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BackgroundGlobally, especially in the low- and middle-income countries (LMICs), rural populations were more susceptible to the negative impact of the COVID-19 pandemic due to lower levels of community awareness, poor hygiene, and health literacy accompanying pre-existing weak public health systems. Consequently, various community-based interventions were engineered in rural regions worldwide to mitigate the COVID-19 pandemic by empowering people to mount both individual and collective public health responses against the pandemic. However, to date, there is paucity of information on the effectiveness of any large-scale community intervention in controlling and mitigating the effects of COVID-19, especially from the perspective of LMICs. ObjectiveThis retrospective impact evaluation study was conducted to evaluate the effect of a large-scale rural community–based intervention, the COVID-Free Village Program (CFVP), on COVID-19 resilience and control in rural populations in Maharashtra, India. MethodsThe intervention site was the rural areas of the Pune district where CFVP was implemented from August 2021 to February 2022, while the adjoining district, Satara, represented the control district where the COVID-Free Village Scheme was implemented. Data were collected during April-May 2022 from 3500 sample households in villages across intervention and comparison arms by using the 2-stage stratified random sampling through face-to-face interviews followed by developing a matched sample using propensity score matching methods. ResultsThe participants in Pune had a significantly higher combined COVID-19 awareness index by 0.43 (95% CI 0.29-0.58) points than those in Satara. Furthermore, the adherence to COVID-appropriate behaviors, including handwashing, was 23% (95% CI 3%-45%) and masking was 17% (0%-38%) higher in Pune compared to those in Satara. The probability of perception of COVID as a serious illness in patients with heart disease was 22% (95% CI 1.036-1.439) higher in Pune compared to that in Satara. The awareness index of COVID-19 variants and preventive measures were also higher in Pune by 0.88 (95% CI 0.674-1.089) points. In the subgroup analysis, when the highest household educational level was restricted to middle school, the awareness about the COVID-control program was 0.69 (95% CI 0.36-1.021) points higher in Pune, while the awareness index of COVID-19 variants and preventive measures was higher by 0.45 (95% CI 0.236-0.671) points. We did not observe any significant changes in the overall COVID-19 vaccination coverage due to CFVP implementation. Furthermore, the number of COVID-19 deaths in both the sampled populations were very low. The probability of observing COVID-19–related stigma or discrimination in Pune was 68% (95% CI 0.133-0.191) lower than that in Satara. ConclusionsCFVP contributed to improved awareness and sustainability of COVID-appropriate behaviors in a large population although there was no evidence of higher COVID-19 vaccination coverage or reduction in mortality, signifying potential applicability in future pandemic preparedness, especially in resource-constrained settings.

Introduction: Noncommunicable disease (NCDs) risk factor clustering multiplies the risk especially in aging populations. The study objective was to estimate the prevalence and determinants of multiple NCD risk factors amongst older adults in India using the Community-Based Assessment Checklist (CBAC). Methods: A secondary analysis was undertaken using the Longitudinal Ageing Study in India (LASI) data wave-I having 40,510 participants aged ≥ 45 years without a history of diabetes or hypertension. The CBAC recommended by the national program consists of assesses six NCD risk factors: age, tobacco use, alcohol use, waist circumference, physical activity, and family history. Results: The prevalence of individuals at high-risk for NCDs defined as a CBAC score ≥ 4 was 55.2 % (95 % CI: 54.1, 56.29). Male gender, widowhood, obesity, and unemployment were independently associated with higher odds of having a high NCD risk factor status. Geographically, Northeastern and Southern states had higher burden of individuals at high-risk for NCDs. Furthermore, 28.44 % of patients at high-risk for NCDs were also having undiagnosed hypertension detected on screening. Conclusion: More than one in two older adults aged ≥ 45 years in India without an established history of diabetes or hypertension have four or more NCD related risk factors that accentuate their NCD risk.

Objectives: To ascertain the prevalence and predictors of sleep disorders and poor sleep quality among older adults with Diabetes (DM) in India, and to assess the relationship between sleep quality and DM. Methods: Data was utilized from the nationally representative Longitudinal Ageing Study in India (Wave-1, 2017–18), with a total sample of 66606 older adults (≥45 years) selected for the study. Sleep problems and sleep quality score were assessed using an adaptation based on the Jenkins Sleep Scale. Multivariate linear and logistic regressions were conducted to determine the effect of sociodemographic and clinical factors on sleep quality. Mediation analysis (Karlson-Holm-Breen) was done to assess the direct and indirect effects of independent variables on the sleep quality scores. Further, Propensity score matching (PSM) was done to assess the impact of diabetes on sleep problems. Results: The prevalence of DM was 12.34% (n = 8564, 95% CI: 11.54, 13.20) among whom 24.38% (95% CI: 21.38, 27.65) reported sleep problems. On adjusted analysis, sleep problems were significantly associated with increasing education, higher wealth quintile, lack of physical activity, and multimorbidity. Mediation analysis showed adherence to anti-diabetes medication improved sleep quality (aB = −0.28 (95% CI: −0.54, −0.02)), while comorbidities worsened sleep quality (aB = 0.79 (95% CI: 0.67, 0.92)). Analysis from PSM indicated that DM was associated with a 6.2% higher chance of sleep problems. Conclusions: Poor sleep quality is present in nearly one in four individuals diagnosed with DM in India and linked with certain adverse social determinants. Focused interventions to improve assessment and treatment of sleep problems in resource-limited primary care settings require prioritization.

Abstract Background Pregnancy-related complications and insufficiencies in antenatal care services are leading causes of maternal and infant morbidity and mortality in low-resource settings. However, there has been an undue focus on achieving a minimum number of Antenatal Care (ANC) visits without adequate focus on the factors affecting ANC service utilization. This secondary data analysis from the fifth round of the National Family Health Survey (NFHS-5, 2019-21) was conducted to estimate the coverage of adequate quality ANC service and its determinants in India. Methods The study sample included 176,877 women aged 15–49 years who had experienced a pregnancy in the last 5 years. The primary outcome variable was the utilization of ANC services by women during their last pregnancy assessed by the frequency of ANC visits and the quality of ANC services. Quality of ANC service utilisation was categorised as adequate quality, inadequate quality and ≥ 4 ANC visits and, inadequate quality and

Abstract Background Hypertension care cascade in resource-limited settings is compromised with a majority of patients with hypertension remaining undiagnosed, untreated, non-adherent, and poorly controlled at every stage. However, there is paucity of information on care and management of hypertensive patients in community-based settings of low-income urban neighbourhoods in India. Methods This was a community-based cross-sectional study conducted in an urban resettlement colony and slum area in the Northeast District of Delhi. The adult population was screened for hypertension using standardized methods, and adherence to medications was assessed using the Morisky Green Levine scale. Binary logistic regression analysis was conducted to ascertain the sociodemographic predictors of the outcome (presence of hypertension, adherence to antihypertensive medication, blood pressure control). A p-value

We ascertained the burden, determinants, and care cascade in the young and middle-aged patients having co-existing hypertension (HTN), Diabetes Mellitus (DM), and abdominal obesity in India from a secondary data analysis of nationally representative data. The study examined cross-sectional data from the National Family Health Survey (NFHS-5) conducted in India from 2019 to 2021 in 788974 individuals aged 15-49 years including 695707 women and 93267 men. The weighted prevalence of DM-HTN comorbidity with high waist circumference in the sample was 0.75% (95% CI: 0.71 to 0.79) including 46.33% (95% CI: 44.06 to 48.62) newly diagnosed cases detected for HTN and high blood sugars. The weighted prevalence of Metabolic syndrome as per NCEP ATPIII criteria was found to be 1.13% (95% CI: 1.08 to 1.17). Only 46.16% existing cases were treated with both anti-diabetes and antihypertensive medication (full treatment), while 34.71% cases were untreated. On adjusted analysis, increasing age, females, higher wealth index, high fat diet, obesity and comorbidities were significantly associated with having DM-HTN comorbidity along with high-waist circumference. More than half of young and middle aged-population in India with DM-HTN-abdominal obesity triad are not initiated on treatment for DM and HTN comorbidities, while a majority of the previously diagnosed cases have uncontrolled blood pressure and poor glycemic control. The poor cascade of care for DM and HTN in these high-risk group of patients may substantially increase their risk for early progression and severity of microvascular and macrovascular complications especially cardiovascular disease.

Introduction Metabolic syndrome is a significance driver of mortality and morbidity in India, but nationally representative data regarding disease burden and treatment status are lacking. Here, a cross-sectional study was undertaken to establish national and regional estimates of disease burden and explore reasons for lack of treatment of component conditions of metabolic syndrome in Indian older adults (45 years and older).Methods A cross-sectional study was undertaken using data from the first wave of the Longitudinal Ageing Study in India (2017–2018). Data for 66 606 individuals aged 45 years and above were analysed. The primary outcome was metabolic syndrome prevalence, defined by the National Cholesterol Education Programme ATP III criteria as an individual having any three of four component conditions: diabetes mellitus (DM), hypertension, abdominal obesity and hypercholesterolaemia. The secondary outcome of this study was treatment status of patients with component conditions.Results Metabolic syndrome was found to have an overall weighted prevalence of 4.83% (n=3630, 95% CI 4.24 to 5.51). Females, urban residents, obese individuals and physically inactive people exhibited greater prevalence. The most prevalent component of metabolic syndrome was hypertension followed by abdominal obesity, DM and hypercholesterolaemia. 8.85% metabolic syndrome patient reported no treatment for component conditions, while 17.58% reported only partial treatment. Elderly individuals between 60 and 69 (crude relative risk ratios, cRRR 2.20, 95% CI 1.20 to 4.01) and 80 years and above (cRRR 7.48, 95% CI 1.99 to 28.16), urban residents (cRRR 2.45, 95% CI 1.48 to 4.05), those from richer monthly per capita consumption expenditure quintiles (cRRR 2.55, 95% CI 1.00 to 6.47) and those with additional comorbidities (cRRR 2.17, 95% CI 1.28 to 3.70) were more likely to report comprehensive treatment.Conclusions This study highlights a substantial prevalence of metabolic syndrome in older adults in India and reveals remarkable disparities in provision of treatment. Better prevention, earlier detection and improved provision of treatment are urgently required to combat the rising prevalence of metabolic syndrome and reduce the burden of cardiovascular disease in India.

Background: Children with Severe acute malnutrition (SAM) experience a high risk of disease and developmental delays contributing to large scale morbidity and mortality particularly in the developing world with existing progress inadequate to attain the Sustainable Development Goal for improved nutrition, and the cessation of all forms of undernourishment by 2030.The study objective was to assess the functioning and effectiveness of facility-based management of children with SAM in terms of their recovery (anthropometric indicators), adherence to discharge, and follow-up guidelines. Methods: This secondary data analysis obtained data from the physical patient registers of two malnutrition treatment centres (MTCs) located in the Jamtara district of Jharkhand. Information of 245 children admitted to these MTCs from April 2019-April 2020 was obtained consecutively including anthropometric outcome (weight, length, and Mean Upper Arm Circumference) measurements during the period of their admission. The primary outcome was the proportion of children who attained the recommended discharge criterion of greater than 15% weight gain at the time of discharge. Results: The mean (SD) age of the children with SAM was 1.52 (0.73) years including 55.1% females and 44.9% males. There were 38% of children had a MUAC below 11.5 cm, and 62% had a Z score for weight for height below -3SD. The mean (SD) length of admission stay at the MTCs was 17.16 (5.76) days. A statistically significant improvement in the mean weight and MUAC at discharge was found although the effect size was small (0.98 kg). Only 105 (44.3%) (n=237) children with SAM achieved recovery as per the discharge criterion requirement of ≥15% weight gain since the time of admission. The mean (SD) duration of stay of the children who recovered was 20.43 (5.64) days, being significantly higher compared to the children who failed to recover as per the weight guidelines 14.59 (4.4) days (p < 0.001). Conclusion: MTCs were effective in the management of children with SAM although the recovery rate through weight gain criterion was poor due to premature discharge and lack of follow-up suggestive of a high-burden of adverse social determinants and inadequate health system sensitization and preparedness.

Background: Non-communicable diseases (NCDs) are a leading cause of death globally and disproportionately affect those in low- and middle-income countries lower-middle-income countries. Poor medication adherence among patients with NCDs is prevalent in India due to lack of initiation, missed dosing or cessation of treatment, and represents a growing healthcare and financial burden.Objective: This study aimed to identify factors influencing medication adherence in adults with NCDs in India.Methods: We performed a cross-sectional study, conducting secondary data analysis on the second wave of the World Health Organisation’s ‘Study on global AGEing and adult health (SAGE)’, a survey that collected data from predominantly older adults across India. Bivariate analysis and multivariate logistic regression modelling were conducted to specifically interrogate the reasons for lack of initiation and cessation of treatment. Reporting of this study was informed by the STROBE guidelines.Results: The average medication adherence rate was 51% across 2,840 patients with one or more NCDs, reflecting non-initiation and lack of persistence of treatment. The strongest factor significantly predicting non-adherence to medication across these components was multimorbidity (odds ratio 0.47, 95% CI 0.40–0.56). Tobacco use (OR = 0.76, CI 0.59–0.98) and never having attended school (OR = 0.75, CI 0.62–0.92) were significantly associated with poor medication adherence (p < 0.05) while rural living (OR = 0.70, CI 0.48–1.02), feelings of anxiety (OR = 0.84, CI 0.66–1.08) and feelings of depression (OR = 0.90, CI 0.70–1.16) were factors lacking statistically significant association with medication adherence on multivariate analysis. Older age (OR = 2.02, CI 1.51–2.71) was significantly associated with improved medication adherence whilst there was a weak association between increased wealth and improved medication use.Limitations: The SAGE2 survey did not capture whether patients were taking their medication doses according to prescribed instructions—as a result our findings may under-estimate the true prevalence of medication non-adherence.Conclusion: Our analysis provides evidence that poor medication adherence in India is multifactorial, with distinct socioeconomic and health-system factors interacting to influence patient decision making. Future large-scale surveys interrogating adherence should assess all components of adherence specifically, whilst public health interventions to improve medication adherence should focus on barriers that may exist due to multimorbidity, comorbid depression and anxiety, and low educational status.

Abstract Background Much scholarly debate has centered on Bangladesh's family planning program (FPP) in lowering the country's fertility rate. This study aimed to investigate the prevalence of using modern and traditional contraceptive methods and to determine the factors that explain the contraceptive methods use. Methods The study used data from the 2017–18 Bangladesh Demographic and Health Survey (BDHS), which included 11,452 (weighted) women aged 15–49 years in the analysis. Multilevel multinomial logistic regression was used to identify the factors associated with the contraceptive method use. Results The prevalence of using modern contraceptive methods was 72.16%, while 14.58% of women used traditional methods in Bangladesh. In comparison to women in the 15–24 years age group, older women (35–49 years) were more unwilling to use modern contraceptive methods (RRR: 0.28, 95% CI: 0.21–0.37). Women who had at least a living child were more likely to use both traditional and modern contraceptive methods (RRR: 4.37, 95% CI: 3.12–6.11). Similarly, given birth in the previous 5 years influenced women 2.41 times more to use modern method compared to those who had not given birth (RRR: 2.41, 95% CI: 1.65–3.52). Husbands'/partners’ decision for using/not using contraception were positively associated with the use of both traditional (RRR: 4.49, 95% CI: 3.04–6.63) and modern methods (RRR: 3.01, 95% CI: 2.15–4.17) rather than using no method. This study suggests rural participants were 21% less likely to utilize modern methods than urban participants (RRR: 0.79, 95% CI: 0.67–0.94). Conclusion Bangladesh remains a focus for contraceptive use, as it is one of the most populous countries in South Asia. To lower the fertility rate, policymakers may design interventions to improve awareness especially targeting uneducated, and rural reproductive women in Bangladesh. The study also highlights the importance of male partners’ decision-making regarding women's contraceptive use.

Objectives Menstrual hygiene management (MHM) in developing countries is linked to human rights, social justice, and the education and empowerment of young girls. The objective of this study was to assess menstrual hygiene practices and their determinants among adolescent girls, including school dropouts, and the effects of pad distribution programs in urban resettlement areas of Delhi, India. Methods A cross-sectional study was conducted from March 2019 to February 2020 in urban resettlement colonies and 2 villages of Delhi among 1,130 adolescent girls aged 10 to 19 years, who were interviewed face to face. Results In total, 954 participants (84.4%) used only disposable sanitary pads, 150 (13.3%) used both sanitary pads and cloths, and 26 (2.3%) used only cloths (n=1,130). Most school-going girls utilized the scheme for pad distribution, but only two-thirds of the girls who were out of school utilized the scheme. In the adjusted analysis, girls with lower educational status, those who had dropped out of school, and those from the Muslim religious community were more likely to use cloths for MHM. Conclusion More than 4 out of 5 adolescent girls in Delhi in low-income neighborhoods preferred sanitary pads for MHM. The government free pad scheme reached near-universal utilization among school-going girls (97%), but the subsidized pad scheme for girls who did not attend school was insufficiently utilized (75%).

IntroductionCost-effective interventions that improve medication adherence are urgently needed to address the epidemic of non-communicable diseases (NCDs) in India. However, in low- and middle-income countries like India, there is a lack of analysis evaluating the effectiveness of adherence improving strategies. We conducted the first systematic review evaluating interventions aimed at improving medication adherence for chronic diseases in India.MethodsA systematic search on MEDLINE, Web of Science, Scopus, and Google Scholar was conducted. Based on a PRISMA-compliant, pre-defined methodology, randomized control trials were included which: involved subjects with NCDs; were located in India; used any intervention with the aim of improving medication adherence; and measured adherence as a primary or secondary outcome.ResultsThe search strategy yielded 1,552 unique articles of which 22 met inclusion criteria. Interventions assessed by these studies included education-based interventions (n = 12), combinations of education-based interventions with regular follow up (n = 4), and technology-based interventions (n = 2). Non-communicable diseases evaluated commonly were respiratory disease (n = 3), type 2 diabetes (n = 6), cardiovascular disease (n = 8) and depression (n = 2).ConclusionsAlthough the vast majority of primary studies supporting the conclusions were of mixed methodological quality, patient education by CHWs and pharmacists represent promising interventions to improve medication adherence, with further benefits from regular follow-up. There is need for systematic evaluation of these interventions with high quality RCTs and their implementation as part of wider health policy.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022345636, identifier: CRD42022345636.

Objectives The aim of this study was to assess changes in the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin G (IgG) seroprevalence among children and adolescents in Delhi, India from January 2021 to October 2021 Methods This was a repeated cross-sectional analysis of participants aged 5 to 17 years from 2 SARS-CoV-2 seroprevalence surveys conducted in Delhi, India during January 2021 and September to October 2021. Anti-SARS-CoV-2 IgG antibodies were detected by using the VITROS assay (90% sensitivity, 100% specificity). Results The seroprevalence among 5- to 17-year-old school-age children and adolescents increased from 52.8% (95% confidence interval [CI], 51.3%−54.3%) in January 2021 to 81.8% (95% CI, 80.9%−82.6%) in September to October 2021. The assay-adjusted seroprevalence was 90.8% (95% CI, 89.8%−91.7%). Seropositivity positively correlated with participants’ age (p

We interviewed 221 antenatal women in the second or third trimester of pregnancy attending a primary care antenatal clinic at a low-income area in Delhi, India, during 2019–20. The Minimum Dietary Diversity-Women (MDD-W) score for 10 food groups was calculated using the open recall method during a 24-h recall period. The median MDD-W score was 6 (IQR 4–7). Low dietary diversity (MDD-W

The present study was conducted among accredited social health activists (ASHAs), female frontline health workers of India, to assess their knowledge of self-care management for diabetes mellitus (DM) and hypertension (HTN) and understand their readiness to promote medical adherence. Only 21 (41.2%) participants (n = 51) were aware of all the four major behavioral risk factors, including physical inactivity, unhealthy diet, tobacco smoking, and harmful alcohol use that increased the risk of development and progression of DM and HTN. The ASHAs were positively inclined toward participation in health education activities through home visits but were disinclined to be involved in the home distribution of medications.

Objective: This study aimed to determine the effect of a mHealth (text message) intervention compared with a structured health educational session on the oral care and hygiene practices of pregnant women. Materials and Methods: We conducted a pilot randomized control trial, parallel design superiority trial, with a 1:1 allocation ratio. A total of 76 pregnant women up to 20 weeks of gestational age and capable of reading mobile phone text messages were recruited during August–October 2020 from the antenatal clinic of a primary health center in a low-income urban agglomeration in Delhi, India. The mHealth intervention arm participants were sent a daily text message for 30 days, while all participants were provided a one-time, face-face, brief didactic structured educational session toward oral health promotion. Results: The baseline characteristics of both groups were comparable in terms of age structure, education, parity, and oral hygiene but differed in terms of oral health problems. Postintervention, although the twice-brushing frequency increased in both arms, only the mHealth arm revealed a statistically significant reduction in the incidence of missed twice-daily brushing episodes (P = 0.016). Conclusions: A mHealth-based daily text-message intervention for 1 month was not superior to a one-time brief didactic structured educational intervention for oral health promotion in antenatal women.

Background: India has over 50 million workers employed in industries with exposure to very high sound levels, predisposing them to noise-induced hearing loss (NIHL). Methods: We conducted a systematic review and meta-analysis by using the following criteria: (1) Observational or experimental studies conducted in India; (2) English language studies; (3) Published during January 2010–December 2019; (4) Primary outcome: proportion of participants detected with NIHL. We reviewed bibliographic databases (PubMed, Scopus, and DOAJ) and Google Scholar, and extracted the relevant data. Results: A total of 160 documents were identified after removing duplicates, and 33 full texts were screened, of which 22 studies were included. The mean (SD) effective sample size of the studies was 107.1 (78.9). The pooled proportion of participants with NIHL irrespective of the category was 0.49 (95%CI: 0.22–0.76) and that of hearing loss was 0.53 (95%CI: 0.28– 0.78). Most studies reported that none of the workers, especially in the informal sectors, used auditory protection. Conclusions: NIHL is a major neglected public health occupational health challenge in India linked with adverse social determinants of health. Sustained advocacy for implementation of legislative and behavior change communication for protecting the hearing of workers is warranted.

Background: Globally the prevalence of non- communicable diseases is on a rise. Adolescents are vulnerable to such diseases later on in life because of the susceptibility to behavioural risk factors like insufficient physical activity, unhealthy dietary practices and tobacco and alcohol consumption during this transition stage of their life. Adolescents who are from low-income families are also at increased risk of dual states of malnutrition such as underweight and obesity. So, this study aimed to estimate the prevalence of such behavioural risk factors among adolescents of low-income urban areas of Delhi. Methodology: A cross-sectional study was conducted among 264 adolescents (10–19 years) of low-income Urban areas of Delhi. Results: A total of 122 (46.2%) boys and 142 (53.8%) girls were enrolled in the study. The mean age of adolescents were 14.2 ± 2.4 years. The most prevalent NCD risk factor was physical inactivity (98.1% [96.4–99.7])). The screen time for television was significantly higher among boys than girls (p value 0.022). An age stratified analysis of risk factors showed that the intake of carbonated drinks (p value 0.026) and social media utilisation time (p value 0.037) was significantly higher among late adolescent boys (≥15 years) compared to early adolescents. Conclusion: There is high prevalence of physical inactivity and unhealthy dietary behaviours among adolescents which could be a warning sign for prompt actions as they are at risk of NCD in future. Hence healthier practices should be promoted among adolescents at community level.

Objectives: Adult immunisation has recently emerged as an area of emphasis in research and policy. Increasing life expectancy, outbreaks like COVID-19, and the endemic nature of diseases like dengue, malaria have underscored its importance. Therefore, this study was carried out to assess hesitancy and the factors influencing the uptake of vaccines in adults. Methods: A descriptive cross-sectional study was conducted among the medical students and doctors affiliated to a medical college and tertiary care hospital in Delhi, India and their immediate family members in January 2021. Online data collection was done using the Google Form platforms. Data on awareness and perceptions regarding adult vaccination and immunisation status of participants was collected. The dataset was exported in the Microsoft Excel format and analysed with IBM SPSS Version 25 (Armonk, NY: IBM Corp). Results: A total of 461 adults responded to the survey. The most common reasons for vaccine hesitancy were fear of side effects (51.41%), lack of awareness of vaccines (49.46%), and the lack of national guidelines on adult vaccination (32.97%). Hesitancy for vaccines among those who were informed by healthcare workers of vaccine availability was highest for zoster vaccine (97.80%) and least for tetanus toxoid (57.62%). Significant hesitancy was also observed for pneumococcal, human papillomavirus, influenza and varicella vaccines. Conclusions: Reduced vaccine uptake due to vaccine hesitancy in adulthood is a major health concern. Framing national guidelines for adult vaccination in India and awareness generation to create a public demand for adult vaccination warrants prioritization.

The choice of the vaccine packaging type either as single- or multi-dose vial is a crucial determinant of vaccine coverage. The experience of vaccination strategies in lower-middle-income countries suggests that multi-dose vaccine vials translate into greater economic-logistic advantages due to lower packaging and storage costs with significant environmental benefits accrued from reduced medical waste generation. However, the use of multi-dose vials is associated with a theoretical risk of contamination particularly from human error. Moreover, the overall economic advantage of multi-dose vials is contingent on the reduction of the extent of vaccine wastage associated with their use. Robust data collection for monitoring of vaccine wastage rates and adverse effects following immunization is therefore needed to understand the extent of economic benefit and risks involved with multi-dose vial use.

Summary: Background: Tuberculosis is the leading cause of death from a single infectious agent among the HIV-negative population and ranks first among the HIV-positive population. However, few studies have assessed tuberculosis trends in Brazil, Russia, India, China and South Africa (BRICS) or with an emphasis on HIV status. This study assesses the time trends of tuberculosis mortality across the BRICS with an emphasis on HIV status from 1990 to 2019. Methods: We obtained tuberculosis data from the Global Burden of Disease 2019 study (GBD 2019). We calculated the relative proportion of tuberculosis to all communicable, maternal, neonatal, and nutritional diseases by HIV status across the BRICS. We used age-period-cohort modelling to estimate cohort and period effects in tuberculosis from 1990 to 2019, and calculated net drift (overall annual percentage change), local drift (annual percentage change in each age group), longitudinal age curves (expected longitudinal age-specific rate), and period (cohort) relative risks. Findings: There were 549,522 tuberculosis deaths across the BRICS in 2019, accounting for 39.3% of global deaths. Among HIV-negative populations, the age-standardised mortality rate (ASMR) of tuberculosis in BRICS remained far higher than that of high-income Asia Pacific countries, especially in India (36.1 per 100 000 in 2019, 95% UI [30.7, 42.6]) and South Africa (40.1 per 100 000 in 2019, 95% UI [36.8, 43.7]). China had the fastest ASMR reduction across the BRICS, while India maintained the largest tuberculosis death numbers with an annual decrease much slower than China's (-4.1 vs -8.0%). Among HIV-positive populations, the ASMR in BRICS surged from 0.24 per 100 000 in 1990 to 5.63 per 100 000 in 2005, and then dropped quickly to 1.70 per 100 000 in 2019. Brazil was the first country to reverse the upward trend of HIV/AIDS-tuberculosis (HIV-TB) mortality in 1995, and achieved the most significant reduction (-3.32% per year). The HIV-TB mortality in South Africa has realised much progress since 2006, but still has the heaviest HIV-TB burden across the BRICS (ASMR: 70.0 per 100 000 in 2019). We also found unfavourable trends among HIV-negative middle-aged (35-55) adults of India, men over 50 in the HIV-negative population and whole HIV-positive population of South Africa, and women aged 45-55 years of Russia. China had little progress in its HIV-positive population with worsening period risks from 2010 to 2019, and higher risks in the younger cohorts born after 1980. Interpretation: BRICS’ actions on controlling tuberculosis achieved positive results, but the overall improvements were less than those in high-income Asia Pacific countries. BRICS and other high-burden countries should strengthen specified public health approaches and policies targeted at different priority groups in each country. Funding: National Natural Science Foundation of China (82073573; 72074009), Peking University Global Health and Infectious Diseases Group.

Background: The high prevalence of vaccine booster hesitancy, with the concomitant waning of humoral vaccine or hybrid immunity, and the emergence of SARS-CoV-2 variants of concern can accentuate COVID-19 morbidity and mortality. The study objective was to ascertain the COVID-19 vaccination coverage, including the administration of precaution (booster) dose vaccination, among the older population in an urban slum and resettlement colony population in Delhi, India. Methods: We conducted a cross-sectional survey in an urban resettlement colony, slum, and village cluster in the Northeast district of Delhi among residents aged ≥50 years. Results: A total of 2217 adults (58.28%) had obtained a COVID-19 booster (precaution) dose vaccine, 1404 (36.91%) had received two doses of a COVID-19 vaccine without booster dose, 121 (3.18%) were unvaccinated, while 62 (1.63%) participants received a single dose. Based on adjusted analysis, older adults (>65 years), higher education, and higher per-capita income were statistically significant predictors of booster dose vaccination. Conclusions: More than four in ten adults in an urban slum and resettlement colony in Delhi lacked COVID-19 booster dose vaccination despite high rates of double-dose vaccination (~95%). Public health programming should provide an enhanced focus on reducing complacency with renewed prioritization for improving ease of access to COVID-19 vaccination services, particularly in underserved areas.

Objectives Healthcare workers (HCWs) are at a high risk of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to the increased likelihood of clinical exposure during patient management. The study objective was to determine the seroprevalence of antibodies to SARS-CoV-2 and its predictors among hospital employees. Methods The cross-sectional study was conducted at a teaching hospital from August 2020 to September 2020 among 1,401 employees, including 1,217 HCWs, in New Delhi, India. The serum samples were examined for immunoglobulin G (IgG) antibodies to SARS-CoV-2 using the COVID Kavach-Anti-SARS-CoV-2 IgG Antibody Detection enzyme-linked immunosorbent assay kit. Data were collected electronically using the EpiCollect mobile platform. A p < 0.05 was considered to indicate statistical significance. Results A total of 169 participants (12.1%) had detectable IgG antibodies to SARS-CoV-2. The highest seropositivity rate was observed in the administrative staff (20.1%), while it was lowest among medical doctors (5.5%, p < 0.001). Male sex and ever having lived in a containment zone were independently associated with past infection with SARS-CoV-2. Conclusion The seroprevalence of SARS-CoV-2 infection in health workers may be lower than in the general population in New Delhi. However, nonpharmaceutical interventions were not associated with a reduction in the risk of acquisition of SARS-CoV-2.

Minimizing vaccine wastage and associated costs is considered a key target for appropriate vaccine management. In India, the Rotavirus Vaccine (RVV) (2019) and the fractionated injectable polio vaccine (f-IPV) (2016) are more prone to wastage with high procurement costs. In this operational research study, we determined the effectiveness of a (self-designed) dose based reporting tool (DBRT) in reducing vaccine (f-IPV and RVV) wastage at primary care facilities in India during December 2019 to March’ 2020. Data reports of all the immunization sessions conducted at three primary care facilities were analyzed to calculate the wastage rates of the RVV and the f-IPV for the following periods: (1). Period of initiation (August-November’ 2019) (2). Pre-intervention with sensitization of healthcare providers (December’ 2019-January’ 2020) (3). Post-intervention after application of the DBRT. Intervention: The DBRT is a paper-based reporting format that assigns a unique code to each RVV and IPV vial. The health facility is required to report the total doses administered from each coded vial during every immunization session by updating it on the assigned reporting format. Pre-intervention, the average monthly wastage of f-IPV was 23.5% and of the RVV ranged from 18%-31%. Post-intervention, on using the DBRT, the monthly wastage of both RVV and f-IPV dropped significantly to 8.6% and 11.4%, respectively. During the subsequent month, the IPV wastage further decreased to only 4.7%. In conclusion, the DBRT reduces vaccine wastage in government primary care facilities by enabling a paper audit trail that promotes responsiveness and accountability among healthcare workers directly involved in vaccine administration.

Background: The average Indian woman has early onset menopause compared to the global average. Assessment of the quality of life (QOL) among Indian women with perimenopause or postmenopause at health facilities using a rapidly administered, validated instrument is required. Objective: To assess the QOL among perimenopause and postmenopausal women in India and to ascertain the factors influencing their QOL using a brief instrument suitable for clinical use. Methods: A cross-sectional study was conducted during August to October 2019 in the medical outpatient department at a government secondary care hospital in a rural area of Delhi, India. We enrolled women in the age group of 40–59 years. Results: We recruited 136 participants with a response rate of 92%. The mean (standard deviation) age of the participants was 49.2 (6.1) years. A majority (51.2%) of the participants were illiterate, and only 22 (16.6%) were employed. The Cronbach's alpha of the Utian QOL was 0.824, indicating good reliability. The QOL scores of the participants were below average for the occupational and emotional domains, but higher for the health and sexual domains. On bivariate analysis, we found education not more than primary school, not being employed, and having more than two children were associated with lower QOL scores. Conclusion: Women with greater education, employment, with up-to two children and without depressive symptoms reported a better QOL, but it did not differ significantly between perimenopausal and postmenopausal women.

Objective: Postpartum depression is a nonpsychotic mental health condition that impairs both the immediate and long-term health of both the mother and her child. Materials and Methods: We conducted a cross-sectional study from January to June 2019 at a primary care clinic in Delhi, India, to estimate the burden of postpartum depression in women having an infant child. The Hindi version of the Edinburgh Postnatal Depression Scale was used to screen for the depression in the participants. Data were analyzed with IBM SPSS software version 25. P

Introduction: Menstruation, a physiological phenomenon, till date is associated with myths, taboos, and malpractices. These interfere with the emotional, physical, and mental health of adolescent girls. This study attempts to draft a validated questionnaire to measure menstruation-related activity restriction. Objective: The objective was to study activities restricted during menstruation among adolescent girls residing in urban resettlement colonies of Delhi and to develop and validate a questionnaire for menstruation-related activity restriction. Materials and Methods: A community-based cross-sectional study was conducted among adolescent girls residing in urban resettlement colonies of Delhi during 2019. A multistage random sampling technique was used to select 1100 girls across four districts of Delhi. A 15-item questionnaire was developed by an expert committee and validated with principal component analysis (PCA). Results: In total, 1100 adolescent girls were included in the study whose mean age was 15.8 (±2.1) years. School/college/work was missed due to menstruation in 60% of the adolescent girls, 66% were not comfortable during menstruation, and 92% were restricted from entering religious places. In exploratory factor analysis using PCA, 6 principal components were identified which had eigenvalues more than 1. Conclusion: Religious restrictions during menstruation (94%) were highly prevalent among adolescent girls, followed by restriction of routine activity (69%) and work/academically related activity (60%). Construct validity has identified a six-factor structure for the menstruation-related activity restriction questionnaire. This was identified as a valid and internally consistent tool to assess activities restricted during menstruation among Indian adolescent girls.

Background: Suboptimal adherence to anti-tuberculosis medication in patients is associated with adverse treatment outcomes including treatment failure, relapse, and emergence of drug resistance. Objectives: We conducted the present study with the objectives of evaluating the effectiveness of a mHealth package on the medication adherence of patients with tuberculosis (TB) on antitubercular (directly observed treatment short-course [DOTS]) treatment. Methods: We conducted Quasi-experimental study at six DOTS centers of Delhi among 220 newly diagnosed TB patients. We included adult TB patients (18 years and above) who were on DOTS therapy ≥30 days, had access to a mobile phone and were able to read messages and receive calls. We excluded patients with impaired hearing, blindness and those on non-DOTS therapy or having multidrug-resistant/extensively drug-resistant TB. Participants in the intervention group received amHealth package for 90 days. The medication adherence of the study participants was measured using Morisky, Green, and Levine Adherence Scale. Results: A total of 130 men and 90 women were recruited for the study. Occupational interference and forgetfulness were the most common reasons for medication nonadherence in the patients. In the intervention group, the medication adherence to antitubercular medication (daily DOTS regimen) was 85.5% at baseline which increased to 96.4% at endline (postintervention) (P = 0.004). No significant change was observed in the control group (P = 0.328). The increase in adherence was observed across the following subgroups: age, gender, education, and Socioeconomic status. Conclusions: The mHealth intervention in TB patients was effective in improving the adherence to DOTS therapy.

Background: Government schemes for the promotion of Menstrual Hygiene Management (MHM) among adolescent girls in India are underpinned by crucial implementation efforts from the frontline health workers, community health workers, and school teachers. Aim: The aim of the study is to identify the perspectives on menstrual health and hygiene management with regard to government schemes for sanitary pad distribution to adolescent girls among the frontline workers and the government school teachers located in urban resettlement colonies in Delhi. Methods: In-depth interviews were conducted with 30 accredited social health activisits, 30 Anganwadi Workers (AWW), and 30 auxiliary nurse midwives (ANMs) and five focus group discussions among 28 government school teachers from the middle, high, and secondary standard. Results: Most participants recognized the phenomenon of menstruation-related problems in adolescent girls and were aware of some of the common sociocultural, religious, and hygiene-related menstrual restrictions prevalent in their communities. All the participants believed that the pad distribution scheme was highly beneficial. However, in spite of inclusion of menstrual health promotion in the school curriculum, teachers often lacked self-efficacy in discussing challenges and health concerns related to MHM with their students. Conclusions: Despite their potential as community resources for adolescent girls, FHWs, ANMs, and school teachers often fail to impart crucial menstrual hygiene information and skills-building needed toward achieving effective, safe, and optimal MHM.

Background: Six diverse Demographic Development and Environmental Surveillance System (DDESS) sites were established in urban slum, urban resettlement, peri-urban, rural, and tribal areas located in Northern, North-East, Eastern, and Southern regions of India from June 2020 to March 2022. Understanding the community dynamics and engaging people in the community is critically important in the process of establishing DDESS. We ascertained the barriers, challenges, and facilitators during the establishment of multiple DDESS sites across India. Methods: This was a cross-sectional descriptive mixed-methods study. Results: Multiple barriers and challenges encountered were reported in the process of community engagement (CE), such as geographical inaccessibility, language barriers, adverse weather, non-responsiveness due to perceived lack of individual benefit or financial gain, fear of contracting COVID-19, COVID-19 vaccine hesitancy, etc. Facilitators in the CE process were pre-existing links with the community, constitution of community advisory boards, community need assessment, concomitant delivery of outreach health services, and skill-building facilities. Conclusion: Most community barriers in the development of DDESS sites in resource-limited settings can be overcome through a multipronged approach, including effective community engagement by focusing on demonstrating trust at the local level, enlisting community mobilization and support, utilizing pre-existing community linkages, initiating community diagnosis, and meeting perceived community health needs.

Introduction: There is a continued quest towards developing protective vaccines to halt and end the global pandemic of COVID-19 with the research predominantly driven by the developed world. Induction of herd immunity requires mass vaccination, and any avoidable delays would cause enormous health and economic losses. However, developing countries will experience extensive vaccine allocation challenges due to limited indigenous manufacturing and cold chain facilities. Methods: Literature searches were conducted on MEDLINE (accessed by PubMed).The reference list of the selected articles was also screened to find other relevant articles with an emphasis on ethical consideration in COVID-19 vaccine deployment and distribution. Results: Most developing countries are likely to face shortage and consequent uncertainty over timely COVID-19 vaccine availability. Developing countries are also at risk of significant pre-existing vaccine hesitancy and also compromising justice because of the socioeconomic divide, enabling the rich to access retail vaccines before the poor. Finally, the recommended measures for implementing a mandatory vaccination policy are mostly devoid of feasibility in the global south. We identified ethical challenges and their feasibility of resolution by establishing ethically valid mechanisms for allocation and distribution of COVID-19 vaccine as a scarce resource in these resource-constrained settings. Ethical frameworks for assessing government measures towards vaccinating their respective populations are limited in their scope due to scientific uncertainty with regards to the timeliness of vaccine availability and the unpredictable frequency and severity of vaccine-related adverse effects. Conclusion: governments may escape moral culpability despite failing to ensure adequacy and timeliness of vaccination coverage in the absence of specific and measurable ethical benchmarks developed as part of a robust ethical framework.

Introduction Medical doctors are expected to play a proactive role during the COVID-19 pandemic through effective patient management and the implementation and adherence to best practices as per the expert consensus in their country. Strengthening the self-efficacy and addressing the reasons for risk perceptions among medical doctors is essential towards successfully combating the COVID-19 pandemic. In this study, we ascertained the perceived awareness, practices and perspectives regarding the COVID-19 pandemic among medical doctors in India. Methods We conducted a cross-sectional study with two rounds of data collection from 3 April to 24 May 2020 among medical doctors (allopathic) and trainees (medical interns) working at any health facility across India. The data were collected using a self-administered questionnaire utilizing the Google Forms platform. Results A total of 432 medical doctors responded to the survey with 251 in the first round (3–9 April), and 181 in the second round (18–24 May). Official government sources were considered as the most authentic source of information by most (84.2%) participants. However, the perceived awareness on aspects of COVID-19 epidemiology, prevention and policy was inadequate in a majority (52.8%). Moreover, 52.3% of the respondents reported never having received institutional training related to COVID-19 management protocols. The individual perceived risk of contracting COVID-19 (median score = 4) was lower than the perceived threat of disease transmission to the family members (median score = 5). Access to personal protective equipment (PPE) was suboptimal but it significantly improved with the progression of the pandemic (p

Background Due to restrictions in social gatherings imposed due to the COVID-19 pandemic, physical and other daily activities were limited among the older adults. The present study aimed to estimate the change in osteoarthritis prevalence among older adults during the COVID-19 pandemic in Bangladesh. Methods This repeated cross-sectional study was conducted through telephone interviews among older adults aged 60 years and above on two successive occasions (October 2020 and September 2021) during the COVID-19 pandemic in Bangladesh. The prevalence of osteoarthritis was measured by asking the participants if they had osteoarthritis or joint pain problems. Results A total of 2077 participants (1032 in 2020-survey and 1045 in 2021-survey) participated in the study. The prevalence of self-reported joint pains or osteoarthritis significantly increased from 45.3% in 2020 to 54.7% in 2021 (P = 0.006), with an increasing odd in the adjusted analysis (aOR 1.27, 95% CI 1.04–1.54). We also found that osteoarthritis prevalence significantly increased among the participants from the Chattogram and Mymensingh divisions, aged 60–69 years, males, married, rural residents, and living with a family. A significant increase was also documented among those who received formal schooling, had a family income of 5000–10000 BDT, resided with a large family, were unemployed or retired, and lived away from a health facility. Conclusions Our study reported a significant increased prevalence of osteoarthritis among older adults from 2020 to 2021 during this pandemic in Bangladesh. This study highlights the need for the development and implementation of initiatives for the screening and management of osteoarthritis through a primary health care approach during any public health emergencies.

Introduction: Adherence to Iron-Folic Acid Supplementation (IFAS) in pregnant women can safeguard them against nutritional anemia and the related adverse pregnancy outcomes. The objective of this study was to assess the adherence to oral IFAS in women attending an antenatal clinic in an urban resettlement colony of Delhi, India. Material and Methods: We conducted a cross-sectional study and enrolled 211 antenatal women through consecutive sampling during a 4-month period from December 2018 to April 2019. IFAS adherent status was defined as women taking ≥80% of their prescribed IFAS in the previous 7 days, equivalent to IFAS intake for at least 6 days in the previous week. We also estimated adequacy of IFAS drug stocks with the patient during the past 30 days. The data were analyzed using IBM SPSS Version 25. A P < 0.05 was considered statistically significant. Results: The mean (± standard deviation) age of the women was 24.6 (±3.4) years, ranging from 19 to 35 years. Median years of education was 11, and all the women were currently married. A total of 54 (25.6) women reported being non-adherent to their prescribed IFA medication. Only 175 (82.9%) women had adequate IFAS stocks during the past 30 days. On adjusted analysis, running out of IFAS stocks was a significant predictor of IFAS non-adherence (P = 0.004). Conclusion: The present study indicates that adherence to IFAS among pregnant women is suboptimal. Non-adherence was usually because of running out of drug-stocks but rarely due to drug side-effects.

Background: Internet gaming disorder (IGD) is emerging as an important source of behavioral addiction in young people globally. Objective: The aim of this study was to assess addiction to internet gaming in medical students using a self designed research instrument. Materials and Methods: We conducted a cross-sectional study and enrolled 264 male and 160 female MBBS students (n = 424) in Delhi, India. The study instruments included: a 2-item Internet gaming screening questionnaire (IGSQ), a 14-item self-designed Internet gaming addiction scale (IGAS) to measure addiction-like behavior associated with multiplayer Internet gaming, and the Pittsburgh Sleep Quality Index to measure sleep quality. Results: After preliminary screening, 91 male and 6 female participants were found to be multiplayer Internet gamers, and were further assessed using the 14-item IGAS. The Cronbach's alpha of the IGAS was 0.879. Principal component analysis revealed a three-component IGAS structure based on eigenvalue cutoff (>1), loading score >0.4, and inspection of the scree-plot that explained 66.71% of the total variance. The IGAS score and the average weekly gaming time of the participants showed a moderate positive correlation (r = 0.45, P < 0.001). Only 17 (4.0%) participants reported agreement/strong agreement across ≥5 domains of addiction. The mean (standard deviation) IGAS score was significantly higher in the participants reporting poor sleep quality (PQSI > 6) (P = 0.047). Conclusion: IGD has low prevalence among medical students, and the problem is negligible among female students. The 14-item IGAS, in conjunction with the 2-item IGSQ, are reliable and valid tools for the assessment of IGD.

Background: Increasing stress has been recognized as a major public health problem in the developing world accelerated by an ongoing demographic, economic, and sociocultural transition. Our study objectives were to validate a Hindi version of the 10-item Perceived Stress Scale (PSS-10) and to also assess the extent of perceived stress and its correlates among an adult population in an urban area of Delhi. Methodology: A community-based cross-sectional study was conducted in an urban resettlement colony of Delhi among 480 adult subjects aged 25--65 years, during the period from January to December 2015. The PSS-10 was translated into Hindi and validated in the study population. Data was analyzed using IBM SPSS Version 25. Results: A total of 243 (50.6%) men and 237 (49.4%) women were enrolled. The scale had an acceptable level of internal consistency (Cronbach's alpha = 0.731). A principal component analysis was run on the PSS-10 data, based on which a three-component structure was accepted, which explained 61% of the total variance. The mean PSS score was 19.25 (SD = 4.50) years. Perceived stress was highest in the 35--50 age group. On multivariate analysis, low socioeconomic status and a white-collar occupation were found to be associated with increased perceived stress (P < 0.001)Conclusion: A high burden of perceived stress exists in residents of a low-income urban population in India.

Background: Despite the cultural sanctity and elevation of breastfeeding practices, nearly one in two Indian women nationwide are unable to practice exclusive breastfeeding (EBF). Early identification of mothers at risk of reduced breastfeeding through a suitable instrument can enable targeted interventions for breastfeeding support. Objectives: We conducted this study with the objectives of translation into Hindi and to psychometrically test the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) and to ascertain the sociodemographic and other correlates of breastfeeding self-efficacy. Methods: The BSES-SF was translated into Hindi using a back and forth translation process to ensure linguistic validity. We enrolled a total of 210 married women who were mothers of infants at an urban primary health center in Delhi, India. Results: The Cronbach's alpha for the Hindi translation of the BSES-SF was 0.87 with all except one correlation coefficient

Objective: To assess the determinants of out-of-pocket (OOP) expenses on diabetes-related treatment incurred in patients attending outpatient clinics in a tertiary care hospital in Delhi, India. Study Design: A cross-sectional analysis of baseline data from a quasi-experimental study was conducted over 8 months in 2016 in a major tertiary care hospital in Delhi. Methods: The study included 375 diabetes patients up to 65 years of age on treatment for at least a year without significant complications. Data were collected through a patient interview schedule. Results: Of the previous six scheduled appointments, at least two missed appointments were seen in 267 (71.2%) patients. The average patient's OOP expenditure on diabetes-related medicines was ₹63.5 a month, a similar amount was spent on traveling to and from health facilities. Sixty-four (17.1%) patients took antidiabetic medication for

Background & aim: Most maternal mortalities are preventable; however, there are significant regional and global disparities in this regard. Maternal Death Surveillance and Response (MDSR) launched in India is a continuous cycle of identification, notification, and review of maternal mortalities to improve the quality of care and prevent future deaths. The Ministry of Health and Family Welfare in India conducted five national capacity-building workshops for MDSR during October 2017 and February 2018 with the objective of training medical doctors as future trainers and developing competency-based skills for each component of the program. Methods: A training evaluation study was carried out on 144 workshop participants. Workshop outcomes in terms of trainees’ knowledge were assessed using a 20-item pre-post questionnaire and skill evaluations through group work. The data were analyzed using SPSS software (version 25). The difference in proportions was ascertained using the Chi-square test. Results: The mean score of the participants (n=144) increased from 13.2±2.3 in the pretest to 17±1.9 in the posttest (maximum score: 20). Themes generated during community and facility review sessions indicated the need for the capacity building of peripheral health facilities, sensitization for mandatory birth preparedness, complication readiness of all pregnant mothers by the frontline health workers, and regional-level MDSR training of all stakeholders involved in maternal mortality reporting. Conclusion: Training sessions were effective in the skill development of the participants in understanding the structure and function of the MDSR program.

Background: Tuberculosis (TB) during pregnancy accentuates the risk of adverse maternal and fetal outcomes, including perinatal deaths, preterm births, and low birth weight babies. Screening for active TB during pregnancy by healthcare providers can potentially allow early identification of the disease to initiate prompt treatment in this vulnerable population. Objectives: To determine the yield of presumptive TB using the four symptom complex screening model as an intensified case finding tool. Methods: We conducted a prospective observational study among pregnant women attending the outpatient antenatal clinics at a secondary and tertiary care government hospital in Delhi, India from February to July 2020. The participants were symptomatically screened for presumptive TB and appropriately referred for smear examination at designated microscopy centers. Results: We recruited a total of 1306 participants in the study, having a mean (S.D.) age of 24.9 (3.9) years. The yield of presumptive tuberculosis among pregnant women attending the antenatal clinic was 3.0% (95% CI: 2.1–3.9) and the yield of TB was 0.23%. Multigravida mothers (aPR = 2.1, 95% CI: 1.04–4.4), Muslim religion (aPR = 2.8, 95% CI: 1.5–5.4) and mothers in the first trimester (aPR = 3.4, 95% CI: 1.6–7.4) had a statistically significant higher prevalence of presumptive TB than primigravida, non-Muslims and other trimesters respectively. Conclusion: The yield of TB obtained through systematic symptom screening was low among antenatal women attending the two antenatal health clinics of Delhi. However, the process has minimal resource requirements which advocate its implementation among pregnant mothers as per the recommendations from the collaborative framework for management of TB in pregnant women.

Background: Poor oral health status is more likely among socioeconomically disadvantaged women and low literacy due to poor oral hygiene. Onset of menopausal symptoms also triggers hormonal changes, adversely influencing oral health. The study objective was to determine the self-reported oral health status and self-care practices among perimenopausal women attendees of the medical outpatient department of a government hospital in Delhi, India Methods: We conducted a cross-sectional study at a secondary care hospital among 136 women aged 40-59 years, having either perimenopause symptoms or with menopause. Data were collected through face-to-face interviews using the Hindi version of the WHO Steps Module on Oral Health. A p-value < 0.05 was considered statistically significant. Results: Sixty-nine (51.2%) participants had not received any schooling. Oral health status was reported as average or poor by 61 (44.85%) and 59 (43.4) participants for their teeth and gums, respectively. Pain or discomfort in teeth was reported by 77 (56.6%) participants, along with chewing 66 (48.5%) and speech difficulties 21 (15.4%). Most participants 114 (83.8%) brushed their teeth only once a day, and rarely (3.7%) flossed. Participants with low education and a greater number of missing teeth were significantly more likely to report suboptimal dental health status. Conclusion: A large proportion of mid-life socioeconomically vulnerable women in India report poor oral health and hygiene with self-perceived suboptimal teeth or gum status. Visually oriented information, education, and communication (IEC) campaigns for oral health promotion should be evaluated in public health facilities.

Complete postexposure prophylaxis with 4 doses of anti-rabies vaccine (ARV) in a previously vaccinated (nonnaïve) individual results in administration of two extra ARV doses resulting in wastages of precious resources comprising vaccine logistics, human resources, physician, and patient time. This cross-sectional study conducted in a secondary care hospital in Delhi among 175 incident animal bite cases observed 39 (22.3%) had an animal-bite history within the previous 5 years. A total of 19 (10.8%) cases reported a history of complete ARV vaccination during a previous animal-bite exposure. However, in the absence of supportive patient medical documentation, all the animal bite cases without exception were prescribed a full course of ARV irrespective of their previous exposure status. Rabies immunoglobulins (anti rabies serum) were also re-administered in 13 (81.2%) cases. National guidelines for rabies prophylaxis should, therefore, consider the inclusion of an explicit decision-making algorithmic mechanism when the health-care provider is confronted with this situation carrying the potential for hidden vaccine wastage.

Background: Delayed vaccination in infants significantly increases the susceptibility window for vaccine preventable diseases. Objective: We conducted a retrospective audit of secondary data to determine the rates of delayed vaccination among infants reporting for routine immunization at an urban primary healthcare clinic in Delhi, India. Methods: Data were extracted from the manual register of the health clinic and entered in MS-Excel 2013. Results: We analyzed a total of 811 vaccination encounters in infants. Delayed vaccination was observed in 144 (17.8%) vaccination encounters. The proportion of delayed vaccination encounters progressively increased from penta-1 (lowest) to penta-3 (highest). However, the proportion of overall delayed vaccination encounters did not differ significantly across gender (P = 0.71). Conclusions: Delayed vaccination among infants continues to exist as a significant but largely avoidable public health challenge in certain health settings in India.

Improving patient survival and quality of life in chronic diseases requires prolonged and often lifelong medication intake. Less than half of patients with chronic diseases globally are adherent to their prescribed medications which preclude the full benefit of treatment, worsens therapeutic outcomes, accelerates disease progression, and causes enormous economic losses. The accurate assessment of medication adherence is pivotal for both researchers and clinicians. Medication adherence can be assessed through both direct and indirect measures. Indirect measures include both subjective (self-report measures such as questionnaire and interview) and objective (pill count and secondary database analysis) measures and constitute the mainstay of assessing medication adherence. However, the lack of an inexpensive, ubiquitous, universal gold standard for assessment of medication adherence emphasizes the need to utilize a combination of measures to differentiate adherent and nonadherent patients. The global heterogeneity in health systems precludes the development of a universal guideline for evaluating medication adherence. Methods based on the secondary database analysis are mostly ineffectual in low-resource settings lacking electronic pharmacy and insurance databases and allowing refills without updated, valid prescriptions from private pharmacies. This significantly restricts the choices for assessing adherence until digitization of medical data takes root in much of the developing world. Nevertheless, there is ample scope for improving self-report measures of adherence. Effective interview techniques, especially accounting for suboptimal patient health literacy, validation of adherence questionnaires, and avoiding conceptual fallacies in reporting adherence can improve the assessment of medication adherence and promote understanding of its causal factors.

Background: Mobile phone addiction is a type of technological addiction or nonsubstance addiction. The present study was conducted with the objectives of developing and validating a mobile phone addiction scale in medical students and to assess the burden and factors associated with mobile phone addiction-like behavior. Materials and Methods: A cross-sectional study was conducted among undergraduate medical students aged ≥18 years studying in a medical college in New Delhi, India from December 2016 to May 2017. A pretested self-administered questionnaire was used for data collection. Mobile phone addiction was assessed using a self-designed 20-item Mobile Phone Addiction Scale (MPAS). Data were analyzed using IBM SPSS Version 17. Results: The study comprised of 233 (60.1%) male and 155 (39.9%) female medical students with a mean age of 20.48 years. MPAS had a high level of internal consistency (Cronbach's alpha 0.90). Bartlett's test of sphericity was statistically significant (P < 0.0001), indicating that the MPAS data were likely factorizable. A principal component analysis found strong loadings on items relating to four components: harmful use, intense desire, impaired control, and tolerance. A subsequent two-stage cluster analysis of all the 20-items of the MPAS classified 155 (39.9%) students with mobile phone addiction-like behavior that was lower in adolescent compared to older students, but there was no significant difference across gender. Conclusion: Mobile phone use with increasing adoption of smartphones promotes an addiction-like behavior that is evolving as a public health problem in a large proportion of Indian youth.

Background Noncommunicable diseases (NCDs) are responsible for more than two-third cases of premature mortality (30–69 years) in India. Screening for NCDs is the most effective means for detection of undiagnosed NCD cases and early treatment initiation that lowers morbidity and mortality due to these diseases. The objective of the present study was to assess the NCD screening status in an urban resettlement colony of Delhi. Materials and Methods A community-based cross-sectional study was conducted among residents of the area. Patients with preexisting hypertension and diabetes and aged below 30 years were excluded. The patients were further screened for hypertension by taking three separate readings using an aneroid sphygmomanometer. The Indian Diabetes Risk Score (IDRS) was calculated to evaluate diabetes risk. Results A total of 110 men and 103 women (N = 213) met the inclusion criteria. The mean (±standard deviation) age of the patients was 40 (±9.3) years. A history of previous screening for hypertension and diabetes was reported by 73 (34.2%) and 40 (35.4%) patients, respectively. A medium or high-risk of having diabetes mellitus as per the IDRS score was present in most (88.4%) patients. On current screening, nine (8.2%) men and nine (8.7%) women were identified as undiagnosed hypertension cases. Only four (3.8%) women had undergone a clinical breast exam, and just nine (8.7%) women ever had a Pap smear examination. Conclusion The present study shows that the current strategy of opportunistic screening for NCDs has been unable to reach large segments of vulnerable and at risk populations.

Obesity in both children and adults is a major public health problem globally and is also increasing in the developing world which contributes to the epidemic of early onset of non-communicable diseases and associated premature mortality. Dietary consumption of unhealthy foods rich in sugar, salt and saturated fats is a significant risk factor for obesity. There is growing evidence that taxation on sugar sweetened beverages (SSBs) and fat rich foods along with restricting access to such unhealthy foods in school premises can shift dietary consumption patterns of school students towards healthier foods and reduce their risk of developing obesity and lifestyle diseases. However, despite some limited initiatives, the application of taxes on SSBs as a public health intervention have yet to be unequivocally applied in Indian settings due to inadequate advocacy from public health groups and political reluctance due to the industry being a major source of tax revenue. Efforts in combating obesity through tax on unhealthy foods like SSBs and fats is overdue in India but the barriers and challenges against their successful implementation cannot be overlooked. These include the necessity of application of a sufficiently high tax which would compel manufacturers of unhealthy foods like SSBs to pass the burden of the tax upon consumers by significantly increase retail prices. Furthermore, India's vast informal food sector producing local counterparts of branded SSB and fat foods should not be spared and kept out of the taxation net out of any political considerations. Similarly, the restriction on sale of unhealthy foods in school premises should also include implementation in areas and markets in the vicinity to which students have easy access.