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Introduction: Common approaches to measure health behaviors rely on participant responses and are subject to bias. Technology-based alternatives, particularly using GPS, address these biases while opening new channels for research. This study describes the development and implementation of a GPS-based approach to detect health facility visits in rural Pune district, India.Methods: Participants were mothers of under-five year old children within the Vadu Demographic Surveillance area. Participants received GPS-enabled smartphones pre-installed with a location-aware application to continuously record and transmit participant location data to a central server. Data were analyzed to identify health facility visits according to a parameter-based approach, optimal thresholds of which were calibrated through a simulation exercise. Lists of GPS-detected health facility visits were generated at each of six follow-up home visits and reviewed with participants through prompted recall survey, confirming visits which were correctly identified. Detected visits were analyzed using logistic regression to explore factors associated with the identification of false positive GPS-detected visits.Results: We enrolled 200 participants and completed 1098 follow-up visits over the six-month study period. Prompted recall surveys were completed for 694 follow-up visits with one or more GPS-detected health facility visits. While the approach performed well during calibration (positive predictive value (PPV) 78%), performance was poor when applied to participant data. Only 440 of 22 251 detected visits were confirmed (PPV 2%). False positives increased as participants spent more time in areas of high health facility density (odds ratio (OR) = 2.29, 95% confidence interval (CI) = 1.62-3.25). Visits detected at facilities other than hospitals and clinics were also more likely to be false positives (OR = 2.78, 95% CI = 1.65-4.67) as were visits detected to facilities nearby participant homes, with the likelihood decreasing as distance increased (OR = 0.89, 95% CI = 0.82-0.97). Visit duration was not associated with confirmation status.Conclusions: The optimal parameter combination for health facility visits simulated by field workers substantially overestimated health visits from participant GPS data. This study provides useful insights into the challenges in detecting health facility visits where providers are numerous, highly clustered within urban centers and located near residential areas of the population which they serve

Background An estimated 1.2 million children under five years of age die each year in India, with pneumonia and diarrhea among the leading causes. Increasing care-seeking is important to reduce mortality and morbidity from these causes. This paper explores the determinants and patterns of care-seeking for childhood illness in rural Pune district, India. Methods Mothers having at least one child

Traditionally, health care-seeking for child illness is assessed through population-based and nationally representative demographic and health surveys (DHS) that are conducted once every five to seven years and are based on maternal recall. These maternal reports are subject to recall bias. Mobile phones (with the use of GPS technology) have the potential to constantly track movements of phone owners and provide high quality and more accurate data at a population level in low and middle income countries (LMICs) to assess the validity of maternal recall. We provided a group of mothers with smartphones installed with a location-aware application and visited them monthly to administer a survey questionnaire on care-seeking for diarrhoea, fever and cough with fever. This paper assesses for any reactivity to smartphones or repeated study contacts for measuring care-seeking and if this resulted in change in health care provider preference.We enrolled 749 mothers from rural areas of Pune district in Maharashtra, India and randomly allocated them to one of three groups - a longitudinal phone group, a longitudinal control group and a cross-sectional control group. We collected baseline information from mothers, including individual and household demographic and socio-economic characteristics and care-seeking preferences for child illness. We followed up both longitudinal groups monthly and each cross-sectional sub-group once over a period of 6 months. At each follow up, we administered questions identical to those in the National Family Health Survey (NFHS) questionnaire to determine an episode of diarrhoea, fever or cough within the last 15 days, care seeking for the same, and the type of provider. The data were analysed using the χAll three groups were similar in their socio-demographic characteristics at baseline. We did not observe any significant difference in care seeking for diarrhoea, fever or cough with fever between groups. Also, we did not observe any significant difference in proportion of children seeking care from the private sector.We did not observe any reactivity in this study due to the presence of the phone (Hawthorne effect) or repeated study visits. The study also shows the potential of using GPS enabled smartphones to enrich DHS surveys in LMICs like India. However, further studies need to be conducted in other population groups before the findings can be generalised.

Water, sanitation and hygiene (WASH) installations are indispensable in health care facilities. Their quality might also influence the decision whether to visit a health facility. We investigated the WASH infrastructure in small health facilities in rural Pune, India, and surveyed expectations and satisfactoriness among women. The availability and quality of WASH installations was assessed in 12 facilities using a checklist. Dedicated questions in a household survey provided the community perspective, complemented by qualitative methods. A few public facilities had no latrine or hand washing station. On the contrary, all private facilities offered such installations. The bed/outpatient-to-installation ratio was also lower in private compared to public facilities. While most latrines were functional and well maintained, they often lacked garbage bins. Soap was often missing from hand washing stations. Dedicated latrines for women were rare. Women were generally satisfied with the WASH installations in the local health facility, but considered private facilities as better. WASH installations in health facilities are generally acceptable in private facilities while improvements are needed in some government facilities. Women expect WASH installations in health facilities, and view their quality in a broader framework of ‘cleanliness,’ which they consider when choosing facilities.

This study examined sources of psychosocial stress related to the use of toilet facilities or open defecation by women and adolescent girls at home, public places, workplaces and in schools in a rural community in Pune, India. The mixed methods approach included focus group discussions among women, key informant interviews, free listing and a community survey of 306 women. Nine per cent of the study households and most seasonal migrant women workers lacked access to toilets. Fear for personal safety, injury or accidents, lack of cleanliness, indignity, shame and embarrassment due to a lack of privacy were significant sources of stress related to open defecation. Seasonal migrant women workers perceived the lack of privacy as a significant source of psychosocial stress but did not fear for their personal safety or injuries, despite their general lack of access to toilet facilities. Women resorting to open defecation feel stressed and harassed by community leaders trying to enforce open defecation-free policies. Our study highlights the need for sanitation programs to consider the specific needs of women with regard to latrine maintenance, safety and privacy offered by sanitation installations. Specific strategies to address the sanitation and hygiene issues of seasonal migrant populations are also required.

Objective: To use anchoring vignettes to evaluate reporting heterogeneity (RH) in self-rated mobility and cognition in older adults. Method: We analyzed vignettes and self-rated mobility and cognition in 2,558 individuals aged 50 years and above. We tested for assumptions of vignette equivalence (VE) and response consistency (RC). We used a joint hierarchical ordered probit (HOPIT) model to evaluate self-rating responses for RH. Results: The assumption of VE was met except for “learning” vignettes. Higher socioeconomic status (SES) and education significantly lowered thresholds for cognition ratings. After correction for RH, women, lower SES, and older respondents were significantly more likely to report greater difficulty in mobility. The influence of age, SES, and education on thresholds was less apparent for cognition. Discussion: Our study provides strong evidence of RH in self-rated mobility and cognition. We highlight the need to formally test basic assumptions before using vignettes to adjust self-rating responses for RH.

The global burden of influenza is increasingly recognized, but data from India remain sparse. We conducted a multi-site population-based surveillance study to estimate and compare rates of influenza-associated hospitalization at two rural Indian health and demographic surveillance system (HDSS) sites at Ballabgarh and Vadu during 2010-2012.Prospective facility-based surveillance for all hospitalizations (excluding those for trauma, elective surgery and obstetric, ophthalmic or psychiatric reasons) was conducted at 72 health facilities. After collection of clinical details, patients had nasopharyngeal swabs taken and tested by reverse transcription polymerase chain reaction for influenza viruses. Annual healthcare utilization surveys (HUS) were conducted in HDSS households to identify proportion of hospitalizations occurring at non-study facilities to adjust for hospitalizations missed through facility-based surveillance.HUS showed that 69% and 67% of hospitalizations occurred at study facilities at Ballabgarh and Vadu, respectively. Overall, 6004 patients hospitalized with acute medical illness at participating facilities were enrolled (1717 from Ballabgarh; 4287 from Vadu). The proportion of patients with influenza was higher at Vadu than Ballabgarh annually (2010: 21% vs. 5%, p 0.05; 2011: 18% vs. 5%, p 0.05; 2012: 23% vs. 5%, p 0.05). Annual adjusted influenza-associated hospitalization rates were 5-11 fold higher in Vadu (20.3-51.6 per 10,000) vs Ballabgarh (4.4-6.3 per 10,000). At both sites, influenza A/H1N1pdm09 and B predominated during 2010, A/H3N2 and B during 2011, and A/H1N1pdm09 and B during 2012.The markedly different influenza hospitalization rates by season and across communities in India highlight the need for sustained multi-site surveillance system for estimating national influenza disease burden. That would be the first step for initiating discussions around Influenza prevention and control strategies in the country.

The Study on Global Ageing and Adult Health (SAGE) aims to improve empirical understanding of health and well-being of adults in developing countries. We examine the role of self-rated health (SRH) in predicting mortality and assess how socio-demographic and other disability measures influence this association.In 2007, a shortened SAGE questionnaire was administered to 5087 adults aged ≥50 years under the Health Demographic Surveillance System in rural Pune district, India. Respondents rated their own health with a single global question on SRH. Disability and well-being were assessed using the WHO Disability Assessment Schedule Index, Health State Score and quality-of-life score. Respondents were followed up every 6 months till June 2011. Any change in spousal support, migration or death during follow-up was updated in the SAGE dataset.In all, 410 respondents (8%) died in the 3-year follow-up period. Mortality risk was higher with bad/very bad SRH [hazard ratio (HR) in men: 3.06, 95% confidence interval (CI): 1.93-4.87; HR in women: 1.64, 95% CI: 0.94-2.86], independent of age, disability and other covariates. Disability measure (WHO Disability Assessment Schedule Index) and absence of spousal support were also associated with increased mortality risk.Our findings confirm an association between bad/very bad SRH and mortality for men, independent of age, socio-demographic factors and other disability measures, in a rural Indian population. This association loses significance in women when adjusted for disability. Our study highlights the strength of nesting cross-sectional surveys within the context of the Health Demographic Surveillance System in studying the role of SRH and mortality.

Background Influenza is vaccine-preventable; however, the burden of severe influenza in India remains unknown. We conducted a population-based study to estimate the incidence of laboratory confirmed influenza-associated hospitalizations in a rural community in western India. Methods We conducted active surveillance for hospitalized patients with acute medical illnesses or acute chronic disease exacerbations in Pune during pandemic and post pandemic periods (May 2009–April 2011). Nasal and throat swabs were tested for influenza viruses. A community health utilization survey estimated the proportion of residents hospitalized with respiratory illness at non-study facilities and was used to adjust incidence estimates from facility-based surveillance. Results Among 9,426 hospitalizations, 3,391 (36%) patients were enrolled; 665 of 3,179 (20.9%) tested positive for influenza. Of 665 influenza positives, 340 (51%) were pandemic A(H1N1)pdm09 and 327 (49%) were seasonal, including A/H3 (16%), A/H1 (3%) and influenza B (30%). The proportion of patients with influenza peaked during August 2009 (39%) and 2010 (42%). The adjusted annual incidence of influenza hospitalizations was 46.8/10,000 during pandemic and 40.5/10,000 during post-pandemic period with comparable incidence of A(H1N1)pdm09 during both periods (18.8 and 20.3, respectively). The incidence of both pH1N1 and seasonal hospitalized influenza disease was highest in the 5–29 year olds. Conclusions We document the previously unrecognized burden of influenza hospitalization in a rural community following the emergence of influenza A(H1N1)pdm09 viruses in India. During peak periods of influenza activity circulation i.e during the monsoon period, 20% of all hospital admissions in the community had influenza positivity. These findings can inform development of influenza prevention and control strategies in India.

OBJECTIVE: To assess case definitions for influenza in a rural community in India. METHODS: Residents of the study area who were hospitalized for any acute medical condition for at least one night between May 2009 and April 2011 were enrolled. Respiratory specimens were collected and tested for influenza viruses in a reverse-transcription polymerase chain reaction (PCR). The PCR results were taken as the "gold standard" in evaluating the performance of several case definitions. FINDINGS: Of the 3179 patients included in the final analysis, 21% (665) were PCR-positive for influenza virus, 96% reported fever and 4% reported shortness of breath. The World Health Organization (WHO) case definition for severe acute respiratory illness had a sensitivity of 11% among patients aged < 5 years and of 3% among older patients. When shortness of breath was excluded from the definition, sensitivities increased (to 69% and 70%, respectively) and corresponding specificities of 43% and 53% were recorded. Among patients aged ≥ 5 years, WHO's definition of a case of influenza-like illness had a sensitivity of 70% and a specificity of 53%. The addition of "cough and reported or measured fever" increased sensitivity to 80% but decreased specificity to 42%. CONCLUSION: The inclusion of shortness of breath in WHO's case definition for severe acute respiratory illness may grossly underestimate the burden posed by influenza in hospitals. The exclusion of shortness of breath from this definition or, alternatively, the inclusion of "cough and measured or reported fever" may improve estimates of the burden.