Prevalence and clustering of diarrhoea within households in India: some evidence from NFHS-4, 2015-16.

Diarrhoeal disease is one of the major causes of morbidity and mortality in children and is usually measured at individual level. Shared household attributes, such as improved water supply and sanitation, expose those living in the same household to these same risk factors for diarrhoea. The occurrence of diarrhoea in two or more children in the same household is termed 'diarrhoea clustering'. The aim of this study was to examine the role of improved water supply and sanitation in the occurrence of diarrhoea, and the clustering of diarrhoea in households, among under-five children in India. Data were taken from the fourth round of the National Family and Health Survey (NFHS-4), a nationally representative survey which interviewed 699,686 women from 601,509 households in the country. If any child was reported to have diarrhoea in a household in the 2 weeks preceding the survey, the household was designated a diarrhoeal household. Household clustering of diarrhoea was defined the occurrence of diarrhoea in more than one child in households with two or more children. The analysis was done at the household level separately for diarrhoeal households and clustering of diarrhoea in households. The presence of clustering was tested using a chi-squared test. The overall prevalences of diarrhoea and clustering of diarrhoea were examined using exogenous variables. Odds ratios, standardized to allow comparison across categories, were computed. The household prevalence of diarrhoea was 12% and that of clustering of diarrhoea was 2.4%. About 6.5% of households contributed 12.6% of the total diarrhoeal cases. Access to safe water and sanitation was shown to have a great impact on reducing diarrhoeal prevalence and clustering across different household groups. Safe water alone had a greater impact on reducing the prevalence in the absence of improved sanitation when compared with the presence of improved sanitation. It may be possible to reduce the prevalence of diarrhoea in households by targeting those households with more than one child in the under-five age group with the provision of safe water and improved sanitation.

Treatment and rehabilitation of stroke patients in India: A gendered analysis based on repeated cross-sectional national sample surveys on health, 2014 and 2019.

We attempt a gendered inspection of sex differentials in care following stroke in India using data from two rounds of NSSO. While almost all men and women receive allopathic care, a higher percentage of women (51.8%) were treated in public hospitals compared to men (32.6%) in 2014 and 2017-18 (45.8% vs 41.4%). Men were preponderantly treated in private hospitals (67.4%) compared to women (48.2%) in 2014 and 2017-18 (58.6% vs 54.2%). We provide evidence that for rehabilitation, at the highest decile for expenditure, men spend more than women. This preliminary exploration is indicative of a gendered dimension in care-seeking for stroke.

Exclusion of married adolescents in a study of gestational diabetes mellitus: a case study.

A study on gestational diabetes mellitus (GDM) among 200 married women in Malappruam, Kerala, India, chose to exclude married women below the age of 18 from participation. Marriages before age 18 are not considered legally valid and persons below age 18 do not have the status of an adult. Parents are considered the legal guardians of married women under age 18, but because marriages are patrilocal, obtaining consent from parents would have time costs. Further, obtaining parental consent may also be considered disrespectful of the in-laws. The inclusion of married adolescents in this study was considered difficult for these reasons. This exclusion can also result in wrongly estimating the levels of GDM among all women at risk. We argue that such exclusion is also unethical; it unfair to exclude women who stand to benefit from participation by enabling them to identify the enhanced life time risk for diabetes mellitus and monitor their future health status better. Recognizing married adolescents as emancipated minors would enable their participating without violating confidentiality regarding their GDM status to parents and in-laws.

Conceptual model for dietary behaviour change at household level: a 'best-fit' qualitative study using primary data.

BACKGROUND: Interventions having a strong theoretical basis are more efficacious, providing a strong argument for incorporating theory into intervention planning. The objective of this study was to develop a conceptual model to facilitate the planning of dietary intervention strategies at the household level in rural Kerala. METHODS: Three focus group discussions and 17 individual interviews were conducted among men and women, aged between 23 and 75 years. An interview guide facilitated the process to understand: 1) feasibility and acceptability of a proposed dietary behaviour change intervention; 2) beliefs about foods, particularly fruits and vegetables; 3) decision-making in households with reference to food choices and access; and 4) to gain insights into the kind of intervention strategies that may be practical at community and household level. The data were analysed using a modified form of qualitative framework analysis, which combined both deductive and inductive reasoning. A priori themes were identified from relevant behaviour change theories using construct definitions, and used to index the meaning units identified from the primary qualitative data. In addition, new themes emerging from the data were included. The associations between the themes were mapped into four main factors and its components, which contributed to construction of the conceptual model. RESULTS: Thirteen of the a priori themes from three behaviour change theories (Trans-theoretical model, Health Belief model and Theory of Planned Behaviour) were confirmed or slightly modified, while four new themes emerged from the data. The conceptual model had four main factors and its components: impact factors (decisional balance, risk perception, attitude); change processes (action-oriented, cognitive); background factors (personal modifiers, societal norms); and overarching factors (accessibility, perceived needs and preferences), built around a three-stage change spiral (pre-contemplation, intention, action). Decisional balance was the strongest in terms of impacting the process of behaviour change, while household efficacy and perceived household cooperation were identified as 'markers' for stages-of-change at the household level. CONCLUSIONS: This type of framework analysis made it possible to develop a conceptual model that could facilitate the design of intervention strategies to aid a household-level dietary behaviour change process.

Reducing neonatal mortality in Jhagadia Block, Gujarat: we need to go beyond promoting hospital deliveries.

BACKGROUND AND METHODS: We examined data from a cohort of births that occurred in the period 2004-08 in the SEWA-Rural project area, covering a population of ∼175000, in Gujarat, India, to assess the trends and risk factors for neonatal mortality. RESULTS: In this population living in 168 villages, there has been a significant declining trend in infant and neonatal mortality, more marked in the tribal population, in whom this paralleled a rise in the proportion of women delivering in hospitals. The more important risk factors for neonatal mortality risk to emerge from multivariate analysis are low birth weight, prematurity, young age of mother, older mother and high birth order. CONCLUSION: Although community based interventions along with promotion of hospital birth has an impact in reducing neonatal deaths in this community, sustaining this momentum may demand more long-term policy interventions to promote better living standards and better reproductive health.

Methodological challenges in studying the chronically ill elderly: Ethical need to include caregivers.

In low- and middle-income countries, caring for the elderly is a responsibility that is undertaken within households with minimal institutional support from the community or structural support from the state [1,2]. Usually, this responsibility is shared within the home, with the physical and emotional work of caring falling to the one who does not have too many extra-residential responsibilities. The gendered nature of caring responsibility is such that, usually it is women who are not in the formal or informal labour markets who share the responsibility [2,3].

Infertility - an unfinished reproductive rights agenda in India.

Twenty-five years after the International Conference on Population and Development (ICPD) mandate in 1994, India has fallen far short of providing universal access to preventive and treatment services for infertility. This mandate was a call to "prioritize the reproductive health and rights of all people" (1), and reproductive health was defined as.

Public perceptions on Controlled Human Infection Model (CHIM) studies-a qualitative pilot study from South India.

Research using Controlled Human Infection Models is yet to be attempted in India. This study was conducted to understand the perceptions of the lay public and key opinion makers prior to the possible introduction of such studies in the country. 110 respondents from urban and rural Bangalore district were interviewed using qualitative research methods of Focus Group Discussions and In-depth Interviews. The data was analyzed using grounded theory. Safety was a key concern of the lay public, expressed in terms of fear of death. The notion of infecting a healthy volunteer, the possibility of continued effects beyond the study duration and the likelihood of vulnerable populations volunteering solely for monetary benefit, were ethical concerns. Public good outcomes such as effective treatments, targeted vaccines and prevention of diseases was necessary justification for such studies. However, the comprehension of this benefit was not clear among non-medical, non-technical respondents and suggestions to seek alternatives to CHIMs repeatedly arose. There was a great deal of deflection-with each constituency feeling that people other than themselves may be ideally suited as participants. Risk takers, those without dependents, the more health and research literate, financially sound and those with an altruistic bent of mind emerged as possible CHIM volunteers. While widespread awareness and advocacy about CHIM is essential, listening to plural voices is the first step in public engagement in ethically contentious areas. Continued engagement and inclusive deliberative processes are required to redeem the mistrust of the public in research and rebuild faith in regulatory systems.

Public health research ethics - Indian case studies.

Public Health research and practice exposes individual researchers and practitioners to dilemmas that are slightly different from those of clinical research. This is because in public health, the focus of research is not an individual patient, but the population. The nature of dilemmas confronted in public health research impinges upon community identities, individual vs collective risks and benefits, and power relations between gate keepers and actual participants.

Covariates of diarrhoea among under-five children in India: Are they level dependent?

Program interventions like access to improved water supply, sanitation and hygiene do not have a systematic response to the aggregate health outcomes. Therefore, this is an attempt at recognising the concept of level sensitivity while verifying the association between prevalence of diarrhoea in under-five children in a district and its corresponding coverage of improved water supply and sanitation and hygiene. Information obtained in the DLHS-4 including 275 districts from 19 states and 2 union territories of India forms the database for this analysis. Universal access to safe drinking water, improving coverage of sanitation in a district beyond 71 percent across the country and beyond 78 percent among the non-south DLHS districts, has the potential to realise reductions in the prevalence of diarrhoea in under-five children in a district. The effect of improved sanitation seems to work synergistically with these indicators only at better levels of prevalence of diarrhoea in under-five children in a district. This offers lessons for the Clean India Mission in terms of universalising access to safe water and coverage up to three-fourths of households with sanitation in a district for the positive externalities to manifest in reduced prevalence of diarrhoea in under-five children.

Gender Differences in Self-Reported Heart Disease and Multiple Risk Factors in India: Evidence from the 71st Round of the National Sample Survey Office, 2014.

This study examined gender differences in the prevalence of heart disease in India in terms of type of care sought and biological risk factors. The analysis included 142,620 people aged 30 and above from the National Sample Survey Office's 71st round of 2014. While men and women have the same prevalence of seven per 1,000 persons, using a form of prevalence odds ratio the analysis indicated that women were likely to seek care at lower levels of service provision, even though they carried a higher level of multiple morbidities. This difference is not because of the survival effect of women living longer with heart diseases when compared to men. It is possible that women with heart disease complicated by multiple co-morbidities have limited treatment options. Nevertheless, these constraints are not entirely biological and therefore whether these are a consequence of gender discrimination in care options needs further examination.

The interactions of ethical notions and moral values of immediate stakeholders of immunisation services in two Indian states: a qualitative study.

OBJECTIVES: This study examines the existing norms regarding immunisation within the communities and the ethical notions that govern the actions of different health professionals and their collective synergistic or conflicting effects on the governance of the programme. DESIGN: We used descriptive and analytical qualitative methods as it suited the research question. SETTING: The data were collected from areas under 16 primary health centres in Kerala and Tamil Nadu identified through a three-step sampling process. PARTICIPANTS: This involved in-depth interviews with stakeholders including providers, beneficiaries and other stakeholders, focus group discussions with mothers of under-five children and participant and non-participant observations of vaccination-related activities. RESULTS: Unlike most other ethical analyses that look at the ethics of vaccination policies, the interactions of normative principles and notions are analysed in this article. Moral obligation of parents towards their children, beneficence of healthcare providers and the utilitarian aspirations of the state are the key normative principles involved. Our analysis points to the interplay of both synergy and conflict in ethical notions and moral values in the context of immunisation services. Paternalistic interventions like special immunisation campaigns against polio and Japanese encephalitis are a case in point: they generate conflict at the normative level and create mistrust. CONCLUSIONS: Analysis of vaccination policies and programmes needs to go beyond factors that assess monetary benefits or herd immunity. Understanding the interactions of normative notions that shape the social organisation of the providers and the users of vaccination is important in creating a sustainable environment for the programme.