To leave no one behind: Assessing utilization of maternal newborn and child health services by all the 13 particularly vulnerable tribal groups (PVTGs) of Odisha, India.

BACKGROUND: Indigenous tribal people experience lower coverage of maternal, newborn and child healthcare (MNCH) services worldwide, including in India. Meanwhile, Indian tribal people comprise a special sub-population who are even more isolated, marginalized and underserved, designated as particularly vulnerable tribal groups (PVTGs). However, there is an extreme paucity of evidence on how this most vulnerable sub-population utilizes health services. Therefore, we aimed to estimate MNCH service utilization by all the 13 PVTGs of the eastern Indian state of Odisha and compare that with state and national rates. METHODS: A total of 1186 eligible mothers who gave birth to a live child in last 5 years, were interviewed using a validated questionnaire. The weighted MNCH service utilization rates were estimated for antenatal care (ANC), intranatal care (INC), postnatal care (PNC) and immunization (for 12-23-month-old children). The same rates were estimated for state (n = 7144) and nationally representative samples (n = 176 843) from National Family Health Survey-5. RESULTS: The ANC service utilization among PVTGs were considerably higher than national average except for early pregnancy registration (PVTGs 67% versus national 79.9%), and 5 ANC components (80.8% versus 82.3%). However, their institutional delivery rates (77.9%) were lower than averages for Odisha (93.1%) and India (90.1%). The PNC and immunization rates were substantially higher than the national averages. Furthermore, the main reasons behind greater home delivery in the PVTGs were accessibility issues (29.9%) and cultural barriers (23.1%). CONCLUSION: Ours was the first study of MNCH service utilization by PVTGs of an Indian state. It is very pleasantly surprising to note that the most vulnerable subpopulation of India, the PVTGs, have achieved comparable or often greater utilization rates than the national average, which may be attributable to overall significantly better performance by the Odisha state. However, PVTGs have underperformed in terms of timely pregnancy registration and institutional delivery, which should be urgently addressed.

Development, validation & pilot testing of a questionnaire to assess healthcare seeking behaviour, healthcare service utilization & out-of-pocket expenditure of Particularly Vulnerable Tribal Groups of Odisha, India.

Background & objectives: Assessing healthcare seeking behaviour (HSB), healthcare utilization and related out-of-pocket expenditures of Particularly Vulnerable Tribal Groups (PVTGs) of India through a prism of the health system may help to achieve equitable health outcomes. Therefore, this comprehensive study was envisaged to examine these issues among PVTGs of Odisha, India. However, there exists no validated questionnaire to measure these variables among PVTGs. Therefore, a study questionnaire was developed for this purpose and validated. Methods: Questionnaire was constructed in four phases: questionnaire development, validity assessment, pilot testing and reliability assessment. Nine domain experts face validated questionnaire in two rounds, followed by a single round of quantitative content validity. Next, the questionnaire was pretested in three rounds using cognitive interviews and pilot-tested among 335 and 100 eligible individuals for the two sections healthcare seeking behaviour (HSB-Q) and maternal and child healthcare service utilization (MCHSU-Q). Internal consistency reliability was assessed for de novo HSB-Q. Results: On two rounds of expert-driven face validity, 55 items were eliminated from 200 items. Questionnaire showed moderate to high content validity (item-level content validity index range: 0.78 to 1, scale-level content validity index/universal agreement: 0.73; scale-level content validity index/average: 0.96 and multirater kappa statistics range: 0.6 to 1). During the pre-test, items were altered until saturation was achieved. Pilot testing helped to refine interview modalities. The Cronbach alpha and McDonald's omega assessing internal consistency of HSB-Q were 0.8 and 0.85, respectively. Interpretation & conclusions: The questionnaire was found to be valid and reliable to explore healthcare seeking behaviour, maternal and child healthcare utilization and related out-of-pocket expenditure incurred by PVTGs of Odisha, India.

To what extent classic socio-economic determinants explain trends of anaemia in tribal and non-tribal women of reproductive age in India? Findings from four National Family Heath Surveys (1998-2021).

BACKGROUND: Despite unprecedented socio-economic growth experienced by Indians in the past few decades, and a long history of anti-anaemia public health measures, prevalence of anaemia in Indian non-pregnant women of reproductive age group (NPWRA) has not declined. This warrants a firm understanding of what explains the anaemia situation over time, preferably by sub-populations. Therefore, we aimed to examine the trends of anaemia in tribal NPWRA (least privileged) and compare with the trends in the NPWRA of general caste (most privileged) between 1998 to 2021. Additionally, the study also explored explanation of any decline and tribal/general narrowing of these trends. METHODS: We studied four rounds of National Family Health Survey (1998-99, 2005-06, 2015-16, 2019-21). We examined the trend of anaemia (haemoglobin < 12 g/dl) and its possible determinants in tribal and general NPWRA and estimated the portion of "decline" and "narrowing" that could be explained by the underlying and intermediate determinants (wealth, education, residence, parity and food security) using multiple logistic regression. RESULTS: The distribution of determinants improved over 23 years in both the groups but more in tribals. But anaemia either remained unchanged or increased in both except 7.1 points decline in tribals between 2006-2016, leading also to 7 points narrowing of tribal/general gap. The modest attenuation of beta coefficients representing the change of anaemia prevalence (log of odds) in tribals from -0.314(-0.377, -0.251) to -0.242(-0.308, -0.176) after adjustment with determinants could explain only 23% of the decline. Similarly, only 7% of the narrowing of the tribal/general anaemia gap could be explained. CONCLUSIONS: The structural determinants wealth, education, food security, parity and urban amenities improved immensely in India but anaemia did not decline in this 23-year period. This implies that the "usual suspects" - the structural determinants are not the main drivers of anaemia in the country. The main driver may be absolute and/or functional deficiency status of micronutrients including iron attributable to inadequate uptake and absorption of these elements from Indian diets; and therefore, their effects are noticeable in every socio-economic stratum of India. Future research for aetiologies and new interventions for anaemia alleviation in India may focus on these factors.

An ethnographic approach to understand cultural perspectives of tribes on branding practice for sick children in Odisha, India.

Background & objectives: Traditional beliefs on child healthcare at time lead to potentially harmful practices like branding. However, there is a gap in people's perceptions, attitudes and beliefs about branding practice. Therefore, the present study was undertaken to document the cultural motivation, ability and opportunity for branding practice in a tribal district of Odisha, India. Methods: Initially, such practices were observed in the tribal community for three months. Then, 18 in-depth interviews were conducted - ten among women having under-five children, and eight among traditional healers. Six focus group discussions were conducted with community health workers as well. The responses were digitally recorded, transcribed and translated and were further used for thematic framework analysis. Results: The primary determinants of branding practice were cultural beliefs compounded with low-health literacy, proximity to conventional care and influence of family and friends. The key driver for branding practices was traditional cultural beliefs on child healthcare decisions and health-seeking behaviours. Opportunities in the health system - availability and quality of health services - frequently drive them to seek healthcare from the system structure and routine health communication improves their ability to make better healthcare decisions. Interpretation & conclusions: Culture significantly affects the conceptualisation of illness and care-seeking pathways in a society. The indigenous community used to consult local traditional healers for their health concerns. While the government has made efforts to increase community health literacy through various platforms and multiple stakeholders' engagements, the doorstep availability of modern care and health promotion interventions remains critical for meeting the health needs of the indigenous community.

Out-of-pocket expenditure and its predictors for illness of under-five children: A cross-sectional study in urban slums of Eastern India.

INTRODUCTION: Out-of-pocket (OOP) expenditure influences the access to the healthcare of the marginalized and vulnerable population including under-five children (U5C). The aim of the study is to estimate the OOP expenditure and its predictors in Bhubaneswar, a region of eastern India. METHODS: A cross-sectional study was conducted using a semi-structured interview schedule in 20 urban slums of Bhubaneswar. The survey was carried out by using the National Sample Survey Office (NSSO) health consumption schedule 25.0 in which mothers of U5C with illness (n = 530) were interviewed. For data analysis, the nonparametric Wilcoxon rank-sum test and Kruskal-Wallis test were used as tests of significance. RESULTS: The study revealed that the mean OOP expenditure for outpatient department (OPD) care was ₹375.9 (₹219.48). The mean approximated expenditure was ₹1669.8 (₹1131.9) for inpatient department (IPD) care. In OPD care, doctors' fee and medicine cost constituted 65.01% and 50.46% of OOP expenditure, respectively. In IPD care, medicine cost and doctors' fee contributed to 36.62% and 30.54% of OOP expenditure, respectively. The major significant predictors that contributed to increased OOP were gender and delay in approaching the source of treatment in OPD, whereas in IPD no such predictors were observed. CONCLUSIONS: This study prominently sheds light on the issue of accessibility and affordability of health services without a comprehensive health insurance scheme for U5C illness among the vulnerable urban slum dwellers to achieve universal health coverage.

Achievements and challenges of India's sanitation campaign under clean India mission: A commentary.

Universal access to safe sanitation is yet to be accomplished in India. Although Clean India Mission (named as "Swachh Bharat Mission (Gramin)" for rural India) claims that the sanitation coverage in rural India has increased from 39% to 100% of households from 2014 and 2019, yet open defaecation continues in India in large numbers. This article discusses the achievements on Swachh Bharat Mission (Gramin) and identifies the existing challenges that need to be acted on to achieve the success of India's Swachh Bharat Mission. We searched international database mainly Google scholar, Pubmed, Medline, Scopus, and Science direct using "Clean India," "Swachh Bharat," "Sanitation," "Open defecation," "Environmental heath," and "India" as search keywords in different combinations. In addition, websites of relevant United Nations (UN) agencies, Government of India and leading newspaper and national agencies were also searched manually for related publications and reports. In the last 5 years (2014-2019), significant efforts have been made for the Swachh Bharat Mission by creating various social movements and awareness program to improve toilet coverage throughout India. Over 100 million, latrines have been built as of the end of the first phase of Swachh Bharat Mission (Gramin) as on October 2, 2019 and all villages across the districts of India have been declared Open Defaecation Free. Still, nearly half of the rural population (52.1%) defecate in the open. Lack of piped water supply, poor construction of toilet substructures and misconception among people about toilet use remain as key challenges in the achievement of India's sanitation mission. Sanitation-related behavioral change and improvement in toilet facilities must be prioritized to ensure usage of built toilets and eventually can accelerate the universal access to sanitation and meet Sustainable Development Goals.

Out-of-pocket health expenditure on diarrheal illness among under-five children in a teaching hospital ins Odisha, India.

BACKGROUND: Diarrhea is the most common illness in children under 5 years of age, accounting for a financial burden for families in developing countries. OBJECTIVE: The aim of this study is to determine the out-of-pocket health expenditure for the management of diarrhoeal illness among the under-five children in in-patient and out-patient cases. METHODS: A cross-sectional study was conducted during January-April 2018 among 60 under-five children with diarrheal illness reporting to pediatric outpatient department (OPD) and 60 under-five children admitted to pediatric ward of a tertiary care teaching hospital. For determining the out-of-pocket health expenditure, both direct and indirect costs for the management of diarrheal illness were estimated both for out-patient and in-patient cases. The cost of the treatment has been presented as the cost of prehospital visits, during a hospital visit and posthospital visit. RESULTS: Overall, median out-of-pocket health expenditure for the management of diarrheal illness for out-patient and in-patient cases were Rs. 1186 (interquartile range [IQR]: Rs. 510) and Rs. 6385 (IQR: Rs. 5889), respectively. The median direct expenditure for OPD cases was Rs. 778.50 (IQR: Rs. 263) and indirect expenditure for OPD cases were Rs. 407.50 (IQR: Rs. 336) The median direct and indirect expenditure for inpatient cases were Rs. 3823 (IQR: Rs. 1942) and Rs. 2237 (IQR: Rs. 4256) respectively. Only 13% of in-patient cases had some kind of medical insurance. CONCLUSION: A considerable economic burden is faced by the families for treating diarrhea in under-five children. Improved access to safe drinking water and sanitation, promotion of hand hygiene, exclusive breastfeeding, rotavirus vaccination, and use of oral rehydration therapy will reduce hospitalization and out-of-pocket expenditure. The study findings recommend for appropriate policy for provision of financial protection while seeking health care services.

Pesticide Residues in Peri-Urban Bovine Milk from India and Risk Assessment: A Multicenter Study.

Pesticides residue poses serious concerns to human health. The present study was carried out to determine the pesticide residues of peri-urban bovine milk (n = 1183) from five different sites (Bangalore, Bhubaneswar, Guwahati, Ludhiana and Udaipur) in India and dietary exposure risk assessment to adults and children. Pesticide residues were estimated using gas chromatography with flame thermionic and electron capture detectors followed by confirmation on gas chromatography-mass spectrometer. The results noticed the contamination of milk with hexachlorocyclohexane (HCH), dichloro-diphenyl trichloroethane (DDT), endosulfan, cypermethrin, cyhalothrin, permethrin, chlorpyrifos, ethion and profenophos pesticides. The residue levels in some of the milk samples were observed to be higher than the respective maximum residue limits (MRLs) for pesticide. Milk samples contamination was found highest in Bhubaneswar (11.2%) followed by Bangalore (9.3%), Ludhiana (6.9%), Udaipur (6.4%) and Guwahati (6.3%). The dietary risk assessment of pesticides under two scenarios i.e. lower-bound scenario (LB) and upper-bound (UB) revealed that daily intake of pesticides was substantially below the prescribed acceptable daily intake except for fipronil in children at UB. The non-cancer risk by estimation of hazard index (HI) was found to be below the target value of one in adults at all five sites in India. However, for children at the UB level, the HI for lindane, DDT and ethion exceeded the value of one in Ludhiana and Udaipur. Cancer risk for adults was found to be in the recommended range of United States environment protection agency (USEPA), while it exceeded the USEPA values for children.

Costing of Febrile Illness among Under Five Children, A Study in a Tertiary Care Teaching Hospital in Odisha, India.

OBJECTIVE: The objective of this study was to determine the cost of treatment, both direct and indirect costs, of febrile illness among under-five children in Odisha, India. METHODS: This was a cross-sectional study of thirty under-five children with febrile illness reporting to the pediatric outpatient (OP) department and thirty more under-five children admitted to the pediatric ward who were included in the study during January-April 2018. The parents/caretakers of the ailing children were interviewed using the WHO questionnaire contextualized to the local situation. Both direct (medicine, diagnostics, registration/doctor's fees, bed charges, and cost of personal medical appliances) and indirect (transportation, food, loss of income, and lodging) costs of febrile illness and pre-, during, and posthospital visit cost were estimated. RESULTS: The median direct and indirect costs for OP cases were Rs. 1201.00 and Rs. 1375.00, respectively. For the hospitalization (indoor patients), direct and indirect costs were Rs. 7015.00 and Rs. 5190.00, respectively. People also spent money in pre-, during, and posthospital visits for the same episode of febrile illness. Only four OP cases had some kind of medical insurance. CONCLUSION: High expenditure on both OP and indoor patients calls for appropriate policy for provision of financial protection while seeking health-care services. Health facilities should be tuned to do cost analysis enabling comparison among health facilities.