Utility of opportunistic screening to assess the impact of urinary incontinence on quality of life and barriers to seeking treatment among women attending a tertiary healthcare centre in North India.

INTRODUCTION: Urinary incontinence (UI) is a common but frequently neglected problem in females, significantly impacting their psychosocial health. The available estimates are an underestimation of a bigger problem. Thus, the study aimed to estimate the prevalence of UI, its associated risk factors, its impact on the Quality of life (QoL), and barriers to treatment-seeking behaviour in women attending tertiary healthcare centres. METHODS: We conducted a cross-sectional study using an opportunistic screening among women visiting a tertiary care hospital in Punjab recruited using multi-stage systematic random sampling. UI was classified as Stress (SUI), Urge (UUI), mixed (MUI), and No Incontinence (UI less than once a week or a month or no complaints) using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF). Bivariate analyses were done using the chi-square test to test the association between the dependent and independent variables. The predictors of UI were explored using univariable and multivariable binary logistic regression and depicted using Odds ratio with 95% confidence intervals. The impact of UI on Quality of Life (QoL) was assessed using the Incontinence Impact Questionnaire-Short Form (IIQ-7), and compared among the three UI types using One-Way ANOVA. Treatment barriers were explored using open-ended questions. RESULTS: Of the 601 women, 19.6% reported UI (stress UI: 10.1%, mixed UI: 6.0%, and urge UI: 3.5%). There were significant clinical-social factors that predicted different types of UI. The UI depicted a significant effect on QoL across all domains of the IIQ-7 (total mean score: 50.8 ± 21.9) compared to women with no incontinence (0.1 + 1.9). The score was highest in women with MUI, followed by SUI and UUI. About two-thirds of the affected women never consulted a doctor and considered it a non-serious condition or a normal ageing process. CONCLUSIONS: The present study found a high prevalence of UI through opportunistic screening across all the women's age groups with different conditions. Due to the associated stigma, clinicians should make every attempt to talk more about this, especially in women with medical conditions that can precipitate UI. Furthermore, the results call for generating more robust estimates through community-based screening studies.

Association of anaemia with indoor air pollution among older Indian adult population: multilevel modelling analysis of nationally representative cross-sectional study.

INTRODUCTION: Anaemia is a disease of public health importance with multi-causal pathways. Previous literature suggests the role of indoor air pollution (IAP) on haemoglobin levels, but this has been studied less due to logistic constraints. A high proportion of the population in developing countries, including India, still depends on unclean fuel, which exacerbates IAP. The objective was to study the association between anaemia and IAP among the older Indian adult population (≥ 45 years) as per gender. METHODS: Our study analysed the nationally representative dataset of the Longitudinal Ageing Study in India (LASI 2017-18, Wave-1). We have documented the association of anaemia (outcome variable) with IAP (explanatory variable). To reduce the confounding effects of demographic and socioeconomic; health related and behavioural covariates; propensity score matching (PSM) was conducted. Nested multilevel regression modelling was conducted. States and union territories were categorised cross tabulated as low, middle and high as per anaemia and IAP exposure. P value < 0.05 was considered statistically significant. SATA version 17 was used for analysis. RESULTS: More than half (52.52%) of the participants were exposed to IAP (male (53.55%) > female (51.63%)). The odds of having anaemia was significantly 1.19 times higher (AOR 1.19 (1.09-1.31)) among participants using unclean/ solid fuel. The adjusted odds were significantly higher among participants exposed to pollution-generating sources (AOR 1.30; 1.18-1.43), and household indoor smoking (AOR 1.17 (1.07-1.29). The odds of having anaemia were significantly higher (AOR 1.26; 1.15-1.38) among participants exposed to IAP, which was higher in males (AOR 1.36; 1.15-1.61) than females (AOR 1.21; 1.08-1.35). Empowered Action Group (EAG) states like Uttar Pradesh, Chhattisgarh, Madhya Pradesh, Bihar had both high anaemia and IAP exposure. CONCLUSION: This study established the positive association of anaemia with indoor air pollution among older Indian adults through a nationally representative large dataset. The association was higher among men. Further research is recommended to understand detailed causation and to establish temporality. It is a high time to implement positive intervention nationally to decrease solid/ unclean fuel usage, vulnerable ventilation, indoor smoking, IAP and health hazards associated with these with more focused actions towards EAG states.

Prevalence and associated factors of impaired kidney functions among children and adolescents in India: insights from the Comprehensive National Nutrition Survey (CNNS) 2016-18.

BACKGROUND: Chronic kidney disease (CKD) is a significant public health problem. The burden of CKD in children and adolescents in India is not well described. We used data from the recent Comprehensive National Nutrition Survey (CNNS) to estimate the prevalence of impaired kidney function (IKF) and its determinants in children and adolescents between the ages of 5 and 19. METHODS: CNNS 2016-18 adopted a multi-stage sampling design using probability proportional to size sampling procedure after geographical stratification of urban and rural areas. Serum creatinine was tested once in 24,690 children and adolescents aged 5-19 years. The estimated glomerular filtration rate (eGFR) was derived using the revised Schwartz equation. The eGFR value below 60 ml/min/1.73 m2 is defined as IKF. Bivariate analysis was done to depict the weighted prevalence, and multivariable logistic regression examined the predictors of IKF. RESULTS: The mean eGFR in the study population was 113.3 + 41.4 mL/min/1.73 m2. The overall prevalence of IKF was 4.9%. The prevalence in the 5-9, 10-14, and 15-19 year age groups was 5.6%, 3.4% and 5.2%, respectively. Regression analysis showed age, rural residence, non-reserved social caste, less educated mothers, Islam religion, children with severe stunting or being overweight/obese, and residence in Southern India to be predictors of IKF. CONCLUSIONS: The prevalence of IKF among children and adolescents in India is high compared to available global estimates. In the absence of repeated eGFR-based estimates, these nationally representative estimates are intriguing and call for further assessment of socio-demographic disparities, genetics, and risk behaviours to have better clinical insights and public health preparedness.

Indian Model of Integrated Healthcare (IMIH): a conceptual framework for a coordinated referral system in resource-constrained settings.

INTRODUCTION: With the escalating burden of chronic disease and multimorbidity in India, owing to its ageing population and overwhelming health needs, the Indian Health care delivery System (HDS) is under constant pressure due to rising public expectations and ambitious new health goals. The three tired HDS should work in coherence to ensure continuity of care, which needs a coordinated referral system. This calls for optimising health care through Integrated care (IC). The existing IC models have been primarily developed and adopted in High-Income Countries. The present study attempts to review the applicability of existing IC models and frame a customised model for resource-constrained settings. METHODS: A two-stage methodology was used. Firstly, a narrative literature review was done to identify gaps in existing IC models, as per the World Health Organization framework approach. The literature search was done from electronic journal article databases, and relevant literature that reported conceptual and theoretical concepts of IC. Secondly, we conceptualised an IC concept according to India's existing HDS, validated by multiple rounds of brainstorming among co-authors. Further senior co-authors independently reviewed the conceptualised IC model as per national relevance. RESULTS: Existing IC models were categorised as individual, group and disease-specific, and population-based models. The limitations of having prolonged delivery time, focusing only on chronic diseases and being economically expensive to implement, along with requirement of completely restructuring and reorganising the existing HDS makes the adoption of existing IC models not feasible for India. The Indian Model of Integrated Healthcare (IMIH) model proposes three levels of integration: Macro, Meso, and Micro levels, using the existing HDS. The core components include a Central Gateway Control Room, using existing digital platforms at macro levels, a bucket overflow model at the meso level, a Triple-layered Concentric Circle outpatient department (OPD) design, and a three-door OPD concept at the micro level. CONCLUSION: IMIH offers features that consider resource constraints and local context of LMICs while being economically viable. It envisages a step toward UHC by optimising existing resources and ensuring a continuum of care. However, health being a state subject, various socio-political and legal/administrative issues warrant further discussion before implementation.

The Barocene Era.

This communication defines and describes the Barocene era, as that phase of human development which is characterized by a major impact of overweight and obesity. We use this term to highlight the fact that overweight and obesity need to be prevented and managed on an urgent footing. If not checked, these endocrine diseases will retard our growth and reduce our well being.

Obesity is a communicable disease.

Obesity has multiple causes and correlates. Usually studied as a metabolic and endocrine disease, with mechanical and musculoskeletal comorbidities, obesity also has a communicable angle to it. Obesity can be considered a communicable disease from the conventional point of view, as it is associated with viral etiology in animal and human models. It is also associated with increased prevalence and worse prognosis of infectious diseases. Not only that, obesity is a 'socially communicable' disease, as it 'spreads' amongst people living in similar environments.

Implications of vitamin D deficiency in systemic inflammation and cardiovascular health.

Clinical, epidemiological, and molecular studies have sufficiently highlighted the vitality of vitamin D [25(OH)D and 1,25(OH)2D] in human health and wellbeing. Globally, vitamin D deficiency (VDD) has become a public health concern among all age groups. There is a very high prevalence of VDD per the estimates from several epidemiological studies on different ethnic populations. But, population-specific scales do not support these estimates to define VDD clinically and consistent genetic associations. However, clinical studies have shown the relevance of serum vitamin D screening and oral supplementation in improving health conditions, pointing toward a more prominent role of vitamin D in health and wellness. Routinely, the serum concentration of vitamin D is measured to determine the deficiency and is correlated with physiological conditions and clinical symptoms. Recent research points toward a more inclusive role of vitamin D in different disease pathologies and is not just limited to otherwise bone health and overall growth. VDD contributes to the natural history of systemic ailments, including cardiovascular and systemic immune diseases. Considering its significant impact on premature morbidity and mortality, there is a compelling need to comprehensively review and document the direct and indirect implications of VDD in immune system deregulation, systemic inflammatory conditions, and cardio-metabolism. The recommendations from this review call for furthering our research concerning vitamin D and its direct and indirect implications.

Is there a ubiquitous association between sleep disorder and frailty? findings from LASI (2017-18).

BACKGROUND: Relatively little is known about how sleep disorders affect frailty of seniors. The study uses Fried's frailty index, to investigate the relationship between sleep disorder and frailty among older Indian adults. METHODS: The study analysed Longitudinal Ageing Study in India (2017-18) data which uses a multistage stratified area probability cluster sampling design. The association between frailty was studied for which the total sample size was 31,902. The principal dependent variable was frailty. Descriptive statistics and cross-tabulation were presented in the study. A binary logistic regression analysis was used to fulfil the study objectives to find the possible association. RESULTS: The prevalence of frailty in India was 21.3 percent. Older adults with sleep disorder had 66 percent higher likelihood to be frail than their counterparts. The benefits of physical activity in containing frailty is huge, the association were quite high. Poor Self-rated health was significantly associated with higher frailty (OR = 1.73; CI = 1.47-2.04). CONCLUSIONS: Frailty is an enormously growing public health issue and has bi-directional relation with sleep disorders. The study has clinical relevance since sleep complaints offer a means for identifying those who are vulnerable to frailty and through appropriate intervention, the causes of sleep disorder would help to delay and in some cases reverse frailty.

Epidemiology of type 2 diabetes mellitus and treatment utilization patterns among the elderly from the first wave of Longitudinal Aging study in India (2017-18)using a Heckman selection model.

INTRODUCTION: Unmanaged Type 2 diabetes mellitus (T2DM) substantially contributes to the multi-morbidity of the elderly. Fewer research has concentrated on understanding the determinants of treatment utilization among older people, with even lesser concerns about missing data in outcome variables leading to biased estimates. The present study intends to evaluate the epidemiology of T2DM in the elderly in India and explore the socioeconomic and behavioral risk factors determining the treatment utilization among the elderly > 60 years in India by addressing the missing data to generate robust estimates. METHODS: The secondary analysis used data from the Longitudinal Ageing Study in India. The key dependent variables were the presence or absence of T2DM and treatment utilization. Descriptive statistics were used to understand the differences in the prevalence of diabetes and the utilization of treatment across various socio-demographic characteristics. Heckman's statistical technique evaluated the predictors of T2DM and treatment utilization. Analysis was done using STATA software version 14.0. RESULTS: Almost 14% elderly reported to be living with T2DM. The odds of living with T2DM increased with non-working status, a sedentary lifestyle, and a higher BMI. A higher proportion of the elderly was on oral drugs than insulin and had been practicing lifestyle modifications to control their disease. The probability of developing T2DM was lower among females than males, but females had better odds for treatment utilization of health medication than males. Lastly, treatment utilization was significantly affected by socio-demographic characteristics like education and monthly per capita expenditure. CONCLUSIONS: Treatment utilization by the elderly living with T2DM is significantly affected by socio-demographic characteristics. Keeping in mind the increasing proportion of the geriatric population in our country, it is pertinent to tailor-made counseling sessions for the elderly to improve medication utilization and adherence and realize our goals concerning non-communicable diseases.

Exploring the influence of food labels and advertisements on eating habits of children: a cross-sectional study from Punjab, India.

BACKGROUND: Maintaining healthy eating habits among children is challenging due to industrial tactics. There is little research on the effect of nutritional labels and tv ads on the eating habits of children. So the primary aim of the study was to explore the noticeability of the food packaging labels by the children, the information retrieved from the food nutrition labels, and their role in increased frequency of eating out in addition to the perceptions of their parents about the television ads. METHODS: A cross-sectional study was conducted at schools in Punjab, India. Using multi-stage stratified random sampling, we included 722 school-going children aged 14-18 and their parents. A structured predefined questionnaire collected data using a four-point Likert scale. Descriptive statistics and binary logistic regression were used to draw our inferences. RESULTS: About 46% of children were eating out > 3 times a week. Nearly 49% said they never looked at the expiry dates on the food packet, and 40% have yet to notice the quality certification. Nearly half do not understand the components of the food label, and 59% said they never changed their buying behavior because of the label. Only 37% of parents expressed their concerns about the timing of the ads when children watch television, while only 25.5% were concerned about the accuracy of the information. Concerns of the parents regarding the timing of the ads, and celebrity endorsements, were potential predictors for the increased frequency of eating out by the children. CONCLUSIONS: Low awareness regarding the utility of nutrition labels and minimal concerns of the parents increase the frequency of eating out. Unification of our existing policies regarding food labels and tv advertisements to develop family-centric interventions will bring us one step closer to improving the enabling environment to curb the growing menace of childhood obesity.

Mapping the stability of febrile illness hotspots in Punjab from 2012 to 2019- a spatial clustering and regression analysis.

INTRODUCTION: Febrile illnesses (FI) represent a typical spectrum of diseases in low-resource settings, either in isolation or with other common symptoms. They contribute substantially to morbidity and mortality in India. The primary objective was to study the burden of FI based on Integrated Disease Surveillance Programme (IDSP) data in Punjab, analyze geospatial and temporal trends and patterns, and identify the potential hotspots for effective intervention. METHODS: A retrospective ecological study used the district-level IDSP reports between 2012 and 2019. Diseases responsible for FI on a large scale, like Dengue, Chikungunya, Malaria (Plasmodium Falciparum, P. Vivax), Enteric fever, and Pyrexia of Unknown Origin (PUO), were included in the analysis. The digital map of Punjab was obtained from GitHub. Spatial autocorrelation and cluster analysis were done using Moran's I and Getis-Ord G* to determine hotspots of FI using the incidence and crude disease numbers reported under IDSP. Further, negative binomial regression was used to determine the association between Spatio-temporal and population variables per the census 2011. Stable hotspots were depicted using heat maps generated from district-wise yearly data. RESULTS: PUO was the highest reported FI. We observed a rising trend in the incidence of Dengue, Chikungunya, and Enteric fever, which depicted occasional spikes during the study period. FI expressed significant inter-district variations and clustering during the start of the study period, with more dispersion in the latter part of the study period. P.Vivax malaria depicted stable hotspots in southern districts of Punjab. In contrast, P. Falciparum malaria, Chikungunya, and PUO expressed no spatial patterns. Enteric Fever incidence was high in central and northeastern districts but depicted no stable spatial patterns. Certain districts were common incidence hotspots for multiple diseases. The number of cases in each district has shown over-dispersion for each disease and has little dependence on population, gender, or residence as per regression analysis. CONCLUSIONS: The study demonstrates that information obtained through IDSP can describe the spatial epidemiology of FI at crude spatial scales and drive concerted efforts against FI by identifying actionable points.

Hidden hunger and diabetes care.

This communication discusses the concept of hidden hunger, or micro- nutrient deficiency, and its link with diabetes care. It provides simple tools to help diabetes care providers suspect and identify micronutrient deficiency in their clinic. The authors highlight the need to tackle the third frontier of malnutrition - micronutrient deficiency, and add a third component -electrolyte and fluid balance, to the definition of hidden hunger.

The 5A model for non- communicable disease advocacy.

We share a comprehensive 5A model which puts in perspective a clear-cut method to approach and address non communicable disease (NCD) advocacy. We suggest that the first step towards NCD control is awareness amongst health care professionals, and acceptance of their responsibility towards public health. Once this is done, active assertion follows, and leads to action on the ground. Regular audit, however, is necessary, to ensure effective and efficient advocacy for NCD. This model should be followed in all health care settings, including primary care diabetes.

Exercise And Physical Activity Diversity.

In this reflective opinion piece, we introduce the concepts of exercise diversity and physical activity diversity. Similar to dietary diversity and dietary variety, exercise/physical activity diversity represents part of a comprehensive target of ideal health, an objective parameter to audit one's progress towards such a goal, and a means of accomplishing this aim. We define this concept as the number of types of exercise, the number of limbs and body parts exercised or muscle groups involved, the variety of intensity, or the number of variations in methods of exercise used. A non-weighted score may be allocated to each exercise, limb, and muscle group to get a raw idea of diversity.

Awareness regarding the antitobacco laws and perceptions regarding interventions for effective tobacco control among young adults of Haryana, India.

Background: Tobacco is one of the major behavioral risk factors for noncommunicable diseases in India. Tobacco control depends on public awareness regarding prevalent antitobacco measures. Objectives: The present study documents the understanding of young adults (<25 years) regarding the antitobacco laws and their perception regarding interventions for effective tobacco control. Methods: A cross-sectional study was conducted in two districts of Haryana. A semistructured questionnaire was used to assess tobacco use, participants' awareness of sections 4, 5, 6 (a), and 8 of the Cigarette and Other Tobacco Products Act (COTPA, 2003), sources of information about antitobacco laws, and their implementation. The perception of participants about the effectiveness of laws and provisions was assessed using a three-point Likert scale. Results: Of the 1470 participants, 517 (35.2%) smoked or used smokeless products. They reported the media (84.6%) to be the most critical source of information about antitobacco laws, followed by the health department (57.6%) and family/peer group (44.9%). Most participants were aware of the prohibition of smoking in offices or banks, educational institutions, hospitals, and other public places. Both tobacco users and nonusers perceived health education programs to be an effective intervention to reduce tobacco use (P < 0.01). Conclusion: The awareness regarding COTPA has increased among the general population. The media could be a powerful tool to counteract the pro-tobacco cues in society. The need of the hour is to focus on improving compliance with antitobacco laws at the population level to achieve a tobacco-free India.

Hypertension in India: Trends in Wealth-related Inequalities from the National Family Health Surveys.

INTRODUCTION: India depicts a very high prevalence of hypertension. We need to learn more about the effect of wealth-related disparities on the prevalence of hypertension. The primary objective of this study was to assess temporal changes in the epidemiology of hypertension and associated wealth-related disparities among adults using two waves of nationally representative datasets from India. METHODS: We did a secondary data analysis of the National Family Health Survey (NFHS) rounds 4 and 5. We included information from the two rounds from 699,686 and 108,791 males and 92,804 and 677,803 females. Weighted analysis and multivariate binomial regression were used to depict the prevalence and predictors of hypertension. Inequalities were estimated using the concentration index (CI) and concentration curves. RESULTS: The weighted prevalence of hypertension among males increased from 14.6% to 16.7% among males, and from 8.8% to 9.9% among females, between NFHS-4 and NFHS-5. Prehypertension rose from 43.3% to 48.3% for males, and females, from 30.2% to 36.2% between the NFHS rounds. Overall, the CI among the males (0.078 and 0.050) and females (0.102 and 0.059) decreased from rounds 4 to 5, depicting a decrease in pro-poor wealth-related inequalities in hypertension prevalence in India. CONCLUSIONS: To conclude, the current analysis depicts that inequalities due to which hypertension was more prevalent in the wealthier classes in India are slowly disappearing. Therefore, we need to target the already exhausted poor patients with limited access to health-care resources to prevent them from further shifting beyond the line of poverty before these differences narrow down further.

Sexual violence as a predictor of unintended pregnancy among married women of India: evidence from the fourth round of the National Family Health Survey (2015-16).

BACKGROUND: Sexual Intimate Partner Violence (IPV) is a public health problem globally, with about one in three women experiencing sexual IPV ever in their lifetime. Unintended pregnancy is one of the consequences of sexual IPV and has its repercussions that can span generations. The present study was conducted to estimate the prevalence of sexual intimate partner violence (IPV) and assess the association between sexual IPV and unintended childbirth in India among married women aged 15-49 years. METHODS: The National Family Health Survey-India (NFHS-4) fourth-round dataset was used for the present study. Pregnancies intention was the primary outcome variable, and the main predictor variable was self-reported sexual IPV in the past 12 months. Women's current age, age at marriage, education and occupation, place of residence, wealth quintile, parity, religion, caste, region, mass media exposure, and husband's education were other control variables. Weighted analysis depicted the prevalence of unintended pregnancies and their association with different socio-demographic variables. Binary logistic regression was done in two steps respecting a hierarchical approach for potential confounders. RESULTS: Approximately 6.4% of study participants had ever experienced sexual IPV in India. Prevalence of sexual IPV was significantly higher when the age of marriage was < 19 years, among uneducated, in the lowest wealth index quintile, belonging to scheduled caste, having multiparity, and not having mass media exposure. About 12.1% of pregnancies were considered unintended by the respondents, and 22.9% of women who ever had a history of sexual IPV considered the last pregnancy to be unintentional. Women who experienced sexual IPV were in younger age groups, having parity ≥1, and bigger families had significantly higher odds of having an unintended pregnancy compared to their reference groups. CONCLUSIONS: We observed that sexual IPV has a significant role in unintended pregnancies. Effective counseling means should be rolled out for victims of sexual IPV as it is a taboo subject. The significant factors that can predict unintended pregnancies highlighted in our study should be acknowledged while counseling.

Variations in the patterns of tobacco usage among indian females - findings from the global adult tobacco survey India.

BACKGROUND: Males dominate in tobacco usage, as well as in tobacco research, knowing that women face more severe health consequences. There is a specific lack of information on epidemiological statistics, risks, and the level of knowledge among women regarding tobacco. This study examines the Global Adult Tobacco Survey (GATS)-India dataset to estimate female tobacco usage and assess socio-economic variations in tobacco consumption, awareness regarding the adverse effects of tobacco, noticing pack health warnings (PHW), and intention to quit tobacco use well as factors influencing these domains. METHODS: Using a geographically clustered multistage sampling method, the nationally representative GATS II (2016-17) interviewed 40,265 female respondents aged 15 years and above from all Indian states and union territories. Standard operational definitions were used to estimate the primary independent variables (community, individual, and household categories) and dependent variables like awareness regarding the adverse effects of tobacco, noticing pack health warning (PHW), and intention to quit tobacco. Sampling weights were adjusted while performing the analysis. Bivariate and multivariable analysis were used to generate the estimates. RESULTS: Of the total female respondents, 84.2% were never-users, 13.3% ever consumed Smokeless Tobacco (SLT) products, 1.8% ever smoked tobacco, and 0.8% were dual users once in their lives. Around 16% of the women had exposure to Second Hand Smoke (SHS) either at their homes, workplaces or in public places. Overall, maximum awareness was seen among non-smoker females (64.7%) and dual users (64.7%), followed by women exposed to SHS, SLT users, and smokers. PHW was noticed more by the bidi smokers, followed by SLT users and cigarette smokers. Factors that positively affected intention to quit smoking included younger age, secondary school education, self-employed status, the habit of buying packed cigarettes/bidi, believing that smoking causes serious illness, and attempted quitting in the last 12 months. CONCLUSION: A high proportion of women consume tobacco which is significantly influenced by socio-demographic factors. Tobacco regulators should be especially concerned about women as the tobacco marketing experts target them. Mobilizing self-help groups and organizations working for women and children could assist broader campaigns to generate awareness and motivate quitting attempts.

Regional Water Availability and WASH Indicators as Predictors of Malnutrition in Under-5 Children: Analysis of the National Family Health Survey, India (2015-16).

BACKGROUND: Water, sanitation and hygiene (WASH) practices determine child nutrition in resource-constrained countries and are influenced by regional water availability. We assessed any relationship between malnutrition and WASH practices among under-5 children in India's areas as per water availability. METHODS: We did a secondary data analysis of the National Family Health Survey-IV. Stunting, wasting and being underweight were the significant outcomes. Regional water availability, households' source of water, sanitation and disposal of the child stool were the major independent variables. We report the prevalence estimates, bivariate associations and adjusted odds ratio to predict the child's malnutrition per regional water availability after using appropriate sampling weight. RESULTS: Of the 186 875 children, 41%, 20% and 36% were stunted, wasted and underweight. Only 26% of children had access to improved drinking water sources, whereas 50.0% were defecating in open. Around 65% of children's stools were disposed of in unhygienic ways. Undernutrition depicted a significant association with independent variables. There were higher chances of stunting with a decrease in regional water availability, unimproved sanitation and unhygienic ways of stool disposal. Wasting was intensified by all these factors, except the safe disposal of stools. CONCLUSIONS: WASH indicators exert a protective effect on undernutrition.

Impact of Health Warning Labels on Cigarette Packs in India: Findings from the Global Adult Tobacco Survey 2016-17.

Two rounds of Global Adult Tobacco Survey (GATS) were conducted in 2009-10 and 2016-17 in India. These two surveys provide national comparable data on tobacco usage and its related aspects in India. This study used the data from GATS 2016-17 to examine the salience and impact of cigarette pack pictorial health warnings (PHWs) on quit intention among current cigarette smokers in India. The nationally representative survey interviewed 74, 037 respondents aged ≥15 years with an overall response rate of 92.9% using a multi-stage sampling method. Results of multivariate analysis showed that the strongest predictor for quit intention because of health warnings was "ever made a quit attempt in the past 12 months" and buying cigarette packs instead of loose cigarettes. Compared to GATS 2009-10, GATS 2016-17 observed an increase in salience of cigarette health warnings by 16% and increase in the impact of PHWs on quit intention by 50%. PHWs have a significant impact on intention to quit among cigarette smokers in India with a rising trend. The efforts of Government of India in terms of periodic introduction of new PHWs and increase in the size of warning labels to 85% of the cigarette packs is laudable. The study results support ban on loose cigarettes and warrants stricter implementation of the act prohibiting sale of loose cigarettes.