective neighbourhood groups in the intervention arm. Households in the control arm received general dietary information leaflets. Data from 478 households (239 in each arm) were included in the intention-to-treat analysis, with the household as the unit of analysis. Results There was significant, modest increase in fruit intake from baseline in the intervention arm (12.5%); but no significant impact of the intervention on vegetable intake over the control arm. There was a significant increase in vegetable procurement in the intervention arm compared to the control arm with the actual effect size showing an overall increase by19%; 34% of all households in the intervention arm had increased their procurement by at least 20%, compared to 17% in the control arm. Monthly household consumption of salt, sugar and oil was greatly reduced in the intervention arm compared to the control arm with the actual effect sizes showing an overall reduction by 45%, 40% and 48% respectively. Conclusions The intervention enabled significant reduction in salt, sugar and oil consumption and improvement in fruit and vegetable procurement at the household level in the intervention arm. However, there was a disconnect between the demonstrated increase in FV procurement and the lack of increase in FV intake. We need to explore fruit and vegetable intake behaviour further to identify strategies or components that would have made a difference. We can take forward the lessons learned from this study to improve our understanding of human dietary behaviour and how that can be changed to improve health within this context.

Saritha P Viswan,1 T K Sundari Ravindran,1,2 Ngianga-Bakwin Kandala,1,3,4 Max G Petzold,1,5 Sharon Fonn1 1School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; 2Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India; 3Division of Epidemiology and Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; 4Department of Mathematics, Physics and Electrical Engineering, Faculty of Engineering and Environment, Northumbria University, Newcastle upon Tyne, UK; 5Department of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden Context: The persistent low contraceptive use and high fertility in Nigeria despite improvements in educational achievements calls for an examination of the role of factors, which may moderate the use of modern contraception. This article explores the influence of sexual autonomy on the use of modern contraceptive methods among women and its relative importance compared with other, more traditional, indicators of women’s autonomy such as education and occupation.Data and methods: Data from two Demographic and Health Surveys (DHS), 2008 and 2013, were used in this study. An index of sexual autonomy was constructed by combining related DHS variables, and its association with current use of modern contraception was examined at each time point as well as over time using multivariate regression analysis.Results: The observed prevalence for use of modern contraception was 2.8 and 2.6 times higher among women who had high sexual autonomy in 2008 and 2013, respectively. The corresponding figures for women with secondary or higher education were 8.2 and 11.8 times higher, respectively, compared with women with no education. But after controlling for wealth index, religion, place of residence, autonomy and experience of intimate partner violence (IPV), the likelihood of use of modern contraception was lowered to about 2.5 (from 8.2) and 2.8 (from 11.8) times during 2008 and 2013, respectively, among women with secondary or higher education. The likelihood of use of modern contraception lowered only to 1.6 (from 2.8) and 1.8 (from 2.6) times among women with high sexual autonomy after controlling for other covariates, respectively, during the same period.Conclusion: Sexual autonomy seems to play an important role in women’s use of modern contraceptive methods independent of education and a number of other factors related to women’s status. Sexual autonomy needs to be simultaneously promoted alongside increasing educational opportunities to enhance women’s ability to use modern contraception. Keywords: family planning, sexuality, decision making, education, empowerment, intimate partner violence&nbsp

Evidence on the community knowledge and perceptions on malaria are crucial to design appropriate health communication strategies for malaria control. Orissa, an Indian state with a large proportion of indigenous populations and hilly terrains contributes to the highest malaria burden in India. A study was undertaken to assess the knowledge on malaria among community members who had experienced fever and chills in the endemic district of Boudh in Orissa.A cross-sectional community-based survey was carried out with respondents (n=300) who had fever with chills within two weeks prior to data collection through a multi-stage sampling and interviewed them using a pre-tested, structured interview schedule.About 90% of respondents recognized fever as a common symptom of malaria, 72.3% said mosquito bites cause malaria, 70.3% of respondents reported mosquito control and personal protection to be the method of malaria prevention, and 24.6% identified chloroquine as the drug used for treatment. Women and scheduled tribe (ST) respondents were found to have lower level of appropriate knowledge of causes, symptoms, and prevention methods of malaria than their counterparts.The study population had a fair knowledge of malaria about the causes, symptoms, treatment, modes of prevention and outcomes of non-treatment compared to most of the studies conducted in similar settings. However, the relatively low awareness among women and tribal population calls for more context specific communication strategies. Such strategies should be based on information needs assessment of different population subgroups, especially of women and members of the ST community, using media that is accessible and clearly understood by different groups.