Curious eyes and awkward smiles: Menstruation and adolescent boys in India.

INTRODUCTION: Most Indian studies on menstruation include only girls/women as participants, making it a 'women's' topic. This exclusion of adolescent boys fails to understand menstruation as a social epidemiological entity with existing gender inequalities. For engaging boys to play a meaningful role in improving women's health, studying their knowledge, beliefs regarding topics such as menstruation and socioeconomic characteristics influencing their menstruation-related experiences need attention. Addressing this is an essential step for reducing gender disparities in adolescent health. Thus, we explore boys' knowledge, beliefs and attitudes regarding menstruation and the impact of social determinants on their menstruation-related experiences. METHODS: A sequential mixed-methods study comprising 21 semi-structured interviews, 5 Focus Group Discussions and 12 key respondent interviews; followed by a cross-sectional survey of 744 boys from Nashik district, India was conducted. We employed thematic analysis for qualitative data and multivariable regression to model risk ratios for outcomes. RESULTS: An amalgam of curiosity and awkwardness regarding menstruation was observed. Many lacked accurate knowledge and possessed misinformation. Social and individual-level determinants influenced boys' menstruation related experiences. Fully adjusted models revealed that being admitted in private unaided schools; having mothers with at least a college education; and comfort with teacher positively influenced boys'knowledge, attitudes and beliefs (incidence rate ratios at 95% CI: 2.67 [1.02, 6.95], p < 0 0.05; 3.16 [1.35, 7.38], p < .05 and 1.92 [1.24, 2.99],p < .01, respectively). CONCLUSION: Our study highlights the need of improving Indian boys' understanding and beliefs about menstruation by addressing the social determinants that influence their menstruation-related experiences.

School climate and physical adolescent relationship abuse: Differences by sex, socioeconomic status, and bullying.

Little is known about the association between school climate and adolescent relationship abuse (ARA). We used 2011-2012 data from surveys of California public school students (in the United States of America) who were in a dating relationship in the last year (n = 112 378) to quantify the association between different school climate constructs and physical ARA. Fifty-two percent of students were female, and all students were in 9th or 11th grade (approximately ages 14-17). Over 11% of students reported experiencing physical ARA in the last year. Increased school connectedness, meaningful opportunities for participation, perceived safety, and caring relationships with adults at school were each significantly associated with lower odds of physical ARA. Increased violence victimization and school-level bullying victimization were associated with higher odds of physical ARA. These school climate-ARA associations were significantly moderated by student sex, school socioeconomic status, and school-level bullying victimization. School climate interventions may have spillover benefits for ARA prevention.

Limits to Economic Growth: Why Direct Investments Are Needed to Address Child Undernutrition in India.

About two of every five undernourished young children of the world live in India. These high levels of child undernutrition have persisted in India for several years, even in its relatively well-developed states. Moreover, this pattern was observed during a period of rapid economic growth. Evidence from India and other developing countries suggests that economic growth has little to no impact on reducing child undernutrition. We argue that a growth-mediated strategy is unlikely to be effective in tackling child undernutrition unless growth is pro-poor and leads to investment in programs addressing the root causes of this persistent challenge.

Theory and health disparities: Explaining the relevance of theory in public health research in India.

This paper aims to address the concern that quantitative public health studies do not integrate theoretical considerations. This qualitative study uses content analysis to explore the application of theory in Indian public health articles listed on PubMed. Social determinants such as poverty, income, social class, education, gender, caste, socioeconomic position, socioeconomic status, immigrant status, and wealth were the keywords used to identify the articles analysed in this study. From a selection of 91 public health articles, we identified potential theoretical frameworks based on the pathways/recommendations/explanations mentioned. Additionally, using the case of tuberculosis in India, we highlight how theoretical perspectives play a critical role in providing a holistic view of major health challenges. Finally, by emphasising the need to adopt a theoretical perspective in empirical quantitative research on public health in India, we hope to motivate scholars to include a theory or theoretical paradigm in their future research.

Effectiveness of Health Promotion Curriculum in Enhancing Non-communicable Diseases Health Literacy in Indian Youth.

Background There is a theory-praxis gap related to health literacy interventions focused on non-communicable diseases (NCDs) among young people. We designed an NCD curriculum and investigated its' effect on health literacy in non-medical, non-nursing college students in India. We deliberately selected non-medical and non-nursing college students (age 17 to 22 years) as we hypothesized, they would have a minimum baseline knowledge of NCDs. Methods We initially carried out a pilot study on 85 students in a four-day-long workshop (32 teaching hours) using empirically developed health literacy instrument. We administered the curriculum to 120 randomly selected students in four colleges, while 50 students were assigned to the comparison group. The curriculum was given over four days for a total of 32 hours. Approval was sought to give four credits for completion of the course. Each lecture comprised didactics, followed by discussion, and skills testing of measuring blood pressure and blood sugar. Health literacy was measured using a specifically designed tool at baseline and endline. The difference in health literacy scores between the two time-points (timepoint 1: before delivering the curriculum, time-point 2: at the end of four days of training) was analyzed using the t-test. Multiple linear and Poisson regression models were used to account for covariates. Results The average difference between the intervention and the control group in baseline scores was 0.05% points (unpaired t-test statistics: -1.36, degrees of freedom 103.15, p>0.05). The same at endline was 20.59% points (unpaired t-test statistics: -11.31, degrees of freedom 138.14, p<0.001). The endline to baseline difference in health literacy scores was 18.54% points higher in the intervention group versus the control group (unpaired t-test statistics: -10.88, degrees of freedom 161.32, p<0.001). The difference-in-difference scores remained significant after accounting for college setting and baseline score (Multivariable linear regression model, ß: 19.62% points, p<0.001). None of the socio-economic characteristics were significantly associated with the difference in the difference scores, independent of the intervention effect. The proportion of participants scoring 40% or above on the health literacy measure at endline was significantly higher in the intervention versus the control group (p<0.001). Conclusions We provide empirical data to support the incorporation of NCDs as a credit course in college curricula in low- and middle-income countries. Our findings showed that a theory-driven skills-focused curriculum may be a tool for enhancing NCD health literacy in Indian youth from diverse academic and socio-economic backgrounds.

How to ensure full vaccination? The association of institutional delivery and timely postnatal care with childhood vaccination in a cross-sectional study in rural Bihar, India.

Incomplete and absent doses in routine childhood vaccinations are of major concern. Health systems in low- and middle-income countries (LMIC), in particular, often struggle to enable full vaccination of children, which affects their immunity against communicable diseases. Data on child vaccination cards from a cross-sectional primary survey with 1,967 households were used to assess the vaccination status. The association of timely postnatal care (PNC) and the place of delivery with any-dose (at least one dose of each vaccine) and full vaccination of children between 10-20 months in Bihar, India, was investigated. Bivariate and multivariable logistic regression models were used. The vaccines included targeted tuberculosis, hepatitis B, polio, diphtheria/pertussis/tetanus (DPT) and measles. Moreover predictors for perinatal health care uptake were analysed by multivariable logistic regression. Of the 1,011 children with card verification, 47.9% were fully vaccinated. Timely PNC was positively associated with full vaccination (adjusted odds ratio (aOR) 1.48, 95% confidence interval (CI) 1.06-2.08) and with the administration of at least one dose (any-dose) of polio vaccine (aOR 3.37 95% CI 1.79-6.36), hepatitis B/pentavalent vaccine (aOR 2.11 95% CI 1.24-3.59), and DPT/pentavalent vaccine (aOR 2.29 95% CI 1.35-3.88). Additionally, delivery in a public health care facility was positively associated with at least one dose of hepatitis B/pentavalent vaccine administration (aOR 4.86 95% CI 2.97-7.95). Predictors for timely PNC were institutional delivery (public and private) (aOR 2.7 95% CI 1.96-3.72, aOR 2.38 95% CI 1.56-3.64), at least one ANC visit (aOR 1.59 95% CI 1.18-2.15), wealth quintile (Middle aOR 1.57 95% CI 1.02-2.41, Richer aOR 1.51 95% CI 1.01-2.25, Richest aOR 2.06 95% CI 1.28-3.31) and household size (aOR 0.95 95% CI 0.92-0.99). The findings indicate a correlation between childhood vaccination and timely postnatal care. Further, delivery in a public facility correlates with the administration of at least one dose of hepatitis B vaccine and thus impedes zero-dose vaccination. Increasing uptake of timely PNC, encouraging institutional delivery, and improving vaccination services before discharge of health facilities may lead to improved vaccination rates among children.

Is economic growth associated with reduction in child undernutrition in India?

BACKGROUND: Economic growth is widely perceived as a major policy instrument in reducing childhood undernutrition in India. We assessed the association between changes in state per capita income and the risk of undernutrition among children in India. METHODS AND FINDINGS: Data for this analysis came from three cross-sectional waves of the National Family Health Survey (NFHS) conducted in 1992-93, 1998-99, and 2005-06 in India. The sample sizes in the three waves were 33,816, 30,383, and 28,876 children, respectively. After excluding observations missing on the child anthropometric measures and the independent variables included in the study, the analytic sample size was 28,066, 26,121, and 23,139, respectively, with a pooled sample size of 77,326 children. The proportion of missing data was 12%-20%. The outcomes were underweight, stunting, and wasting, defined as more than two standard deviations below the World Health Organization-determined median scores by age and gender. We also examined severe underweight, severe stunting, and severe wasting. The main exposure of interest was per capita income at the state level at each survey period measured as per capita net state domestic product measured in 2008 prices. We estimated fixed and random effects logistic models that accounted for the clustering of the data. In models that did not account for survey-period effects, there appeared to be an inverse association between state economic growth and risk of undernutrition among children. However, in models accounting for data structure related to repeated cross-sectional design through survey period effects, state economic growth was not associated with the risk of underweight (OR 1.01, 95% CI 0.98, 1.04), stunting (OR 1.02, 95% CI 0.99, 1.05), and wasting (OR 0.99, 95% CI 0.96, 1.02). Adjustment for demographic and socioeconomic covariates did not alter these estimates. Similar patterns were observed for severe undernutrition outcomes. CONCLUSIONS: We failed to find consistent evidence that economic growth leads to reduction in childhood undernutrition in India. Direct investments in appropriate health interventions may be necessary to reduce childhood undernutrition in India. Please see later in the article for the Editors' Summary.

Intersectional role of paternal gender-equitable attitudes and maternal empowerment in child undernutrition: a cross-sectional national study from India.

OBJECTIVES: To investigate the role of the intersection of maternal empowerment, paternal gender-equitable attitudes, and household wealth in stunting and severe stunting among underfives in India. DESIGN: Cross-sectional study. SETTING: Community-based setting, nationally representative household survey from India. PARTICIPANTS: We used a sample of 22 867 mother-father-child triads from the fourth round of India's National Family Health Survey (2015-2016). Our inclusion criterion was children below the age of 5 years. The exclusion criterion was a lack of information on paternal gender-equitable attitudes and maternal empowerment. Observations with missing data on any of the covariates were also excluded. PRIMARY OUTCOME: Stunting and severe stunting among underfives in India. RESULTS: Our survey-adjusted logistic regression models revealed that even among children from poorer households, those with either an empowered mother or a father with gender-equitable attitudes versus those with none such parents, had a lower odds of stunting (adjusted OR (AOR): 0.92, 95% CI: 0.84 to 1.02) and severe stunting (AOR: 0.87, 95% CI: 0.77 to 0.98), independent of all covariates. We also found substantially lower odds of severe stunting in groups with parental concordance in a woman-friendly outlook, whether non-affluent (AOR: 0.80, 95% CI: 0.67 to 0.94) or affluent (AOR: 0.50, 95% CI: 0.38 to 0.67). CONCLUSION: We argue that while women's autonomy could reduce the risk of child undernutrition, focusing on men's attitudes towards gender equity also holds promise for reducing undernutrition. Our findings not only underscore how patriarchy is embodied in undernourished children, but also suggest programmatic interventions to address this deep-rooted scourge in India.

Community-level women's education and undernutrition among Indian adolescents: A multilevel analysis of a national survey.

BACKGROUND: Little research has explored the influence of social context on health of Indian adolescents. We conceptualized community-level women's education (proxy for value placed on women's wellbeing) as exerting contextual influence on adolescent hemoglobin level and body mass index (BMI). METHODS: We derived our sample of more than 62,000 adolescent aged 15 through 17 years from the Indian National Family Health Survey 2015-16. The sample consisted of a total of 62648 adolescents (54232 girls and 8416 boys) for the hemoglobin, and 62846 adolescents (54383 girls and 8463 boys) for the BMI analysis. We fitted multilevel random intercepts linear regression models to test the association of village- and urban-ward-level-women's education with hemoglobin level and BMI of adolescents, accounting for their own and their mother's education; as well as relevant covariates. FINDINGS: Our fully adjusted model estimated that if the 52% of communities with less than 20 percent of women having a tenth-grade education in our sample were to achieve 100 percent tenth-grade completion in women, hemoglobin would be 0·2 g/dl higher (p<0·001) and BMI would be 0·62 kg/m2 higher on average among all adolescents in such communities. Unexplained variance estimates at the contextual level remained statistically significant, indicating the importance of context on adolescent undernutrition. INTERPRETATIONS: Adolescents are deeply embedded in their context, influenced by contextual factors affecting health. Promoting adolescent health therefore implies altering social norms related to adolescent health and health behaviors; along with structural changes creating a health-promoting environment. Integrating our empirical findings with theoretically plausible pathways connecting community-level women's education with adolescent undernutrition, we suggest that enhancing community-level women's education beyond high school is necessary to facilitate these processes. IMPLICATIONS: Addressing contextual determinants of adolescent undernutrition might be the missing link in India's adolescent anemia and undernutrition prevention efforts, which are currently focused heavily on individual-level biomedical determinants of the problem.

Pregnancy anaemia, child health and development: a cohort study in rural India.

OBJECTIVE: To assess how pregnancy anaemia affects the offspring's early childhood development, child haemoglobin (Hb) levels child growth and diseases incidence 2 years after birth in a low-income setting. Furthermore, we investigate the mediating role of childhood Hb levels with disease incidences and skills. DESIGN: Prospective cohort study. SETTING AND PARTICIPANTS: The study participants are 941-999 mother-child dyads from rural Madhepura in Bihar, India. In 2015, the women were recruited during pregnancy from registers in mother-child centres of 140 villages for the first wave of data collection. At the time of the second wave in 2017, the children were 22-32 months old. PRIMARY AND SECONDARY OUTCOME MEASURES: The recruited women were visited at home for a household survey and the measurement of the women's and child's Hb level, child weight and height. Data on the incidence of diarrhoea and respiratory diseases or fever were collected from interviews with the mothers. To test motor, cognitive, language and socioemotional skills of the children, we used an adapted version of the child development assessment FREDI. RESULTS: The average Hb during pregnancy was 10.2 g/dL and 69% of the women had pregnancy anaemia. At the age of 22-32 months, a 1 g/dL increase in Hb during pregnancy was associated with a 0.17 g/dL (95% CI: 0.11 to 0.23) increase in Hb levels of the child. Children of moderately or severely anaemic women during pregnancy showed 0.57 g/dL (95% CI: -0.78 to -0.36) lower Hb than children of non-anaemic women. We find no association between the maternal Hb during pregnancy and early skills, stunting, wasting, underweight or disease incidence. While childhood anaemia does not correlate with childhood diseases, we find an association of a 1 g/dl increase in the child's Hb with 0.04 SDs higher test scores. CONCLUSIONS: While pregnancy anaemia is a risk factor for anaemia during childhood, we do not find evidence for an increased risk of infectious diseases or early childhood development delays.

The effect of bearing and rearing a child on blood pressure: a nationally representative instrumental variable analysis of 444 611 mothers in India.

BACKGROUND: At the individual level, it is well known that pregnancies have a short-term effect on a woman's cardiovascular system and blood pressure. The long-term effect of having children on maternal blood pressure, however, is unknown. We thus estimated the causal effect of having children on blood pressure among mothers in India, a country with a history of high fertility rates. METHODS: We used nationally representative cross-sectional data from the 2015-16 India National Family and Health Survey (NFHS-4). The study population comprised 444 611 mothers aged 15-49 years. We used the sex of the first-born child as an instrumental variable (IV) for the total number of a woman's children. We estimated the effect of an additional child on systolic and diastolic blood pressure in IV (two-stage least squares) regressions. In additional analyses, we stratified the IV regressions by time since a mother last gave birth. Furthermore, we repeated our analyses using mothers' husbands and partners as the regression sample. RESULTS: On average, mothers had 2.7 children [standard deviation (SD): 1.5], a systolic blood pressure of 116.4 mmHg (SD: 14.4) and diastolic blood pressure of 78.5 mmHg (SD: 9.4). One in seven mothers was hypertensive. In conventional ordinary least squares regression, each child was associated with 0.42 mmHg lower systolic [95% confidence interval (CI): -0.46 to -0.39, P < 0.001] and 0.13 mmHg lower diastolic (95% CI: -0.15 to -0.11, P < 0.001) blood pressure. In the IV regressions, each child decreased a mother's systolic blood pressure by an average of 1.00 mmHg (95% CI: -1.26 to -0.74, P < 0.001) and diastolic blood pressure by an average of 0.35 mmHg (95% CI: -0.52 to -0.17, P < 0.001). These decreases were sustained over more than a decade after childbirth, with effect sizes slightly declining as the time since last birth increased. Having children did not influence blood pressure in men. CONCLUSIONS: Bearing and rearing a child decreases blood pressure among mothers in India.

A cross-sectional study of psychological wellbeing of Indian adults during the Covid-19 lockdown: Different strokes for different folks.

The psychological impacts of the lockdown due to the Covid-19 pandemic are widely documented. In India, a family-centric society with a high population density and extreme social stratification, the impact of the lockdown might vary across diverse social groups. However, the patterning in the psychological impact of the lockdown among LGBT adults and persons known to be at higher risk of the complications of Covid-19 (such as persons with comorbidities or a history of mental illness) is not known in the Indian context. We used mixed methods (online survey, n = 282 and in-depth interviews, n = 14) to investigate whether the psychological influence of the lockdown was different across these groups of Indian adults. We fitted linear and logistic regression models adjusted for sociodemographic covariates. Thematic analysis helped us identify emergent themes in our qualitative narratives. Anxiety was found to be higher among LGBT adults (ß = 2.44, CI: 0.58, 4.31), the high-risk group (persons with comorbidities) (ß = 2.20, CI:0.36, 4.05), and those with a history of depression/loneliness (ß = 3.89, CI:2.34, 5.44). Persons belonging to the LGBT group reported a greater usage of pornography than the heterosexuals (ß = 2.72, CI: 0.09, 5.36) during the lockdown. Qualitative findings suggested that LGBT adults likely used pornography and masturbation to cope with the lockdown, given the limited physical access to sexual partners in a society that stigmatizes homosexuality. Moreover, both qualitative and quantitative study findings suggested that greater frequency of calling family members during lockdown could strengthen social relationships and increase social empathy. The study thereby urgently calls for the attention of policymakers to take sensitive and inclusive health-related decisions for the marginalized and the vulnerable, both during and after the crisis.

Dynamics of psychological responses to COVID-19 in India: A longitudinal study.

The novel COVID-19 pandemic has created chaos around the globe. To curb its spread, the Government of India announced a nationwide lockdown on March 24th, 2020 for 21 days, which was extended further for a longer time. This long period of lockdown disrupted the routine of all citizens, affecting their psychological well-being. While recent studies showed the psychological burden of Indians during the pandemic, no study has assessed whether the psychological toll changed over time due to repeated extensions of the lockdown. We followed up 159 Indian adults during the first two months of the lockdown to assess any change in their anxiety, stress, and depressive symptoms. Multilevel linear regression models of repeated observations nested within individuals adjusted for sociodemographic covariates showed that anxiety (ß = 0.81, 95% CI: 0.03, 1.60), stress (ß = 0.51, CI: 0.32, 0.70), and depressive symptoms (ß = 0.37, CI: 0.13, 0.60) increased over time during the lockdown. This increase was higher among women than men independent of covariates. Individual resilience was negatively associated with adverse psychological outcomes. Our findings suggested that while the lockdown may help in effectively addressing this pandemic, the state and society at large need to be sensitive to the mental health impacts of a long-drawn-out lockdown. Such effects likely have long-term sequelae. The disproportionate impact on women needs immediate attention. Moreover, it behooves society to address the root causes driving the unequal distribution of psychological distress during such crises.

Psychological wellbeing of middle-aged and older queer men in India: A mixed-methods approach.

Borrowing concepts from public health, we examined the association of several social determinants with the mental health of middle-aged and older queer men in India by combining quantitative and qualitative methodologies. A cross-sectional survey guided by Meyer's Minority Stress Model was carried out to assess the links between minority stressors (internalized homophobia and degree of closetedness), age-related stressors (ageism and fear of ageing) and psychological wellbeing (loneliness, depressive symptoms and sexual compulsivity) among 207 Indian men (aged 40 years and above) who identified themselves as non-heterosexuals. Results from simple and multivariable linear regression models showed significant positive associations of ageism, internalized homophobia, and fear of ageing with loneliness, even after accounting for sociodemographic and stress mitigating factors. Ageism was not significantly related to depressive symptoms. However, fear of ageing and internalized homophobia was positively associated with depressive symptoms after accounting for covariates. Further, regression models demonstrated a consistent and statistically significant inverse association between income and adverse psychological outcomes suggesting the centrality of social class in the lived experience of Indian gay and bisexual men. The qualitative inquiry addressed the same research questions as the quantitative survey through in-depth interviews of thirty middle-aged and older gay and bisexual men in Mumbai. We found that older and midlife gay and bisexual men with higher income (a proxy for social class) found ways to manage their masculinities with no discernible adverse psychological outcomes. Depressive symptoms and loneliness in this population made them further vulnerable to excessive sexual impulses, especially in the older queer men who were passing off as heterosexuals. Overall, the theory-driven empirical findings suggest that even in India, where family and friends are social insurance for later life, the issues of ageism and internalized homophobia have the potential to lead to worse mental health outcomes among older queer men.

Utilization of Integrated Child Development Services in India: Programmatic Insights from National Family Health Survey, 2016.

The Integrated Child Development Services (ICDS) program launched in India in 1975 is one of the world's largest flagship programs that aims to improve early childhood care and development via a range of healthcare, nutrition and early education services. The key to success of ICDS is in finding solutions to the historical challenges of geographic and socioeconomic inequalities in access to various services under this umbrella scheme. Using birth history data from the National Family Health Survey (Demographic and Health Survey), 2015-2016, this study presents (a) socioeconomic patterning in service uptake across rural and urban India, and (b) continuum in service utilization at three points (i.e., by mothers during pregnancy, by mothers while breastfeeding and by children aged 0-72 months) in India. We used an intersectional approach and ran a series multilevel logistic regression (random effects) models to understand patterning in utilization among mothers across socioeconomic groups. We also computed the area under the receiver operating characteristic curve (ROC-AUC) based on a logistic regression model to examine concordance between service utilization across three different points. The service utilization (any service) by mothers during pregnancy was about 20 percentage points higher for rural areas (60.5 percent; 95% CI: 60.3; 30.7) than urban areas (38.8 percent; 95% CI: 38.4; 39.1). We also found a lower uptake of services related to health and nutrition education during pregnancy (41.9 percent in rural) and early childcare (preschool) (42.4 percent). One in every two mother-child pairs did not avail any benefits from ICDS in urban areas. Estimates from random effects model revealed higher odds of utilization among schedule caste mothers from middle-class households in rural households. AUC estimates suggested a high concordance between service utilization by mothers and their children (AUC: 0.79 in rural; 0.84 in urban) implying a higher likelihood of continuum if service utilization commences at pregnancy.

Are self-reports of health and morbidities in developing countries misleading? Evidence from India.

Self-reported measures of poor health and morbidities from developing countries tend to be viewed with considerable skepticism. Examination of the social gradient in self-reported health and morbidity measures provides a useful test of the validity of self-reports of poor health and morbidities. The prevailing view, in part influenced by Amartya Sen, is that socially disadvantaged individuals will fail to perceive and report the presence of illness or health-deficits because an individual's assessment of their health is directly contingent on their social experience. In this study, we tested whether the association between self-reported poor health/morbidities and socioeconomic status (SES) in India follows the expected direction or not. Cross-sectional logistic regression analyses were carried out on a nationally representative population-based sample from the 1998 to 1999 Indian National Family Health Survey (INFHS); and 1995-1996 and 2004 Indian National Sample Survey (INSS). Four binary outcomes were analyzed: any self-reported morbidity; self-reported sickness in the last 15 days; self-reported sickness in the past year; and poor self-rated health. In separate adjusted models, individuals with no education reported higher levels of any self-reported, self-reported sickness in the last 15 days, self-reported sickness in the last year, and poor self-rated health compared to those with most education. Contrary to the prevailing thesis, we find that the use of self-rated ill-health has face validity as assessed via its relationship to SES. A less dismissive and pessimistic view of health data obtained through self-reports seems warranted.

Menstrual health communication among Indian adolescents: A mixed-methods study.

BACKGROUND: Research in health communication frequently views it as an information dissemination strategy, thus neglecting the intricacies involved in communicating a sensitive topic such as menstruation. The social patterning in menstrual communication, a taboo in India, and its consequent health-effects on adolescents are under-studied. METHODS: We studied the social determinants of menstrual communication influencing menstrual- health through semi-structured interviews of 21 boys and girls each, 12 key-respondent interviews, followed by a cross-sectional survey of 1421 adolescents from Nashik district, India. We thematically analysed the qualitative data and fit multivariable logistic regression to model risk ratios. FINDINGS: We found social disparities in adolescents' experiences of communication taboo regarding menstruation. While boys curbed their curiosity about the topic, girls too faced resistance to their experience-sharing and treatment-seeking for menstrual illnesses. The inequality in menstruation-related communication was evident as more boys than girls faced avoidance to their questions [IRR at 95%CI: 2.75 (2.04, 3.71)]], and fewer tribal than rural girls were communicated severe taboos (OR at 95% CI: 0.18 (0.09, 0.36))]. Girls who had been communicated severe (versus no/mild) taboos reported greater stress about menstrual staining (IRR at 95% CI: 1.31 (1.10, 1.57)], emphasizing the health consequences of such communication inequalities. CONCLUSIONS: Our study highlights the need to address gender and setting-specific communication experiences of adolescents in India, a patriarchal society. The inequality in communication needs attention as it creates unequal patterns in Indian adolescents' menstrual health and experiences, which may manifest as inequities in reproductive health-related outcomes even in their adult-lives.

Domestic violence is associated with adult and childhood asthma prevalence in India.

BACKGROUND: Little is known on the influence of stressful psychosocial circumstances in predicting asthma. We examine the link between asthma prevalence and domestic violence (DV) in a nationally representative sample of adults and children in India. METHODS: Analyses were based on the 1998-99 cross-sectional nationally representative Indian National Family Health Survey administered in 92 486 households. Individual-level prevalence of asthma was the primary outcome for this study. Exposure to DV was based on women's self-report of DV. RESULTS: In adjusted models, women who experienced DV either recently or in the past were at greater risk of being asthmatic [odds ratio (OR) range 1.26-1.37], compared with those who did not report any abuse. In households where women reported to have experienced DV, asthma risk was higher for all individuals in those households (OR range 1.15-1.19). The association between household DV and individual risk for asthma was also observed in gender-stratified analysis, and also in age-stratified analysis, with strong association observed in age groups of under-five, 5-14, 15-24 and 25-44 years. CONCLUSIONS: We find a consistent association between being exposed to, and having experienced, DV and asthma prevalence. Stress-induced mechanisms, partially captured through violence and social circumstances, may be a critical explanatory link in furthering our understanding of the social disparities in asthma.

Indigenous health and socioeconomic status in India.

BACKGROUND: Systematic evidence on the patterns of health deprivation among indigenous peoples remains scant in developing countries. We investigate the inequalities in mortality and substance use between indigenous and non-indigenous, and within indigenous, groups in India, with an aim to establishing the relative contribution of socioeconomic status in generating health inequalities. METHODS AND FINDINGS: Cross-sectional population-based data were obtained from the 1998-1999 Indian National Family Health Survey. Mortality, smoking, chewing tobacco use, and alcohol use were four separate binary outcomes in our analysis. Indigenous status in the context of India was operationalized through the Indian government category of scheduled tribes, or Adivasis, which refers to people living in tribal communities characterized by distinctive social, cultural, historical, and geographical circumstances.Indigenous groups experience excess mortality compared to non-indigenous groups, even after adjusting for economic standard of living (odds ratio 1.22; 95% confidence interval 1.13-1.30). They are also more likely to smoke and (especially) drink alcohol, but the prevalence of chewing tobacco is not substantially different between indigenous and non-indigenous groups. There are substantial health variations within indigenous groups, such that indigenous peoples in the bottom quintile of the indigenous-peoples-specific standard of living index have an odds ratio for mortality of 1.61 (95% confidence interval 1.33-1.95) compared to indigenous peoples in the top fifth of the wealth distribution. Smoking, drinking alcohol, and chewing tobacco also show graded associations with socioeconomic status within indigenous groups. CONCLUSIONS: Socioeconomic status differentials substantially account for the health inequalities between indigenous and non-indigenous groups in India. However, a strong socioeconomic gradient in health is also evident within indigenous populations, reiterating the overall importance of socioeconomic status for reducing population-level health disparities, regardless of indigeneity.