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Objectives This study investigated the intention to migrate among pharmacists in Kerala and explored the factors driving pharmacist migration in Kerala. Methods A sequential mixed-methods study was carried out to explore the intention to migrate among pharmacists in Kerala, India. A survey of 256 registered pharmacists and in-depth interviews with 15 pharmacists having high migration intentions were undertaken. Quantitative data were analysed employing univariate approaches and binary logistic regression. Qualitative data were analysed employing thematic analysis. Key findings About 44.5% (n = 114) of pharmacists expressed a high intention to migrate. Younger age of up to 30 years (AOR = 8.31, 95% CI = 2.24–30.82), more opportunities abroad (AOR = 4.28, 95% CI = 1.87–9.80), better salaries (AOR = 2.48, 95% CI = 1.04–5.95) and a general negative outlook towards a pharmacy career in Kerala (AOR = 2.83, 95% CI = 1.22–6.56) predicted a high level of intention to migrate among pharmacists. Lower incomes, working conditions, respect and recognition in the society, professional conflict and social connections were observed to be major push factors influencing pharmacists’ migration intentions. Conclusions Just under half of the registered pharmacists in Kerala has a high intention to migrate abroad. Economic factors, workplace factors, lack of opportunities, social status and so on, were influencers of the intention to migrate among pharmacists. Ensuring implementation of equitable wage policies, preventing unlicensed pharmacy practice, improving societal awareness and providing clear job roles for pharmacists with PharmD and MPharm degrees are needed.

PurposeThis study estimated the prevalence of depressive disorders among PhD students and analyzed the underlying factors in the Indian context.Design/methodology/approachThe authors utilized an “Integrative framework” and a mixed-method approach involving survey and in-depth interviews. The survey was conducted among 240 PhD students using multistage cluster sampling in two public universities of Kerala, India. Data were collected using a self-administered Patient Health Questionnaire-9. In-depth interviews were conducted among 12 students using semi-structured interview guide. Multinomial regression and thematic analyses were undertaken to examine the factors associated with depressive disorders.FindingsAbout 31.7, 41.7, 17.9, 6.7 and 2.1% had no/minimal, mild, moderate, moderately severe and severe depressive disorders, respectively. Students belonging to economically weaker section (OR = 3.06; 95% CI = 1.32–7.12), having limited knowledge of local language (OR = 4.24; 95% CI = 1.00–17.95) and earning less than INR 20,000/month (OR = 2.36; 95% CI = 1.12–5.00) were more likely to report moderate to severe depressive disorders. In addition, thematic analyses of interviews found that financial hardship, disagreement between student-supervisor, compromised students' support services and an uncertain job market were the key factors affecting the mental health of students and inhibiting academic performance.Originality/valueThis study adds to the existing literature by examining the prevalence and underlying factors of depressive disorders among doctoral students in the Indian context. The results of this study can act as a guide for universities and educational regulatory bodies to address the burgeoning issue of depressive disorders among research students in India.

Limited evidence exists on the presence of collective non-communicable disease (NCD) risk factors among adolescents in Kerala, India. We aimed to assess the prevalence and factors associated with multiple NCD risk factors and the clustering of these risk factors among adolescents in Kasaragod District, Kerala.We selected 470 adolescents (mean age 16.6 years, male 53.8%) through multi-stage cluster sampling from higher secondary schools of Kasaragod district. Self-administered questionnaires were used, and anthropometric measurements were taken using standard techniques and protocols. Tobacco use, alcohol consumption, low fruits and vegetable consumption, inadequate physical activity, extra salt intake, overweight, consumption of soft drinks and packed foods were the eight NCD risk factors included.The factors associated with one, two and three or more NCD risk factors were analysed using multinomial logistic regression and the standard errors were adjusted for the four clusters.Risk factor clusters with two risk factors (dyads) and three risk factors (triads) were observed in 163 (34.7%) and 102 (21.7%) of the sample, respectively. Adolescents residing in urban areas (odds ratio (OR) = 3.55; 95% confidence interval (CI) = 1.45-8.73), whose father's education level was lower (OR = 3.54; 95% CI = 1.24-10.10), whose mother's education was lower (OR= 4.13; 95% CI = 1.27-13.51), who had restrictions on physical activity (OR = 5.41; 95% CI = 1.20-24.30) and who did not have a kitchen garden (an area where fruits and vegetables are grown for domestic use) (OR=4.51;95% CI = 1.44-14.12) were more likely to have three or more NCD risk factors compared to their counterparts.Clustering of NCD risk factors was prevalent in more than half of the adolescents. Efforts are warranted to reduce multiple risk factors, focussing on children of low educated parents and urban residents.

Data on prevalence of hardcore smoking (HCS) among different socioeconomic status (SES) groups in low- and middle-income countries are limited. We looked at the prevalence and pattern of HCS in India with the following objectives: 1) to analyse the association between SES and HCS, 2) to find trends in HCS in different SES groups and 3) to find state-wide variations in hardcore smoking.Data of individuals aged ≥25 years from the Global Adult Tobacco Survey (GATS) India 2009-10 (N= 9223) and 2016-17 (N= 7647) were used for this study. If an individual met all the following criteria: (1) current smoker, (2) smokes 10 or more cigarettes/day, (3) smokes first puff within 30 minutes after waking up, (4) no quit attempt in last 12 months, (5) no intention to quit at all or in the next 12 months, (6) lack of knowledge of harmful effect of smoking, s/he was identified as a hardcore smoker. Multiple regression analysis was done to find the factors associated with HCS.Prevalence of HCS deceased from 2.5% in GATS 1 to 1.9% in GATS 2: males from 6.2% to 3.9% and females from 0.3% to 0.2%. Compared to the richest group the poorest, poor and those who belonged to the middle-income group were more likely to report HCS in GATS 1 and 2. However, only in the poorest SES group there was an increase in the proportion of hardcore smokers in GATS 2 compared to GATS 1. Other factors that were significantly associated with HCS in both surveys were male gender, working adults, those with lower education, early initiation of smoking and households without any rules for smoking inside the home.Tobacco control and cessation efforts need to focus on individuals of poor SES groups particularly in the high prevalence Indian states.

Bullying victimization among adolescents is a serious concern as it leads to poor psycho-social adjustments in the future. Literature on bullying at schools in Kerala is limited. This study aimed to investigate the magnitude of bullying and the factors associated with it among adolescents.A sequential explanatory study design was used. A cross-sectional study among 764 adolescents (mean age 13.3 years, males 58.5%) selected through multistage cluster sampling was done. We used the Olweus Bully-Victim Questionnaire, Global School Health Survey, and Patient Health Questionnaire 9 for data collection. Binary logistic regression was performed to identify predictors of bullying victimization. After this, in-depth interviews were carried out among key stakeholders.About 117 (15.3%) respondents reported being bullied at least twice a month. Verbal bullying was reported by 30% (n=229), physical bullying by 23.3% (n=178), sexual bullying by 11% (n=89) and cyber-bullying by 3.3% (n=25). Adolescents aged 14 years and above (OR 2.09, 95% CI: 1.34-3.26), being male (OR 3.50, 95% CI: 1.97-5.87), the parent's response to bullying (OR 5.27, 95% CI: 2.44-11.36), the victim's reaction to being bullied (OR 8.101, CI: 4.53-14.36) and the teacher's action against the bully (OR 3.59, CI: 1.91-6.73) were major predictors of bullying. Qualitative exploration of pathways of bullying phenomena revealed the influence of parenting on a child being a victim or a bully, and a lack of competence and training among teachers to address bullying at school.Bullying is highly prevalent among adolescents in schools and has short- and long-term implications. Targeted interventions for bullying prevention should focus on older adolescent boys and those who report being bullied. Anti-bullying policies at school are vital to sensitize teachers, parents, and students to bullying.

Objective: This study examined the characteristics and quality of publicly available COVID-19 information education and communication (IEC) materials in India between March and December 2020. Design: An explanatory sequential mixed-method design was employed to examine the characteristics and quality of 265 purposefully selected IEC materials. Setting: The IEC materials analysed were those published between March and December 2020 on the Ministry of Health and Family Welfare website, Government of India. Methods: A checklist was utilised to examine the quality and characteristics of the materials. Thereafter, qualitative analysis provided insights into the contents of the materials with specific focus on the ‘COVID-19 continuum of care’. Results: The majority (73.96%, n = 196) of the selected materials were directed towards the general public and had a focus on prevention (67.55 %, n = 179). Despite COVID-19-associated stigma, only 56 (21.13%) of the materials addressed this issue. However, most (95.47%, n = 253) of the materials adhered to quality standards for contents, readability and aesthetics. This qualitative analysis focused on the contents of selected IEC materials using the concept of ‘continuum of care’. The analysis identified three important themes: prevention to early diagnosis and treatment; mitigation of stigma and discrimination surrounding COVID-19; and addressing the infodemic caused by COVID-19. Conclusion: The quality of materials was mostly satisfactory and appropriate to the emergent requirements. Strengthening audience engagement and attractiveness of the materials might enhance readability and actionability. A bottom–up approach to the development of future IEC materials, involving the community might widen the coverage of vulnerable populations in future crisis events.

Introduction: This study was undertaken with the following objectives: (a) to find out the awareness of warning symptoms and risk factors of stroke, (b) response to acute stroke, and (c) factors associated with awareness, risk factors, and response to acute stroke among community-dwelling adults in Biswanath district of Assam. Methods: Using a cross-sectional design, a community-based study was done among 340 adults (mean age 38 years, men 55%) selected using multistage cluster sampling. Information on sociodemographic variables, stroke warning symptoms, risk factors, and response to acute stroke was collected using an adapted World Health Organization (WHO) STEPs stroke surveillance tool. Bivariate and logistic regression analysis were done to find out the factors associated with stroke warning symptoms, risk factors, and response to acute stroke. A “ P” value < .05 was considered for statistical significance. Results: Awareness of stroke was significantly higher among males ( P < .01), better educated ( P < .01), government employees ( P < .05), high-income group ( P < .01), and those who reported receiving information from a professional source ( P < .01) compared to their counterparts. Knowledge of at least one stroke risk factor and providing at least one correct response to acute stroke was higher among males, better educated, government employees, higher income groups, and those who received information from professional source compared to their counterparts ( P < .05). Conclusion: Awareness of stroke warning symptoms, risk factors, and response to acute stroke needs to be improved focusing on women, low education groups, those working in the nongovernment sector, and low-income groups by health professionals.

Background: Limited evidence exists on the presence of collective non-communicable disease (NCD) risk factors among adolescents in Kerala, India. We aimed to assess the prevalence and factors associated with multiple NCD risk factors and the clustering of these risk factors among adolescents in Kasaragod District, Kerala. Methods: We selected 470 adolescents (mean age 16.6 years, male 53.8%) through multi-stage cluster sampling from higher secondary schools of Kasaragod district. Self-administered questionnaires were used, and anthropometric measurements were taken using standard techniques and protocols. Tobacco use, alcohol consumption, low fruits and vegetable consumption, inadequate physical activity, extra salt intake, overweight, consumption of soft drinks and packed foods were the eight NCD risk factors included.The factors associated with one, two and three or more NCD risk factors were analysed using multinomial logistic regression and the standard errors were adjusted for the four clusters. Results: Risk factor clusters with two risk factors (dyads) and three risk factors (triads) were observed in 163 (34.7%) and 102 (21.7%) of the sample, respectively. Adolescents residing in urban areas (odds ratio (OR) = 3.55; 95% confidence interval (CI) = 1.45-8.73), whose father’s education level was lower (OR = 3.54; 95% CI = 1.24-10.10), whose mother’s education was lower (OR= 4.13; 95% CI = 1.27-13.51), who had restrictions on physical activity (OR = 5.41; 95% CI = 1.20-24.30) and who did not have a kitchen garden (an area where fruits and vegetables are grown for domestic use) (OR=4.51;95% CI = 1.44-14.12) were more likely to have three or more NCD risk factors compared to their counterparts. Conclusions: Clustering of NCD risk factors was prevalent in more than half of the adolescents. Efforts are warranted to reduce multiple risk factors, focussing on children of low educated parents and urban residents.

Background: Bullying victimization among adolescents is a serious concern as it leads to poor psycho-social adjustments in the future. Literature on bullying at schools in Kerala is limited. This study aimed to investigate the magnitude of bullying and the factors associated with it among adolescents. Methods: A sequential explanatory study design was used. A cross-sectional study among 764 adolescents (mean age 13.3 years, males 58.5%) selected through multistage cluster sampling was done. We used the Olweus Bully-Victim Questionnaire, Global School Health Survey, and Patient Health Questionnaire 9 for data collection. Binary logistic regression was performed to identify predictors of bullying victimization. After this, in-depth interviews were carried out among key stakeholders. Results: About 117 (15.3%) respondents reported being bullied at least twice a month. Verbal bullying was reported by 30% (n=229), physical bullying by 23.3% (n=178), sexual bullying by 11% (n=89) and cyber-bullying by 3.3% (n=25). Adolescents aged 14 years and above (OR 2.09, 95% CI: 1.34-3.26), being male (OR 3.50, 95% CI: 1.97-5.87), the parent's response to bullying (OR 5.27, 95% CI: 2.44-11.36), the victim's reaction to being bullied (OR 8.101, CI: 4.53-14.36) and the teacher's action against the bully (OR 3.59, CI: 1.91-6.73) were major predictors of bullying. Qualitative exploration of pathways of bullying phenomena revealed the influence of parenting on a child being a victim or a bully, and a lack of competence and training among teachers to address bullying at school. Conclusions: Bullying is highly prevalent among adolescents in schools and has short- and long-term implications. Targeted interventions for bullying prevention should focus on older adolescent boys and those who report being bullied. Anti-bullying policies at school are vital to sensitize teachers, parents, and students to bullying.

Background: Limited evidence exists on the presence of collective non-communicable disease (NCD) risk factors among adolescents in Kerala, India. We aimed to assess the prevalence and factors associated with multiple NCD risk factors and clustering of these risk factors among adolescents in Kasaragod District, Kerala. Methods: We selected 470 adolescents (mean age 16.6 years, male 53.8%) through multi-stage cluster sampling from higher secondary schools of Kasaragod district. Self-administered questionnaires were used, and anthropometric measurements were taken using standard techniques and protocols. Tobacco use, alcohol consumption, low fruits and vegetable consumption, inadequate physical activity, extra salt intake, overweight, consumption of soft drinks and packed foods were the eight NCD risk factors included. Multinomial logistic regression analysis was done to find out the factors associated with one, two and three or more NCD risk factors. Results: Risk factor clusters with two risk factors (dyads) and three risk factors (triads) were observed in 163 (34.7%) and 102 (21.7%) of the sample, respectively. Adolescents residing in urban areas (odds ratio (OR) = 3.55; 95% confidence interval (CI) = 1.45-8.73), whose father’s education level was lower (OR = 3.54; 95% CI = 1.24-10.10), whose mother’s education was lower (OR= 4.13; 95% CI = 1.27-13.51), who had restrictions on physical activity (OR = 5.41; 95% CI = 1.20-24.30) and who did not have a kitchen garden (an area where fruits and vegetables are grown for domestic use) (OR=4.51;95% CI = 1.44-14.12) were more likely to have three or more NCD risk factors compared to their counterparts. Conclusions: Clustering of NCD risk factors was prevalent in more than half of the adolescents. Efforts are warranted to reduce multiple risk factors, focussing on children of low educated parents and urban residents. Parents of adolescents may be encouraged to have kitchen gardens and not to restrict adolescent’s physical activity.

Introduction: Electronic medical records (EMRs) are computerized medical information systems that collect, store, and display patient information and essential for the achievement of primary health-care goals. This study explores the availability and utilization of EMR and analyzed the barriers inhibiting their implementation at primary health centers (PHCs) in Nalgonda district of Telangana, India. Methods: The research employed a sequential mixed-method design. Quantitative data were collected using a questionnaire by conducting facility surveys across 75 PHCs and in-depth interviews with district health authorities were conducted using a predesigned guide. Quantitative data were analyzed using descriptive statistics and thematic analysis of interviews resulted in four themes focusing on the factors inhibiting PHCs to use EMR. Results: The availability of EMR facility was low (19.14%) and they are routinely used for maintaining immunization data in 83% of the PHCs. In contrast, none of the PHCs used EMR for prescribing medications to patients. Budgetary constraints, unavailability of dedicated information technology staff, gaps in technical knowledge, and perceptions about EMR as a time-consuming system were the commonly reported barriers inhibiting PHCs to go digital. Conclusion: The availability and utilization of EMR keeping was low across PHCs of Nalgonda district. The study identified multiple barriers which hinder the implementation of EMR facilities at PHCs. Addressing these barriers is crucial for the successful implementation of EMR.

FHWs are among the most utilized health workforce in majority of LMIC especially in India. Effective use of the FHWs was considered instrumental in the provision of Primary health care (PHC) and the potency of FHW was recognized to be essential to achieve the targets of MDG. FHWs consists of a wide range of health workers such as CHWs, Mid-level care providers, Physician-assistants, Nurses, Doctors etc., who are most of the time the first level contact of the health system to the people, majorly engaged in provision of PHC and the services focusing on disease prevention and health promotion. Unlike the most of FHWs the CHWs are the group of FHWs whose potency is greatly explored and well documented since there conception in 1950’s as barefoot doctors in china. FHWs by itself is a wide area of research and this review does not talk much about already well known areas in frontline health workers. The review is split in to two parts with first part talking about the theoretical perspectives in-terms of FHWs and second part talks about operational challenges. First part focuses much on other theoretical concepts in FHWs such as Task-shifting, Public-health nurses and mid-level care providers etc., which are not very much known, compared to their counter parts and majority of the times ignored. The second part of the review has its emphasis on the prime operational challenges which are faced by the FHWs. By summing-up the majority of literature related to the different theoretical concepts in the area of FHW it reflects on the options available to provide efficient health care to the underserved populations and the challenges being faced while dealing with FHWs. It could be helpful in guiding the planning and implementation of sustainable, holistic and cost effective interventions to provide universal PHC.

Background: Malnutrition is one of the most important public health challenges faced by the country. With more than 35% of its population in the productive age group being malnourished. Even though malnutrition in children and pregnant mothers are some of the most discussed topics in Indian public health, under nutrition among adolescents was not given much importance. In this article we try to look into the concept of under nutrition among adolescents and how government of India’s mid-day meal programme is able to influence it. Materials and Methods: Cross-sectional study design, sample was obtained by the means of multi-stage systemic random sampling, data was obtained from total sample size of 197 participants was obtained according to inclusion criteria, statistical techniques of correlation and Multivariate regression are used to analyze the results. Results: around 76.1% of the total participants are malnourished; malnutrition among adolescent boys is slightly higher than that of girls. Malnutrition among low economic status is higher than the students belonging to High income status. Correlation showed that age of the participants (Mean=14.37 years, and SD=1.05 years) and “BMI of the participants” (Mean=17.35 and SD=2.70) r= 0.174, p≤ 0.05, N=197, were significantly related with each other. Regression results yielded the influence of independent variables on BMI, for age b=0.497, t(197)=2.661, p≤0.01, for economic status b=0.225, t(197)=0.582, for gender b=-0.525, t(197)=-1.303. Conclusion: Around three quarters of the adolescents who were availing the midday meal scheme clearly show that midday meal scheme which is the sole source of essential protein and nutrients is not able to meet the need for the adolescents clearly showing need for the policy changes to be pitched in. behavior modification towards low-cost healthy diet, subsidies, and fortification of mid-day meal might be considered. Key words: Adolescent health, BMI, Health policy, Malnutrition, Mid-day Meal Programme.

Introduction: Alcohol is a psychoactive substance with dependence-producing properties. Adolescents account for a quarter of current drinkers in the world. Early initiation of alcohol use is one of the most important predictors of future physical and social health. Materials and Methods: A cross-sectional descriptive study among a sample of 210 adolescent males (aged 18–19 years), was conducted to identify the prevalence of alcohol consumption and the factors associated with it. The data were statistically analyzed using frequencies, percentages, Chi-square tests of independence and binary logistic regression. Results: About 62.3% (n = 131) of the respondents have consumed alcohol and 54.3% (n = 114) were current drinkers. Alcohol consumption was significantly associated with monthly pocket money (N = 210, χ2 = 17.834, df = 5), parents-consuming alcohol (N = 210, χ2 = 6.926, df = 1), friends-consuming alcohol (N = 210, χ2 = 24.549, df = 1), smoking status (N = 210, χ2 = 54.189, df = 1), and awareness about health effects of alcohol (N = 210, χ2 = 193.482, df = 2). Social influences of “friends-consuming alcohol” and “parents-consuming alcohol” were strongly associated with alcohol consumption among adolescents with odds ratio (OR) of 4.048 (95% confidence interval [CI] = 1.485–11.032) and 2.172 (95% CI = 1.076–4.386), respectively. In addition, it was also observed that smoking status and high monthly pocket money of INR 8000–12000 was strongly associated with alcohol consumption status with OR of 15.161 (95% CI = 5.076–45.286) and 25.660 (95% CI = 1.323–498.489), respectively. Conclusion: The study highlights the possible role of the individual, economic and social dimensions in the initiation of alcohol consumption among adolescents. The alcohol prevention interventions should be delivered through a multi-pronged approach focusing on these dimensions to be more effective.

Background: The burden of noncommunicable diseases (NCDs) is high with significant impact on households in the form of out-of-pocket expenditure. Provision of NCD services through public health facilities is considered as cost-effective and efficient means. Aim: The study aimed to assess the proportion of individuals using NCD services provided through public health facilities and identify the factors associated with its use in Kasaragod district of Indian state of Kerala. Materials and Methods: A cross-sectional survey of 375 individuals was conducted in Kasaragod District of Kerala state. The data obtained were analyzed using descriptive and analytical statistical methods using Statistical Package for the Social Sciences version 20. Results: About 56.28% of individuals with NCD, received NCD services from public health facilities; these services were primarily comprised screening services. In addition, 40.69% of total individuals with NCDs received treatment services from government health facilities. Insurance coverage, perception about quality, perceived barriers in accessing health services, health worker visit, knowledge about NCD services, and information provided by frontline health workers were significantly influencing NCD service utilization in public health facilities. Conclusion: Individual's usage of screening services provided by government facilities is higher than that of treatment services. Overall, the utilization of NCD services provided through the public health system could be said to be less than satisfactory. It could be improved by addressing the perceived barriers with respect to the quality of services provided in public health facilities. In addition, employing the frontline health workers to bridge the awareness gap in NCD service provision could help in improving NCD service utilization.

Purpose: Hearing Impairment is one of the most neglected forms of disability. It accounts for the loss of thousands of disability adjusted life years (DALYs) worldwide (WHO, 2005). Developed countries have made some progress in the measuring and management of hearing impairment (HI), but this is still in the initial stages in developing countries such as India. The International Classification of Functioning disability and Health (ICF) has shifted the approach towards a holistic perspective in defining and measuring disability. This paper tries to measure HI from the perspective of social and emotional functioning of individuals. Method: The sample population consisted of 1160 individuals, selected by systematic random sampling from among those who complied with inclusion criteria. 51.7% of the total respondents were females, and 48.3% were males. The participants were administered a questionnaire (Standardised) and their responses were quantified. The data was analysed using Statistical Package for Social Sciences (SPSS) version 20. Results: Prevalence of HI was found more among males than females. 84.6% of the total population had no hearing impairment, whereas 13.7% had mild to moderate impairment, and 1.7% had significant hearing impairment. The Total Impairment score obtained by the individuals was divided into Social Impairment score and Emotional Impairment score. Correlation and Multivariate regression analysis were used. Correlation - Age and Social Dimension Score r= 0.609, p≤0.01, n=1160, R2= 0.370; Age and Emotional Dimension score: r= 0.622, p≤0.01, n=1160, R2= 0.386; Regression- Gender and Social Dimension score b= 0.703, t (1160) = 2.988, p Conclusion: Measuring HI in terms of social and emotional functioning is more holistic and cost-effective, and could be used in resource-poor settings, and for initial screening in large-scale studies.

Background: Maternal and child health is one of the priority areas in Indian context, particularly in Empowered Action Group (EAG) states of the country. Institutional deliveries are prioritized as one of the important means to reduce MMR and IMR. The current study aims to estimate and compare the out of pocket expenditure associated with institutional deliveries in EAG states of Bihar, Uttar Pradesh, Madhya Pradesh and Chhattisgarh in India. Methodology: The study was conducted through secondary analysis of NFHS 4 data. The study adheres to the approach of ecological study design and aims at comparing the OOPE and its variations at the state level. The data was analysed using SPSS version 20. Statistics of mean, standard deviation and 95% confidence levels for OOPE were computed and compared. Results: Uttar Pradesh had the highest OOPE with mean OOPE for institutional delivery of INR 7616.77, 95% CI (7310.26 – 7923.28), Chhattisgarh had the least OOPE with mean OOPE per institutional delivery being INR 3917.80, 95% CI (3513.40 - 4294.25). Presence/absence of health insurance had profound impact on the OOPE. Institutional deliveries in UP which were not covered under any Insurance had mean OOPE of INR 11596.54, 95% CI (8832.62 – 14360.45), on contrary institutional deliveries in Chhattisgarh which were covered under insurance schemes had OOPE of INR 3964.84, 95% CI (3220.70 – 4709.00) Conclusion: While OOPE fluctuated with insurance and other socio-demographic factors, existence of inter-state differences reflects on the importance of health service availability in reducing OOPE. Interventions focussing on reducing OOPE should also focus on health system strengthening by improving availability and accessibility of health services.