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This paper examines various features of energy and groundwater irrigation nexus in a highly irrigated ecosystem of north western India. The study is based both on primary and secondary sources of data. Electric tube-wells account for about 72 percent of the total tube-wells population and consume about 40 percent of the total electricity consumption. Power subsidies account approximately 46 percent of the total subsidies disbursed which stimulate the groundwater development. The area irrigated by means of tube-wells has enlarged from 22 to 58 percent. Rice and sugarcane crops are the key consumers of energy both in terms of average energy consumption as well as per hectare of cultivated land. The average use factor of tube-wells is about 7.5 times high during kharif than in rabi season. Farmers have yielded high economic productivity under all crops with the exception of rice than other states such as Uttar Pradesh, Bihar and Gujarat. [ABSTRACT FROM AUTHOR]

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The disease control program is critical to the agenda of social justice. A generalist approach to the disease control program involves understanding its complexity and prevention from various perspectives, including ecological theory. The integration of the disease control program into the existing healthcare delivery system has been advocated over many decades, with an emphasis on the medical model of disease control. Integration has been widely considered as a means to achieve an effective and efficient health system. This approach has been widely adopted in low-middle-income countries to integrate vertical programs such as leprosy, malaria, HIV/AIDs, and others. However, studies suggest that there is a lack of evidence about the effectiveness of health system integration. The available evidence shows that integration of the health system can have a mixed, negative, or no impact on the health system. This growing enthusiasm toward health system integration is primarily based on the perceived benefits of an integrated approach. This discussion paper draws on the experience of the integration of the National Leprosy Elimination Program in India. It highlights the factors that affected the integration of leprosy programs in Bihar and also affected the pursuit of social justice for people who have been marginalized in our modern world. [ABSTRACT FROM AUTHOR]

Background: Asymptomatic Leishmania donovani infections outnumber clinical presentations, however the predictors for development of active disease are not well known. We aimed to identify serological, immunological and genetic markers for progression from L. donovani infection to clinical Visceral Leishmaniasis (VL). Methods: We enrolled all residents >2 years of age in 27 VL endemic villages in Bihar (India). Blood samples collected on filter paper on two occasions 6–12 months apart, were tested for antibodies against L. donovani with rK39-ELISA and DAT. Sero converters, (negative for both tests in the first round but positive on either of the two during the second round) and controls (negative on both tests on both occasions) were followed for three years. At the start of follow-up venous blood was collected for the following tests: DAT, rK39- ELISA, Quantiferon assay, SNP/HLA genotyping and L.donovani specific quantitative PCR. Results: Among 1,606 subjects enrolled,17 (8/476 seroconverters and 9/1,130 controls) developed VL (OR 3.1; 95% CI 1.1–8.3). High DAT and rK39 ELISA antibody titers as well as positive qPCR were strongly and significantly associated with progression from seroconversion to VL with odds ratios of 19.1, 30.3 and 20.9 respectively. Most VL cases arose early (median 5 months) during follow-up. Conclusion: We confirmed the strong association between high DAT and/or rK39 titers and progression to disease among asymptomatic subjects and identified qPCR as an additional predictor. Low predictive values do not warrant prophylactic treatment but as most progressed to VL early during follow-up, careful oberservation of these subjects for at least 6 months is indicated. [ABSTRACT FROM AUTHOR]

Indoor residual spraying (IRS) is used to control visceral leishmaniasis (VL) in India, but it is poorly quality assured. Quality assurance was performed in eight VL endemic districts in Bihar State, India, in 2014. Residual dichlorodiphenyltrichloroethane (DDT) was sampled from walls using Bostik tape discs, and DDT concentrations [grams of active ingredient per square meter (g ai/m²)] were determined using HPLC. Pre-IRS surveys were performed in three districts, and post-IRS surveys were performed in eight districts. A 20% threshold above and below the target spray of 1.0 g ai/m² was defined as "in range." The entomological assessments were made in four districts in IRS and non- IRS villages. Vector densities were measured: pre-IRS and 1 and 3 mo post-IRS. Insecticide susceptibility to 4% DDT and 0.05% deltamethrin WHO-impregnated papers was determined with wild-caught sand flies. The majority (329 of 360, 91.3%) of pre-IRS samples had residual DDT concentrations of <0.1 g ai/m². The mean residual concentration of DDT post-IRS was 0.37 g ai/m²; 84.9% of walls were undersprayed, 7.4% were sprayed in range, and 7.6% were oversprayed. The abundance of sand flies in IRS and non-IRS villages was significantly different at 1 mo post-IRS only. Sand flies were highly resistant to DDT but susceptible to deltamethrin. The Stockholm Convention, ratified by India in 2006, calls for the complete phasing out of DDT as soon as practical, with limited use in the interim where no viable IRS alternatives exist. Given the poor quality of the DDT-based IRS, ready availability of pyrethroids, and susceptibility profile of Indian sand flies, the continued use of DDT in this IRS program is questionable. [ABSTRACT FROM AUTHOR]

This paper investigates the underlying causes of poor economic growth of Bihar and Uttar Pradesh (UP), India, despite being endowed with relatively rich natural resources. Against the conventional view, the analysis reveals that poor economic growth is not due to a particular factor but an outcome of a myriad of social, economic and political factors rooted in structural, historical and macro-economic policies. The economic marginalization of Bihar and UP began in the colonial era through the establishment of an exploitative landlord class, which constantly resisted economic and social development even after independence in 1947. The process of marginalization has further been reinforced by the federal central government's policy of 'freight equalization', which nullified the comparative advantage of Bihar and UP in natural resources by subsidizing railway freights of industrial inputs like coal, iron ore, steel, cement and other bulk resources. This, combined with relatively low financial resources received from central government over the consecutive plan periods, has undermined these states' capacity to invest in health, education, and other social and physical infrastructure and resulted in low human development. The poor performance of Bihar and UP may be attributed to low human capital, weak institutions and poor infrastructure coupled with political instability and social conflict rooted in sectarian politics based on caste, class and ethnic division. [ABSTRACT FROM AUTHOR]

Poverty affects many people, but the ramifications and impacts affect all aspects of society. Information about the incidence of poverty is therefore an important parameter of the population for policy analysis and decision making. In order to provide specific, targeted solutions when addressing poverty disadvantage small area statistics are needed. Surveys are typically designed and planned to produce reliable estimates of population characteristics of interest mainly at higher geographic area such as national and state level. Sample sizes are usually not large enough to provide reliable estimates for disaggregated analysis. In many instances estimates are required for areas of the population for which the survey providing the data was unplanned. Then, for areas with small sample sizes, direct survey estimation of population characteristics based only on the data available from the particular area tends to be unreliable. This paper describes an application of small area estimation (SAE) approach to improve the precision of estimates of poverty incidence at district level in the State of Bihar in India by linking data from the Household Consumer Expenditure Survey 2011–12 of NSSO and the Population Census 2011. The results show that the district level estimates generated by SAE method are more precise and representative. In contrast, the direct survey estimates based on survey data alone are less stable. [ABSTRACT FROM AUTHOR]

In which settings can bicycles help to improve girls' education in low-income countries? This paper analyzes the complementarity between all-weather roads and a bicycle program in India aimed at increasing girls' secondary school enrollment. Using a triple-difference strategy, I find that the program benefits girls living 3–10 km away from schools with all-weather road connections, increasing their enrollment by 60 percent and reducing the gender enrollment gap by 51 percent. There are no effects for girls in villages without all-weather roads or girls living more than 10 km from school. The findings emphasize the importance and interdependence of road infrastructure, mode of transport, and distance to school for improving girls' education in India. • Bicycle program for girls in Bihar, India, reduces the gender education gap. • Bicycle program is only effective if high-quality road infrastructure is available and schools are nearby. • Interdependence of mode of transport (bicycles), road infrastructure, and nearby schools for girls' education choice in India. • Triple-difference estimation. [ABSTRACT FROM AUTHOR]

Background: Numerous studies have demonstrated that high-risk fertility behaviour (HRFB), which includes maternal age below 18 or above 34 years, short birth intervals (less than 24 months), and high parity (birth order above 4), is associated with adverse maternal and child health outcomes. There is a substantial research gap in the domain of high-risk fertility behaviour in the Indian context. Therefore, this study is designed to investigate the current trends and patterns in the prevalence of high-risk births among Indian women, with a primary focus on identifying contributing factors associated with this prevalence. Methods: The study utilized data from the nationally representative National Family Health Survey (NFHS), which has been conducted in five rounds since 1992–93. Data from all rounds were used to assess the overall trend. However, data from the most recent round of NFHS, conducted during 2019–21, were employed to evaluate current levels and patterns of HRFB prevalence and to identify socio-economic and demographic predictors of HRFB using binomial and multinomial logistic regression models. Results: The prevalence of HRFB has exhibited a consistent decreasing pattern from 1992 to 93 to 2019–21 in India. However, 29.56% of married women continue to experience high-risk births with notably higher rates in several states (e.g., 49.85% in Meghalaya and 46.41% in Bihar). Furthermore, socio-demographic factors like wealth index, educational level, social group, religion, mass media exposure, family size, age at marriage, type and region of residence, and reproductive factors like birth intention, place and type of delivery, ANC visits and current contraceptive use were identified as significant predictors of high-risk births among women in India. Conclusion: Despite a 20.4 percentage point decline in HRFB prevalence over the past three decades, a significant proportion of women in specific regions and demographic subgroups continue to experience high-risk births. Therefore, the present study recommends interventions aimed at preventing high-risk births among women in India, with particular emphasis on states with high HRFB prevalence and women from socioeconomically disadvantaged backgrounds. [ABSTRACT FROM AUTHOR]

Despite having equally vast endowments of natural resources and similar socioeconomic profiles, the Indian states of Bihar and Odisha pursued markedly different development strategies during India's first decade of economic liberalization. Whereas Bihar turned away from its natural resource sector and adopted policies of social empowerment, Odisha courted private investment in extractive industries and aggressively pursued market reforms. To account for this divergence, we argue that the social composition of political power in each state directly shaped the strategies that leaders embraced towards the natural resource sector and overall development. This paper makes contributions to the writings on natural resources and the political economy of India. We show that the presence of abundant natural resources does not necessarily result in a predictable pathway of sectoral and economic policy outcomes. Instead, social factors can be a powerful determinant of how resource-rich states approach their economies. [ABSTRACT FROM AUTHOR]

The paper examines the nature and development of the participatory water institutions in the eastern Indo-Gangetic plains of India, focusing on the aspects of structure, participation, and devolution. Though the physical development of irrigation has made considerable progress in India, the proper management and distribution of water has poised many difficulties. The consequences of this are poor efficiency in water use, inequity in distribution, disputes, high cost, and substantial under-utilization of the potential created. On the other hand, institutional initiatives that aim to improve water management and distribution are seen in some areas/locations, and show a process of arriving at better institutional arrangements. Water institutions are crucial for eastern India and though there are a few examples of spontaneous bottom-up initiatives, much of this development is driven by external interventions including laws, policies, and government programs. Even though under the government interventions, the guidelines and policies are usually uniform and top-down, the local uptake and adoption show substantial variation and divergence and this deserves study. The research is based on review of the literature as well as on six in-depth case studies, and also responses of 510 households involved with 51 participatory water institutions in the setting of the eastern Indo-Gangetic plains states of Assam and Bihar. The paper first takes a brief look at the literature on the foundations and experiences of participatory irrigation management (PIM), and then examines through the case studies and data, the development and variation in the PIM water institution in the given setting. It examines features such as laws, membership, structure, inclusion, participation/involvement and devolution. It finds that inclusion of various groups of people in the institutions is quite good except for women and youth. However, actual involvement of different people varies substantially. The issue of devolution/decentralization versus centralization in decision-making is very important to PIM, and varies across the structure and functions. The association of involvement and devolution to performance indicates that the active involvement of some functionaries and groups is very important, and that devolution in several decisions can considerably enhance performance. The observations provide many useful insights for policy and institutional design which can help improve water resource management in the eastern Indo-Gangetic plains. [ABSTRACT FROM AUTHOR]

Objective Visceral Leishmaniasis (VL) is highly prevalent in Bihar, India. India and its neighbours aim at eliminating VL, but several knowledge gaps in the epidemiology of VL may hamper that effort. The prevalence of asymptomatic infections with Leishmania donovani and their role in transmission dynamics are not well understood. We report data from a sero-survey in Bihar. Methods Demographic and immunological surveys were carried out in July and November 2006, respectively in 16 highly VL endemic foci in Muzaffarpur district in Bihar. Household and individual information was gathered and capillary blood samples were collected on filter papers. Direct agglutination test (DAT) was used to determine infected individuals (cut-off titre 1:1600). DAT results were tabulated against individual and household variables. A multivariate generalized estimating equation (GEE) model was used to study the prevalence of serologically positive individuals taking into account the clustering at household and cluster levels. Results Of study subjects 18% were DAT positive, and this proportion increased with age. Women had a significantly lower prevalence than men >14 years old. Owning domestic animals (cows, buffaloes or goats) was associated with a higher risk of being DAT positive [OR 1.16 (95% CI 1.01–1.32)], but socio-economic status was not. Conclusions Prevalence of leishmanial antibodies was high in these communities, but variable. Demographic factors (i.e. marriage) may explain the lower DAT positivity in women >14 years of age. Within these homogeneously poor communities, socio-economic status was not linked to L. donovani infection risk at the individual level, but ownership of domestic animals was. [ABSTRACT FROM AUTHOR]

Background: Circular migration is the dominant pattern of movement in India and is a livelihood strategy used by many food insecure rural households. Repeated shifts in food environments have important implications on household food security and dietary patterns but have not been studied. Objective: To explore differences in the food environment, food security, and food availability between home and destination spaces. Methods: Mixed-methods research was conducted among circular migrant families working and residing on brick kilns in the state of Bihar. Utilizing stratified cluster sampling, 2 rounds of cross-sectional data were collected from 2564 families. Additionally, 25 in-depth interviews were conducted with circular migrant parents, kiln owners, and labor contractors. The Food Insecurity Experience Scale was validated for use in our study population. Bivariate analyses were conducted to estimate the association of food insecurity with sociodemographic variables. Qualitative data were analyzed using descriptive thematic methods. Results: Seventy percent of respondents utilized at least one nonmarket source of food at the origin; at the destination, sources of food were limited to the private market. Despite higher food prices at the destination, perceived food affordability was higher during periods of migration, resulting in improved food security. Tubers, rice, and wheat were typically available in the household daily, whereas fruits, eggs, and dairy were typically unavailable during the week. Conclusions: Circular migration can enable short-term food security by improving food affordability. Policy frameworks must address the root causes of chronic food insecurity, especially among rural-to-rural circular migrant families. [ABSTRACT FROM AUTHOR]

The COVID‐19 crisis re‐shaped many livelihood options and placed significant burdens on those with precarious incomes exacerbating persisting vulnerabilities, especially among a large section of the migrant population. This group faced a dual threat – both to their livelihood and health. To understand the consequences of this pandemic on the income of the migrant population, a household level survey was conducted in the state of Bihar, India, which is one of the highest migrant‐sending states. We examine the role of differences in the socio‐economic status of migrants and their households in determining the extent of vulnerability caused by the COVID‐19 crisis. Vulnerability is proxied by the income lost by migrants during the lockdown. The results suggest that households with diversified income portfolio, larger landholdings, and those receiving government benefits suffered significantly lower income loss whereas, larger household size and greater distance from town tended to escalate income loss. Additionally, private salaried workers faced higher income loss and an increment in years of education lowers the losses significantly. It is observed that individual‐level characteristics also played a significant role in determining economic loss due to the lockdown. Our findings suggest a binding necessity to actively shape policies considering the financial insecurity of vulnerable migrants at their destination and the household members at the origin. [ABSTRACT FROM AUTHOR]

The paper examines the nature and performance of participatory water institutions in eastern India using structural equation modelling. There is a crisis in the management of water in India, and this is often not about having too little water but about managing it poorly. It is now being widely recognized that engineering structures and solutions are not enough, and having effective water institutions is critical. These are urgently needed in eastern India for helping lift the region out of low incomes and poverty. However, creating good institutions is complex, and in this context, the fundamentals of new institutional economics, and management governance theory have suggested the importance of a number of key factors including five institutional features and eight rationalities. Based on this, a study was conducted in eastern India, sampling from the states of Assam and Bihar, covering 510 farm households across 51 water institutions. In order to understand and map the relationship and pathways across these key factors, a structural equation model is hypothesized. In the model, the five institutional features are considered determinants of the eight rationalities, and the rationalities are considered determinants of four performance goals. The performance on the goals determines the overall performance/success of the institution. Besides this, the institutional features and rationalities can also directly influence performance on the goals and the overall performance. The model is tested with data from the survey and different pathways that are robust are identified. The results can provide useful insights into the interlinkages and pathways of institutional behavior and can help policy and institution design for delivering more robust performance. The results show that one of the most important factors determining overall performance/success is technical rationality, and this deserves great attention. It includes technical expertise, sound location and quality of structures and equipment, and good maintenance. However, success is also strongly linked to performance on production/income goals, equity, and environment goals. These are, in turn, strongly related to achievement of economic, social, technical, and organizational rationalities, which call for attention to economic aspects such as crop choice and marketing, besides social aspects such as inclusion of women and poorer social groups, and organizational aspects such as member involvement and regular meetings. Further, the institutional features of clear objectives, good interactions, adaptive, correct scale, and compliance are important for achievement of almost all rationalities through various pathways, and should be strongly focused on in all the institutions. [ABSTRACT FROM AUTHOR]

The paper examines the extent, nature, and factors affecting women's involvement in participatory irrigation institutions of eastern India. Effective participatory water institutions are urgently needed to improve water management in eastern India, and a significant aspect of this is the involvement of women. There is inadequate representation, participation, and involvement of women in most water institutions. From the participatory and social point of view, this is a significant concern. The relevant data are obtained from the states of Assam and Bihar through a focused survey administered to 109 women in 30 water institutions, and a larger farmer-institutional survey covering 510 households and 51 water institutions. The research examines the extent and nature of the involvement of women in these institutions, as well as in farm decision-making, and the factors that prevent or foster their participation. Additionally, it examines the gender congruence in views regarding water institution activities and their performance, and the perceived benefits of formal involvement of women. The results show that their inclusion is very low (except required inclusion in Bihar), and the concerns of women are usually not being taken into account. Women are involved in farming and water management decisions jointly with men but not independently. Findings indicate that the views of women and men differ on many aspects, and so their inclusion is important. Responses indicate that if women participate formally in water user associations, it would enhance their social and economic standing, achieve greater gender balance, expand their awareness of water management, and contribute to better decision-making in the water institutions. [ABSTRACT FROM AUTHOR]

The paper examines the performance of participatory water institutions in India's Eastern Indo-Gangetic plains region using new institutional economics and management governance fundamentals. Water institutions are of great importance for water resource management in India's Eastern Indo-Gangetic plains since the region has relatively abundant water but lags behind significantly in economic development and growth with a high incidence of poverty. Engineering solutions to water management have been implemented but have not given good results principally because of weak institutional development and design in the region. Effective and efficient participatory water institutions are urgently needed. The research uses concepts from new institutional economics and management governance theory to build a conceptual framework for explaining the performance of participatory water institutions. The framework identifies eight institutional rationalities: technical, environmental, economic, social, political organizational, financial and government; as well as five institutional features: clear objectives, good interaction, adaptiveness, right scale, and compliance, as linked to performance. Based on this, a survey instrument was developed and a survey conducted obtaining responses from more than 500 households across 51 such institutions in the eastern Indo-Gangetic plains states of Assam and Bihar. The data were analyzed through statistical and econometric techniques including Ordered-Probit. The results support the relevance of the concepts in explaining performance of water institutions, and a number of drivers of performance were identified through Ordered-Probit, particularly, four rationalities—technical, economic, social and organizational, (with coefficients (0.4622, 0.3803, 0.4303, 0.2457) and three institutional features—good interaction, adaptiveness and appropriate scale (with coefficients 0.4242, 0.2703, 0.6756) (based on a 5-point Likert scale), as playing a positive and significant role in enhancing performance. The results provide a number of useful insights which can help guide interventions and policy towards better design and development of the water institutions, and help improve water resource management and livelihoods in the region. [ABSTRACT FROM AUTHOR]

Background: The study examined the prevalence of self-reported menstrual irregularities during adolescence and explored the association of depressive symptoms with self-reported menstrual irregularities in adolescents in two major states of Uttar Pradesh and Bihar in India. Methods: This study is based on the data obtained from the first round of the "Understanding the lives of adolescents and young adults" (UDAYA, 2016) survey. The effective sample size for the study was 12,707 adolescent girls aged 10–19 years. A bivariate analysis with chi-square test was conducted to determine the self-reported menstrual irregularity by predictor variables. Multivariable logistic regression models were employed to examine the associations between self-reported menstrual irregularity, depressive symptoms and other explanatory variables. Results: A proportion of 11.22% of adolescent girls reported menstrual irregularity and 11.40% of the participants had mild depressive symptoms. Adolescent girls with mild (AOR: 2.15, CI: 1.85–2.51), moderate (AOR: 2.64, CI: 2.03–3.42) and severe depressive symptoms (AOR: 2.99, CI: 2.19–4.10) were more likely to have menstrual irregularity as compared to those who had minimal depressive symptoms. Physically active adolescent girls were less likely to report menstrual irregularity (AOR: 0.82, CI: 0.73–0.93) than physically inactive girls. Adolescent girls who used piece of cloth for menstrual hygiene practices (AOR: 1.17; CI: 1.02–1.35) and those who used either napkin or cloth or other materials (AOR: 1.32; CI: 1.14–1.54) had higher likelihood of menstrual irregularity as compared to those who used only sanitary napkins. Conclusion: A significant association of depressive symptoms with self-reported menstrual irregularity among adolescent girls was observed. Therefore, while treating females with irregular menstrual cycles, clinicians may need to pay greater attention to thir mental health peoblems. [ABSTRACT FROM AUTHOR]

Background: Glucocorticoids (GCs) are anti-inflammatory steroid medications prescribed globally by doctors for various illnesses and they are known to produce quick symptom relief. In India, they are among the cheapest and easily accessible over-the-counter medications. Thus, it can be misused, leading to many life-threatening illnesses such as diabetes mellitus, hypertension, overwhelming infections, Cushing's syndrome, and hypo-adrenal crisis. Objective: This study reports the misuse of GCs in a rural community in the state of Kerala, India, and compares it with the only other community GC misuse study in India, from the state of Bihar. Methods: A community-based cross-sectional survey of 452 households comprising 1,734 people was conducted in rural Konni, Kerala, during June and July of 2019. In each house, people who had been taking medications over the previous 6 months were interviewed. Results: Almost 2% (n = 31) had consumed one or more GCs in the last 6 months (95% CI: 1.3–2.5%). Of these, 26% (n = 8) were taking oral GCs and 36% (n = 11) of them were inappropriately using them based on current clinical guidelines. 29% (n = 9) had used GCs for more than 1 month. Conclusions: GC misuse exists in Kerala but not to the extent seen in Bihar. In Kerala, inhaled GCs are more common than oral GCs, and the prescription is obtained predominantly from qualified medical practitioners. The prevalence of prolonged GC use could be implicated as an underlying factor for diabetes, hypertension, osteoporosis, and cataracts. It is possible that approximately 220,000 people in Kerala may have a suppressed hypothalamus-pituitary-adrenal axis which can predispose them to a fatal hypo-adrenal crisis. [ABSTRACT FROM AUTHOR]

In high-income countries, population health surveys often measure mental health. This is less common in low- and middle-income countries (LMICs), including in India, where mental health is under-researched relative to its disease burden. The objective of this study is to assess the performance of two questionnaires for measuring population mental health in a mobile phone survey. We adapt the Kessler-6 screening questionnaire and the World Health Organization's Self-Reporting Questionnaire (SRQ) for a mobile phone survey in the Indian states of Bihar, Jharkhand and Maharashtra. The questionnaires differ in the symptoms they measure and in the number of response options offered. Questionnaires are randomly assigned to respondents. We consider a questionnaire to perform well if it identifies geographic and demographic disparities in mental health that are consistent with the literature and does not suffer from selective non-response. Both questionnaires measured less mental distress in Maharashtra than in Bihar and Jharkhand, which is consistent with Maharashtra's higher human development indicators. The adapted SRQ, but not the adapted Kessler-6, identified women as having worse mental health than men in all three states. Conclusions about population mental health based on the adapted Kessler-6 are likely to be influenced by low response rates (about 82% across the three samples). Respondents were different from non-respondents: non-respondents were less educated and more likely to be female. The SRQ's higher response rate (about 94% across the three states) may reflect the fact that it was developed for use in LMICs and that it focuses on physical, rather than emotional, symptoms, which may be less stigmatized. [ABSTRACT FROM AUTHOR]

Background: In the endgame of the elimination initiative of visceral leishmaniasis (VL) on the Indian subcontinent, one of the main questions remaining is whether asymptomatically infected individuals also contribute to transmission. We piloted a minimally invasive microbiopsy device that could help answer this question. While the potential of this device has been previously illustrated in Ethiopia, no such information is available for the setting of the Indian subcontinent. In this proof of concept study we aimed to assess 1) to what extent skin parasite load obtained with the new microbiopsy device correlates with disease status, 2) to what extent skin parasite load correlates with blood parasite load in the same subject, and 3) to what extent the skin parasite load obtained from different sampling sites on the body correlates with one another. Methods: We performed a pilot study in Bihar, India, including 29 VL patients, 28 PKDL patients, 94 asymptomatically infected individuals, 22 endemic controls (EC), and 28 non-endemic controls (NEC). Presence of infection with L. donovani in the blood was assessed using Direct Agglutination Test, rK39 ELISA, Whole Blood Analysis measuring IFN-γ and qPCR. A skin sample was collected with the microbiopsy device on two different locations on the body. PKDL patients provided a third skin sample from the edge of a PKDL lesion. Parasite load in the skin was measured by qPCR. Findings: We found a clear correlation between the skin parasite load obtained with the microbiopsy device and disease status, with both higher skin parasite loads and higher proportions of positive skin samples in VL and PKDL patients compared to asymptomatics, EC, and NEC. No clear correlation between skin parasite load and blood parasite load was found, but a moderate correlation was present between the skin parasite load in arm and neck samples. In addition, we found four positive skin samples among asymptomatic individuals, and 85% of PKDL lesions tested positive using this microbiopsy device. Conclusions: In line with previous pilot studies, our results from an Indian setting suggest that the microbiopsy device provides a promising tool to measure skin parasite load, and – if validated by xenodiagnosis studies – could facilitate much needed larger scale studies on infectiousness of human subgroups. In addition, we advocate further evaluation of this device as a diagnostic tool for PKDL. [ABSTRACT FROM AUTHOR]

Visceral leishmaniasis (VL) is a potentially deadly parasitic disease. In the Indian sub-continent, VL is caused by Leishmania donovani and transmitted via the bite of an infected Phlebotomus argentipes female sand fly, the only competent vector species in the region. The highest disease burden is in the northern part of the Indian sub-continent, especially in the state of Bihar. India, Bangladesh, and Nepal embarked on an initiative, coordinated by World Health Organization, to eliminate VL as a public health problem by the year 2020. The main goal is to reduce VL incidence below one case per 10,000 people through early case-detection, prompt diagnosis and treatment, and reduction of transmission using vector control measures. Indoor residual spraying, a major pillar of the elimination program, is the only vector control strategy used by the government of India. Though India is close to its VL elimination target, important aspects of vector bionomics and sand fly transmission dynamics are yet to be determined. To achieve sustained elimination and to prevent a resurgence of VL, knowledge gaps in vector biology and behavior, and the constraints they may pose to current vector control methods, need to be addressed. Herein, we discuss the successes and failures of previous and current vector-control strategies implemented to combat kala-azar in Bihar, India, and identify gaps in our understanding of vector transmission towards development of innovative tools to ensure sustained vector control in the post-elimination period. [ABSTRACT FROM AUTHOR]

Brucellosis is one of the most common zoonotic diseases in the world. This study aimed at assessing farmers' knowledge about brucellosis as well as practices relevant to transmission of brucellosis and their associated determinants. Few farmers knew about brucellosis (3.4%, n = 18) and its zoonotic importance (0.8%, n = 4). Knowledge about brucellosis was higher for farmers with a larger herd size (p < 0.001) and fully using a stall-fed system (p < 0.001). Training on dairy cattle management (p < 0.001), training on animal disease (p < 0.01), consultation with veterinarians (p < 0.001) and farms being in urban areas (p < 0.01) were also significantly positively associated with knowledge about brucellosis. No significant association was observed between farmers' knowledge about brucellosis and state, family size, education, age or gender of the farmers. Farmers knowledge about brucellosis was significantly associated with certain practices that include use of disinfectant while cleaning farms (p < 0.05), animal movement (p < 0.01), introduction of new animals (p < 0.05) and raw milk consumption (p < 0.05). The study did not find any association between knowledge about brucellosis and method of disposal of aborted materials, personal hygiene and quarantine practices. More interaction with veterinarians and training on animal management may be an important tool for generating awareness among the farming community for reducing transmission of the disease. [ABSTRACT FROM AUTHOR]

The objective of the current study is to examine the cultural ecology of health associated with mitigating perinatal risk in Bihar, India. We describe the occurrences, objectives and explanations of health-related beliefs and behaviours during pregnancy and postpartum using focus group discussions with younger and older mothers. First, we document perceived physical and supernatural threats and the constellation of traditional and biomedical practises including taboos, superstitions and rituals used to mitigate them. Second, we describe the extent to which these practises are explained as risk-preventing versus health-promoting behaviour. Third, we discuss the extent to which these practises are consistent, inconsistent or unrelated to biomedical health practises and describe the extent to which traditional and biomedical health practises compete, conflict and coexist. Finally, we conclude with a discussion of the relationships between traditional and biomedical practises in the context of the cultural ecology of health and reflect on how a comprehensive understanding of perinatal health practises can improve the efficacy of health interventions and improve outcomes. This article is part of the theme issue 'Ritual renaissance: new insights into the most human of behaviours'. [ABSTRACT FROM AUTHOR]

Background: Monitoring of a program is a continuous assessment of certain key indicators of it through periodic reports. The efficiency of a health program is assessed by comparing its achievements with the expectations. Methods: The study was conducted based on the annual TB report of India for the year 2018 in order to monitor (Revised National Tuberculosis Control Program) RNTCP performance in the Bihar State and its various districts. Results: Case notification rate of various districts Bihar was far below the national average of 138 per lakh. Considering treatment initiation, the performance of various districts of Bihar were less than national figures (79.0%). In newly diagnosed TB cases, the treatment success rate of Bihar was 73%. This performance was more compared to Uttar Pradesh (66.0%) but less compared to Jharkhand (92.0%), West Bengal (88.0%), and national data (79.5%). Considering human resources, the total human resources in the states of Bihar (61.9%) and Jharkhand (58.3%) were similar. However, in Bihar, there was a vast shortage of ground-level staff [i.e. (senior treatment supervisor) STS, (senior TB lab supervisor) STLS, (public-private mix) PPM Co-ordinator, and (TB health visitor) TBHV)]. Conclusion: It was found that Bihar was one of the less performing states in RNTCP with a vast shortage of ground-level staff and low overall treatment success rate compared to its neighboring states. Stringent monitoring and evaluation in every step of the program implementation should be done in order to improve RNTCP performance in Bihar. [ABSTRACT FROM AUTHOR]

Community health workers (CHWs) play major roles in delivering primary healthcare services, linking communities to the formal health system and addressing the social determinants of health. Available evidence suggests that the performance of CHW programmes in low- and middle-income countries can be influenced by context-dependent causal mechanisms such as motivation to perform. There are gaps regarding what these mechanisms are, and what their contribution is to CHW performance. We used a theory-driven case study to characterize motivational mechanisms among Accredited Social Health Activists (ASHAs) in Bihar, India. Data were collected through semi-structured interviews with CHWs and focus group discussions with beneficiary women. Data were coded using a combined deductive and inductive approach. We found that ASHAs were motivated by a sense of autonomy and self-empowerment; a sense of competence, connection and community service; satisfaction of basic financial needs; social recognition; and feedback and answerability. Findings highlight the potential of ASHAs' intrinsic motivation to increase their commitment to communities and identification with the health system and of programme implementation and management challenges as sources of work dissatisfaction. Efforts to nurture and sustain ASHAs' intrinsic motivation while addressing these challenges are necessary for improving the performance of Bihar's ASHA programme. Further research is needed to characterize the dynamic interactions between ASHAs' motivation, commitment, job satisfaction and overall performance; also, to understand how work motivation is sustained or lost through time. This can inform policy and managerial reforms to improve ASHA programme's performance. [ABSTRACT FROM AUTHOR]

Service quality of household toilets is an important determinant of toilet adoption and sustained use in rural India. In many instances, household toilets constructed using subsidies provided under sanitation programs remain unused or used for other purposes because they fail to meet the users' expectations and preferences. The present study aims to analyze the service quality of household toilets based on expectations and preferences of households practicing open defecation in rural settlements of Gaya district of Bihar. This would contribute to improving the existing sanitation programs in India and other developing countries. The service quality of household toilets and preferences of attributes is analyzed using the stated importance, service quality gap analysis and willingness to pay for toilets with expected service quality. The results show that varying proportion of households expects improvement in many of the service quality of household toilet attributes specified under sanitation programs. The improvement in the capacity of disposal systems is considered as the most important attribute by most of the respondents. The households are even willing to pay for expected improvement in attributes of household toilets. [ABSTRACT FROM AUTHOR]

Objective: Since 2009, Médecins Sans Frontières has implemented a community management of acute malnutrition (CMAM) programme in rural Biraul block, Bihar State, India that has admitted over 10 000 severely malnourished children but has struggled with poor coverage and default rates. With the aim of improving programme outcomes we undertook a qualitative study to understand community perceptions of childhood undernutrition, the CMAM programme and how these affected health-seeking behaviour.Design: Semi-structured and narrative interviews were undertaken with families of severely malnourished children, non-undernourished children and traditional and allopathic health-care workers. Analysis of transcripts was by qualitative content analysis.Setting: Biraul, Bihar State, India, 2010.Subjects: One hundred and fifty people were interviewed in individual or group discussions during fifty-eight interviews.Results: Undernutrition was not viewed as a disease; instead, local disease concepts were identified that described the clinical spectrum of undernutrition. These concepts informed perception, so caregivers were unlikely to consult health workers if children were 'only skinny'. Hindu and Muslim priests and other traditional health practitioners were more regularly consulted and perceived as easier to access than allopathic health facilities. Senior family members and village elders had significant influence on the health-seeking behaviour of parents of severely malnourished children.Conclusions: The results reaffirm how health education and CMAM programmes should encompass local disease concepts, beliefs and motivations to improve awareness that undernutrition is a disease and one that can be treated. CMAM is well accepted by the community; however, programmes must do better to engage communities, including traditional healers, to enable development of a holistic approach within existing social structures. [ABSTRACT FROM AUTHOR]

Background. Preventive vitamin A supplementation (VAS) is an essential child survival intervention. In India, VAS program coverage has remained relatively low, with wide interstate variation. Objective. To review the VAS program in India, particularly in Bihar and Odisha, the two states that have had the most successful VAS programs, to define best practices and identify critical success factors. Methods. A thorough review of existing relevant literature was carried out, supplemented by field visits and interviews with selected partners. Results. Both states have adopted a biannual approach to reach out to children 1 to 5 years of age with VAS every 6 months, while infants below 1 year of age receive their first VAS dose with the measles immunization at 9 months. The critical success factors for the VAS program in the two states include strong leadership and ownership by the state government; close coordination between the two departments that are involved in the VAS program; effective microplanning prior to each biannual round; flexible dosing mechanisms that enhance coverage in hard-to-reach areas; a stable procurement and distribution mechanism to ensure an adequate, timely, and sustainable supply of VAS; intensive social mobilization and communication; and appropriate training and supervision of staff. Conclusions. The governments of Bihar and Odisha have demonstrated that it is feasible to implement a successful and inclusive VAS program in India. The challenge now is to reach out to the remaining 30% to 40% of children who are undoubtedly the hardest to reach and potentially the most vulnerable. [ABSTRACT FROM AUTHOR]

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Simple Summary: Large ruminant dairy animals (i.e., cattle and buffalo) suffer from several reproductive problems (such as abortion) that reduce ther ability to produce milk and offspring, resulting in huge economic costs to farmers; however, there are few studies in India that estimate such costs. Therefore, an attempt was made to assess the economic cost of five major reproductive problems in two of the poorest Indian states—Assam and Bihar. We estimated the cost by interviewing 534 randomly selected dairy farming households in both the states. Based on this, we found that 32.9% of dairy animals (milking, not-milking and heifer) in Assam and 43.1% dairy animals in Bihar suffered from one or more reproductive problems. The most common reproductive problem was failing to conceive after breeding (23.2% of surveyed dairy animals) followed by retained placenta (6.1%), abortion (4.9%), purulent vaginal discharge (2.9%) and stillbirths (1.0%). It was estimated that the selected reproductive problems caused an annual economic cost of Indian Rupees (INR), 3963.1 million (USD 59.0 million) in Assam, and INR 30,500.0 million (USD 453.9 million) in Bihar. The study concludes that adequate awareness, capacity building, adoption of good reproductive health management practices, proper farm record keeping and improved access to quality veterinary services are essential to address reproductive problems and reduce the cost caused by these reproductive problems. Reproductive problems in dairy animals reduce fertility, prevent conception, create problems in the delivery of healthy calves, lead to postpartum complications, increase inter-calving periods, reduce milk yield, and lower overall lifetime productivity. This study aimed at understanding the incidence of reproductive problems and the cost caused by these. The study covered 954 dairy animals in Bihar and 1348 dairy animals in Assam that were selected using a multi-stage random sampling method. The costs were calculated as the sum of income losses and expenditures incurred. The major cost incurred resulted from extended calving intervals (46.1% of the total cost), followed by loss through salvage selling (38.1%), expenditure for treatment of repeat breeders (5.9%), loss of milk production (5.3%) and expenditure for extra inseminations (2.0%). About one fifth of the selected reproductive problems were left untreated. The estimated cost of reproductive problems was Indian Rupees (INR) 2424.9 (USD 36.1) per dairy animal per year (of the total dairy animal population) which represented approximately 4.1% of the mean value loss of dairy animals (INR 58,966/USD 877) per year. Reproductive problems were significantly (p < 0.001) higher among improved (exotic breed or cross-bred) dairy animals than indigenous (native breed or nondescript indigenous) dairy animals. The study suggests that with the increase of improved dairy animal population, the loss may further increase. The study concludes that any economic estimation of reproduction problems based on aetiology without confirmatory diagnoses could be highly misleading because of the complex nature of the problems. [ABSTRACT FROM AUTHOR]

Background: The objectives of this study were to understand the differences in mortality rate, risk factors for mortality, and cause of death distribution in three neonatal age sub-groups (0-2, 3-7, and 8-27 days) and assess the change in mortality rate with previous assessments to inform programmatic decision-making in the Indian state of Bihar, a large state with a high burden of newborn deaths.Methods: Detailed interviews were conducted in a representative sample of 23,602 live births between January and December 2016 (96.2% participation) in Bihar state. We estimated the neonatal mortality rate (NMR) for the three age sub-groups and explored the association of these deaths with a variety of risk factors using a hierarchical logistic regression model approach. Verbal autopsies were conducted using the PHMRC questionnaire and the cause of death assigned using the SmartVA automated algorithm. Change in NMR from 2011 to 2016 was estimated by comparing it with a previous assessment.Results: The NMR 0-2-day, 3-7-day, and 8-27-day mortality estimates in 2016 were 24.7 (95% CI 21.8-28.0), 13.2 (11.1 to 15.7), 5.8 (4.4 to 7.5), and 5.8 (4.5 to 7.5) per 1000 live births, respectively. A statistically significant reduction of 23.3% (95% CI 9.2% to 37.3) was seen in NMR from 2011 to 2016, driven by a reduction of 35.3% (95% CI 18.4% to 52.2) in 0-2-day mortality. In the final regression model, the highest odds for mortality in 0-2 days were related to the gestation period of ≤ 8 months (OR 16.5, 95% CI 11.9-22.9) followed by obstetric complications, no antiseptic cord care, and delivery at a private health facility or home. The 3-7- and 8-27-day mortality was driven by illness in the neonatal period (OR 10.33, 95% CI 6.31-16.90, and OR 4.88, 95% CI 3.13-7.61, respectively) and pregnancy with multiple foetuses (OR 5.15, 95% CI 2.39-11.10, and OR 11.77, 95% CI 6.43-21.53, respectively). Birth asphyxia (61.1%) and preterm delivery (22.1%) accounted for most of 0-2-day deaths; pneumonia (34.5%), preterm delivery (33.7%), and meningitis/sepsis (20.1%) accounted for the majority of 3-7-day deaths; meningitis/sepsis (30.6%), pneumonia (29.1%), and preterm delivery (26.2%) were the leading causes of death at 8-27 days.Conclusions: To our knowledge, this is the first study to report a detailed neonatal epidemiology by age sub-groups for a major Indian state, which has highlighted the distinctly different mortality rate, risk factors, and causes of death at 0-2 days versus the rest of the neonatal period. Monitoring mortality at 0-2 and 3-7 days separately in the traditional early neonatal period of 0-7 days would enable more effective programming to reduce neonatal mortality. [ABSTRACT FROM AUTHOR]