Influence of gender and parental migration on IYCF practices in 6-23-month-old tribal children in Banswara district, India: findings from the cross-sectional PANChSHEEEL study.

BACKGROUND: The interdisciplinary Participatory Approach for Nutrition in Children: Strengthening Health, Education, Engineering and Environment Linkages (PANChSHEEEL) study used a participatory approach to develop locally-feasible and tailored solutions to optimise Infant and Young Child Feeding (IYCF) practices at an individual, household, community, and environmental level. This paper aims to evaluate the influence of gender; migration; and Health, Education, Engineering and Environmental (HEEE) factors on IYCF practices, with the primary outcomes being three key complementary-feeding practices of Minimum Dietary Diversity (MDD), Minimum Meal Frequency (MMF) and Minimum Acceptable Diet (MAD). METHODS: A cross-sectional survey of 325 households with children aged 6-23 months was conducted in nine purposively selected villages in two blocks of Banswara district, Rajasthan, India. A survey tool was developed, translated into the local language, pre-tested, and administered in a gender-sensitive manner. Data-collection processes were standardized to ensure quality measures. Association of the primary outcome with 27 variables was tested using a Chi-square test (Mantel-Haenszel method); backward stepwise regression analysis was conducted to assess the impact of effect modifiers (gender, parental migration). RESULTS: Half of the surveyed children were of each gender, and fathers from half of the households were found to have migrated within the previous year to search for additional income. Parental literacy ranged from 60 to 70%. More than half of the households had access to milk-producing animals. Consumption of each of the seven food groups, eggs (4.7% vs 0.7%; p < 0.02), MDD (10.5% vs 3.2%; p < 0.02) and MAD (9.4% vs 2.6%; p < 0.02) were higher for boys than for girls. After controlling for contextual factors, a male child was 4.1 times more likely to get a diet with MDD and 3.8 times more likely to get a diet with MAD. A child from a non-migrant household was 2.0-2.1 times more likely to get a diet with MDD and MAD as compared to a child from a migrant household. However, this association was not found to be statistically significant after regression. Presence of milk-producing animals in households and consumption of milk/milk products by children in the previous 24 h were the other two strong predictors of MDD and MAD, although access to animal milk in the house did not translate to an increase in consumption of milk/milk products by a child. CONCLUSION: Gender discrimination in diet diversity and complementary-feeding practices starts early in childhood with boys having a distinct advantage over girls. In the case of parental migration, further research is required to establish if it has an adverse impact on feeding practices. Emphasis needs to be given to gender issues and other contextual factors when developing strategies to optimise complementary feeding practices. TRIAL REGISTRATION: With UCL ethics [Ethics ID 4032/002] in United Kingdom and with Sigma IRB [10,025/IRB/D/17-18] in India.

State and socio-demographic group variation in out-of-pocket expenditure, borrowings and Janani Suraksha Yojana (JSY) programme use for birth deliveries in India.

BACKGROUND: High out-of-pocket-expenditure (OOPE) deters families from seeking skilled/institutional care. 'Janani Suraksha Yojana (JSY), a conditional cash transfer programme launched in 2005 to mitigate OOPE and to promote institutional deliveries among the poor, is part of Government of India's efforts to achieve Millennium Development Goals (MDGs) 4 and 5. The objective of this study is to estimate variations in OOPE for normal/caesarean-section deliveries, JSY-programme use and delivery associated borrowings - by states and union territories, and socio-demographic profiling of families, in India. METHODS: Secondary analysis of data from the District Level Household Survey (DLHS-3), 2007-08. Mean and median OOPE, percentage use of JSY and percentage of families needing to borrow money to pay for delivery associated expenditure was estimated for institutional and home deliveries. RESULTS: Half (52%) of all deliveries in India occurred at home in 2007/08. OOPE for women having institutional deliveries remained high, with considerable variation between states and union territories. Mean OOPE (SD) of a normal delivery in public and private institution respectively in India were Rs. 1,624 and Rs. 4,458 and for a caesarean-section it was Rs. 5,935 and Rs. 14,276 respectively. There was considerable state-level variation in use of the JSY programme for normal deliveries (15% nationally; ranging from 0% in Goa to 43% in Madhya Pradesh) and the percentage of families having to borrow money to pay for a caesarean-section in a private institution (47% nationally; ranging from 7% in Goa to 69% in Bihar). Increased literacy and wealth were associated with a higher likelihood of an institutional delivery, higher OOPE but no major variations in use of the JSY. CONCLUSIONS: Our study highlights the ongoing high OOPE and impoverishing impact of institutional care for deliveries in India. Supporting families in financial planning for maternity care, additional investment in the JSY programme and strengthening state level planning are required to increase the proportion of institutional deliveries.

Indicators of mobility, socio-economic vulnerabilities and HIV risk behaviours among mobile female sex workers in India.

This paper examines the relationship between indicators of mobility, socio-economic vulnerabilities, and HIV risk behaviours among 5,498 mobile female sex workers (FSWs) living in the four high HIV prevalence states in India. Female sex workers with greater degree of mobility reported significantly more often than the FSWs with lesser degree of mobility that they experienced physical violence, and consumed alcohol prior to sex. Further, FSWs with greater degree of mobility reported significantly more often than the FSWs with lesser degree of mobility that they had inconsistent condom use in sex with clients, even after controlling for several demographic characteristics and socio-economic vulnerabilities including experiences of violence. Additionally, short duration visits and visit to the Jatra (religious fairs) places found to have significant association with their inconsistent condom use in sex with clients as well as continuation of sex despite having STI symptoms. These findings suggest the need for screening FSWs for higher degree of mobility and to mobilize them to form community networks so as to deal with violence, reduce alcohol use and promote consistent condom use along the routes of mobility. HIV prevention interventions aimed at FSWs require an increased attention to address the socio-economic vulnerabilities including alcohol use, with particular emphasis on those FSWs who are on the move in India and elsewhere.

Motivations for entry into sex work and HIV risk among mobile female sex workers in India.

This paper assesses the reasons for entry into sex work and its association with HIV risk behaviours among mobile female sex workers (FSWs) in India. Data were collected from a cross-sectional survey conducted in 22 districts across four high HIV prevalence states in India during 2007-2008. Analyses were limited to 5498 eligible mobile FSWs. The reasons given by FSWs for entering sex work and associations with socio-demographic characteristics were assessed. Reported reasons for entering sex work include poor or deprived economic conditions; negative social circumstances in life; own choice; force by an external person; and family tradition. The results from multivariate analyses indicate that those FSWs who entered sex work due to poor economic conditions or negative social circumstances in life or force demonstrated elevated levels of current inconsistent condom use as well as in the past in comparison with those FSWs who reported entering sex work by choice or family tradition. This finding indicates the need for a careful assessment of the pre-entry contexts among HIV prevention interventions since these factors may continue to hinder the effectiveness of efforts to reduce the spread of HIV/AIDS in India and elsewhere.

Relationship between reported prior condom use and current self-perceived risk of acquiring HIV among mobile female sex workers in southern India.

BACKGROUND: With the evolution of Health Belief Model, risk perception has been identified as one of several core components of public health interventions. While female sex workers (FSWs) in India continue to be at most risk of acquiring and transmitting HIV, little is known about their perception towards risk of acquiring HIV and how this perception depends upon their history of consistent condom use behavior with different type of partners. The objective of this study is to fill this gap in the literature by examining this relationship among mobile FSWs in southern India. METHODS: We analyzed data for 5,413 mobile FSWs from a cross-sectional behavioral survey conducted in 22 districts from four states in southern India. This survey assessed participants' demographics, condom use in sex with different types of partners, continuation of sex while experiencing STI symptoms, alcohol use before having sex, and self-perceived risk of acquiring HIV. Descriptive analyses and multilevel logistic regression models were used to examine the associations between risky sexual behaviors and self-perceived risk of acquiring HIV; and to understand the geographical differences in HIV risk perception. RESULTS: Of the total mobile FSWs, only two-fifths (40%) perceived themselves to be at high risk of acquiring HIV; more so in the state of Andhra Pradesh (56%) and less in Maharashtra (17%). FSWs seem to assess their current risk of acquiring HIV primarily on the basis of their past condom use behavior with occasional clients and less on the basis of their past condom use behaviors with regular clients and non-paying partners. Prior inconsistent condom use with occasional clients was independently associated with current perception of high HIV risk (adjusted odds ratio [aOR)] = 2.1, 95% confidence interval [CI]: 1.7-2.6). In contrast, prior inconsistent condom use with non-paying partners was associated with current perception of low HIV risk (aOR= 0.7, 95% CI: 0.5-0.9). The congruence between HIV risk perception and condom use with occasional clients was high: only 12% of FSWs reported inconsistent condom use with occasional clients but perceived themselves to be at low risk of acquiring HIV. CONCLUSION: The association between high risk perception of acquiring HIV and inconsistent condom use, especially with regular clients and non-paying partners, has not been completely internalized by this high risk group of mobile FSWs in India. Motivational efforts to prevent HIV should emphasize the importance of accurately assessing an individual's risk of acquiring HIV based on condom use behavior with all types of partners: occasional and regular clients as well as non-paying partners; and encourage behavior change based on an accurate self-assessment of HIV risk.