Unmet Surgical Needs and Trust Deficit in Marginalized Communities in India: A Comparative Cross-Sectional Survey.

INTRODUCTION: We carried out a household study of surgical unmet needs and trust in the physician and perception of quality in the health system in a rural Tribal area and an urban slum in India. METHODS: A community-based, cross-sectional study was carried out in a Tribal and in an urban slum in Gujarat, India. We surveyed 7914 people in 2066 households in urban slum and 5180 people of 1036 households in rural Tribal area. The Surgeons Overseas Assessment of Surgical need was used to identify surgical met and unmet needs. Two instruments for trust deficit 'the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting' and 'Patient perceptions of quality' were also administered to understand perception about healthcare. Frequencies and proportions (categorical variable) summarized utilization of surgical services and surgical needs. P < 0.05 was statistically significant. RESULTS: Slums and Tribal areas were significantly different in sociodemographic indicators. Unmet surgical needs in Tribal area were less than 5% versus 39% in the urban slum. Major need of surgery in Tribal area was for eye conditions in older population, while surgical conditions in extremities and abdomen were predominant in the urban area. Trust level was high for physicians in both areas. CONCLUSIONS: Surgical unmet needs were significantly lower in Tribal versus urban area, possibly due to high priority given by the Indian government to alleviate poverty, social deprivation and participation of NGOs. Our study will give impetus to study unmet surgical needs and formulation of health policies in India and low-and-middle- income countries.

Climate change and 2030 cooling demand in Ahmedabad, India: opportunities for expansion of renewable energy and cool roofs.

Most of India's current electricity demand is met by combustion of fossil fuels, particularly coal. But the country has embarked on a major expansion of renewable energy and aims for half of its electricity needs to be met by renewable sources by 2030. As climate change-driven temperature increases continue to threaten India's population and drive increased demand for air conditioning, there is a need to estimate the local benefits of policies that increase renewable energy capacity and reduce cooling demand in buildings. We investigate the impacts of climate change-driven temperature increases, along with population and economic growth, on demand for electricity to cool buildings in the Indian city of Ahmedabad between 2018 and 2030. We estimate the share of energy demand met by coal-fired power plants versus renewable energy in 2030, and the cooling energy demand effects of expanded cool roof adaptation in the city. We find renewable energy capacity could increase from meeting 9% of cooling energy demand in 2018 to 45% in 2030. Our modeling indicates a near doubling in total electricity supply and a nearly threefold growth in cooling demand by 2030. Expansion of cool roofs to 20% of total roof area (associated with a 0.21 TWh reduction in cooling demand between 2018 and 2030) could more than offset the city's climate change-driven 2030 increase in cooling demand (0.17 TWh/year). This study establishes a framework for linking climate, land cover, and energy models to help policymakers better prepare for growing cooling energy demand under a changing climate.

Assessing mortality risk attributable to high ambient temperatures in Ahmedabad, 1987 to 2017.

BACKGROUND: Studies on high temperatures and mortality have not focused on underdeveloped tropical regions and have reported the associations of different temperature metrics without conducting model selection. METHODS: We collected daily mortality and meteorological data including ambient temperatures and humidity in Ahmedabad during summer, 1987-2017. We proposed two cross-validation (CV) approaches to compare semiparametric quasi-Poisson models with different temperature metrics and heat wave definitions. Using the fittest model, we estimated heat-mortality associations among general population and subpopulations. We also conducted separate analyses for 1987-2002 and 2003-2017 to evaluate temporal heterogeneity. FINDINGS: The model with maximum and minimum temperatures and without heat wave indicator gave the best performance. With this model, we found a substantial and significant increase in mortality rate starting from maximum temperature at 42 °C and from minimum temperature at 28 °C: 1 °C increase in maximum and minimum temperatures at lag 0 were associated with 9.56% (95% confidence interval [CI]: 6.64%, 12.56%) and 9.82% (95% CI: 6.33%, 13.42%) increase in mortality risk, respectively. People aged ≥65 years and lived in South residential zone where most slums were located, were more vulnerable. We observed flatter increases in mortality risk associated with high temperatures comparing the period of 2003-2017 to 1987-2002. INTERPRETATION: The analyses provided better understanding of the relationship of high temperatures with mortality in underdeveloped tropical regions and important implications in developing heat warning system for local government. The proposed CV approaches will benefit future scientific work.

Role of extreme weather events and El Niño Southern Oscillation on incidence of Enteric Fever in Ahmedabad and Surat, Gujarat, India.

INTRODUCTION: Enteric Fever (EF) affects over 14.5 million people every year globally, with India accounting for the largest share of this burden. The water-borne nature of the disease makes it prone to be influenced as much by unsanitary living conditions as by climatic factors. The detection and quantification of the climatic effect can lead to improved public health measures which would in turn reduce this burden. METHODOLOGY: We obtained a list of monthly Widal positive EF cases from 1995 to 2017 from Ahmedabad and Surat Municipalities. We obtained population data, daily weather data, and Oceanic Niño Index values from appropriate sources. We quantified the association between extreme weather events, phases of El Niño Southern Oscillations (ENSO) and incidence of EF. RESULTS: Both cities showed a seasonal pattern of EF, with cases peaking in early monsoon. Risk of EF was affected equally in both cities by the monsoon season -- Ahmedabad (35%) and Surat (34%). Extreme precipitation was associated with 5% increase in EF in Ahmedabad but not in Surat. Similarly, phases of ENSO had opposite effects on EF across the two cities. In Ahmedabad, strong El Niño months were associated with 64% increase in EF risk while strong La Niña months with a 41% reduction in risk. In Surat, strong El Niño was associated with 25% reduction in risk while moderate La Niña with 21% increase in risk. CONCLUSIONS: Our results show that the risk of EF incidence in Gujarat is highly variable, even between the two cities only 260 kms apart. In addition to improvements in water supply and sewage systems, preventive public health measures should incorporate variability in risk across season and phases of ENSO. Further studies are needed to characterize nationwide heterogeneity in climate-mediated risk, and to identify most vulnerable populations that can benefit through early warning systems.

Secondary attack rate in household contacts of COVID-19 Paediatric index cases: a study from Western India.

BACKGROUND: Role of pediatric cases in secondary transmission of COVID-19 is not well understood. We aim to study secondary attack rate (SAR) of COVID-19 in household contacts of pediatric index cases from Gujarat, Western Indian state. METHODS: For this cross-sectional study, details of 2412 paediatric patients were collected from Government records. Through stratified random sampling 10% (n = 242) of the patients were selected for the study and were telephonically contacted for obtaining the details of household secondary infection; 72 pediatric index cases having 287 household contacts were included in the study. RESULTS: The SAR in household contacts of pediatric index cases was 1.7% (95% CI: 0.74-4%). Majority of the index cases were males (94.4%) with 66% of the patients being admitted at various hospitals and isolation facilities (45%); 37% were home quarantine. Of 72, 50 (74%) cases were aged between 12 and 18 years. The family size of the index cases causing secondary infection was comparatively larger than index cases without secondary household infection (6.75 ± 2.3 versus 4.9 ± 1.9; P = 0.034). CONCLUSIONS: The household SAR from pediatric patients is low and is closely associated with the family size of the index cases. Hence, home quarantine should be advocated in smaller families with appropriate isolation facilities.

Surgical Unmet Need in a Low-Income Area of a Metropolitan City in India: A Cross-Sectional Study.

INTRODUCTION: We investigated the burden of surgical conditions, level of unmet needs and reasons for non-utilization of surgical services in a slum of Ahmedabad, India. METHODS: A community-based cross-sectional study was carried out from August to December 2019. Inclusion criteria was age > 14 years; any type of injury/condition that requires surgery; subject has had surgery in last 1 year, and death information of family members. Data were stored and coded in Microsoft excel and exported to IBM SPSS statistics version 25 software for data analysis. Frequencies and proportions (categorical variable) are used to summarize utilization of surgical services and understanding surgical need. The Surgeons Overseas Assessment of Surgical was used to identify surgical met and unmet needs translated into local language. Open Data Kit software was used to install questionnaire in the "Tablet" to collect information and stress-free workflow in field. RESULTS: Out of 10,330 population in 2066 households, 7914 were more than 14 years of age. 3.46% (n = 274) people needed surgery; 116 did not avail surgery and were categorized in "unmet need." Fifty percent of individuals with surgical needs had abdominal- or extremities-related problems followed by eyes surgery need (14%); back, chest and breast surgical need was 13.5%. Seventeen percent of participants with surgical needs had wounds related to injury or accident while 63% had wounds that were not related to injury. Almost all participants had gone to a physician to seek healthcare, however 42% did not avail surgical care needed for a variety of reasons. Forty-six percent of participants needing surgical care underwent major surgical procedure, while 11% had minor procedures. Financial reasons (34.5%) and lack of trust (35.3%) were major reasons for not availing surgical care. CONCLUSIONS AND RELEVANCE: Ahmedabad is a relatively high income metropolitan city, has universally free health care and multiple healthcare facilities. Despite this, we have shown that there is significant unmet need for surgical procedures in the low-income population. A unique finding was that most patients sought a consultation but approximately 50% did not avail of the free surgical procedures under the universally free health care system in this city. We propose creation of community healthcare workers focused on surgical conditions.

Cluster-randomised trial to test the effect of a behaviour change intervention on toilet use in rural India: results and methodological considerations.

BACKGROUND: Effective and scalable behaviour change interventions to increase use of existing toilets in low income settings are under debate. We tested the effect of a novel intervention, the '5 Star Toilet' campaign, on toilet use among households owning a toilet in a rural setting in the Indian state of Gujarat. METHODS: The intervention included innovative and digitally enabled campaign components delivered over 2 days, promoting the upgrading of existing toilets to achieve use by all household members. The intervention was tested in a cluster randomised trial in 94 villages (47 intervention and 47 control). The primary outcome was the proportion of households with use of toilets by all household members, measured through self- or proxy-reported toilet use. We applied a separate questionnaire tool that masked open defecation questions as a physical activity study, and excluded households surveyed at baseline from the post-intervention survey. We calculated prevalence differences using linear regression with generalised estimating equations. RESULTS: The primary study outcome was assessed in 2483 households (1275 intervention and 1208 control). Exposure to the intervention was low. Post-intervention, toilet use was 83.8% in the control and 90.0% in the intervention arm (unadjusted difference + 6.3%, 95%CI 1.1, 11.4, adjusted difference + 5.0%, 95%CI -0.1, 10.1. The physical activity questionnaire was done in 4736 individuals (2483 intervention and 2253 control), and found no evidence for an effect (toilet use 80.7% vs 82.2%, difference + 1.7%, 95%CI -3.2, 6.7). In the intervention arm, toilet use measured with the main questionnaire was higher in those exposed to the campaign compared to the unexposed (+ 7.0%, 95%CI 2.2%, 11.7%), while there was no difference when measured with the physical activity questionnaire (+ 0.9%, 95%CI -3.7%, 5.5%). Process evaluation suggested that insufficient campaign intensity may have contributed to the low impact of the intervention. CONCLUSION: The study highlights the challenge in achieving high intervention intensity in settings where the proportion of the total population that are potential beneficiaries is small. Responder bias may be minimised by masking open defecation questions as a physical activity study. Over-reporting of toilet use may be further reduced by avoiding repeated surveys in the same households. TRIAL REGISTRATION: The trial was registered on the RIDIE registry ( RIDIE-STUDY-ID-5b8568ac80c30 , 27-8-2018) and retrospectively on clinicaltrials.gov ( NCT04526171 , 30-8-2020).

Effect of previous utilization and out-of-pocket expenditure on subsequent utilization of a state led public-private partnership scheme "Chiranjeevi Yojana" to promote facility births in Gujarat, India.

BACKGROUND: In Gujarat, India, a state led public private partnership scheme to promote facility birth named Chiranjeevi Yojana (CY) was implemented in 2005. Institutional birth is provided free of cost at accredited private health facilities to women from socially disadvantaged groups (eligible women). CY has contributed in increasing facility birth and providing substantially subsidized (but not totally free) birth care; however, the retention of mothers in this scheme in subsequent child birth is unknown. Therefore, we conducted a study aimed to determine the effect of previous utilization of the scheme and previous out of pocket expenditure on subsequent child birth among multiparous eligible women in Gujarat. METHODS: This was a retrospective cohort study of multiparous eligible women (after excluding abortions and births at public facility). A structured questionnaire was administered by trained research assistant to those with recent delivery between Jan and Jul 2013. Outcome of interest was CY utilization in subsequent child birth (Jan-Jul 2013). Explanatory variables included socio-demographic characteristics (including category of eligibility), pregnancy related characteristics in previous child birth, before Jan 2013, (including CY utilization, out of pocket expenditure) and type of child birth in subsequent birth. A poisson regression model was used to assess the association of factors with CY utilization in subsequent child birth. RESULTS: Of 997 multiparous eligible women, 289 (29%) utilized and 708 (71%) did not utilize CY in their previous child birth. Of those who utilized CY (n = 289), 182 (63%) subsequently utilized CY and 33 (11%) gave birth at home; whereas those who did not utilize CY (n = 708) had four times higher risk (40% vs. 11%) of subsequent child birth at home. In multivariable models, previous utilization of the scheme was significantly associated with subsequent utilization (adjusted Relative Risk (aRR): 2.7; 95% CI: 2.2-3.3), however previous out of pocket expenditure was not found to be associated with retention in the CY scheme. CONCLUSION: Women with previous CY utilization were largely retained; therefore, steps to increase uptake of CY are expected to increase retention of mothers within CY in their subsequent child birth. To understand the reasons for subsequent child birth at home despite previous CY utilization and previous zero/minimal out of pocket expenditure, future research in the form of systematic qualitative enquiry is recommended.

Utilization of the state led public private partnership program "Chiranjeevi Yojana" to promote facility births in Gujarat, India: a cross sectional community based study.

BACKGROUND: "Chiranjeevi Yojana (CY)", a state-led large-scale demand-side financing scheme (DSF) under public-private partnership to increase institutional delivery, has been implemented across Gujarat state, India since 2005. The scheme aims to provide free institutional childbirth services in accredited private health facilities to women from socially disadvantaged groups (eligible women). These services are paid for by the state to the private facility with the intention of service being free to the user. This community-based study estimates CY uptake among eligible women and explores factors associated with non-utilization of the CY program. METHODS: This was a community-based cross sectional survey of eligible women who gave birth between January and July 2013 in 142 selected villages of three districts in Gujarat. A structured questionnaire was administered by trained research assistant to collect information on socio-demographic details, pregnancy details, details of childbirth and out-of-pocket (OOP) expenses incurred. A multivariable inferential analysis was done to explore the factors associated with non-utilization of the CY program. RESULTS: Out of 2,143 eligible women, 559 (26 %) gave birth under the CY program. A further 436(20 %) delivered at free public facilities, 713(33 %) at private facilities (OOP payment) and 435(20 %) at home. Eligible women who belonged to either scheduled tribe or poor [aOR = 3.1, 95 % CI:2.4 - 3.8] or having no formal education [aOR = 1.6, 95 % CI:1.1, 2.2] and who delivered by C-section [aOR = 2.1,95 % CI: 1.2, 3.8] had higher odds of not utilizing CY program. Of births at CY accredited facilities (n = 924), non-utilization was 40 % (n = 365) mostly because of lack of required official documentation that proved eligibility (72 % of eligible non-users). Women who utilized the CY program overall paid more than women who delivered in the free public facilities. CONCLUSION: Uptake of the CY among eligible women was low after almost a decade of implementation. Community level awareness programs are needed to increase participation among eligible women. OOP expense was incurred among who utilized CY program; this may be a factor associated with non-utilization in next pregnancy which needs to be studied. There is also a need to ensure financial protection of women who have C-section.

Considerations of private sector obstetricians on participation in the state led "Chiranjeevi Yojana" scheme to promote institutional delivery in Gujarat, India: a qualitative study.

BACKGROUND: In India a lack of access to emergency obstetric care contributes to maternal deaths. In 2005 Gujarat state launched a public-private partnership (PPP) programme, Chiranjeevi Yojana (CY), under which the state pays accredited private obstetricians a fixed fee for providing free intrapartum care to poor and tribal women. A million women have delivered under CY so far. The participation of private obstetricians in the partnership is central to the programme's effectiveness. We explored with private obstetricians the reasons and experiences that influenced their decisions to participate in the CY programme. METHOD: In this qualitative study we interviewed 24 purposefully selected private obstetricians in Gujarat. We explored their views on the scheme, the reasons and experiences leading up to decisions to participate, not participate or withdraw from the CY, as well as their opinions about the scheme's impact. We analysed data using the Framework approach. RESULTS: Participants expressed a tension between doing public good and making a profit. Bureaucratic procedures and perceptions of programme misuse seemed to influence providers to withdraw from the programme or not participate at all. Providers feared that participating in CY would lower the status of their practices and some were deterred by the likelihood of more clinically difficult cases among eligible CY beneficiaries. Some providers resented taking on what they saw as a state responsibility to provide safe maternity services to poor women. Younger obstetricians in the process of establishing private practices, and those in more remote, 'less competitive' areas, were more willing to participate in CY. Some doctors had reservations over the quality of care that doctors could provide given the financial constraints of the scheme. CONCLUSIONS: While some private obstetricians willingly participate in CY and are satisfied with its functioning, a larger number shared concerns about participation. Operational difficulties and a trust deficit between the public and private health sectors affect retention of private providers in the scheme. Further refinement of the scheme, in consultation with private partners, and trust building initiatives could strengthen the programme. These findings offer lessons to those developing public-private partnerships to widen access to health services for underprivileged groups.

Evaluation of a virtual, simulated international public health peer-to-peer exchange learning experience.

Introduction: Public Health's (PH) global rise is accompanied by an increasing focus on training the new generation of PH graduates in interdisciplinary skills for multisectoral and cross-cultural engagement to develop an understanding of commonalities in health system issues and challenges in multi-cultural settings. Online teaching modalities provide an opportunity to enhance global health skill development through virtual engagement and peer exchange. However, current teaching pedagogy is limited in providing innovative modes of learning global health issues outside of traditional classroom settings with limited modalities of evidence-informed implementation models. Methods: This study designed, implemented, and evaluated a novel global health online synchronous module as proof of concept that incorporated elements of virtual Practice-based learning (PBL) using a case study approach offered to currently enrolled public health students at the University of Canberra (UC) and a partnering public health university from India, the Indian Institute of Public Health Gandhinagar (IIPH-G). Using constructive learning theory and the Social Determinants of Health framework, four online sessions were designed and implemented in August-September 2022. Formal process and outcome evaluation using a quantitative adapted survey of the validated International Student Experience survey (IES) at session end and findings provided. Results: Over 100 participating public health students from Australia and India provided narrative feedback and quantitative responses from the adapted IES instrument across four key dimensions, namely "motivation," "personal development," intellectual development, and "international perspectives" reporting an overall high mean impact of 4.29 (out of 5) across all four themes seen together. In essence, the sessions supported students to explore global health issues from a different cultural perspective while developing intercultural communication skills and enhancing their global exposure in real-time. Discussions: This innovation, implemented as a proof of concept, provided evidence, and demonstrated the implementation feasibility of a flexible virtual integrated practice-based module that can supplement classroom teaching. It provides participating students with the opportunity to develop intercultural understanding and communication competence as well as support global mindedness by engaging with international peers around focused global health case studies.

Community health workers to reduce unmet surgical needs in an urban slum in India: an implementation study.

BACKGROUND: The Surgical Accredited & Trained Healthcare Initiative (SATHI) project demonstrates how community healthcare workers (CHWs) with merely 8 y of formal schooling and training for a short period can reduce unmet surgical needs. METHODS: A pilot study was carried out in the slums of a metropolitan city in India to know the effectiveness of a SATHI in reducing the burden of unmet surgical needs. In total, 12 730 people from 3000 households were included in the study for a duration of 6 months. RESULTS: We found 10% surgical needs (n=293) out of which 57% had unmet surgical needs. Out of total surgical needs, about half of the needs were cataract and abdominal, followed by extremities and chest conditions. SATHIs were able to convert 99 patients (60%) from unmet to met needs, who underwent surgery/treatment. The conversion from unmet to met among all surgery needs was highest for abdominal conditions (29%) followed by cataracts (17%). CONCLUSIONS: SATHIs with short training can reduce the burden of unmet surgical needs. SATHIs were able to convert a significant proportion of unmet to met needs by trust building, facilitating access to healthcare and ensuring post-operative adherence. Scaling up could help in the achievement of equitable healthcare across India.

Air quality and health co-benefits of climate change mitigation and adaptation actions by 2030: an interdisciplinary modeling study in Ahmedabad, India.

Climate change-driven temperature increases worsen air quality in places where coal combustion powers electricity for air conditioning. Climate solutions that substitute clean and renewable energy in place of polluting coal and promote adaptation to warming through reflective cool roofs can reduce cooling energy demand in buildings, lower power sector carbon emissions, and improve air quality and health. We investigate the air quality and health co-benefits of climate solutions in Ahmedabad, India-a city where air pollution levels exceed national health-based standards-through an interdisciplinary modeling approach. Using a 2018 baseline, we quantify changes in fine particulate matter (PM2.5) air pollution and all-cause mortality in 2030 from increasing renewable energy use (mitigation) and expanding Ahmedabad's cool roofs heat resilience program (adaptation). We apply local demographic and health data and compare a 2030 mitigation and adaptation (M&A) scenario to a 2030 business-as-usual (BAU) scenario (without climate change response actions), each relative to 2018 pollution levels. We estimate that the 2030 BAU scenario results in an increase of PM2.5 air pollution of 4.13 µg m-3 from 2018 compared to a 0.11 µg m-3 decline from 2018 under the 2030 M&A scenario. Reduced PM2.5 air pollution under 2030 M&A results in 1216-1414 fewer premature all-cause deaths annually compared to 2030 BAU. Achievement of National Clean Air Programme, National Ambient Air Quality Standards, or World Health Organization annual PM2.5 Air Quality Guideline targets in 2030 results in up to 6510, 9047, or 17 369 fewer annual deaths, respectively, relative to 2030 BAU. This comprehensive modeling method is adaptable to estimate local air quality and health co-benefits in other settings by integrating climate, energy, cooling, land cover, air pollution, and health data. Our findings demonstrate that city-level climate change response policies can achieve substantial air quality and health co-benefits. Such work can inform public discourse on the near-term health benefits of mitigation and adaptation.

Reproductive health, and child health and nutrition in India: meeting the challenge.

India, with a population of more than 1 billion people, has many challenges in improving the health and nutrition of its citizens. Steady declines have been noted in fertility, maternal, infant and child mortalities, and the prevalence of severe manifestations of nutritional deficiencies, but the pace has been slow and falls short of national and Millennium Development Goal targets. The likely explanations include social inequities, disparities in health systems between and within states, and consequences of urbanisation and demographic transition. In 2005, India embarked on the National Rural Health Mission, an extraordinary effort to strengthen the health systems. However, coverage of priority interventions remains insufficient, and the content and quality of existing interventions are suboptimum. Substantial unmet need for contraception remains, adolescent pregnancies are common, and access to safe abortion is inadequate. Increases in the numbers of deliveries in institutions have not been matched by improvements in the quality of intrapartum and neonatal care. Infants and young children do not get the health care they need; access to effective treatment for neonatal illness, diarrhoea, and pneumonia shows little improvement; and the coverage of nutrition programmes is inadequate. Absence of well functioning health systems is indicated by the inadequacies related to planning, financing, human resources, infrastructure, supply systems, governance, information, and monitoring. We provide a case for transformation of health systems through effective stewardship, decentralised planning in districts, a reasoned approach to financing that affects demand for health care, a campaign to create awareness and change health and nutrition behaviour, and revision of programmes for child nutrition on the basis of evidence. This agenda needs political commitment of the highest order and the development of a people's movement.

An evaluation of two large scale demand side financing programs for maternal health in India: the MATIND study protocol.

BACKGROUND: High maternal mortality in India is a serious public health challenge. Demand side financing interventions have emerged as a strategy to promote access to emergency obstetric care. Two such state run programs, Janani Suraksha Yojana (JSY)and Chiranjeevi Yojana (CY), were designed and implemented to reduce financial access barriers that preclude women from obtaining emergency obstetric care. JSY, a conditional cash transfer, awards money directly to a woman who delivers in a public health facility. This will be studied in Madhya Pradesh province. CY, a voucher based program, empanels private obstetricians in Gujarat province, who are reimbursed by the government to perform deliveries of socioeconomically disadvantaged women. The programs have been in operation for the last seven years. METHODS/DESIGNS: The study outlined in this protocol will assess and compare the influence of the two programs on various aspects of maternal health care including trends in program uptake, institutional delivery rates, maternal and neonatal outcomes, quality of care, experiences of service providers and users, and cost effectiveness. The study will collect primary data using a combination of qualitative and quantitative methods, including facility level questionnaires, observations, a population based survey, in-depth interviews, and focus group discussions. Primary data will be collected in three districts of each province. The research will take place at three levels: the state health departments, obstetric facilities in the districts and among recently delivered mothers in the community. DISCUSSION: The protocol is a comprehensive assessment of the performance and impact of the programs and an economic analysis. It will fill existing evidence gaps in the scientific literature including access and quality to services, utilization, coverage and impact. The implementation of the protocol will also generate evidence to facilitate decision making among policy makers and program managers who currently work with or are planning similar programs in different contexts.

Trust Deficit in Surgical Systems in an Urban Slum in India Under Universal Health Coverage: A Mixed Method Study.

Objectives: We carried out a mixed method study to understand why patients did not avail of surgical care in an urban slum in India. Methods: In our earlier study, we found that out of 10,330 people, 3.46% needed surgery; 42% did not avail of surgery (unmet needs). We conducted a follow-up study to understand reasons for not availing surgery, 141 in met needs, 91 in unmet needs. We administered 2 instruments, 16 in-depth interviews and 1 focused group discussion. Results: Responses from the 2 groups for "the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting" scale did not have significant difference except for, prescription of medicines, patients with unmet needs were less likely to agree (p = 0.076). Results between 2 groups regarding "Patient perceptions of quality" did not show significant difference except for doctors answering questions where a higher proportion of unmet need group agreed (p = 0.064). Similar observations were made in the in depth interviews and focus group. Conclusion: There is a need for understanding trust issues with health service delivery related to surgical care for marginalized populations.

Challenges in the execution of public health research: Reflections from Public Health Research Initiative (PHRI) grant management in India.

Background: Well-planned health research is fundamental to the success of any public health system in leading to better population health outcomes. Although the Indian public health system is unique, it lacks strong linkages between research and practice. There is a pressing need to address the gap in the research to reduce the disease burden in the country. Although various efforts are made to enhance public health research, such research is rarely documented as a process. The objective of the present paper is to document issues and challenges in managing public health research grants awarded to the PHRI fellows from 2013-to 2021 under the PHRI project. Method: A mixed-method approach, including qualitative (in-depth) interviews and secondary review, was adopted to collect the challenges in executing PHRI grants (during 2013-2021). The in-depth interviews were conducted among the PHRI execution team, whereas the secondary document review was conducted among the PHRI fellows, and the findings are documented under major themes like administrative, technical, and financial issues and/or challenges. Result: A total of 35 candidates 16 intramural (IM) candidates affiliated with PHFI or IIPH institutes and 19 extramural (EM) candidates affiliated to other academic institutes were selected for the fellowship, The common challenges identified amongst intra & extramural fellows were inability to disseminate the study findings, challenges in communication and getting audited statements, changes in study methods without prior permission, mid study attrition of CO-PIs and high budget utilization. The specific difficulties identified from extramural fellows were change in institute affiliation, lack of support to fund utilization from the parent institute and difficulties in field validation. Conclusion: The present perspective emphasizes that the management and implementation of a research grant is the crucial part of achieving a project's desired outcome. The learnings of PHRI grant execution allows the researchers to understand the issues in terms of methodological rigour and financial guidelines, rigorous tracking of the project activities, and complying with the terms of funding agreement are crucial. The challenges explored in this grant execution recommend developing a structured public health grant management leadership program for researchers and executors.

Infection control in delivery care units, Gujarat state, India: a needs assessment.

BACKGROUND: Increasingly, women in India attend health facilities for childbirth, partly due to incentives paid under government programs. Increased use of health facilities can alleviate the risks of infections contracted in unhygienic home deliveries, but poor infection control practices in labour and delivery units also cause puerperal sepsis and other infections of childbirth. A needs assessment was conducted to provide information on procedures and practices related to infection control in labour and delivery units in Gujarat state, India. METHODS: Twenty health care facilities, including private and public primary health centres and referral hospitals, were sampled from two districts in Gujarat state, India. Three pre-tested tools for interviewing and for observation were used. Data collection was based on existing infection control guidelines for clean practices, clean equipment, clean environment and availability of diagnostics and treatment. The study was carried out from April to May 2009. RESULTS: Seventy percent of respondents said that standard infection control procedures were followed, but a written procedure was only available in 5% of facilities. Alcohol rubs were not used for hand cleaning and surgical gloves were reused in over 70% of facilities, especially for vaginal examinations in the labour room. Most types of equipment and supplies were available but a third of facilities did not have wash basins with "hands-free" taps. Only 15% of facilities reported that wiping of surfaces was done immediately after each delivery in labour rooms. Blood culture services were available in 25% of facilities and antibiotics are widely given to women after normal delivery. A few facilities had data on infections and reported rates of 3% to 5%. CONCLUSIONS: This study of current infection control procedures and practices during labour and delivery in health facilities in Gujarat revealed a need for improved information systems, protocols and procedures, and for training and research. Simply incentivizing the behaviour of women to use health facilities for childbirth via government schemes may not guarantee safe delivery.

A review of health system infection control measures in developing countries: what can be learned to reduce maternal mortality.

A functional health system is a necessary part of efforts to achieve maternal mortality reduction in developing countries. Puerperal sepsis is an infection contracted during childbirth and one of the commonest causes of maternal mortality in developing countries, despite the discovery of antibiotics over eighty years ago. Infections can be contracted during childbirth either in the community or in health facilities. Some developing countries have recently experienced increased use of health facilities for labour and delivery care and there is a possibility that this trend could lead to rising rates of puerperal sepsis. Drug and technological developments need to be combined with effective health system interventions to reduce infections, including puerperal sepsis. This article reviews health system infection control measures pertinent to labour and delivery units in developing country health facilities. Organisational improvements, training, surveillance and continuous quality improvement initiatives, used alone or in combination have been shown to decrease infection rates in some clinical settings. There is limited evidence available on effective infection control measures during labour and delivery and from low resource settings. A health systems approach is necessary to reduce maternal mortality and the occurrence of infections resulting from childbirth. Organisational and behavioural change underpins the success of infection control interventions. A global, targeted initiative could raise awareness of the need for improved infection control measures during childbirth.

Climate Change Adaptation: Prehospital Data Facilitate the Detection of Acute Heat Illness in India.

INTRODUCTION: Extreme heat is a significant cause of morbidity and mortality, and the incidence of acute heat illness (AHI) will likely increase secondary to anthropogenic climate change. Prompt diagnosis and treatment of AHI are critical; however, relevant diagnostic and surveillance tools have received little attention. In this exploratory cross-sectional and diagnostic accuracy study, we evaluated three tools for use in the prehospital setting: 1) case definitions; 2) portable loggers to measure on-scene heat exposure; and 3) prevalence data for potential AHI risk factors. METHODS: We enrolled 480 patients who presented to emergency medical services with chief complaints consistent with AHI in Ahmedabad, India, from April-June 2016 in a cross-sectional study. We evaluated AHI case definition test characteristics in reference to trained prehospital provider impressions, compared on-scene heat index measured by portable loggers to weather station measurements, and identified AHI behavioral and environmental risk factors using logistic regression. RESULTS: The case definition for heat exhaustion was 23.8% (12.1-39.5%) sensitive and 93.6% (90.9-95.7%) specific. The positive and negative predictive values were 33.5% (20.8-49.0%) and 90.1% (88.5-91.5%), respectively. Mean scene heat index was 6.7°C higher than the mean station heat index (P < 0.001), and station data systematically underestimated heat exposure, particularly for AHI cases. Heat exhaustion cases were associated with on-scene heat index ≥ 49°C (odds ratio [OR] 2.66 [1.13-6.25], P = 0.025) and a history of recent exertion (OR 3.66 [1.30-10.29], P = 0.014), while on-scene air conditioning was protective (OR 0.29 [0.10-0.85], P = 0.024). CONCLUSION: Systematic collection of prehospital data including recent activity history and presence of air conditioning can facilitate early AHI detection, timely intervention, and surveillance. Scene temperature data can be reliably collected and improve heat exposure and AHI risk assessment. Such data may be important elements of surveillance, clinical practice, and climate change adaptation.