Validation of the Fertility Norms Scale and Association with Fertility Intention and Contraceptive Use in India.

Social norms related to fertility may be driving pregnancy desire, timing and contraceptive use, but measurement has lagged. We validated a 10-item injunctive Fertility Norms Scale (FNS) and examined its associations with family planning outcomes among 1021 women and 1020 men in India. FNS captured expectations around pronatalism, childbearing early in marriage and community pressure. We assessed reliability and construct validity through Cronbach's alpha and exploratory factor analysis (EFA) respectively, examining associations with childbearing intention and contraceptive use. FNS demonstrated good reliability (α = 0.65-0.71) and differing sub-constructs by gender. High fertility norm among women was associated with greater likelihood of pregnancy intention [RRR = 2.35 (95% CI: 1.25,4.39); ARRR = 1.53 (95% CI: 0.70,3.30)], lower likelihood of delaying pregnancy [RRR = 0.69 (95% CI: 0.50,0.96); ARRR = 0.72 (95% CI: 0.51,1.02)] and greater ambivalence on delaying pregnancy [RRR = 1.92 (95% CI: 1.18,3.14); ARRR = 1.99 (95% CI: 1.21,3.28)]. Women's higher FNS scores were also associated with higher sterilization [RRR = 2.17 (95% CI: 1.28,3.66); ARRR = 2.24 (95% CI: 1.32,3.83)], but the reverse was noted for men [RRR = 0.61 (95% CI: 0.36,1.04); ARRR = 0.54 (95% CI: 0.32,0.94)]. FNS indicated better predictive value among women compared to men for key reproductive outcomes. This measure may be useful for social norms-focused evaluations in family planning and warrants cross-contextual study.

Understanding feasibility and acceptability of implementation of linking delivery of family planning and infant vaccination care in rural Maharashtra, India: a qualitative study.

BACKGROUND: Linking family planning with infant vaccination care has the potential to increase contraceptive use among postpartum women in rural settings. We explored the multilevel factors that can facilitate or impede uptake of contraception at the time of infant vaccination among postpartum women and couples in rural Maharashtra, India. METHODS: We conducted 60 semi-structured interviews with key stakeholders including: postpartum married women (n = 20), husbands (n = 10), and mothers-in-law (n = 10) of postpartum women, frontline healthcare workers (auxiliary nurse midwives (ANMs) and Accredited Social Health Activists (ASHAs), (n = 10), and community leaders (physician medical officers and village panchayat leaders) (n = 10). We sought to assess the feasibility and acceptability of delivering community-based postpartum family planning care in rural India at the time of infant vaccination. The Consolidated Framework for Implementation Research (CFIR) was used to design a structured interview guide and codebook. Data were analyzed via directed content analysis. RESULTS: Three major themes emerged: (1) Social fertility and gender norms including son preference and male control over contraceptive decision-making influence postpartum contraceptive access and choice. (2) Linking contraceptive care and infant vaccination is perceived as potentially feasible and acceptable to implement by families, health workers, and community leaders. The intervention provides care to women and families in a convenient way where they are in their community. (3) Barriers and facilitators to linked infant postpartum contraception and infant vaccination were identified across the five CFIR domains. Key barriers included limited staff and space (inner setting), and contraceptive method targets for clinics and financial incentives for clinicians who provide specific methods (outer setting). Key facilitators included convenience of timing and location for families (intervention characteristics), the opportunity to engage husbands in decision-making when they attend infant vaccination visits (participant characteristics), and programmatic support from governmental and community leaders (process of implementation). CONCLUSIONS: Linked provision of family planning and infant vaccination care may be feasible and accessible in rural India utilizing strategies identified to reduce barriers and facilitate provision of care. A gender-transformative intervention that addresses gender and social norms has greater potential to impact reproductive autonomy and couples' contraceptive decision-making.

The association between early in marriage fertility pressure from in-laws' and family planning behaviors, among married adolescent girls in Bihar and Uttar Pradesh, India.

BACKGROUND: Married adolescent girls are vulnerable to risky sexual and reproductive health outcomes. We examined the association of fertility pressure from in-laws' early in marriage with contraceptive use ever, parity, time until first birth, and couple communication about family size, among married adolescent girls. METHODS: Data were taken from a cross-sectional survey with married girls aged 15-19 years (N = 4893) collected from September 2015 to July 2016 in Bihar and Uttar Pradesh, India. Multivariable regression assessed associations between in-laws' fertility pressure and each outcome, adjusting for sociodemographic covariates. RESULTS: We found that 1 in 5 girls experienced pressure from in-laws' to have a child immediately after marriage. In-laws' fertility pressure was associated with lower parity (Adj. ß Coef. - 0.10, 95% CI - 0.17, - 0.37) and couple communication about family size (AOR = 1.77, 95% CI 1.39, 2.26), but not contraceptive use or time until birth. CONCLUSIONS: Our study adds to the literature identifying that in-laws' pressure on fertility is common, affects couple communication about family size, and may be more likely for those yet to have a child, but may have little effect impeding contraceptive use in a context where such use is not normative.

Disrupting gender norms in health systems: making the case for change.

Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

Health needs, access to healthcare, and perceptions of ageing in an urbanizing community in India: a qualitative study.

BACKGROUND: India's elderly population is rising at an unprecedented rate, with a majority living in rural areas. Health challenges associated with ageing, changing social networks and limited public health infrastructure are issues faced by the elderly and caregivers. We examined perceptions of health needs of the elderly across local stakeholders in an urbanizing rural area. METHODS: The qualitative study was conducted among participants in the Andhra Pradesh Children and Parents Study (APCAPS) site in Rangareddy district, Telangana. We collected data using focus group discussions and interviews among communities (n = 6), health providers (n = 9) and administrators (n = 6). We assessed stakeholders' views on the influence of urbanization on health issues faced and interventions for alleviating these challenges. We used a conceptual-analytical model to derive themes and used an inductive approach to organizing emerging codes as per a priori themes. These were organized as per thematic groups and ranked by different authors in order of importance. Bronfebrenner's theory was used to understand stakeholder perspectives and suggest interventions within four identified spheres of influence - individual, household, community and services. RESULTS: Stakeholders reported frailty, lack of transport and dependence on others as factors impacting health access of the elderly. Existing public health systems were perceived as overburdened and insensitive towards the elderly. Urbanization was viewed positively, but road accidents, crime and loneliness were significant concerns. Interventions suggested by stakeholders included health service outreach, lifestyle counseling, community monitoring of healthcare and engagement activities. CONCLUSIONS: We recommend integrating outreach services and lifestyle counseling within programs for care of the elderly. Community institutions can play an important role in the delivery and monitoring of health and social services for the elderly.

Health inequalities research in India: a review of trends and themes in the literature since the 1990s.

BACKGROUND: Research on health inequalities can be instrumental in drawing attention to the health of socioeconomically vulnerable groups in India in the context of rapid economic growth. It can shape the dialogue for public health action, emphasizing the need for greater investments in health, and monitor effectiveness of health programs. Our objective was to examine trends in studies on health inequalities in the last 25 years. METHODS: We conducted a systematic literature review of studies on health inequalities published from 1990. The year, 1990, marked the beginning of economic reforms and liberalization in India. We searched PubMED using key terms to identify 8800 articles between 1990 and 2016; we identified 1,312 final studies for review. Key domains of analysis included measures of equity, health outcomes, populations studied, year of publication, study methodology, study focus (descriptive versus analytical), and location of main author. RESULTS: We found an increase in studies on health inequalities after 2005. About 88 % of the studies utilized quantitative methods for analysis. About 8 % of the studies related to health interventions or programs; the number of intervention studies have been increasing since 2010. A majority of studies were led by authors based in India. Early studies focused on mortality, communicable and non-communicable diseases, and nutrition, while later studies have focused on non-communicable diseases, mental health, risk factors, and injuries. Studies on women and children comprised nearly half of the literature; studies on the youth (15-24 years or as defined by the study) and elderly have been rising. Wealth and income were the most common measures of equity, followed by education and gender. The proportion of studies on wealth, education, region and caste have stayed consistent over time, while studies on gender disparities have been rising. CONCLUSION: In a country as diverse as India with large social inequalities combined with rapid economic growth, research on health inequalities has a special significance for policy. We recommend that studies on health inequalities in the future focus on evaluations of policy and health programs, and on underrepresented health outcomes and populations.

Have Socioeconomic Inequalities in Tobacco Use in India Increased Over Time? Trends From the National Sample Surveys (2000-2012).

INTRODUCTION: India has experienced marked sociocultural change, economic growth and industry promotion of tobacco products over the past decade. Little is known about the influence of these factors on socioeconomic patterning of tobacco use. This study examines trends in tobacco use by socioeconomic status (SES) in India between 2000 and 2012. METHODS: We analyzed data in 2014 from nationally-representative repeated cross-sectional National Sample Surveys (NSS) in India for 1999-2000, 2004-2005 and 2011-2012 (n = 346 612 households). Prevalence and volume trends in cigarette, "bidi" and smokeless tobacco use were examined by household expenditure, educational attainment and caste/tribe status using Two-part model. RESULTS: Prevalence of any tobacco use remained consistent in the poorest households (61.5% to 62.7%) and declined among the richest (43.8% to 36.8%) between 2000-2012. Bidi use declined across all groups (poorest: 26.3% to 16.8%, richest: 19.8% to 10.7%) while cigarette use increased (poorest: 1.2% to 1.3%, richest: 6.5% to 7.0%). Relative to educated and general caste households, between 2000 and 2012 cigarette use in illiterate households increased by 38% and among Scheduled Tribe households increased by 32%. Smokeless tobacco use increased for all households (poorest: 26.2% to 33.9%, richest: 11.4% to 13.5%, Scheduled Tribe: 31.1% to 34.8%, general caste: 13.6% to 18.5%), with greater increases among richer, more educated and general caste households. CONCLUSION: Marked SES patterning of tobacco use has persisted in India. Improving enforcement of tobacco control policies and monitoring comprehensive smoke-free legislations are needed to address this growing burden. IMPLICATIONS: We found "resilient" tobacco patterns in the last decade despite prevention interventions. SES continues to be inversely associated with tobacco products, with the exception of cigarettes. The declines in bidi use may be getting replaced by increase in cigarette use trends, especially among lower SES groups. The use of smokeless tobacco products has increased across all SES groups and the volume of smokeless tobacco use is not been declining despite a number of policies on tobacco use. This may be attributed to inadequate attention to chewed forms of tobacco in current policies, particularly to implementing pictoral warnings and regulating surrogate advertising. Evaluating the implementation of anti-tobacco policies and ensuring equity dimensions in interventions is urgently needed to address tobacco use inequalities.

Time Trends in Racial and Ethnic Disparities in Asthma Prevalence in the United States From the Behavioral Risk Factor Surveillance System (BRFSS) Study (1999-2011).

OBJECTIVES: We examined whether racial/ethnic disparities in the United States increased over time. METHODS: We analyzed data from 3 868 956 adults across the United States from the Behavioral Risk Factor Surveillance System from 1999 to 2011. We used random intercepts models (individuals nested in states) to examine racial/ethnic disparities and time trends in asthma lifetime and its current prevalence, adjusted for covariates. We also investigated the heterogeneity in asthma prevalence by ethnicity of the major zone of residence. RESULTS: Lifetime and current asthma prevalence were higher among non-Hispanic Black populations, with time trends highlighting increasing differences over time (b = 0.0078; 95% confidence interval [CI] = 0.0043, 0.0106). Lower odds ratios (ORs) of asthma were noted for Hispanic populations (OR = 0.74; 95% CI = 0.73, 0.76). Hispanics in states with more Puerto Rican residents reported greater risks of asthma (OR = 1.55; 95% CI = 1.24, 1.93) compared with Hispanics in states with larger numbers of Mexican or other ethnicities. CONCLUSIONS: Disparities in asthma prevalence by racial/ethnic groups increased in the last decade, with non-Hispanic Blacks and Puerto Rican Hispanics at greater risk. Interventions targeting asthma treatments need to recognize racial, ethnic, and geographic disparities.

The EMERGE framework to measure empowerment for health and development.

RATIONALE: Women's empowerment is a UN Sustainable Development Goal and a focus of global health and development but survey measures and data on gender empowerment remain weak. Existing indicators are often disconnected from theory; stronger operationalization is needed. OBJECTIVE: We present the EMERGE Framework to Measure Empowerment, a framework to strengthen empowerment measures for global health and development. METHOD: We initiated development of this framework in 2016 as part of EMERGE - an initiative designed to build the science of survey research and availability of high-quality survey measures and data on gender empowerment. The framework is guided by existing theories of empowerment, evidence, and expert input. We apply this framework to understand women's empowerment in family planning (FP) via review of state of the field measures. RESULTS: Our framework offers concrete measurable constructs to assess critical consciousness and choice, agency and backlash, and goal achievement as the empowerment process, recognizing its operation at multiple levels-from the individual to the collective. Internal attributes, social norms, and external contexts and resources create facilitators or barriers to the empowerment process. Review of best evidence FP measures assessing empowerment constructs, social norms, and key influencers (e.g., partners and providers) show a strong landscape of measures, including those with women, partners, and providers, but they are limited in assessing translation of choice to agency to achievement of women's self-determined fertility or contraceptive goals, instead relying on assumption of contraceptive use as the goal. We see no measures on collective empowerment toward women's reproductive choice and rights. CONCLUSION: The EMERGE Framework can guide development and analysis of survey measures on empowerment and is needed as the current state of the field shows limited coverage of empowerment constructs even in areas which have received more study, such as family planning.

Slum upgrading strategies involving physical environment and infrastructure interventions and their effects on health and socio-economic outcomes.

BACKGROUND: Slums are densely populated, neglected parts of cities where housing and living conditions are exceptionally poor. In situ slum upgrading, at its basic level, involves improving the physical environment of the existing area, such as improving and installing basic infrastructure like water, sanitation, solid waste collection, electricity, storm water drainage, access roads and footpaths, and street lighting, as well as home improvements and securing land tenure. OBJECTIVES: To explore the effects of slum upgrading strategies involving physical environment and infrastructure interventions on the health, quality of life and socio-economic wellbeing of urban slum dwellers in low and middle income countries (LMIC). Where reported, data were collected on the perspectives of slum dwellers regarding their needs, preferences for and satisfaction with interventions received. SEARCH METHODS: We searched for published and unpublished studies in 28 bibliographic databases including multidisciplinary (for example Scopus) and specialist databases covering health, social science, urban planning, environment and LMIC topics. Snowballing techniques included searching websites, journal handsearching, contacting authors and reference list checking. Searches were not restricted by language or publication date. SELECTION CRITERIA: We included studies examining the impact of slum upgrading strategies involving physical environment or infrastructure improvements (with or without additional co-interventions) on the health, quality of life and socio-economic wellbeing of LMIC urban slum dwellers. Randomised controlled trials (RCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) were eligible for the main analysis. Controlled studies with only post-intervention data (CPI) and uncontrolled before and after (UBA) studies were included in a separate narrative to examine consistency of results and to supplement evidence gaps in the main analysis. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed risk of bias for each study. Differences between the included study interventions and outcomes precluded meta-analysis so the results were presented in a narrative summary with illustrative harvest plots. The body of evidence for outcomes within the main analysis was assessed according to GRADE as very low, low, moderate or high quality. MAIN RESULTS: We identified 10,488 unique records, with 323 screened as full text. Five studies were included for the main analysis: one RCT with a low risk, two CBAs with a moderate risk and two CBAs with a high risk of bias. Three CBAs evaluated multicomponent slum upgrading strategies. Road paving only was evaluated in one RCT and water supply in one CBA. A total of 3453 households or observations were included within the four studies reporting sample sizes.Most health outcomes in the main studies related to communicable diseases, for which the body of evidence was judged to be low quality. One CBA with a moderate risk of bias found that diarrhoeal incidence was reduced in households which received water connections from a private water company (risk ratio (RR) 0.53; 95% confidence interval (CI) 0.27 to 1.04) and the severity of diarrhoeal episodes (RR 0.48; 95% CI 0.19 to 1.22). There was no effect for duration of diarrhoea. Road paving did not result in changes in parasitic infections or sickness in one RCT. After multicomponent slum upgrading, claims for a waterborne disease as opposed to a non-waterborne disease reduced (RR 0.64; 95% CI 0.27 to 0.98) in one CBA with a high risk of bias but there was no change in sanitation-related mortality in a CBA with a moderate risk of bias.The majority of socio-economic outcomes reported within the main studies related to financial poverty, for which the body of evidence was of very low quality. Results were mixed amongst the main studies; one RCT and two CBAs reported no effect on the income of slum dwellers following slum upgrading. One further CBA found significant reduction in monthly water expenditure (mean difference (MD) -17.11 pesos; 95% CI -32.6 to -1.62). One RCT also showed mixed results for employment variables, finding no effect on unemployment levels but increased weekly worked hours (MD 4.68; 95% CI -0.46 to 9.82) and lower risk of residents intending to migrate for work (RR 0.78; 95% CI 0.60 to 1.01).There was no evidence available to assess the impact of slum upgrading on non-communicable diseases or social capital. Maternal and perinatal conditions, infant mortality, nutritional deficiencies, injuries, self-reported quality of life, education and crime were evaluated in one study each.Nine supporting studies were included that measured varying outcomes (6794 households or observations within eight studies reporting sample sizes). One CPI evaluated cement flooring only while three UBAs and five CPIs evaluated multicomponent slum upgrading strategies. All studies but one had a high risk of bias.The studies reinforced main study findings for diarrhoea incidence and water-related expenditure. Findings for parasitic infections and financial poverty were inconsistent with the main studies. In addition, supporting studies reported a number of disparate outcomes that were not evaluated in the main studies.Five supporting studies included some limited information on slum dweller perspectives. They indicated the importance of appropriate siting of facilities, preference for private facilities, delivering synergistic interventions together, and ensuring that infrastructure was fit for purpose and systems were provided for cleaning, maintenance and repair. AUTHORS' CONCLUSIONS: A high risk of bias within the included studies, heterogeneity and evidence gaps prevent firm conclusions on the effect of slum upgrading strategies on health and socio-economic wellbeing. The most common health and socio-economic outcomes reported were communicable diseases and indicators of financial poverty. There was a limited but consistent body of evidence to suggest that slum upgrading may reduce the incidence of diarrhoeal diseases and water-related expenditure. The information available on slum dwellers' perspectives provided some insight to barriers and facilitators for successful implementation and maintenance of interventions.The availability and use of reliable, comparable outcome measures to determine the effect of slum upgrading on health, quality of life and socio-economic wellbeing would make a useful contribution to new research in this important area. Given the complexity in delivering slum upgrading, evaluations should look to incorporate process and qualitative information alongside quantitative effectiveness data to determine which particular interventions work (or don't work) and for whom.

Factors affecting delayed and non-receipt of healthcare during the COVID-19 pandemic for women in rural Maharashtra, India: Evidence from a cross-sectional study.

Background: Pathways to low healthcare utilisation under the COVID-19 pandemic are not well understood. This study aims to understand women's concerns about the health system's priorities and their increased burden of domestic responsibilities during COVID-19 as predictors of delayed or non-receipt of needed care for themselves or their children. Methods: We surveyed married women in rural Maharashtra, India (N = 1021) on their health and economic concerns between Feb 1 and March 26, 2021. This study period was when India emerged from the first wave of the pandemic, which had severely impacted the health systems, and before the second-even more devastating wave had started. We captured if women were concerned about access to non-COVID health services due to healthcare being directed solely to COVID-19) (exposure 1) and whether their domestic responsibilities increased during the pandemic (exposure 2). Our outcomes included women's reports on whether they delayed healthcare seeking (secondary outcome and mediator) and whether they received healthcare for themselves or their children when needed (primary outcome). We conducted adjusted regression models on our predictor variables with each outcome and assessed the mediation effects of delayed healthcare seeking for each of the exposure variables. Findings: We found that women who were concerned that healthcare was directed solely towards COVID-19 were more likely not to receive healthcare when needed (Adjusted Risk Ratio [ARR] = 1.49, 95% CI = 1.14, 1.95). We also found that women whose domestic care burden increased under the pandemic were more likely to delay healthcare seeking (ARR = 1.84, 95% CI = 1.05, 3.21). Delayed healthcare seeking mediated the associations between each of our exposure variables with our outcome variable, non-receipt of needed healthcare. Interpretation: Our findings suggested that women's perceptions of healthcare systems and their domestic labour burdens affected healthcare seeking during the pandemic in India, even before the second wave of COVID-19 incapacitated the health system. Support for women and health systems is needed to ensure healthcare uptake during crises. Funding: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, USA (grant numbers: R01HD084453- 01A1 and RO1HD61115); Department of Biotechnology, Government of India (grant #BT/IN/US/01/BD/2010); the EMERGE project (Bill and Melinda Gates Foundation Grants: OPP1163682 and INV018007; PI Anita Raj), and Bill and Melinda Gates Foundation Grant number INV-002967.

Freedom of Movement and Adolescent Sexual Violence in India.

This study assesses associations between freedom of movement and sexual violence, both in marriage and outside of marriage, among a representative sample of adolescents in India. We analyzed data from girls aged 15 to 19 years (n = 9,593) taken from India's nationally representative National Family Health Survey 2015-2016. We defined freedom of movement using three items on whether girls could go unaccompanied to specified locations; we summated responses and categorized them as restricted, or unrestricted. We used multivariable regression to assess associations between restricted movement and nonmarital violence, and with marital sexual violence among ever-married girls. Results show that only 2% of girls reported nonmarital sexual violence, among married and unmarried girls; 6% of married girls reported marital sexual violence. Most girls (78%) reported some restriction in movement. Restricted movement was negatively associated with nonmarital sexual violence (adjusted odds ratio [AOR] = 0.52, 95% confidence interval [CI] = [0.31, 0.87], p = .01) but positively associated with marital sexual violence (AOR = 3.87, 95% CI = [1.82, 8.25], p < .001). Further analyses highlight that the observed association with nonmarital sexual violence was specific to urban and not rural girls. These findings reveal that approximately one in 30 adolescent girls in India has been a victim of sexual violence. Restricted movement is associated with lower risk for nonmarital sexual violence for urban adolescent girls, possibly due to lower exposure opportunity. Married girls with restricted movement have higher odds of marital sexual violence, possibly because these are both forms of control used by abusive husbands. Freedom of movement is a human right that should not place girls at greater risk for nonmarital violence or be used as a means of control by abusive spouses. Social change is needed to secure girls' safety in India.

Using machine learning to understand determinants of IUD use in India: Analyses of the National Family Health Surveys (NFHS-4).

Intra-uterine devices (IUDs) are a safe and effective method to delay or space pregnancies and are available for free or at low cost in the Indian public health system; yet, IUD uptake in India remains low. Limited quantitative research using national data has explored factors that may affect IUD use. Machine Learning (ML) techniques allow us to explore determinants of low prevalence behaviors in survey research, such as IUD use. We applied ML to explore the determinants of IUD use in India among married women in the 4th National Family Health Survey (NFHS-4; N = 499,627), which collects data on demographic and health indicators among women of childbearing age. We conducted ML logistic regression (lasso and ridge) and neural network approaches to assess significant determinants and used iterative thematic analysis (ITA) to offer insight into related variable constructs generated from a series of regularized models. We found that couples' shared family planning (FP) goals were the strongest determinants of IUD use, followed by receipt of FP services and desire for no more children, higher wealth and education, and receipt of maternal and child health services. Findings highlight the importance of male engagement and family planning services for IUD uptake and the need for more targeted efforts to support awareness of IUD as an option for spacing, especially for those of lower SES and with lower access to care.

Releasing the Tide: How Has a Shock to the Acceptability of Gender-Based Sexual Violence Affected Rape Reporting to Police in India?

National household data suggest that more than four million women in India have experienced nonspousal rape. Fewer than 1.5% of victims of sexual violence in India report their assaults to police, though there is some indication of increased rape reporting to police following a very high-profile fatal gang rape in Delhi in December 2012. This study examines effects of the Delhi gang rape on rape reporting to police in India, and assesses the roles played by geography, media access, and women's status and protection factors in that reporting. Triangulated data from Indian crime, census, and police bureau records were used to assess trends in rape reporting to police at national and district levels from 2005 to 2016, using regressions, spatial mapping, and graphical trend analyses. Nationally, there was a 33% increase in annual rapes reported to police after 2012. Subnationally, there was substantial variation in trends; these district-level changes were particularly affected by distance from Delhi (0.2 fewer rapes reported to police/100,000 women for each 100 km from Delhi), literacy sex ratio (0.6 more rapes for every increase of 0.1 in male: female literacy ratio), and the presence of a women's police station (1.0 fewer rapes reported to police/100,000 women relative to districts with no women's police station). The 2012 Delhi gang rape significantly affected rape reporting to police in India, with greater increases seen closer to Delhi and in districts with compromised gender equity. Further work to support the rights and safety of women is needed, including bolstering an enabling environment for reporting, legal protections, and responsive criminal justice.

Effects of Gender Role Beliefs on Social Connectivity and Marital Safety: Findings From a Cross-Sectional Study Among Married Adolescent Girls in India.

PURPOSE: The purpose of the study was to examine associations of gender role beliefs with marital safety as well as social and digital connectivity among married adolescent girls in India. METHODS: We analyzed cross-sectional survey data from married adolescent girls from rural Bihar and Uttar Pradesh, India in 2015-2016 (N = 4,893). Gender role belief items assessed participants' beliefs regarding appropriateness of female marital choice and economic decision-making, male childcare responsibility, and marital violence. The outcomes were time with friends (social connection), freedom of movement, mobile phone ownership and internet access (digital connection), and safety from marital violence (marital safety). Adjusted regression models examined associations between gender role beliefs and outcomes, caste/religion beliefs related to segregation, and demographics. RESULTS: Beliefs supportive of female marital choice (adjusted odds ratio [AOR] 1.38, 95% confidence interval [CI] 1.00-1.88, p = .048) and female economic decision-making (AOR 1.43, 95% CI 1.03-1.99, p = .03) were associated with social connection. Beliefs supportive of female marital choice (AOR 1.88, 95% CI 1.31-2.71, p = .001), female economic decision-making (AOR 1.67, 95% CI 1.03-2.72, p = .04), and male childcare responsibilities (AOR 1.42, 95% CI 1.05-1.94, p = .03) were associated with freedom of movement. Belief supporting female marital choice was associated with mobile phone ownership (AOR 1.23, 95% CI 1.01-1.50, p = .04), and belief supporting male childcare responsibility was associated with internet access (AOR 1.76, 95% CI 1.11-2.77, p = .02). Beliefs supportive of female marital choice (AOR .73, 95% CI .59-.89, p = .003), male childcare responsibility (AOR 1.26, 95% CI 1.03-1.54, p = .02), and unacceptability of marital violence (AOR 1.72, 95% CI 1.38-2.15, p < .001) were associated with safety from marital violence. CONCLUSIONS: Progressive gender role beliefs regarding female choice, control, and safety in marriage are associated with greater connectivity and safety for married adolescent girls in India. Future studies that can longitudinally assess these associations are warranted.

Gender Differences in the Associations Between Informal Caregiving and Wellbeing in Low- and Middle-Income Countries.

Background: Health risks among informal caregivers have received inadequate attention in low and middle income countries. We examined cross-sectional data from 28611 adults 18 years and older in Ghana, India, Mexico, Russia and South Africa in the WHO Study on Global AGEing and Adult Health (SAGE) to examine gender differences in informal caregiving and wellbeing. Methods: Wellbeing was measured by self-rated health, difficulties with tasks, self-reported and diagnosed depression and anxiety. Informal caregiving was specific to adults and constructed as categorical variable with the respondent as: the main caregiver, non-caregiver but an adult in the household needs care, and no-one ill in the household; multinomial gender-stratified regression models assessed adjusted relative risk ratios (ARRRs). Results: Female caregivers were more likely to report moderate difficulties with life tasks [ARRR = 1.45 (95% CI: 1.01, 2.08)], feel mild-moderate anxiety [ARRR = 1.64 (95% CI: 1.22, 2.22)], and report feeling severely depressed [ARRR = 1.86 (95% CI: 1.28, 2.69)] compared to female non-caregivers. Even when women were not caregivers, having someone ill at home was associated with extreme difficulties with life tasks [ARRR = 2.32 (95% CI: 1.33, 4.04)]. Male caregivers, compared to no-one ill in the household, were more likely to report mild-moderate anxiety [ARRR = 1.8 (95% CI: 1.2, 3.7)] and severe-extreme anxiety [ARRR = 2.22 (95% CI: 1.07, 4.6)]. Conclusions: Caregiving for older adults results in greater health burdens, particularly mental health, for both women and men, though evidence shows that these burdens may be prominent and manifest in more diverse ways for women relative to men.

Erratum to "Sport as a vehicle of change for livelihoods, social participation and marital health for the youth: Findings from a prospective cohort in Bihar, India" [EClinicalMedicine 20 (2020) 100302].

[This corrects the article DOI: 10.1016/j.eclinm.2020.100302.].

Sport as a vehicle of change for livelihoods, social participation and marital health for the youth: Findings from a prospective cohort in Bihar, India.

BACKGROUND: Adolescent participation in pro-social activities such as sport can promote identity formation, self-efficacy and social support, but its benefits in India remain unassessed. We examined longitudinal effects of adolescent sport participation on economic, social and political engagement, marital health and family planning among young adults in India. METHODS: We analyzed prospective data from unmarried adolescents (n = 2,322, ages 15-19) who participated in the Youth in India 2007-8 study (wave 1) and were followed in the UDAYA study 2015-16 (wave 2), in Bihar, India. Sport participation was assessed in wave 1. Outcomes assessed in wave 2 were economic engagement (vocational training, past year paid employment), social group participation, political participation, marriage (any and prior to 18), and among those married, marital violence [MV] and contraceptive use. We used logistic and multinomial models to assess longitudinal associations between sport and our outcomes, adjusting for age, residence and wealth at baseline and secondary schooling completion at follow-up. RESULTS: In multivariate models for males, adolescent sport participation was associated with higher odds of vocational training [AOR: 1.92, 95% CI: 1.17, 3.15], social program engagement [AOR: 1.89, 95% CI: 1.14, 3.15], and a trend effect for political participation [AOR: 1.47, 95% CI: 0.97, 2.24]. Among females, sport in adolescence was associated with lower child marriage [ARRR = 0.67, 95% CI: 0.48, 0.96], and higher vocational training [AOR = 1.28, 95% CI: 1.03, 1.16] and family planning use [AOR = 1.31, 95% CI: 1.05, 1.63]. Crude effects were noted for delayed marriage, paid work and perpetration of marital violence among males. INTERPRETATION: Evidence from India shows that sport can be an instrument supporting pro-social engagement for boys and girls. Further understanding of the gendered nature of sport and the mechanisms linking sport to agency among youth is needed. FUNDING: This work was supported by the David and Lucile Packard Foundation (Grant number: 2017-66705).