Vaccination and associated factors among tribal children of 1 year age in nine Indian districts: A cross-sectional study.

OBJECTIVE: To report on vaccination status by 12 months of age among tribal children from nine districts of India. METHODS: Cross-sectional study of 2631 tribal women having a child aged 12 months or below from nine Indian districts with a considerable proportion of the tribal population. Socio-demographic details, reception of various vaccines by 12 months of age, mother's antenatal care utilisation and health system-related details were collected through a pre-tested, interviewer-administered questionnaire from mothers. Multiple logistic regression analysis was used to identify the factors associated with complete vaccination by 12 months of age. RESULTS: Only 52% of children were fully vaccinated by the age of 12 months among the tribal populations; 11% did not receive any vaccine, and 37% of the tribal children received some vaccines. The age-appropriate vaccination was unsatisfactory as only 75% of the infants received all birth dose vaccines, and only 60.5% received all doses by 14 weeks. Only 73% were vaccinated against measles. Illness of the child, home births and communication gaps concerning vaccination were the main reasons for an infant not being vaccinated appropriately. Frequency of health worker's visits to the village, hospital birth, reception of advice on vaccination and educational status of the head of the households were significantly associated with full vaccination status. CONCLUSION: A relatively low proportion of children were fully vaccinated among the tribal populations. Health systems factors, mainly the outreach services and advice by the health workers, were positively and significantly associated with a child being fully vaccinated by 12 months of age. Improving outreach services is crucial to improve vaccination coverage in tribal areas, and there is a need to address the social determinants in the long run.

Beyond the screening: The need for health systems intervention for prevention and management of sickle cell disease among tribal population of India.

Globally, sickle cell disease (SCD) is one of the major public health problems. In India, it is more prevalent in tribal communities. Tribal communities are socio-economically disadvantaged and constitute 8.6% of India's population. The health and health care seeking of these communities is very poor. Though efficacious interventions are available to manage SCD, they are not reaching these people and no comprehensive programme is in place. The objective of this analysis is to demonstrate the burden of SCD among the tribes in two Indian states of Andhra Pradesh and Telangana, as a case and to highlight the need for public health intervention and health systems strengthening in the country to prevent and manage SCD. One in 10 persons of tribal population of these states carries Hb S gene. A substantial number of children are born every year with the condition. Mostly, the research is limited to screening. Hence, a programme with early detection and an appropriate referral system should be developed. The primary health care system should be strengthened to screen and manage SCD persons with good disease management practices and appropriate community mobilisation activities. The programme should partner with traditional healers and community leaders. People should be encouraged to seek treatment; and counselling for prevention. The study warrants human-centric approaches during the interventions to address the possible threat of fear of being stigmatised. Thus, the transition of evidence-based interventions into the programme and practice can improve the lives of people with SCD, particularly the tribal population.

Migration and health: A systematic review on health and health care of internal migrants in India.

The objective of this paper is to review published studies on various health conditions and health care access of internal migrants in India. The guidelines under PRISMA Statement for Reporting Systematic Reviews and Meta-Analysis were followed. We searched 3 databases-Web of Science, Medline (PubMed), and Google Scholar. By applying selection criteria, we identified a total of 42 papers to include in the review. These studies reported various health problems/morbid conditions, and some studies reported health care access. Major health issues of poor migrants included work-related injuries, noncommunicable diseases like diabetes and hypertension, and communicable diseases like malaria and HIV. In addition, behavioural risks such as the use of tobacco and alcohol are reported. Information on health care seeking and poor access to government health care system are available. This review demonstrates the need to improve the health status and health care access of poor migrants. As health systems-related factors also influence the health care seeking behaviour, they are to be considered along with improving the living conditions of this population. Thus, a comprehensive migrant-sensitive health care should be the part of the urban health care system.

Internal migrants' experiences with and perceptions of frontline health workers: A nationwide study in 13 Indian cities.

The role of frontline health workers is crucial in strengthening primary health care in India. This paper reports on the extent of services provided by frontline health workers in migrants' experiences and perceptions of these services in 13 Indian cities. Cluster random sampling was used to sample 51 055 households for a quantitative survey through interviewer-administered questionnaires. Information was sought on the receipt of health workers' services for general health care overall (from the head/other adult member of the household) and maternal and immunization services in particular (from mothers of children <2 years old). Purposively, 240 key informants and 290 recently delivered mothers were selected for qualitative interviews. Only 31% of the total respondents were aware of the visits of frontline health workers, and 20% of households reported visits to their locality during past month. In 4 cities, approximately 90% of households never saw health workers in their locality. Only 20% of women and 22% of children received antenatal care and vaccination cards from frontline health workers. Qualitative data confirm that the frontline health workers' visits were not regular and that health workers limited their services to antenatal care and childhood immunization. It was further noted that health workers saw the migrants as"outsiders." These findings warrant developing migrant-specific health-care services that consider their vulnerability and living conditions. The present study has implications for India's National Urban Health Mission, which envisions addressing the health care needs of the urban population with a focus on the urban poor.

Mother's Recognition of and Treatment Triggers for Common Childhood Illnesses among Migrant Santal Tribe Living in Bhubaneswar, Odisha, India.

Background: Accelerating reduction in infant and other child mortality rates calls for comprehensive child survival strategies. Early recognition of illness and timely seeking of treatment are critical elements to prevent child deaths, and cultural explanation for these care-seeking behaviours is important. The present article reports (i) mothers' recognition of illness and (ii) triggers of treatment related to some childhood illnesses among a migrant tribal community living in Bhubaneswar city, India. Methods: From the four tribal dominated slums, 175 Santal tribal households were selected based on the criteria, viz. (i) the family should have migrated within the past 12 years and (ii) having a child aged 0-14 years. Semi-structured interviews were conducted with mothers for data related to illnesses occurred to their youngest child during past 1 year. Results: The recognition of illness was made based on multiple symptoms. Triggers of treatment and care-seeking behaviour vary from illness to illness. Usually people wait for 2-3 days after onset of any illness, expecting the symptoms to subside automatically. Late onset symptoms and severity trigger mother to take child for treatment. Conclusion: Mothers were able to recognize the childhood illnesses. There was substantial delay in seeking care. Hence, provision of primary health care and health education-based interventions are needed to improve the mothers' recognition and care-seeking behaviour.

Maternal healthcare seeking and determinants of adequate antenatal care and institutional childbirth among Indian tribes: A cross-sectional study from nine districts.

OBJECTIVE: To report the utilisation of maternal healthcare services and factors associated with adequate antenatal care and institutional childbirths among mothers in the tribal communities from nine districts in India. METHODS: Cross-sectional data were collected from 2636 tribal women who had a childbirth experience in the past 12 months. Socio-demographic, maternal healthcare services and health system-related details were collected. Multiple logistic regression analyses were done to identify factors associated with adequate antenatal care (receiving at least four antenatal care visits, the first visit being in the first trimester and receiving a minimum of 100 iron-folic acid tablets) and institutional childbirth (mother giving birth in a health facility). RESULTS: Only 23% of the mothers received adequate antenatal care. 82% were institutional childbirths. The logistic regression revealed that particularly vulnerable tribal groups (PVTGs), those lacking all-weather roads, and women of advanced age were at risk of inadequate antenatal care. Mother's education, health worker's home visits during pregnancy and reception of advice on antenatal care were significantly associated with the reception of adequate antenatal care. Having all-weather roads, and education of the mother and head of the household were positively associated with institutional childbirths, whereas PVTGs, children of birth order three or above, and working mothers were more likely to give childbirth at home. CONCLUSION: PVTGs are at risk of foregoing adequate antenatal care and are more likely to give childbirth at home. Having all-weather roads is a strong correlate of adequate maternal care. Outreach activities by the health workers are to be strengthened as they are positively and significantly associated with the reception of adequate antenatal care. Investing in education and other social determinants and addressing certain socio-cultural practices is important to improve maternal health.

Migration and access to maternal healthcare: determinants of adequate antenatal care and institutional delivery among socio-economically disadvantaged migrants in Delhi, India.

OBJECTIVE: To identify the determinants of adequate antenatal care (ANC) utilisation and institutional deliveries among socio-economically disadvantaged migrants living in Delhi, India. METHODS: In a cross-sectional survey, 809 rural-urban migrant mothers with a child aged below 2 years were interviewed with a pretested questionnaire. Data on receiving antenatal, delivery and post-natal services, migration history and other social, demographic and income were collected. RESULTS: Recent migrants used the services significantly less than settled migrants. ANC was adequate only among 37% (35% of recent migrant women and 39% of settled migrants). Multinomial regression revealed that being a recent migrant, multiparous, illiterate and married to an unskilled worker were significant risk factors for receiving inadequate ANC. Around 53% of deliveries took place at home. ANC seeking has a strong influence on place of delivery: 70% of births to women who received inadequate ANC were at home. Women who are educated, had their first delivery after the age of 20 years and received adequate ANC were more likely to deliver their child in hospital. Post-natal care is grossly neglected among these groups. CONCLUSION: Migrant women, particularly recent migrants, are at the risk of not receiving adequate maternal healthcare. Because migration is a continuing phenomenon, measures to mitigate disadvantage due to migration need to be taken in the healthcare system.

COVID-19 vaccine acceptance and hesitancy in Indian context: a systematic review and meta-analysis.

Vaccination against COVID-19 is vital for achieving herd immunity, and the Government of India has adopted several strategies to achieve coverage. Vaccine hesitancy was identified as a potential obstacle in combating COVID-19. This study aimed to review the COVID-19 vaccine acceptance and hesitancy, and factors associated with vaccine hesitancy based on studies conducted in Indian populations. The data sources (PubMed, Scopus, and Google Scholar) were searched by following PRISMA guidelines, and the search was done in September 2022. We performed a meta-analysis through a random effect model to estimate pooled hesitancy rate with 95% confidence intervals (CI). A total of 3,339 records were searched, of which 46 studies were found to be eligible for inclusion in the review. The included studies covered 65,551 respondents, 55% were female. Studies reported COVID-19 vaccine acceptance rate of 65.7% in January-February 2021, which increased to 92.8% in May-August 2021. Likewise, the rate of vaccine hesitancy in December 2020 was 37%, dropping to 12.1% through November 2021. The estimated pooled COVID-19 vaccine hesitancy was 31% [95% CI: 27% - 36%, I2 = 99.3%]. Most studies highlighted that fear of the vaccine's side effects, efficacy, and safety were major barriers to vaccine acceptance. However, as the review indicates, it is important to consider and address all factors contributing to vaccine hesitancy.

COVID-19 vaccine acceptance and its determinants: A cross-sectional study among the socioeconomically disadvantaged communities living in Delhi, India.

Background: Vaccination against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the most desired solution to combat COVID-19. We examined the willingness to accept the vaccine and reasons for vaccine hesitancy, and identified some factors associated with the vaccine hesitancy among the socio-economically disadvantaged urban population from Delhi, India. Methods: We conducted a cross-sectional survey of a randomly selected sample of 1539 households from 31 urban clusters. Data on socio-demographics, health beliefs, and willingness to accept the SARS-CoV-2 vaccine were collected through a face-to-face interviewer-administered, pre-tested questionnaire from an adult member. Vaccine acceptance/hesitancy was analysed by various socio-demographic and health belief variables. Multinomial regressions were carried out to identify the factors associated with the vaccine hesitancy. Results: Overall, 64.9% (95% CI: 62.5 to 67.3) of the respondents would accept the vaccine, 17.4% (95% CI: 15.6 to 19.4) were undecided, and 17.7% (95% CI: 15.8 to 19.7) would not accept the vaccine. The reasons for not accepting the vaccine were: belief that they had immunity (12.9%), the corona was a hoax (11.8%), the vaccine was not necessary (7.4%), and did not want to disturb the natural bodily systems by the vaccine (5.6%). The undecided group mainly would like to wait and see (37.7%), decide when the vaccine become available (11.6%), will take if everyone in their community takes (10.4%). Multinomial logistic regression identified older age, low perceived susceptibility of contracting COVID-19, low perceived severity of COVID-19, low self-efficacy to protect against COVID-19, and unawareness and non-use of Arogyasetu App as significant predictors of vaccine hesitancy. Conclusions: Two-thirds of Delhi's low-income groups would accept the vaccine against SARS-CoV-2. Vaccine hesitancy was associated with older age, low perceived susceptibility, low perceived severity, and low self-efficacy to protect themselves from COVID-19. Hence, efforts are needed to address these issues and vaccine concerns to increase the vaccine uptake.

Inclusive partnership and community mobilization approaches to improve maternal health care access among internal migrants in nine Indian cities.

Background: Disparities in healthcare access to internal migrants exist, and the gaps may widen further if appropriate steps are not taken. Innovative approaches are needed to better align the healthcare services with the migrants' needs. Aim: The aim was to develop and test a supportive strategy of healthcare, which would achieve the desired level of access and delivery of maternal healthcare services to internal migrants living in nine Indian cities. Methods: This intervention with the quasi-experimental design was conducted with pre- vs post-intervention comparisons within the interventional groups and with the control group. The intervention was implemented with an inclusive partnership approach. Advocacy and community mobilization were the main intervention components. Findings: An increased proportion of women sought antenatal care during the intervention. More women initiated seeking antenatal care in the first trimester. Due to intervention, health workers' prenatal (41.7% in the post- against 14.7% in the pre-interventional phase) and postnatal home visits increased (11.6% to 34.7%) considerably. Conclusions: Interventions with inclusive partnership would improve healthcare access to vulnerable communities such as migrants. Hence, efforts to strengthen the government healthcare system through novel strategies are crucial to provide better healthcare to migrants.

Knowledge and Willingness to Accept Vaccine Against SARS-CoV-2 Among Undergraduate Medical Students in Delhi, India.

Vaccination against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the most desired solution to combat COVID-19. Understanding the willingness to accept vaccines is essential to make appropriate strategies for the vaccination programme's success. There was a lack of published literature in India among medical students. Hence, we conducted this online, cross-sectional study to assess the knowledge and willingness to accept COVID-19 vaccines among undergraduate medical students of a medical school in Delhi. A complete enumeration of all the undergraduate medical students was done. All the students were invited to participate in this online survey. The questionnaire through Google forms was shared through email and WhatsApp. The questionnaire contained questions on the socio-demographic details, questions related to the knowledge and perceptions about COVID-19 vaccines, willingness to accept the vaccine and vaccination status of the participant. Descriptive and multiple logistic regression analyses were carried out. Out of 320 students contacted, 298 consented to participate in the survey, and 274 participants (85%) completed the questionnaire. Three-fourths of the participants were male; the mean age of the study participants was 19.6 years. Only 70.4% were willing to accept the vaccine. Those who perceived COVID-19 vaccines as safe (AOR=3.946; 95% CI: 1.946 to 7.912); and effective (AOR=2.079; 95% CI: 1.054 to 4.101); and who has knowledge about the vaccines (AOR=2.206; 95% CI: 1.186 to 4.104) were more likely to accept the vaccine. There is a need for enhancing the knowledge on vaccines, and their safety and effectiveness to promote the vaccine acceptance.

Dengue awareness, preventive behaviours and Aedes breeding opportunities among slums and slum-like pockets in Delhi, India: a formative assessment.

BACKGROUND: India is endemic for dengue. The present formative study reports awareness and practices of people regarding dengue and its prevention, personal protection behaviours and peoples' exposure to dengue-related health promotion activities. METHODS: This is a cross-sectional study of 1194 households randomly selected from 20 slum clusters in Delhi. Data were collected from an adult member of the household through an interviewer-administered, pre-tested questionnaire. An observation checklist was used to identify potential breeding sources. RESULTS: People were aware that dengue is transmitted through mosquitoes and sources of breeding (clean, stagnant water -60.1%, domestic water containers -18.7%, coolers -15.0%). Each house had at least one potential source of mosquito breeding. Using mosquito repellents (83.3%) was the most common personal protection behaviour. Peoples' participation is limited in the mosquito prevention and health promotion activities carried out by the local municipality. Still, participation resulted in positive behavioural change. CONCLUSIONS: While people were aware of dengue transmission, preventive measures against mosquito breeding were not satisfactory. People could not relate their existing knowledge on dengue to their household surroundings, and their awareness had not been translated to behavioural change. Community participation is limited, but is significant in the prevention and control of dengue.

Migration and immunization: determinants of childhood immunization uptake among socioeconomically disadvantaged migrants in Delhi, India.

OBJECTIVE: To determine the coverage of childhood immunization appropriate for age among socioeconomically disadvantaged rural-urban migrants living in Delhi and to identify the determinants of full immunization uptake among these migrant children. METHODS: This is a cross-sectional survey of 746 rural-urban migrant mothers with a child aged up to 2 years, who were interviewed with a pretested questionnaire. Data pertaining to the reception of various vaccines, migration history and some other social, demographic and income details were collected. Multiple logistic regression analyses were performed to identify the determinants of full immunization status. RESULTS: Immunization coverage rates were lower among migrants than the general population of Delhi and even lower among recent migrants. The likelihood of a child receiving full immunization rose with age of the mother, her educational attainment and the frequency of her use of health care. The head of household having a secured salaried job also significantly increased the likelihood of full immunization, as did post-natal visits by a health worker. CONCLUSION: Migrant status favours low immunization uptake particularly in the vulnerability context of alienation and livelihood insecurity. Services must be delivered with a focus on recent migrants; investments are needed in education, socio-economic development and secure livelihoods to improve and sustain equitable health care services.

Perceptions on hypertension among migrants in Delhi, India: a qualitative study.

BACKGROUND: The developing countries are experiencing epidemiological transition and hypertension has emerged as a major threat to health in these countries. Understanding people's perceptions is important for any prevention and control activities and lay explanatory models (EMs) provide an opportunity to gain insights into the people's perceptions. This qualitative study is taken up with an objective of understanding EMs of neo- and settled-migrants regarding hypertension. METHODS: Qualitative methods with grounded theory approach were used to elicit EMs of hypertension held by neo- and settled-migrants. In-depth interviews with key-informants and focus group discussions with community members were conducted. The data were subjected to thorough reading and analysed by segregating the text under different themes. RESULTS: Hypertension has been perceived as a common and serious problem in the community. Lay conceptions have identified hypertension as symptomatic with ambiguity over perceived symptoms. City life has been perceived as a major predisposing factor for developing hypertension. City life has been corroborated with pollution and adulteration of food, stress, high fat diet along with physical inactivity and certain attitudes. The concepts of hypertension were interconnected and linked to their day-to-day living in the city. Inadequacy of awareness has been acknowledged and there was a felt need for awareness campaigns and screening programmes in the community. The EMs of hypertension among the neo- and settled-migrants and men and women were broadly similar. However, there were slight variations by gender and migration status in the perceived pathways to hypertension. CONCLUSION: Hypertension has been perceived as a common and serious problem in the community. Hypertension has been perceived as symptomatic; however, ambiguity prevails over perceived symptoms. Awareness and knowledge about hypertension and its consequences are inadequate in these communities. The felt need for awareness campaigns and mass screening programmes has emerged from the community and it provides enabling environment to successfully carry out public health interventions, by addressing the existing gaps, for prevention and control of hypertension and other cardiovascular diseases.

The costs of seeking healthcare: Illness, treatment seeking and out of pocket expenditures among the urban poor in Delhi, India.

The poor often experience illness and the treatment costs are high and even catastrophic for the poor. This paper reports the extent of illness, treatment-seeking behaviour and out of pocket healthcare expenditures and the determinants of treatment-seeking behaviour and healthcare expenditures among the urban poor living in Delhi. A total of 2,998 households participated in the study. Socio-demographic details, illness experiences (episodic illness in the past 3 months, hospitalisation in the past 1 year and any chronic illness), treatment seeking and healthcare expenditures were collected for all household members through a pretested, interviewer-administered questionnaire. Logistic regressions were carried out for factors associated with treatment-seeking choices. Multiple linear regressions were carried for factors associated with out of pocket expenditures (OOPE). Of the total 15,218 household members (of the 2,998 households), 4,052 (26.6%) experienced episodic illness (mainly fever, respiratory illnesses, food- and waterborne diseases and eye infections) in the past 3 months, 230 (1.5%) were hospitalised and 976 (6.4%) have chronic illness (mainly hypertension, diabetes, arthritis and respiratory problems). Of the 2,998 households, 2,225 (74.2%) households reported at least one event of illness. Unqualified practitioners were the main source of care for episodic illnesses. Perceived seriousness of the illness, having Employees State Insurance Scheme (ESIS) benefit, higher educational status of the head of the household, higher monthly household incomes, belonging other backward castes and settled-migrant status led to seeking formal care. Dengue was the main reason for hospitalisation. Government including ESIS hospitals were mainly utilised for hospitalisation. Healthcare expenditures were higher for private healthcare. Possession of mandatory health insurance was protective against OOPEs. OOPEs were more for the men/boys and for the young. Improving access to government healthcare services is important. Extending the ESIS to the unorganised workers including urban poor migrants should be considered so as to bring them under mandatory social protection.

Impact of health education based intervention on community's awareness of dengue and its prevention in Delhi, India.

Dengue is endemic in India. The capital, Delhi, continues to witness a higher number of cases due to urbanization-related factors. This study is intended to implement health education towards prevention of dengue, and to assess its impact on people's knowledge and practices related to causes and prevention of dengue among urban poor in Delhi. Pre- ( n = 484) and post- ( n = 496) intervention surveys from 15 sub-clusters from five slums/slum-like settlements in Delhi were carried out. Health education based intervention was carried out through partnership with the municipal bodies and non-governmental organizations. Socio-demographic characteristics of participants were similar in both surveys. Intervention resulted in significant increase in knowledge on cause, symptom perception and mosquito behaviour in terms of breeding and biting habits. Practice of personal protection measures increased significantly. The participation of people increased during intervention compared to the routine programme. Health education based interventions are instrumental in improving people's knowledge and behaviour. Hence, routine health educational activities as a supportive strategy in the health system need to be strengthened. New integrated approaches such as eco-bio-social approaches with community participation are to be developed and tested in endemic settings like Delhi.

Health Insurance: Awareness, Utilization, and its Determinants among the Urban Poor in Delhi, India.

This study reports the awareness, access, and utilization of health insurance by the urban poor in Delhi, India. The study included 2998 households from 85 urban clusters spread across Delhi. The data were collected through a pretested, interviewer-administered questionnaire. Logistic regression was performed for determinants of health insurance possession. Only 19% knew about health insurance; 18% had health insurance (8% Employees State Insurance Scheme - ESIS - 8% Central Government Health Scheme - CGHS - 1.4%; Rashtriya Swasthya Bima Yojana (RSBY) - 9.4% of the eligible households). In case of health needs, 95% of CGHS, 71% ESIS beneficiaries, and 9.5% of RSBY beneficiaries utilized the schemes for episodic and chronic illnesses. For hospitalization needs, 54% of RSBY, 86% of ESIS, 100% CGHS utilized respective services. Residential area, migration period, possession of ration card, household size, and occupation of the head of the household were significantly associated with possession of RSBY. RSBY played a limited role in meeting the healthcare needs of the people, thus may not be capable of contributing significantly in the efforts of achieving equity in healthcare for the poor. Relatively, ESIS and CGHS served the healthcare needs of the beneficiaries better. Expansion of ESIS to the informal workers may be considered.

Elimination of violence against women and girls as a global action agenda.

This article outlines the goals and targets of Sustainable Development Goals (SDGs) related to elimination of violence against women and girls (VAWG) and to explain the framework to target these goals. Prevention of VAWG has been identified as one of the key agents for sustainable development. SDGs gave enough importance and called for the elimination of "all forms of violence against all women and girls everywhere". It identified different social and political enablers of reducing violence which are targeted under different SDGs. This acknowledges tacitly that VAWG is preventable and it is set to prevent and eliminate it. Evidences show that preventing VAWG is possible through multi-sectorial programs. The United Nations committed to revitalized global partnership to mobilize resources for implementing the agenda. Hence, designing and implementing interventions and subsequently scaling-up and intensifying these interventions are required to end VAWG.

Treatment-seeking and out-of-pocket expenditure on childhood illness in a migrant tribal community in Bhubaneswar, Odisha State, India.

BACKGROUND: In India, migrant status, tribal affiliation and poverty render tribal migrants more vulnerable than any other group which leads to high treatment costs and the risk of low access to health care. OBJECTIVE: To examine treatment-seeking behaviour and out-of-pocket (OOP) expenditure on the treatment of childhood illnesses, with a focus on gender in a migrant tribal community in Bhubaneswar, eastern India. METHODS: A total of 175 households with a child aged 0-14 years and who had migrated within the last 12 years were selected from tribal-dominated slums. Data on health-seeking behaviour and expenditure on a recent illness in the youngest child were collected by interviewing mothers during October 2007 to March 2008. RESULTS: Of the 175 children, 78.8% had at least one episode of illness during the previous year. Of the total number of episodes, 71% had been treated and 61% of them had incurred OOP expenditure. A significantly lower proportion of episodes of illness in girls had been treated than in boys (P = 0.01) and incurred OOP expenditure (P = 0.05). Private health care was preferred and only 16.5% availed themselves of the government sources. About 89 and 87% of households of boys and girls, respectively, incurred OOP expenditure. A child's gender (female) (P = 0.05), mother's education (P = 0.002) and type of illness (P = 0.002) were significantly associated with total OOP expenditure. CONCLUSION: Further studies are warranted to address the low access to government health care and thereby reduce high OOP expenditure by tribal migrants on low incomes. Efforts are required to increase the ability of communities and health providers to identify and address the issues of gender and equity in health care along with a focus on culture-sensitive service provision.

Water and Sanitation Hygiene Practices for Under-Five Children among Households of Sugali Tribe of Chittoor District, Andhra Pradesh, India.

BACKGROUND: Increased mortality is associated with poor household water, sanitation, and hygiene (WaSH) practices. The objective was to study the WaSH practices for under-five children among households of Sugali Tribe, Chittoor district, Andhra Pradesh, India. METHODS: A community-based cross-sectional study was conducted in four mandals in 2012. A total of 500 households with under-five children were identified. Data was collected from mothers/caregivers. A summary WaSH score was generated from four specific indices, water, sanitation, hygiene, and hand washing practices, and determinants were identified. RESULTS: Of the total households, 69% reported doing nothing at home to make the water safe for drinking. Over 90% of the households reported storing water in a utensil covered with a lid and retrieving water by dipping glass in the vessels. Open defecation was a commonly reported practice (84.8%). About three-fifths of the study's households reported using water and soap for cleaning dirty hands and one-third (37.4%) reported using water and soap after defecation. The median WaSH score was 15. In the hierarchical stepwise multiple linear regression, only socioeconomic variables were significantly associated with WaSH score. CONCLUSION: WaSH related practices were generally poor in people of the Sugali Tribe in Andhra Pradesh, India.