Estimated effect of age of marriage on utilisation of India's Integrated Child Development Service programme.

BACKGROUND: Age of marriage among women is considered an important indicator of their readiness for familial integration and parenting. This study estimated the effect of age of marriage of young mothers (aged 15-24 years) on utilisation of various services for their children, provided under the Integrated Child Development Service (ICDS) programme in India. METHODS: Data from the nationally representative 2019-2021 National Family Health Survey of India were analysed. Mothers' age of menarche was used as an instrumental variable to isolate the effect of age of marriage on whether their children received (1) food, (2) health check-up, (3) immunisation, (4) early childhood care or preschooling or (5) weight measurement services from ICDS. RESULTS: Nationally, 67.9% (95% CI 67.6%, 68.3%) of children received food (sample: 60 578), 61.8% (95% CI 61.4%, 62.1%) received a health check-up (sample: 60 316), 60.0% (95% CI 59.6%, 60.4%) received immunisation services (sample: 60 537), 52.0% (95% CI 51.6%, 52.4%) received early childhood care or preschooling (sample: 60 458) and 62.9% (95% CI 62.5%, 63.3%) received weight measurement services (sample: 60 278). Findings from instrumental variable analysis suggest that a 1-year increase in age of marriage could yield a 9 percentage point increase (95% CI 4%-13%; p<0.001) in utilisation of immunisation services. Although postponement of marriage positively affected utilisation of each of the other four ICDS components, these effects were not statistically significant. CONCLUSION: Postponing age of marriage among young women is an effective intervention for promoting uptake of child immunisation services. Our findings support the Government of India's 2021 Bill to raise legal age of marriage of women.

Predictors of Incidence and Remission of Anemia among Never-Married Adolescents Aged 10-19 Years: A Population-Based Prospective Longitudinal Study in India.

Background: Dynamics of the anemia burden among Indian adolescents are poorly understood because of a lack of population-based longitudinal data. Objectives: To examine the burden of anemia among never-married adolescents aged 10-19 y from the states of Bihar and Uttar Pradesh, India, and a wide range of predictors of its incidence and remission. Methods: A sample of 3279 adolescents (male: 1787 and female: 1492) aged 10-19 y were included from baseline (2015-2016) and follow-up (2018-2019) surveys of the UDAYA (Understanding the Lives of Adolescents and Young Adults) project in India. In 2018-2019, all new cases of anemia were considered as incidence, whereas a return to the nonanemic status from being anemic in 2015-2016 was considered remission. Univariate and multivariable modified Poisson regression models with robust error variance were deployed to attain the study objective. Results: The crude prevalence of anemia among males decreased from 33.9% (95% CI: 30.7%-37.3%) in 2015-2016 to 31.6% (95% CI: 28.6%-34.7%) in 2018-2019 but increased among females from 57.7% (95% CI: 53.5%-61.7%) in 2015-2016 to 63.8% (95% CI: 59.9%-67.5%) in 2018-2019. Anemia incidence was estimated to be 33.7% (95% CI: 30.3%-37.2%), whereas nearly 38.5% (95% CI: 35.1%-42.1%) of adolescents experienced remission of anemia. Older adolescents (aged 15-19 y) were less likely to experience anemia incidence. Consumption of eggs daily or weekly was negatively associated with anemia incidence compared with occasional or never consumption. Females had a higher risk of experiencing an incidence of anemia and decreased risk of experiencing anemia remission. The likelihood of adolescents experiencing anemia increased with an increased patient health questionnaire score. Household size was also associated with an increased risk of anemia incidence. Conclusions: Interventions that are sensitive to socio-demographic factors and encouraging access to mental health services and nutritious food consumption could be helpful in further anemia mitigation.

Shooting shadows: India's struggle to reduce the burden of anaemia.

Despite several efforts by the Government of India, the national burden of anaemia remains high and its growing prevalence (between 2015-2016 and 2019-2021) is concerning to India's public health system. This article reviews existing food-based and clinical strategies to mitigate the anaemia burden and why they are premature and insufficient. In a context where multiple anaemia control programmes are in play, this article proposes a threefold strategy for consideration. First, except the Comprehensive National Nutrition Survey, 2016-2018, which measured Hb concentration among children and adolescents aged 1-19 years using venous blood samples, all national surveys use capillary blood samples to determine Hb levels, which could be erroneous. The Indian government should prioritise conducting a nationwide survey for estimating the burden of anaemia and its clinical determinants for all age groups using venous blood samples. Second, without deciding the appropriate dose of Fe needed for an individual, food fortification programmes that are often compounded with layering of other micronutrients could be harmful and further research on this issue is needed. Same is true for the pharmacological intervention of Fe tablet or syrup supplementation programmes, which is given to individuals without assessing its need. In addition, there is a dire need for robust research to understand both the long-term benefit and side effects of Fe supplementation programmes. Third and final, the WHO is in process of reviewing the Hb threshold for defining anaemia, therefore the introduction of new anaemia control programmes should be restrained.

Use of antenatal and delivery care services and their association with maternal and infant mortality in rural India.

Optimum use of antenatal care (ANC) and delivery care services could reduce morbidity and mortality among prospective mothers and their children. However, the role of ANC and delivery services in prevention of both maternal and child mortality is poorly understood, primarily because of dearth of prospective cohort data. Using a ten-years population-based prospective cohort data, this study examined the use of ANC and delivery services and their association with maternal and infant mortality in rural India. Descriptive statistics were estimated, and multivariable logistic regression modelling was used to attain the study objective. Findings revealed that consumption of ≥ 100 iron-and-folic acid (IFA) tablet/equivalent syrup during pregnancy had a protective association with maternal and infant mortality. Lack of maternal blood group checks during pregnancy was associated with increased odds of the death of infants. Caesarean/forceps delivery and delivery conducted by untrained personnel were associated with increased odds of maternal mortality. Findings from this study reemphasizes on increasing coverage and consumption of IFA tablets/equivalent syrup. Improved ANC and delivery services and increased uptake of all types of ANC and delivery care services are equally important for improvement in maternal and child survival in rural India.

Coverage of Quality Maternal and Newborn Healthcare Services in India: Examining Dropouts, Disparity and Determinants.

Background: Abundant research studies has recorded availability, accessibility and quality of antenatal care and safe delivery in India but comparatively less information is known for postnatal care and furthermore limited attempts at capturing the whole spectrum of obstetric and newborn health services. Assessing discontinuity in maternal and child health service utilization provides us holistic information about existing health inequities and barriers in service provision. Objective: Current study evaluated the coverage of quality antenatal care (QANC), delivery care (QDC) and postnatal care (QPNC) in India as a part of a single continuum accounting for significant regional and sub-regional disparities. Methods: This study analyzed nationally representative data obtained from NFHS-4 (2015-16). Included in the data, were 190 898 Indian women who had a recent birth in last five years. Coverage of QANC, QDC and QPNC was examined at the national, state and district level. Bivariate association of key sociodemographic variables with coverage of services was assessed during chi-squared analysis. Multilevel logistic regression analysis examined correlates associated with coverage of services. The output was presented using odds ratios (OR) with 95% CI. Findings: About 23.5% women utilized QANC out of which 92.9% opted for QDC and 35.1% of newborns received QPNC. About 400 and 471 districts out of 640 had less than 30% coverage of QANC and QPNC, respectively. Women residing in rural regions of Bihar and Northeastern states were found with less than 10% coverage of QANC. Regression analysis shows that women with more than 12 years of education and belonging to richest households had increased odds of availing QANC (OR 1.95; 95%CI: 1.84-2.06) and QDC (OR: 2.86; 95%CI: 2.27-3.60), respectively. Conclusion: Focused interventions targeting the delivery of quality services especially ANC and PNC among newborns are imperative to achieve SDG-3 goals to achieve improvement in maternal and newborn health.

Factors associated with minimum dietary diversity failure among Indian children.

Recognising the importance of infant and young child feeding practices during the first 2 years of life, the World Health Organization's Global Nutrition Monitoring Framework developed a minimum dietary diversity (MDD) indicator for feeding children aged 6-23 months. MDD is defined as the consumption of food items from five or more groups out of a total of eight food groups. Food intake from less than five food groups is considered minimum dietary diversity failure (MDDF). Using the nationally representative National Family Health Survey (NFHS) dataset, the present study assessed the trend in MDDF between 2005-6 and 2015-16 and the factors associated with MDDF among children aged 6-23 months during 2015-16. The NFHS conducted in 2005-6 and 2015-16 covered a sample of 14 419 and 74 078 children aged 6-23 months, respectively. Overall, the MDDF reduced from 87⋅4  % (95  % confidence interval (95  % CI) 86⋅8  %, 87⋅9  %) in 2005-6 to 80⋅6  % (95  % CI 80⋅1  %, 81⋅0  %) in 2015-16. Multivariable logistic regression analysis revealed that increased child's age, second and third birth order children, higher maternal age and education, mass media exposure of mothers and more than four antenatal care visits had a negative association with the MDDF. Children living in rural areas and residing in high-focus states of India were observed with higher odds of experiencing MDDF. Exposure to community healthcare services was negatively associated with MDDF, and anaemic children were more likely to have MDDF. Socioeconomic status of mothers and children and encouragement of maternal and child healthcare use could be helpful in devising context-specific intervention to mitigate MDDF.

Health care seeking behaviour and financial protection of patients with hypertension: A cross-sectional study in rural West Bengal, India.

BACKGROUND: Elevated blood pressure or hypertension is responsible for around 10 million annual deaths globally, and people residing in low and middle-income countries are disproportionately affected by it. India is no exception, where low rate of treatment seeking for hypertension coupled with widespread out-of-pocket payments (OOPs) have been a challenge. This study assessed the pattern of health care seeking behaviour and financial protection along with the associated factors among hypertensive individuals in rural West Bengal, India. METHOD AND FINDINGS: A cross-sectional study was conducted in Birbhum district of the state of West Bengal, India, during 2017-2018, where 300 individuals were recruited randomly from a list of hypertensives in a population cohort. Healthcare seeking for hypertension and related financial protection in terms of-OOPs and expenses relative to monthly per-capita family expenditure, were analysed. Findings indicated that 47% of hypertensives were not on treatment. Among those under treatment, 80% preferred non-public facilities, and 91% of them had wide-spread OOPs. Cost of medication was a major share of expenses followed by transportation cost to access public health care facility. Multivariable logistic regression analysis indicated longer duration of disease (adjusted odds ratio (aOR): 5.68, 95% Confidence Interval (CI) 1.24-25.99) and health care seeking from non-public establishment (aOR: 34.33, CI: 4.82-244.68) were associated with more incident of OOPs. Linear regression with generalized linear model revealed presence of co-morbidities (adjusted coefficient (aCoeff)10.28, CI: 4.96,15.61) and poorer economic groups (aCoeffpoorest 11.27, CI 3.82,18.71; aCoefflower-middle 7.83, CI 0.65,15.00 and aCoeffupper-middle 7.25, CI: 0.80,13.70) had higher relative expenditure. CONCLUSION: This study suggests that individuals with hypertension had poor health care seeking behaviour, preferred non-public health facilities and had suboptimal financial protection. Economically poorer individuals had higher burden of health expenditure for treatment of hypertension, which indicated gaps in equitable health care delivery for the control of hypertension.

Estimated effect of vitamin A supplementation on anaemia and anthropometric failure of Indian children.

BACKGROUND: India has an unacceptably high burden of vitamin A deficiency (VAD) among children aged 6-59 months. To mitigate VAD and its adverse effects on child health, the Indian government runs a nationwide vitamin A supplementation (VAS) programme. However, the effect of VAS in reducing child morbidity and mortality remains inconclusive and has been debated globally. In this paper, we estimate the effect of VAS on two indicators of child nutrition-anaemia (categorized into any anaemia, and mild/moderate anaemia) and anthropometric failure (categorized into stunting, wasting, and underweight) among children aged 6-59 months. METHODS: Using the nationally representative 2015-2016 National Family Health Survey data set from India, we set up a quasi-experimental study design and estimated household and mother fixed-effects of VAS on select types of child anaemia and anthropometric failure. RESULTS: Findings from both the household fixed-effects and mother fixed-effects analysis showed that VAS does not influence any types of childhood anaemia and anthropometric failure in India. We discussed the findings considering existing literature and possible limitations of the study. CONCLUSIONS: The infirm effect of Vitamin A on anaemia and anthropometric failure is probably indicative of targeted VAS intervention, as opposed to a universal VAS programme. IMPACT: Effects of vitamin A supplementation (VAS) in treating child morbidity and mortality remain inconclusive, which calls for further rigorous studies. This study set up a quasi-experimental research design and estimated the null effect of VAS on child anaemia and childhood anthropometric failure. While the cautious interpretation of findings is urged, this study reliably supports targeted intervention of VAS, instead of the universal VAS programme. The use of nationally representative data and robust research protocol are the primary strengths of this study.

Iron-and-folic-acid supplementation among adolescents (aged 10-19 years) in two North Indian States, 2015-2016: a sex-stratified analysis.

OBJECTIVE: This study assessed the prevalence and predictors of receiving iron-and-folic-acid (IFA) supplement by male and female adolescents in two north Indian states. DESIGN: The UDAYA (Understanding the lives of adolescents and young adults in Bihar and Uttar Pradesh) survey dataset was used. Conducted during 2015-2016, UDAYA was a state representative cross-sectional survey. To recruit sample, UDAYA adopted a multi-stage systematic sampling method with a household selection probability proportional to size. Weighted bivariate and multivariate logistic regression analyses were deployed. The variance inflation factor was estimated to check the presence of multicollinearity among variables included in regression model. SETTING: The state of Bihar and Uttar Pradesh, India. PARTICIPANTS: A total of 10 433 individuals from Bihar and 10 161 individuals from Uttar Pradesh were included, totalling 20 594 individuals (male: 5969, female: 14 625) aged 10-19 years. RESULTS: Overall, 3·6 % (95 % CI: 2·7, 4·7) of males and 4·8 % (95 % CI: 4·0, 5·7) of female adolescents received IFA supplement in preceding 1 year of survey date. Multivariate results indicate that IFA receipt varied with age, and state of residence among males, whereas religion and mother's education were associated with IFA receipt among females. Irrespective of sex, adolescents living in rural areas had higher odds of receiving IFA supplement than adolescents in urban setting. CONCLUSIONS: Low coverage in receiving IFA supplement among adolescents is a serious concern for the success of anaemia reduction programme. While designing interventions for overall increase in IFA distribution, the socio-economic factors influencing IFA receipt must be considered.

Tipping the scale: the role of a national nutritional supplementation programme for pregnant mothers in reducing low birth weight and neonatal mortality in India.

With over 1·3 million Anganwadi centres (AWC) (meaning 'courtyard shelter'), the Indian government runs a nationwide intervention providing nutrition supplement to pregnant mothers to improve the health of their children. Using two successive rounds of the nationally representative cross-sectional National Family Health Survey data (collected during 2005-2006 and 2015-2016) of India, we assessed whether nutrition supplements given to pregnant mothers through AWC were associated with select child health indicators - extremely low birth weight (ELBW), very low birth weight (VLBW), low birth weight (LBW) and neonatal mortality (death during day 0-27) stratified by death during day 0-1, day 2-6 and day 7-27. A total of 148 019 children and 205 593 children were eligible for analysing birth weight and neonatal mortality, respectively. OR with 95% CI, estimated from multivariate logistic regression models, suggest that receipt of nutrition supplements was associated with decreased risk of VLBW (OR: 0·73, 95% CI 0·63, 0·83, P < 0·001), LBW (OR: 0·92, 95% CI 0·88, 0·96, P < 0·001), but not ELBW (OR: 0·80, 95% CI 0·56, 1·15, P = 0·226). Women who always received nutrition supplements during their pregnancy saw lower risk of death of their neonates (OR: 0·67, 95% CI 0·61, 0·73, P < 0·001), including death on day 0-1 (OR: 0·66, 95% CI 0·58, 0·74, P < 0·001), day 2-6 (OR: 0·69, 95% CI 0·58, 0·82, P < 0·001) and day 7-27 (OR: 0·68, 95% CI 0·53, 0·87, P = 0·002). Therefore, nutritional supplementation to pregnant mothers appears to be helpful in deterring various stages of neonatal mortality, VLBW and LBW, though it might not be effective in mitigating ELBW. Findings were discussed considering possible limitations of the study.

Maternal iron-and-folic-acid supplementation and its association with low-birth weight and neonatal mortality in India.

OBJECTIVE: The current study assessed intake of iron-and-folic-acid (IFA) tablet/syrup (grouped into none, < 100 d of IFA consumption or < 100 IFA and ≥ 100 d of IFA consumption or ≥ 100 IFA) among prospective mothers and its association with various stages of low-birth weight (ELBW, extremely low-birth weight; VLBW, very low-birth weight and LBW, low-birth weight) and neonatal mortality (death during day 0-1, 2-6, 7-27 and 0-27) in India. DESIGN: The cross-sectional, nationally representative, 2015-2016 National Family Health Survey (NFHS-4) data were used. Weighted descriptive analysis and multiple binary logistic regression modelling were used. SETTING: NFHS-4 covered 640 districts from thirty-seven states and union territories of India. PARTICIPANTS: A total of 120 374 and 143 675 index children aged 0-59 months were included to analyse LBW and neonatal mortality, respectively. RESULTS: Overall, 30·7 % mothers consumed ≥ 100 IFA in 2015-2016, and this estimate ranged from 0·0 % in Zunheboto district of Nagaland state to 89·5 % in Mahe district of Puducherry of India. Multiple regression analysis revealed that children of mothers who consumed ≥ 100 IFA had lower odds of ELBW, VLBW, LBW and neonatal mortality during day 0-1, as compared with mothers who did not buy/receive any IFA. Consumption of IFA (< 100 IFA and ≥ 100 IFA) had a protective association with neonatal death during day 7-27 and 0-27. Consumption of IFA was not associated with neonatal death during day 2-6. CONCLUSIONS: While ≥ 100 IFA consumption during pregnancy was found to be associated with preventing select types of LBW and neonatal mortality, a large variation in coverage of ≥ 100 IFA consumption across 640 districts is concerning.

Receipt of Weekly Iron Supplementation among Indian Children, 2005-2016.

BACKGROUND: In response to India's unacceptably high burden of anemia among children aged 6-59 mo, the central government introduced the National Iron Plus Initiative program which recommends an intervention of iron supplementation to mitigate anemia, especially iron deficiency anemia. OBJECTIVE: The objective of this study was to examine the trend (between 2005-2006 and 2015-2016) in receiving weekly iron supplementation (WIS) among children aged 6-59 mo, and factors associated with receiving WIS during 2015-2016. METHODS: Two waves of the nationally representative cross-sectional National Family Health Survey (NFHS) data collected during 2005-2006 (NFHS-3) and 2015-2016 (NFHS-4) were used. The trend was measured using both rounds of datasets, whereas factors associated with WIS receipt were assessed from NFHS-4. The trend was assessed using a sample of 35,650 children from NFHS-3 and 202,227 children from NFHS-4. After exclusion of 8978 cases, a total of 199,110 children were included to analyze the factors associated with receiving WIS. Using appropriate sample weighting, unadjusted and adjusted (multivariate) logistic regression analyses were deployed. Application of the chi-squared test and checking for multicollinearity were also part of the analysis. The possibility of sample selection bias was tested. RESULTS: An increase of WIS receipt (from 4.6% in 2005-2006 to 26% in 2015-2016) was observed. Older children, children living in rural areas, children belonging to Scheduled Tribes, children of mothers with secondary education or higher, and children whose mothers had some mass media exposure had higher odds of receiving WIS. Children of fifth or higher birth order, children who were followers of Islam and Christianity, children from the richest economic group, noninstitutional birth of children, and children from high-focus group states were negatively associated with WIS receipt. CONCLUSIONS: Despite improvement (between 2005-2006 and 2015-2016) in receiving WIS, coverage remains unacceptably low (in absolute terms). The suboptimum performance of WIS intervention demands further investigation.

Rising burden of overweight and obesity among Indian adults: empirical insights for public health preparedness.

With simultaneous efforts to address a huge burden of malnutrition, especially among children and younger women, India also encounters a mushrooming prevalence of overweight and obesity among the adult population. This study analysed data from two consecutive rounds of the National Family Health Survey (NFHS) conducted in 2005-06 and 2015-16, to present the burden of overweight and obesity among adult men and women in India. The findings highlight a rising burden of overweight and obesity, although the level and the extent of change over the study period varied across states. The district-wise analysis revealed geographical clusters of overweight and obesity. Further investigation suggests that overweight or obesity are not exclusive to urban areas, and economically well-off populations are more inclined to be overweight or obese. The trends and patterns of overweight and obesity in India argue for timely public health preparedness and interventions to avoid the rising incidence of non-communicable diseases in India.

Non-communicable diseases are the leading cause of mortality in rural Birbhum, West Bengal, India: a sex-stratified analysis of verbal autopsies from a prospective cohort, 2012-2017.

OBJECTIVES: There is a dearth of data on causes of death in rural India, which impedes identification of public health priorities to guide health interventions. This study aims to offer insights from verbal autopsies, to understand the pattern and distribution of causes of death in a rural area of Birbhum District, West Bengal, India. DESIGN: Causes of death data were retrieved from a prospective vital event surveillance system. SETTING: The Birbhum Population Project, a Health and Demographic Surveillance System, West Bengal, India. PARTICIPANTS: Between January 2012 and December 2017, all deaths were recorded. MAIN OUTCOME MEASURES: Trained Surveyors tracked all deaths prospectively and used a previously validated verbal autopsy (VA) tool to record causes of death. Experienced physicians reviewed completed VA forms, and assigned cause of death using the 10th version of International Classification of Diseases. In addition to cause-specific mortality fraction, cause-specific crude death rate (CDR) among males and females were estimated. RESULTS: A total of 2320 deaths (1348 males and 972 females) were recorded. An estimated CDR was 708/100 000. Over half of all deaths (1176 deaths, 50.7%) were attributed to non-communicable diseases (NCDs), with nearly 30% of all deaths attributed to circulatory system disorders; whereas 24.2% and 3.9% deaths were due to cerebrovascular diseases and ischaemic heart disease, respectively. Equal percent (13%) of males died from external causes and from infectious and parasitic diseases, and 11% died from respiratory system-related diseases. Among females, 12% died from infectious and parasitic diseases. Among children aged 0-4 years, 50% of all male deaths and 45% of all female deaths were attributed to conditions in the perinatal period. CONCLUSIONS: NCDs are the leading cause of death among adults in a select population of rural Birbhum, India. Health programmes for rural India should prioritise plans to mitigate deaths due to NCDs.

Sustainable financing for municipal solid waste management in Nepal.

Financing municipal solid waste (MSW) services is one of the key challenges faced by cities in developing countries. This study used plastic waste, a constituent of MSW, to explore the possibility of generating revenue for financing MSW management in the municipalities of Nepal. The results of this study suggest that plastic material recovery could generate revenue, which is equivalent to 1.38 times of the plastic-waste-related management cost when collection efficiency reaches 66.7%. An increase in 1% of recovery rate and collection efficiency could cover an additional 4.64% and 2.06% of the costs of managing plastic waste, respectively. In addition, an increase in tax on imported plastic materials could also motivate recovery of plastic waste for recycle and reuse. An additional 1% tax on plastic imports would be sufficient to cover plastic-related waste management when plastic waste recovery and collection efficiency rates are low. This plastic recovery- revenue exercise could be expanded to other materials such as paper and metal to fully understand the possibility of sustainable financing of MSW management and reducing environmental harm in developing countries like Nepal.

Public health interventions to improve maternal nutrition during pregnancy: a nationally representative study of iron and folic acid consumption and food supplements in India.

OBJECTIVE: Despite a reduction in maternal mortality in recent years, a high rate of anaemia and other nutrient inadequacies during pregnancy pose a serious threat to mothers and their children in the Global South. Using the framework of the WHO-Commission on Social Determinants of Health, this study examines the socioeconomic, programmatic and contextual factors associated with the consumption of iron and folic acid (IFA) tablets/syrup for at least 100 d (IFA100) and receiving supplementary food (SF) by pregnant women in India. DESIGN: We analysed a nationally representative cross-sectional survey of over 190 898 ever-married women aged 15-49 years who were interviewed as part of the National Family Health Survey (NFHS) conducted during 2015-16, who had at least one live birth preceding 5 years of the survey. SETTING: All twenty-nine states and seven union territories of India. PARTICIPANTS: Ever-married women aged 15-49 years. RESULTS: Less than one-third of women were found to be consuming IFA100, and a little over half received SF during their last pregnancy. The consumption of IFA100 was likely to improve with women's education, household wealth, early and more prenatal visits, and in a community with high pregnancy registration. Higher parity, early and more prenatal visits, contact with community health workers during pregnancy, belonging to a poor household and living in an aggregated poor community and rural area positively determine whether a woman might receive SF during pregnancy. CONCLUSIONS: Continuous monitoring and evaluation of provisioning IFA and SF in targeted groups and communities is a key to expanding the coverage and reducing the burden of undernutrition during pregnancy.

Double burden of malnutrition among adolescents in rural West Bengal, India.

OBJECTIVES: The aims of this study were to investigate the prevalence of underweight, stunting, and overweight among adolescents in rural West Bengal, India, and identify factors contributing to these forms of malnutrition. METHODS: This was a cross-sectional study conducted within the Birbhum Health and Demographic Surveillance System in West Bengal, India. Participants were male and female adolescents 10 to 19 y of age (N = 5521). Body mass index (BMI) was calculated using measured heights and weights and z-scores based on the 2007 World Health Organization growth standards. Information on demographic characteristics, diet, and health behaviors was collected through face-to-face interviews using a standardized questionnaire. Modified Poisson regression was used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for the association between each risk factor and outcome. RESULTS: The proportion of underweight was 26.6% overall: 31.1% among boys, and 21.1% among girls. The proportion of stunting was 25% overall: 23.3% among boys and 26.9% among girls. Of the participants, 4.6% were overweight or obese: 4.1% boys and 5.2% girls. Compared with boys, girls had a reduced likelihood of being underweight (adjusted PR, 0.67; 95% CI, 0.59-0.75). Multivariate models also showed that socioeconomic status was strongly associated with all nutritional outcomes. Not having a toilet facility in one's household and poor hand hygiene were also associated with a greater likelihood of stunting. CONCLUSION: The present results suggested that adolescents in Birbhum, India are substantially affected by the double burden of malnutrition. Nutritional interventions should incorporate efforts to reduce socioeconomic inequality.

Population-level effective coverage of adolescent weekly iron and folic acid supplementation is low in rural West Bengal, India.

OBJECTIVE: To assess the coverage of the adolescent weekly iron and folic acid supplementation (WIFS) programme in rural West Bengal, India. DESIGN: We conducted a population-based cross-sectional survey of intended WIFS programme beneficiaries (in-school adolescent girls and boys and out-of-school adolescent girls). SETTING: Birbhum Health and Demographic Surveillance System. PARTICIPANTS: A total of 4448 adolescents 10-19 years of age participated in the study. RESULTS: The percentage of adolescents who reported taking four WIFS tablets during the last month as intended by the national programme was 9·4 % among in-school girls, 7·1 % for in-school boys and 2·3 % for out-of-school girls. The low effective coverage was due to the combination of large deficits in WIFS provision and poor adherence. A large proportion of adolescents reported they were not provided any WIFS tablets in the last month: 61·7 % of in-school girls, 73·3 % of in-school boys and 97·1 % of out-of-school girls. In terms of adherence, only 41·6 % of in-school girls, 38·1 % of in-school boys and 47·4 % of out-of-school girls reported that they consumed all WIFS tablets they received. Counselling from teachers, administrators and school staff was the primary reason adolescents reported taking WIFS tablets, whereas the major reasons for non-adherence were lack of perceived benefit, peer suggestion not to take WIFS and a reported history of side effects. CONCLUSIONS: The effective coverage of the WIFS programme for in-school adolescents and out-of-school adolescent girls is low in rural Birbhum. Integrated supply- and demand-side strategies appear to be necessary to increase the effective coverage and potential benefits of the WIFS programme.

Incidence of Prehypertension and Hypertension in Rural India, 2012-2018: A Sex-Stratified Population-Based Prospective Cohort Study.

BACKGROUND: India is home to the largest number of hypertensive individuals, and factors responsible for the incidence of hypertension are poorly understood. This study examines predictors of transition to different stages of hypertension-incidence of hypertension, incidence of prehypertension, and incidence of prehypertension to hypertension. METHODS: Population-based survey data from the Birbhum Population Project, located in West Bengal, India were used. A cohort of 8,977 individuals (male: 3,934, female: 5,043), participated in the 2012-13 survey, and were followed up for resurvey in 2017-18. The Seventh Report of the Joint National Committee (JNC 7) guidelines were followed to define hypertension. Bivariate and multivariate Poisson regression analyses were conducted to attain the study objective. RESULTS: The incidence of hypertension, prehypertension among males (7.9% and 45.3%, respectively) is higher than that among females (5.9% and 32.7%, respectively). However, the incidence of prehypertension to hypertension is lower among males (23.6%) than among females (33.6%). Among both sexes, with age, the incidence of hypertension, and incidence of prehypertension to hypertension appeared to increase, whereas incidence of prehypertension among females increased with age. Findings indicate a diverse gradient of socioeconomic, behavioral, and anthropometric characteristics influencing the incidence of different stages of hypertension. CONCLUSIONS: With a focus on females and the richest individuals, this study proposes that an appropriate intervention be designed in keeping with the socioeconomic, behavioral gradient of incidence of different stages of hypertension. The role of anthropometric indicators in hypertension is proposed to be further studied for better population-based screening.

Economics of climate adaptive water management practices in Nepal.

This study analyses costs and benefits of the selected climate adaptive and equitable water management practices and strategies (CAEWMPS) in Dhulikhel Municipality and Dharan Sub-metropolitan city of Nepal. The CAEWMPS adopted the construction of water recharge pit at household level in Dharan and recharge ponds at community level in Dhulikhel. The results of household survey reveal that households have employed different coping strategies including minimizing consumption, purchasing from market, harvesting rain water and installing equipment for storing and pumping in both cities. In Dhulikhel, a significant number of households (18.56%) minimize consumption during the dry season but this is not the case in Dharan. Rather, around one-fifth (19.27%) of the households harvest rainwater in Dharan. In addition, households are forced to give-up their regular activities in order to implement coping strategies such as household chores, leisure time, meeting and gardening. The average estimated annual coping cost in Dharan (USD 87.5) is eight times higher than in Dhulikhel (USD 11.05); however, per unit coping cost is nearly equal in both the cities. In terms of benefit-cost ration, the community level recharge ponds in Dhulikhel (5.15) were found to be cost effective compared to the household level recharge pits of Dharan (1.72). These results provide policy makers with a comparative basis for adopting appropriate strategies to tackle problems related to water shortage under city-specific contexts.