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Background- Menstruation is a major physiological change in a woman's life, but lack of knowledge, poor practices, socio-cultural barriers, poor access to products and their improper disposal have significant consequences on health, dignity and well-being of women and adolescent girls. Objectives-This study aimed to assess the knowledge and practices related to menstrual health and hygiene amongst females of 10-49 years of age; explore the experiences and challenges of women during menstruation; and identify the key predictors of healthy menstrual health and hygiene. Methods- Using a cross-sectional study design, we adopted a mixed methods approach for data collection. For quantitative household survey, a total of 921 respondents were selected from three districts of Odisha. Qualitative findings through focus group discussions and in-depth interviews supplemented the survey findings and helped to identify the barriers affecting good menstrual practices. Epi data version 2.5 and R 4.2.2 was used for data entry and data analysis, respectively. Descriptive statistics was used to calculate proportion, mean and standard deviation; Chi square test was used to measure the association between categorical variables. Bivariate and multivariate logistics analyses were done to identify predictors of healthy menstrual health and hygiene. Results-For 74.3% respondents, mothers were the primary source of information; about 61% respondents were using sanitary pad. The mean age at menarche was 12.9 years and almost 46% of respondents did not receive any information about menstruation before menarche. Lower age and education up to higher secondary level or above had statistically significant associations with the knowledge about menstruation. Age, caste, mother’s education, sanitation facility, and availability of water were found to be strongly associated with good menstrual hygiene practices. Conclusion-Traditional beliefs regarding menstruation still persists at the community level. Educating mothers, increasing awareness about safe menstrual hygiene, providing adequate water and sanitation facilities and ensuring proper disposal of menstruation products need priority attention.

Background Reaching hard to reach populations is key to reduce health inequities. Despite targeted interventions, status of crucial public health indicators like neonatal and maternal mortality is still far from optimal. Complex interplay of social determinants can influence both communities and health care workers to effectively access each other. We argue that culturally sensitive and contextually relevant healthcare provision has potential to increase health care utilization by the vulnerable communities living in remote areas. Methods The study is an exploratory case study using rapid ethnographic techniques to understand the interplay of social determinants in hard to reach areas of Odisha state, India. We used in-depth interviews, focus group discussion, participatory action research and key informant interviews as tools for data collection. The analysis of data has been guided by thematic analysis approach. Results We found that there are further layers within the designated hard to reach areas and those can be designated as-i) extremely remote ii) remote and iii) reachable areas. Degree of geographic difficulties and cultural dynamics are deciding the ‘perceived’ isolation and interaction with health care providers in hard to reach areas. This ultimately leads to impacting the utilization of the facilities. At extremely remote areas, felt health needs are mainly fulfilled by traditional healers and ethno-medical practices. In reachable areas, people are more prone to seek care from the public health facilities because of easy accessibility and outreach. Being in middle people in remote areas, diversify health care seeking depending upon social (e.g. patient’s gender) economic (e.g. avoid catastrophic expenditure) and health system (timely availability of health human resources, language barriers) factors. Conclusion Our research highlights the need to value and appreciate different worldviews, beliefs and practices, and their understanding of and engagement with the pluralistic health care system around them. Other than pursuing the ‘mainstreaming’ of a standardized health system model across hard to reach areas, strategies need to be adaptive as per local factors. To handle that existing policies need revision with a focus on culturally sensitive and contextual care provision.

Climate change poses severe threats to the social, cultural, and economic integrity of indigenous smallholder subsistence farmers, who are intricately linked with their natural ecosystems. Sauria Paharia, a vulnerable indigenous community of Jharkhand, India, are smallholder farmers facing food and nutrition insecurity and have limited resources to cope with climate change. Eighteen villages of Godda district of Jharkhand inhabited by Sauria Paharia community were randomly selected to conduct a mixed methods study. In 11 out of 18 study villages, we conducted focus group discussions (FGDs) to examine the perception of this indigenous community regarding climate change and its impact on agroforestry and dietary diversity. In all 18 villages, household and agricultural surveys were conducted to derive quantitative estimates of household food consumption patterns and agroforestry diversity, which were triangulated with the qualitative data collected through the FGDs. The FGD data revealed that the community attributed local climatic variability in the form of low and erratic rainfall with long dry spells, to reduced crop productivity, diversity and food availability from forests and waterbodies. Declining agroforestry-produce and diversity were reported to cause reduced household income and shifts from subsistence agricultural economy to migratory unskilled wage laboring leading to household food insecurity. These perceptions were supported by quantitative estimates of habitual food consumption patterns which revealed a predominance of cereals over other food items and low agroforestry diversity (Food Accessed Diversity Index of 0.21 ± 0.15). The adaptation strategies to cope with climate variability included use of climate-resilient indigenous crop varieties for farming, seed conservation and access to indigenous forest foods and weeds for consumption during adverse situations and lean periods. There were mixed views on cultivation of hybrid crops as an adaptation strategy which could impact the sustained utilization of indigenous food systems. Promoting sustainable adaptation strategies, with adequate knowledge and technology, have the potential to improve farm resilience, income, household food security and dietary diversity in this population.

Climate-related uncertainty refers to the inability to predict the scale, intensity, and impact of climate change on human and natural environments. Debates of uncertainty in climate change have emerged as a ‘super wicked’ problem for scientists and policy makers alike. The article draws on ongoing research in different socio-ecological and cultural settings in India (Kutch, the Sundarbans and Mumbai) and introduces the heuristic of the ‘above’, ‘middle’ and ‘below’ to explore how climate change and uncertainty are understood and experienced by diverse actors. Responses from ‘above’ (especially by planners and policy makers) tend to be directed towards controlling uncertainty through top-down, techno-managerial solutions whereas scientists tend to rely on quantitative assessments and models based on probabilistic scenarios. These may have little to do with the experiences and lived realities of local people, especially in the global South, who are often at the frontline of climate change. Also at the local level, climate-related uncertainties seldom stand alone, rather they closely interact with other socio-economic drivers of change that create new uncertainties and vulnerabilities, especially for poor and powerless people constraining their adaptation choices. This article demonstrates deep differences in ways different actors understand and experience climate change and uncertainty. It argues that diverse knowledge and approaches need to be deployed to understand and embrace climate related uncertainties in order to facilitate socially just adaptation.

Background: Odisha, a developing state of India, has introduced an innovative scheme known as Biju Swasthya Kalyan Yojana (BSKY), which aims at providing free health care to all the people. This paper examines the scope, key features, challenges and potentiality of BSKY to achieve universal health coverage (UHC) in Odisha.Methods: We reviewed policy documents and conducted qualitative interviews with key state government officials and other stakeholders to understand implement processes and constraints.Results: The scheme intends to provide free health care to all people in public health care institutions and additionally, 71 lakh poor households can avail health care services from the empanelled private hospitals with financial coverage up to 5 lakhs per family and women members up to 10 lakhs annually. This is implemented in assurance mode by merging state-run schemes- Rashtriya Swasthya Bima Yojana (RSBY), Biju Krushak Kalyan Yojana (BKKY) and Odisha State treatment fund (OSTF). The implementing agency is introducing several measures to control unnecessary health care utilisation and cost. Gate keeping mechanism and reserved packages by public hospital are major initiatives in this direction. Further, efforts to settle claims on time and IT related challenges are teething problems of the scheme. The findings further suggest that public expenditure on health stands at 1.3% of GSDP and inadequate human resources and health infrastructure are affecting service delivery.Conclusions: Achieving UHC with such a low public spending on health and different service delivery constraints looks ambitious. Odisha may learn from other countries to implement UHC phase wise.

Background Effective stakeholder engagement in research and implementation is important for improving the development and implementation of policies and programmes. A varied number of tools have been employed for stakeholder engagement. In this paper, we discuss two participatory methods for engaging with stakeholders – participatory social network analysis (PSNA) and participatory impact pathways analysis (PIPA). Based on our experience, we derive lessons about when and how to apply these tools. Methods This paper was informed by a review of project reports and documents in addition to reflection meetings with the researchers who applied the tools. These reports were synthesised and used to make thick descriptions of the applications of the methods while highlighting key lessons. Results PSNA and PIPA both allowed a deep understanding of how the system actors are interconnected and how they influence maternal health and maternal healthcare services. The findings from the PSNA provided guidance on how stakeholders of a health system are interconnected and how they can stimulate more positive interaction between the stakeholders by exposing existing gaps. The PIPA meeting enabled the participants to envision how they could expand their networks and resources by mentally thinking about the contributions that they could make to the project. The processes that were considered critical for successful application of the tools and achievement of outcomes included training of facilitators, language used during the facilitation, the number of times the tool is applied, length of the tools, pretesting of the tools, and use of quantitative and qualitative methods. Conclusions Whereas both tools allowed the identification of stakeholders and provided a deeper understanding of the type of networks and dynamics within the network, PIPA had a higher potential for promoting collaboration between stakeholders, likely due to allowing interaction between them. Additionally, it was implemented within a participatory action research project. PIPA also allowed participatory evaluation of the project from the perspective of the community. This paper provides lessons about the use of these participatory tools. Electronic supplementary material The online version of this article (doi:10.1186/s12961-017-0271-z) contains supplementary material, which is available to authorized users.

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Background The Indian Sundarbans is marked by inhospitable terrain and frequent climatic shocks which jointly hinder access to health care. Community members, and women in particular, have few means to communicate their concerns to local decision makers. Photovoice is one way in which communities can raise their local health challenges with decision makers. This study unlocks mothers’ voices on the determinants of their children’s health to inform local level decision-making on child health issues in the Indian Sundarbans. Methods Photovoice action research was conducted in three blocks in the Sundarbans region of West Bengal, India. The project involved eight groups of eight to ten mothers who had at least one child below 6 years of age across four villages. The mothers received training on photo documentation and ethical concerns before taking two rounds of photographs within 6 months, interspersed by fortnightly group meetings facilitated by researchers. Photographs and key messages were communicated to local decision makers during block and village level interface sessions with the mothers and researchers. Results Mothers’ photos focused on specific determinants of health, such as water and sanitation; health status, such as malnutrition and non-communicable diseases; service accessibility; climate conditions; and social issues such as early marriage and recurrent pregnancy. Some issues were not captured by photos but were discussed in group meetings, including domestic violence and the non-availability of medical practitioners. We found differences by mother’s educational status, livelihood and caste identity in the extent and nature of photographs taken. As a result of the mother’s interface with community decision makers, which included showcasing a selection of their photos, efforts to improve road infrastructure and human resource availability in the primary health centres and local government were realized. Conclusion Photovoice has the potential to express the voices of vulnerable communities regarding their health needs and can help them dialogue with local decision makers to inform community health policy and planning. More needs to be done to understand how social differences among photovoice participants influences how they engage with the methodology.

Background Lack of credible evidence on health challenges of vulnerable populations is a fundamental barrier to reach equitable health outcomes. There is need for mobilising various stakeholders using evidence through effective research/policy linkages. This process is seldom linear and needs to account for stakeholder needs, wider socio-political context, policy development process, changing priorities of stakeholders and differences in their knowledge and ability to use evidence. In this paper, we analyse the development of a knowledge intervention project conducted in one disadvantaged region, the Sundarbans, West Bengal, within a project that aims to engage and mobilise stakeholders for promoting collaborative action for child health. Methods We used a longitudinal multi-method longitudinal approach. Data were collected from project-related one-to-one and group meetings with stakeholders, plans, dissemination and engagement events, monitoring reports, capacity-building activities, stakeholder analysis, theory-of-change diagrams and publications. Our study started in 2012–2013 and is still on-going. Findings At the start of the project we conducted a stakeholder analysis to understand roles, perceptions on use of evidence for decision-making and power to influence change of the actors involved. We found that the academic community, nonprofit non-governmental organisations (NGOs), media, donor agencies and informal healthcare providers were interested in health issues of the region. They wielded moderate to low influence on health matters. Government emerges as both a major in health service provision and a major driver to change. All stakeholders felt a need for generating evidence and for improving collaboration with researchers for knowledge sharing. Need was also felt to mobilise NGOs through capacity development and engagement. Though media scan revealed that journalists were interested in the health sector, their sparse knowledge on health systems prevented them from observing and comprehensively reporting the health demands of the community. Inputs from our stakeholder analysis allowed the development of a knowledge intervention project and a theory of change. The project was designed with three elements: (1) knowledge generation; (2) engagement with and mobilisation of stakeholders using knowledge; and (3) capacity building. The project used multiple dissemination modes including one-to-one meetings, group discussions and evidence dissemination events to engage and mobilise stakeholders. Over time, the project underwent important changes that informed the policy engagement strategy. There was a shift in focus from deliverables to sustained engagement with health system actors. Two years after its introduction, the project again revised its theory of change to focus more on improving research/policy linkages for influencing change. Despite a robust dissemination strategy, the need for policy-driven research became prominent. Discussions with various state and local stakeholders revealed the need for evidence on contextual issues, specifically on how climate and migration impact health in the region. These discussions also prompted a bottom-up approach to disseminating evidence and engaging stakeholders. This resulted in capacity-building workshops for NGOs, to develop project proposals on child health, to engage with local media, and to use innovative action-research techniques like photo voice. The latter enabled bringing together local government ( Panchayat ) and health functionaries face-to-face with the community, deliberating the community9s health demands. Discussion The importance of dynamic, policy-driven and credible research in affecting collaborative actios has been widely documented in literature. Our experience in the present study adds to the understanding of how heterogeneous stakeholder groups can be approached. Generating evidence for priority policy issues and engaging with the community helped in bridging the gaps between research and policy. In this context involving grassroots NGOs and media was a critical step. Our experience shows that knowledge translation strategies need to move from static dissemination outputs to multi-method, responsive and dynamic modes of engagement with multiple stakeholders, including non-health actors. For this shift to positively impact collaborative action, capacity building is a prerequisite. Grant funding (to Future Health Systems Research Consortium by DfID – Department for International Development, London, UK) for research but no other competing interests .

Background Child health status in the Indian Sundarbans – the delta region in the southeast part of West Bengal – is characterized by chronic malnutrition and high prevalence of communicable diseases, and greatly determined by socio-economic and political factors. Mothers9 perception regarding determinants of child health is pertinent to strengthen community level decision-making on health service delivery. In the present study we used ‘photo voice’, a visual action research technique, to glean the perception of the mothers on their children9s health and its determining factors. Methods For the present study, the photo voice technique was conducted in three randomly selected blocks of the Indian Sundarbans, with three groups each (average 8–10 members), the members having at least one child in the age range 0–6 years. Training about the technical process of photo documentation was conducted with each group prior to the research. Respondents took two rounds of photographs within six months, interspersed by fortnightly group meets with researchers as facilitators. The research findings were later communicated to different community policy stakeholders during policy interface sessions. Findings Respondents stressed on specific health issues – disabilities, mental health and non-communicable diseases of their children – that they could manifest through photo, other than documenting common and frequently occurring communicable diseases. While reflecting on the determinants, respondents9 photos and narratives focused on determinants of child health which they prioritise on the basis of lived experiences. The determinants that figured prominently included: (1) food insecurity and related malnutrition among the children; (2) livelihood; (3) shelter; (4) water and sanitation; (5) poor healthcare services; (6) accessibility issues; (7) general health and hygiene awareness; and (8) climate. During the group meets, respondents also stressed on social factors not captured trough photo, including early marriage, recurrent pregnancies and domestic violence. While selecting the priority issues to be presented in the interfaces with community policymakers, respondents selected five issues: (1) malnutrition; (2) livelihood; (3) water and sanitation hygiene; (4) accessibility; and (5) rupture of embankments. During interfaces with local non-government organisations, key community leaders and local health providers, respondents stressed on these determinants, which according to them are intertwined and should be considered in conjunction for improving the health of their children. Respondents9 interface with community policymakers resulted in initiation of road infrastructure, human resource availability in the primary health centres and local government representatives raising related demands at the key forum and committees dedicated to planning on convergence. Discussion Photo voice has the potential in voicing community9s knowledge regarding the determinants of health of their children through the eyes of the mothers. Our study explored the perceived health determinants of geo-climatically vulnerable population of the Sundarbans. The study adds to the existing knowledge of difference in perception of policymakers and implementers of the health system, who have a tendency to compartmentalise issues in terms of health and non-health spheres on the one hand, and the community members viewing health of their children as an integrated phenomenon on the other hand. Our study explored the social determinants of child health through a feminist lens, a major theoretical underpinning of photo voice as a community-based action research method. It also seeked to voice vulnerable populations9 knowledge grounded in experience and to recognize local expertise, an insight that cannot be fully realised from the outside, as against the sectoral perceptions of the largely masculine power and pre-dominantly male bastion of decision-makers in most policy bodies. Our study thus adds to existing literature of how participatory action research techniques like community-owned documentary photography and narratives will empower vulnerable populations to record community health as an integration of medical and socio-political factors to inform basic health policy. Grant funding (DfID – Department for International Development, UK) for research but no other competing interests .

Background In this paper, we describe preliminary findings from an on-going capacity-building project that engages local media as key facilitator to achieve convergence across various health system policy initiatives in a disadvantaged region, the Indian Sundarbans, West Bengal. The purpose is to understand whether and how local media could be used to push for intersectoral action based on the health demands of the community. Subsequently, the project aims at building capacity of the local media for effective advocacy and context-specific facilitation. Methods In the first stage, we performed a detailed scan of news stories from five purposively chosen local print media spanning one-year duration. We simultaneously conducted in-depth interviews with community representatives and local media journalists/owners to explore the role of local media in Sundarbans9 health system. In the on-going second stage, we conduct participatory training workshops with local media associations to orient them on how to better represent the community9s health demands. We provide mentorship to journalists as and when required. Findings News scan and interviews with community representatives and local media journalists/owners on the one hand identified many a range of knowledge gaps among journalists and media owners regarding community9s specific health demands. Community representatives on the other hand see local media as a potential resource to influence community-level policy dynamics and to achieve intersectoral convergence. The identified knowledge gaps, as reflected in media reportage on health, persists in several areas: (1) representation of community9s health demands; (2) details about basic health system elements; (3) links health services with contextual determinants; and (4) use of research findings while making a case. Media reportage on health was predominantly on issues related to curative care (68%) and much less about preventive care and health promotion. Except for a few news stories constituting mere 3.4% of health coverage that were about access and mid-day meal schemes (under Integrated Child Development Scheme), the media did not highlight systemic factors and policy determinants to meet the community9s context-specific health demands. On-going news scan, following a first round of capacity building of local media associations, reveals that health reportage is gradually increasing. A total 2.3% increase in health reportage has been observed in last six-months. Research findings are being used either as standalone stories or to build a case. There has been demand from journalists9 associations from other blocks (geographic units) for similar capacity-building initiatives. Media associations have linked up with the health department and other related departments engaged in improving health services. They also have linked up with community-based organisations for outdoor dissemination of health messages among the community through an edutainment format. Discussion There is need for planned and sustained capacity building of local media for them to play a larger role in facilitating intersectoral action on health. The community9s faith in local media provides an opportunity to act as a conduit for policy actors on intersectoral action. A structured and sustained knowledge sharing with the media on health systems would create an enabling health policy environment for uptake of evidence-informed research, and eventually for better health. Our study has potential to add to the existing knowledge in areas of health system strengthening as well as media and communication research. We hope it encourages researchers to consider the integrating role of media and communication in health system studies as related to intersectoral action for health, as well as uptake of community knowledge and research evidence into policy-making processes. Grant funding (to Future Health Systems Research Consortium by DfID – Department for International Development, London, UK) for research but no other competing interests .

Banalata Sen and colleagues call for urgent and inclusive action to address health impacts of climate change in South Asia