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Introduction: Role of vaginal sex in heterosexual transmission of HIV has been investigated but that of heterosexual anal sex (HAS) is not fully understood. This paper examines practice of HAS among Female Sex Workers (FSWs) and its correlates in India where the HIV epidemic is being primarily driven by core groups like FSWs. Methods: Data for this paper are drawn from Round I survey of 9667 FSWs in the Integrated Biological and Behavioral Assessment (IBBA) from 23 districts of 4 high HIV prevalent states of India. Bivariate and multivariate analysis identified factors associated with HAS. Results: Ever having anal sex was reported by 11.9% FSWs (95% CI: 11.3%–12.6%). Typology (AOR 2.20, 95% CI 1.64–2.95) and literacy (AOR 1.28, 95% CI 1.10–1.49) were positively associated with practice of HAS. Longer duration in sex trade (AOR 1.69, 95% CI 1.44–1.99), entertaining larger number of clients the previous week (AOR 1.78, 95% CI 1.47–2.15), alcohol consumption (AOR 1.21, 95% CI 1.03–1.42) and inability to negotiate condom use (AOR 1.53, 95% CI 1.28–1.83) were also correlated with HAS. Self-risk perception for HIV (AOR 1.46, 95% CI 1.25–1.71) did not impede HAS. Although symptoms of sexually transmitted infections (STIs) in the last 12 months were associated with anal sex (AOR 1.39, 95% CI 1.13–1.72) there was no significant association between laboratory confirmed HIV and other STIs with HAS. Conclusion: Practice of HAS by FSWs might significantly contribute to HIV transmission in India. This study also shows that despite self-risk perception for HIV, even literate FSWs with longer duration in sex work report HAS. General messages on condom use may not influence safe HAS. FSWs need to be targeted with specific messages on HIV transmission during anal sex. Women controlled prevention methods, such as rectal microbicides and vaginal microbicides are needed. [ABSTRACT FROM AUTHOR]

Out-of-pocket spending at out-patient departments (OPD) by households is relatively less analyzed compared to hospitalization expenses in India. This paper provides new evidence on the levels and drivers of expenditure on out-patient care, as well as choice of providers, using household survey data from 8 districts in 3 states of India. Results indicate that the economically vulnerable spend more on OPD as a proportion of per capita consumption expenditure, out-patient care remains overwhelmingly private and switches of providers—while not very prevalent—is mostly towards private providers. A key result is that choice of public providers tend to lower OPD spending significantly. It indicates that an improvement in the overall quality and accessibility of government facilities still remain an important tool that should be considered in the context of financial protection. [ABSTRACT FROM AUTHOR]

Introduction: Malaria is a public health emergency in India and Odisha. The national malaria elimination programme aims to expedite early identification, treatment and follow-up of malaria cases in hot-spots through a robust health system, besides focusing on efficient vector control. This study, a result of mass screening conducted in a hot-spot in Odisha, aimed to assess prevalence, identify and estimate the risks and develop a management tool for malaria elimination. Methods: Through a cross-sectional study and using WHO recommended Rapid Diagnostic Test (RDT), 13221 individuals were screened. Information about age, gender, education and health practices were collected along with blood sample (5 μl) for malaria testing. Altitude, forestation, availability of a village health worker and distance from secondary health center were captured using panel technique. A multi-level poisson regression model was used to analyze association between risk factors and prevalence of malaria, and to estimate risk scores. Results: The prevalence of malaria was 5.8% and afebrile malaria accounted for 79 percent of all confirmed cases. Higher proportion of Pv infections were afebrile (81%). We found the prevalence to be 1.38 (1.1664–1.6457) times higher in villages where the Accredited Social Health Activist (ASHA) didn’t stay; the risk increased by 1.38 (1.0428–1.8272) and 1.92 (1.4428–2.5764) times in mid- and high-altitude tertiles. With regard to forest coverage, villages falling under mid- and highest-tertiles were 2.01 times (1.6194–2.5129) and 2.03 times (1.5477–2.6809), respectively, more likely affected by malaria. Similarly, villages of mid tertile and lowest tertile of education had 1.73 times (1.3392–2.2586) and 2.50 times (2.009–3.1244) higher prevalence of malaria. Conclusion: Presence of ASHA worker in villages, altitude, forestation, and education emerged as principal predictors of malaria infection in the study area. An easy-to-use risk-scoring system for ranking villages based on these risk factors could facilitate resource prioritization for malaria elimination. [ABSTRACT FROM AUTHOR]

Background: As population health and well-being are influenced by multiple factors that cut across sectoral boundaries, an intersectoral approach that acknowledges and leverages the multiple determinants, actors and sectors at play is increasingly seen as critical for achieving meaningful and lasting improvements. In this study, we utilize social network analysis (SNA) to characterize the intersectoral collaboration between the organizations working on maternal & child health (MCH) and water & sanitation (WASH) before and immediately after the implementation of HCL Foundation (HCLF)-funded HCL Samuday Project (2015–2017) in a rural block of Uttar Pradesh state, India. While SNA has been used to examine public health issues, few have used it monitor stakeholder relationships, intervene, improve and facilitate project implementation involving intersectoral partnerships, particularly in the context of a low-and middle-income countries. Method: An organization-level SNA was conducted with 31 key informants from 24 organizations working on MCH and/or WASH in Kachhauna, Uttar Pradesh, India. Data were collected using face-to-face, semi-structured interviews between June and September 2017. Density, centrality and homophily were calculated to describe the network and a qualitative analysis was also conducted to identify the strengths and weaknesses of collaboration between organizations working on MCH and WASH. Results: Overall, our findings showed that the network of organizations working on MCH and WASH in Kachhauna grew in number since the implementation of Samuday. HCLF rapidly achieved centrality, thus positioning the organization to serve as a gatekeeper of information and enabling it to play a coordinator role within the network. Direct collaboration between other organizations working on MCH and WASH was low at both time points. Interviews with key informants indicated widespread interest in increasing interorganizational interactions and engagement throughout the network. Conclusion: This study demonstrates the feasibility and practical application of SNA for projects like Samuday that involve intersectoral collaboration. It also provides lessons about the use of SNA with organizations as the unit of analysis and in the context of rural India, including challenges, practical considerations, and limitations. [ABSTRACT FROM AUTHOR]

Introduction: Health interventions implemented with self-help groups (SHGs) enhance the relevance and acceptability of the health services. The Parivartan program was implemented in eight districts of Bihar with women’s self-help groups to increase adoption of maternal and newborn health behaviors through layering health behavior change communication. This study estimates the cost and cost-effectiveness of a health behavior change program with SHGs in Bihar. Methods: Cost analysis was conducted from a provider’s perspective. All costs have been presented in US dollars for the purpose of international comparisons and converted to constant values. The effectiveness estimate was based on the reported changes in select newborn care practices. A decision model approach was used to estimate the potential number of neonatal deaths averted based on adoption of key newborn care practices. Using India’s life expectancy of 65 years, cost per life year saved was calculated. A one-way sensitivity analysis was conducted using the upper and lower estimates for various variables in the model, and functionality of SHGs. Results: The cost of forming an SHG group was US$254 and that of reaching a woman within the group was US$19. The unit cost for delivering health interventions through the Parivartan program was US$148 per group and US$11 per woman reached. During an 18 months period, Parivartan program reached around 17,120 SHGs and an estimated 20,544 pregnant women resulting in an estimated prevention of 23 neonatal deaths at a cost of US$3,825 per life year saved. Conclusion: SHGs can be an effective platform to increase uptake of women’s health interventions and follow-up care, and also to broaden their utility beyond microfinance, particularly when they operate at a larger scale. [ABSTRACT FROM AUTHOR]

Background: This study evaluates an eight-session behavior change health intervention with women’s self-help groups (SHGs) aimed to promote healthy maternal and newborn practices among the more socially and economically marginalized groups. Methods: Using a pre-post quasi-experimental design, a total of 545 SHGs were divided into two groups: a control group, which received the usual microcredit intervention; and an intervention group, which received additional participatory training around maternal, neonatal, and child health issues. Women members of SHGs who had a live birth in the 12 months preceding the survey were surveyed on demographics, practices around maternal, neonatal and child health (MNCH), and collectivization. Outcome effects were assessed using difference-in-difference (DID) methods. Results: Women from the SHGs with health intervention, relative to controls over time (time 1 to time 2), were more likely to: use contraceptive methods (DID: 9 percentage points [pp], p<0.001), have institutional delivery (DID: 9pp, p<0.05), practice skin-to-skin care (DID: 17pp, p<0.05), delay bathing for 3 or more days (DID: 19pp, p<0.001), initiate timely breastfeeding (DID: 21pp, p<0.001), exclusively breastfeed the child (DID: 27pp, p<0.001), and provide age-appropriate immunization (DID: 9pp, p<0.001). Additionally, women from the SHGs with health intervention when compared to the control group over time were more likely to report: collective efficacy (DID: 17pp, p<0.001), support through accompanying SHG members for antenatal care (DID: 8pp, p<0.05), receive a visit from SHG member within 2 days post-delivery (DID: 32pp, p<0.001), and receive reproductive, maternal, neonatal and child health information from an SHG member (DID: 45pp, p<0.001). Conclusion: Findings demonstrate that structured participatory communication on MNCH with women’s groups improve positive health practices. In addition, SHGs can reach a substantial proportion of women while providing an avenue for pregnant women and young mothers to be assisted by others in learning and practicing healthy behaviors, thus building social cohesion on health. [ABSTRACT FROM AUTHOR]

Background: Community health workers (CHWs) have been placed in many rural areas in India to increase villagers’ connections to basic preventive health care. In this study, we describe how pregnant women and mothers of young children react when CHWs inform them that they, or their child, are at high risk of pregnancy-related complications or early childhood developmental delays, and further screening and health care from a physician is recommended. Methods: In this longitudinal study in rural villages in West Bengal, India, pregnant mothers, as well as mothers of children aged 12–24 months, were screened for high risk complications. They were re-contacted and asked questions regarding how and to what extent did visits by the CHWs improve their household’s overall health behavior, along with details about what additional care, if any, they sought. These responses are presented by different demographic and medical characteristics. Results: Of the 231 pregnant women, all said they had sought additional care in response to the CHW visit, and all stated that feedback from the CHW resulted in improvement to their health behaviors. Most (90%) pregnant women gave birth at an institution. Among the 213 mothers of young children who were followed up, all sought additional care in response to the CHW’s visit. Most (67%) mentioned that they had a significant improvement in their health behaviors following feedback from the CHW, and the rest stated that they had some improvement. Conclusions: With the proper training, CHWs can be partners in health care to improve the health of vulnerable populations, not only in rural areas of India, but also in other developing countries. CHWs can promote positive health outcomes in their villages of residence. [ABSTRACT FROM AUTHOR]

Introduction: Improving maternal health outcomes remains a priority in Low and Middle Income Countries. With the rapid proliferation of mobile health technologies, there is an increased interest in understanding how these technologies can effectively improve maternal health outcomes particularly maternal health seeking knowledge and behaviors. However, few studies present clear explanations of the program developers’ rationale (theory of change) and contextual factors that could influence program outcomes. This mixed-methods study assesses Mobile for Mothers, a community health workers (CHW) utilized maternal mHealth intervention. We present the program developers’ rationale and utilize it as a framework to guide our study that aimed to identify intervention-related and contextual factors, which influence the observed outcomes of a CHW, utilized mHealth intervention. Materials and methods: Quantitative methods (a questionnaire with 740 women who received the intervention and survey of 57 CHWs who utilized the intervention) and qualitative methods (12 interviews and 4 group discussions with CHWs and 20 interviews and 5 group discussions with pregnant and lactating women and 15 interviews and 2 group discussions with men) were conducted. These were used to understand how the mHealth intervention was implemented and to gain insight into contextual factors that potentially influenced the observed intervention outcomes. Results: Results were grouped following three categories: (1) perceptions and experiences of CHWs utilizing the mHealth technology; (2) CHW-related outcomes; and (3) contextual factors that influence maternal health-seeking behavior. The overall response of CHWs and community members to the intervention was positive. However, contextual factors like the relationship between the CHWs and their respective communities, the pregnant women’s decision-making power and lack of access due to financial influenced the observed outcomes. Conclusion: Mobile health applications are promising interventions for improving the performance of CHWs and health-seeking behavior of pregnant women. However, the contextual factors play a crucial role in intervention outcomes and need to be explicated by program developers during intervention design and implementation. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization recommends participatory learning and action (PLA) in women's groups to improve maternal and newborn health, particularly in rural settings with low access to health services. There have been calls to understand the pathways through which this community intervention may affect neonatal mortality. We examined the effect of women's groups on key antenatal, delivery, and postnatal behaviours in order to understand pathways to mortality reduction.Methods and Findings: We conducted a meta-analysis using data from 7 cluster-randomised controlled trials that took place between 2001 and 2012 in rural India (2 trials), urban India (1 trial), rural Bangladesh (2 trials), rural Nepal (1 trial), and rural Malawi (1 trial), with the number of participants ranging between 6,125 and 29,901 live births. Behavioural outcomes included appropriate antenatal care, facility delivery, use of a safe delivery kit, hand washing by the birth attendant prior to delivery, use of a sterilised instrument to cut the umbilical cord, immediate wrapping of the newborn after delivery, delayed bathing of the newborn, early initiation of breastfeeding, and exclusive breastfeeding. We used 2-stage meta-analysis techniques to estimate the effect of the women's group intervention on behavioural outcomes. In the first stage, we used random effects models with individual patient data to assess the effect of groups on outcomes separately for the different trials. In the second stage of the meta-analysis, random effects models were applied using summary-level estimates calculated in the first stage of the analysis. To determine whether behaviour change was related to group attendance, we used random effects models to assess associations between outcomes and the following categories of group attendance and allocation: women attending a group and allocated to the intervention arm; women not attending a group but allocated to the intervention arm; and women allocated to the control arm. Overall, women's groups practising PLA improved behaviours during and after home deliveries, including the use of safe delivery kits (odds ratio [OR] 2.92, 95% CI 2.02-4.22; I2 = 63.7%, 95% CI 4.4%-86.2%), use of a sterile blade to cut the umbilical cord (1.88, 1.25-2.82; 67.6%, 16.1%-87.5%), birth attendant washing hands prior to delivery (1.87, 1.19-2.95; 79%, 53.8%-90.4%), delayed bathing of the newborn for at least 24 hours (1.47, 1.09-1.99; 68.0%, 29.2%-85.6%), and wrapping the newborn within 10 minutes of delivery (1.27, 1.02-1.60; 0.0%, 0%-79.2%). Effects were partly dependent on the proportion of pregnant women attending groups. We did not find evidence of effects on uptake of antenatal care (OR 1.03, 95% CI 0.77-1.38; I2 = 86.3%, 95% CI 73.8%-92.8%), facility delivery (1.02, 0.93-1.12; 21.4%, 0%-65.8%), initiating breastfeeding within 1 hour (1.08, 0.85-1.39; 76.6%, 50.9%-88.8%), or exclusive breastfeeding for 6 weeks after delivery (1.18, 0.93-1.48; 72.9%, 37.8%-88.2%). The main limitation of our analysis is the high degree of heterogeneity for effects on most behaviours, possibly due to the limited number of trials involving women's groups and context-specific effects.Conclusions: This meta-analysis suggests that women's groups practising PLA improve key behaviours on the pathway to neonatal mortality, with the strongest evidence for home care behaviours and practices during home deliveries. A lack of consistency in improved behaviours across all trials may reflect differences in local priorities, capabilities, and the responsiveness of health services. Future research could address the mechanisms behind how PLA improves survival, in order to adapt this method to improve maternal and newborn health in different contexts, as well as improve other outcomes across the continuum of care for women, children, and adolescents. [ABSTRACT FROM AUTHOR]

Health committees are a common strategy to foster community participation in health. Efforts to strengthen committees often focus on technical inputs to improve committee form (e.g. representative membership) and functioning (e.g. meeting procedures). However, porous and interconnected contextual spheres also mediate committee effectiveness. Using a framework for contextual analysis, we explored the contextual features that facilitated or hindered Village Health, Sanitation and Nutrition Committee (VHSNC) functionality in rural north India. We conducted interviews (n = 74), focus groups (n = 18) and observation over 1.5 years. Thematic content analysis enabled the identification and grouping of themes, and detailed exploration of sub-themes. While the intervention succeeded in strengthening committee form and functioning, participant accounts illuminated the different ways in which contextual influences impinged on VHSNC efficacy. Women and marginalized groups navigated social hierarchies that curtailed their ability to assert themselves in the presence of men and powerful local families. These dynamics were not static and unchanging, illustrated by pre-existing cross-caste problem solving, and the committee’s creation of opportunities for the careful violation of social norms. Resource and capacity deficits in government services limited opportunities to build relationships between health system actors and committee members and engendered mistrust of government institutions. Fragmented administrative accountability left committee members bearing responsibility for improving local health without access to stakeholders who could support or respond to their efforts. The committee’s narrow authority was at odds with widespread community needs, and committee members struggled to involve diverse government services across the health, sanitation, and nutrition sectors. Multiple parallel systems (political decentralization, media and other village groups) presented opportunities to create more enabling VHSNC contexts, although the potential to harness these opportunities was largely unmet. This study highlights the urgent need for supportive contexts in which people can not only participate in health committees, but also access the power and resources needed to bring about actual improvements to their health and wellbeing. [ABSTRACT FROM AUTHOR]

Background: Globally, India contributes the largest share in sheer numbers to the burden of maternal and infant under-nutrition, morbidity and mortality. A major gap in our knowledge is how socio-cultural practices and beliefs influence the perinatal period and thus perinatal outcomes, particularly in the rapidly growing urban setting. Methods and Findings: Using data from a qualitative study in urban south India, including in-depth interviews with 36 women who had recently been through childbirth as well as observations of family life and clinic encounters, we explored the territory of familial, cultural and traditional practices and beliefs influencing women and their families through pregnancy, childbirth and infancy. We found that while there were some similarities in cultural practices to those described before in studies from low resource village settings, there are changing practices and ideas. Fertility concerns dominate women’s experience of married life; notions of gender preference and ideal family size are changing rapidly in response to the urban context; however inter-generational family pressures are still considerable. While a rich repertoire of cultural practices persists throughout the perinatal continuum, their existence is normalised and even underplayed. In terms of diet and nutrition, traditional messages including notions of ‘hot’ and ‘cold’ foods, are stronger than health messages; however breastfeeding is the cultural norm and the practice of delayed breastfeeding appears to be disappearing in this urban setting. Marriage, pregnancy and childbirth are so much part of the norm for women, that there is little expectation of individual choice in any of these major life events. Conclusions: A greater understanding is needed of the dynamic factors shaping the perinatal period in urban India, including an acknowledgment of the health promoting as well as potentially harmful cultural practices and the critical role of the family. This will help plan culturally appropriate integrated perinatal health care. [ABSTRACT FROM AUTHOR]

Social networks are believed to affect health-related behaviors and health. Data to examine the links between social relationships and health in low- and middle-income country settings are limited. We provide guidance for introducing an instrument to collect social network data as part of epidemiological surveys, drawing on experience in urban India. We describe development and fielding of an instrument to collect social network information relevant to health behaviors among adults participating in a large, population-based study of non-communicable diseases in Delhi, India. We discuss basic characteristics of social networks relevant to health including network size, health behaviors of network partners (i.e., network exposures), network homogeneity, network diversity, strength of ties, and multiplexity. Data on these characteristics can be collected using a short instrument of 11 items asked about up to 5 network members and 3 items about the network generally, administered in approximately 20 minutes. We found high willingness to respond to questions about social networks (97% response). Respondents identified an average of 3.8 network members, most often relatives (80% of network ties), particularly blood relationships. Ninety-one percent of respondents reported that their primary contacts for discussing health concerns were relatives. Among all listed ties, 91% of most frequent snack partners and 64% of exercise partners in the last two weeks were relatives. These results demonstrate that family relationships are the crux of social networks in some settings, including among adults in urban India. Collecting basic information about social networks can be feasibly and effectively done within ongoing epidemiological studies. [ABSTRACT FROM AUTHOR]

Background: Limited data are available about tuberculosis treatment models of care for internally displaced populations in chronic, low-intensity conflict zones. This study aimed to detail experiences of a Médecins Sans Frontières tuberculosis programme in Andhra Pradesh-Chhattisgarh border area, India, from January to December 2012. Methods: The study was a description of two retrospective, observational cohorts receiving category I tuberculosis treatment, either intermittent directly observed treatment (DOT) or daily self-administered therapy (SAT) depending on the security of the area and access to health care services. Results: A total of 55 and 17 new tuberculosis patients under DOT and SAT respectively, with complete outcomes were included in the study. Most patients registered were new cases suffering from pulmonary, smear-positive tuberculosis. More than half of the patients in both cohorts were cured or completed treatment: 38/55 (69%) patients were successfully treated under DOT compared to 9/17 (53%) under SAT. Of the patients with adverse outcomes, the ratios of loss to follow up: failure: died were 10∶4:3 under DOT and 7∶0:1 under SAT. A much smaller proportion of patients under DOT (18%) were lost to follow up than under SAT (41%). Discussion: Maximum efforts are required to implement successful tuberculosis control programmes for internally displaced populations in conflict zones. Our study suggests that complete tuberculosis treatment can be given to patients using either intermittent DOT or daily SAT, depending on security and access to health services. National TB programmes should include SAT strategies for tuberculosis treatment as these may be an alternative feasible option in conflict settings. [ABSTRACT FROM AUTHOR]

Background: Faced with a massive shortfall in meeting sanitation targets, some governments have implemented campaigns that use subsidies focused on latrine construction to overcome income constraints and rapidly expand coverage. In settings like rural India where open defecation is common, this may result in sub-optimal compliance (use), thereby continuing to leave the population exposed to human excreta. Methods: We conducted a cross-sectional study to investigate latrine coverage and use among 20 villages (447 households, 1933 individuals) in Orissa, India where the Government of India’s Total Sanitation Campaign had been implemented at least three years previously. We defined coverage as the proportion of households that had a latrine; for use we identified the proportion of households with at least one reported user and among those, the extent of reported use by each member of the household. Results: Mean latrine coverage among the villages was 72% (compared to <10% in comparable villages in the same district where the Total Sanitation Campaign had not yet been implemented), though three of the villages had less than 50% coverage. Among these households with latrines, more than a third (39%) were not being used by any member of the household. Well over a third (37%) of the members of households with latrines reported never defecating in their latrines. Less than half (47%) of the members of such households reported using their latrines at all times for defecation. Combined with the 28% of households that did not have latrines, it appears that most defecation events in these communities are still practiced in the open. Conclusion: A large-scale campaign to implement sanitation has achieved substantial gains in latrine coverage in this population. Nevertheless, gaps in coverage and widespread continuation of open defecation will result in continued exposure to human excreta, reducing the potential for health gains. [ABSTRACT FROM AUTHOR]

Background: The nutritional aetiology of obesity remains unclear, especially with regard to the role of dairy products in developing countries. Objective: To examine whether milk/milk product consumption is associated with obesity and high waist circumference among adult Indians. Methods: Information on plain milk, tea, curd and buttermilk/lassi consumption assessed using a Food Frequency Questionnaire was obtained from the cross-sectional sib-pair designed Indian Migration Study (3698 men and 2659 women), conducted at four factory locations across north, central and south India. The anthropometric measures included were Body Mass Index (BMI) and Waist Circumference (WC). Mixed-effect logistic regression models were conducted to accommodate sib-pair design and adjust for potential confounders. Results: After controlling for potential confounders, the risk of being obese (BMI≥25 kg/m2) was lower among women (OR = 0.57;95%CI:0.43−0.76;p≤0.0001) and men (OR = 0.67;95%CI: 0.51−0.87;p = 0.005), and the risk of a high WC (men: >90 cm; women: >80 cm) was lower among men (OR = 0.71;95%CI:0.54−0.93;p = 0.005) and women (OR = 0.79;95%CI:0.59−1.05;p>0.05) who consume ≥1 portions of plain milk daily than those who do not consume any milk. The inverse association between daily plain milk consumption and obesity was also confirmed in sibling-pair analyses. Daily tea consumption of ≥1 portion was associated with obesity (OR = 1.51;95%CI:1.00−2.25;p>0.050) and high WC (OR = 1.65;95%CI:1.08−2.51;p>0.019) among men but not among women but there was no strong evidence of association of curd and buttermilk/lassi consumption with obesity and high waist circumference among both men and women. Conclusions: The independent, inverse association of daily plain milk consumption with the risk of being obese suggests that high plain milk intake may lower the risk of obesity in adult Indians. However, this is an observational finding and uncontrolled confounding cannot be excluded as an explanation for the association. Therefore, confirmatory studies are needed to clarify this relationship. [ABSTRACT FROM AUTHOR]