Development & validation of scales to assess stigma related to COVID-19 in India.

Background & objectives: COVID-19 pandemic has triggered social stigma towards individuals affected and their families. This study describes the process undertaken for the development and validation of scales to assess stigmatizing attitudes and experiences among COVID-19 and non-COVID-19 participants from the community. Methods: COVID-19 Stigma Scale and Community COVID-19 Stigma Scale constituting 13 and six items, respectively, were developed based on review of literature and news reports, expert committee evaluation and participants' interviews through telephone for a multicentric study in India. For content validity, 61 (30 COVID-19-recovered and 31 non-COVID-19 participants from the community) were recruited. Test-retest reliability of the scales was assessed among 99 participants (41 COVID-19 recovered and 58 non-COVID-19). Participants were administered the scale at two-time points after a gap of 7-12 days. Cronbach's alpha, overall percentage agreement and kappa statistics were used to assess internal consistency and test-retest reliability. Results: Items in the scales were relevant and comprehensible. Both the scales had Cronbach's α above 0.6 indicating moderate-to-good internal consistency. Test-retest reliability assessed using kappa statistics indicated that for the COVID-19 Stigma Scale, seven items had a moderate agreement (0.4-0.6). For the Community COVID-19 Stigma Scale, four items had a moderate agreement. Interpretation & conclusions: Validity and reliability of the two stigma scales indicated that the scales were comprehensible and had moderate internal consistency. These scales could be used to assess COVID-19 stigma and help in the development of appropriate stigma reduction interventions for COVID-19 infected, and mitigation of stigmatizing attitudes in the community.

Chronic kidney disease in public renal practices in Queensland, Australia, 2011-2018.

AIM: To describe adults with (non-dialysis) chronic kidney disease (CKD) in nine public renal practice sites in the Australian state of Queensland. METHODS: 7,060 persons were recruited to a CKD Registry in May 2011 and until start of kidney replacement therapy (KRT), death without KRT or June 2018, for a median period of 3.4 years. RESULTS: The cohort comprised 7,060 persons, 52% males, with a median age of 68 yr; 85% had CKD stages 3A to 5, 45.4% were diabetic, 24.6% had diabetic nephropathy, and 51.7% were obese. Younger persons mostly had glomerulonephritis or genetic renal disease, while older persons mostly had diabetic nephropathy, renovascular disease and multiple diagnoses. Proportions of specific renal diagnoses varied >2-fold across sites. Over the first year, eGFR fell in 24% but was stable or improved in 76%. Over follow up, 10% started KRT, at a median age of 62 yr, most with CKD stages 4 and 5 at consent, while 18.8% died without KRT, at a median age of 80 yr. Indigenous people were younger at consent and more often had diabetes and diabetic kidney disease and had higher incidence rates of KRT. CONCLUSION: The spectrum of characteristics in CKD patients in renal practices is much broader than represented by the minority who ultimately start KRT. Variation in CKD by causes, age, site and Indigenous status, the prevalence of obesity, relative stability of kidney function in many persons over the short term, and differences between those who KRT and die without KRT are all important to explore.

Factors influencing the adsorption of antibiotics onto activated carbon in aqueous media.

Widespread use of antibiotics for treating human and animal ailments has increased their discharge in the environment through excreta. Moreover, unscientific disposal of unused antibiotics has further increased their presence in the environmental matrices. Thus, occurrence of used and/or discarded antibiotics in water resources is becoming a growing concern across the globe. Antibiotics and their residues in the aquatic environment are emerging contaminants which pose a serious threat to the aquatic biota as well as human beings by enhancing antibiotic resistance. Various methods are being adopted for the removal of these contaminants. Adsorption over activated carbon is one such promising method which is environmentally friendly, cost-effective, and efficient. However, there are various factors which affect the overall process efficiency, such as, properties of activated carbon/antibiotics/reaction medium etc. In this article, emphasis has been laid down on evaluating these factors, so that the experimental procedures may be optimized to obtain the highest possible removal efficiency for antibiotics in the aqueous media.

Effects of improved information and volunteer support on segregation of solid waste at the household level in urban settings in Madhya Pradesh, India (I-MISS): protocol of a cluster randomized controlled trial.

BACKGROUND: Segregation of household waste at the source is an effective and sustainable strategy for management of municipal waste. However, household segregation levels remain insufficient as waste management approaches are mostly top down and lack local support. The realisation and recognition of effective, improved and adequate waste management may be one of the vital drivers for attaining environmental protection and improved health and well-being. The presence of a local level motivator may promote household waste segregation and ultimately pro-environmental behaviour. The present cluster randomized control trial aims to understand if volunteer based information on waste segregation (I-MISS) can effectively promote increased waste segregation practices at the household level when compared with existing routine waste segregation information in an urban Indian setting. METHODS: This paper describes the protocol of an 18 month two-group parallel,cluster randomised controlled trialin the urban setting of Ujjain, Madhya Pradesh, India. Randomization will be conducted at ward level, which is the last administrative unit of the municipality. The study will recruit 425 households in intervention and control groups. Assessments will be performed at baseline (0 months), midline (6 months), end line (12 months) and post intervention (18 months). The primary outcome will be the comparison of change in proportion of households practicing waste segregation and change in proportion of mis-sorted waste across the study period between the intervention and control groups as assessed by pick analysis. Intention to treat analysis will be conducted. Written informed consent will be obtained from all participants. DISCUSSION: The present study is designed to study whether an external motivator, a volunteer selected from the participating community and empowered with adequate training, could disseminate waste segregation information to their community, thus promoting household waste segregation and ultimately pro-environmental behaviour. The study envisages that the volunteers could link waste management service providers and the community, give a local perspective to waste management, and help to change community habits through information, constant communication and feedback. TRIAL REGISTRATION: The study is registered prospectively with Indian Council of Medical Research- Clinical Trial Registry of India ( CTRI/2020/03/024278 ).

Removal of microplastics from wastewater: available techniques and way forward.

Microplastics are the newly emerged contaminants with a presence in almost every part of the globe. Despite being small in size, microplastic particles have proved to be harmful for plants, animals, humans, and for the ecosystem in general. Water is one of the most important routes through which microplastics transfer from one place to another. Moreover, water is also an important route for the ingestion of microplastics in human, which results in various health issues, such as cancer, mutagenic and teratogenic abnormalities. Thus, microplastics in water is an emerging public health issue which needs attention and, hence, it is important to investigate removal techniques for microplastics in wastewater. Although, there are some biological, chemical/electrochemical, and physical techniques to remove microplastics, their wide scale applicability and cost-effectiveness is an issue. In this review, we have discussed the existing and upcoming treatment technologies for the removal of microplastics from wastewater and also tried to present an overview for the future approaches.

Stable high frequencies of sulfadoxine-pyrimethamine resistance associated mutations and absence of K13 mutations in Plasmodium falciparum 3 and 4 years after the introduction of artesunate plus sulfadoxine-pyrimethamine in Ujjain, Madhya Pradesh, India.

BACKGROUND: Artesunate plus sulfadoxine-pyrimethamine (ASP) is first-line treatment for uncomplicated Plasmodium falciparum malaria in most of India, except for six North-eastern provinces where treatment failure rates were high. In Ujjain, central India, the frequency of mutations associated with increased drug tolerance, but not overt resistance to sulfadoxine and pyrimethamine were 9% and > 80%, respectively, in 2009 and 2010, just prior to the introduction of ASP. The frequency of drug resistance associated mutations in Ujjain in 2015-2016 after 3-4 years of ASP use, are reported. METHODS: Blood samples from patients with P. falciparum mono-infection verified by microscopy were collected on filter-paper at all nine major pathology laboratories in Ujjain city. Codons pfdhfr 16-185, pfdhps 436-632 and K13 407-689 were identified by sequencing. Pfcrt K76T and pfmdr1 N86Y were identified by restriction fragment length polymorphism. RESULTS: Sulfadoxine-pyrimethamine resistance-associated pfdhfr 108 N and 59R alleles were found in 100/104 (96%) and 87/91 (96%) samples, respectively. Pfdhps 437G was found in 10/105 (10%) samples. Double mutant pfdhfr 59R + 108 N were found in 75/81 (93%) samples. Triple mutant pfdhfr 59R + 108 N and pfdhps 437G were found in 6/78 (8%) samples. Chloroquine-resistance-associated pfcrt 76T was found in 102/102 (100%). Pfmdr1 N86 and 86Y were identified in 83/115 (72%) and 32/115 (28%) samples, respectively. CONCLUSION: The frequency of P. falciparum with reduced susceptibility to sulfadoxine-pyrimethamine remained high, but did not appear to have increased significantly since the introduction of ASP. No polymorphisms in K13 associated with decreased artemisinin susceptibility were found. ASP probably remained effective, supporting continued ASP use.

A mixed-methods community-based participatory research to explore stakeholder's perspectives and to quantify the effect of crop residue burning on air and human health in Central India: study protocol.

BACKGROUND: Crop residue burning adversely affects air quality and consequently human health. India, being one of the largest agro-economies of the world, produces around 500 Million tonnes of crop residue annually most of which is burnt on-farm. However, integrated studies that simultaneously quantify the effects of crop residue burning while exploring the subjective determinants of the practice are lacking in India. This paper describes the protocol for a longitudinal mixed methods research study employing a community-based participatory approach to fill this gap. METHODS: Both quantitative and qualitative data will be collected in a rural setting of the central Indian province of Madhya Pradesh, over 1 year. A steering committee comprising of the research team and community representatives will be formed. The proportion of cultivable land burnt in one crop burning season will be estimated. The association between crop residue burning, level of ambient air pollutants, and pulmonary function of village residents will be determined. Focus groups, interviews, and participatory rural appraisal methods will be used to explore stakeholder perspectives about crop residue burning. Potential barriers and opportunities for substituting burning with an alternative crop residue management technique will be ascertained as the basis for future interventions. Ethics approval has been obtained from the Institutional Ethics Committee of the National Institute for Research in Environmental Health (No: NIREH/BPL/IEC/2019-20/1494, dt 06/01/2020). DISCUSSION: This manuscript describes the protocol for a novel community-based participatory study to investigate thoroughly the phenomenon of crop residue burning from the perspective of the agricultural community through their active collaboration. The lack of comprehensive evidence regarding the factors responsible for crop residue burning in India underlines the importance of implementing this study protocol to fill in this critical gap in knowledge. While acknowledging that findings of this study will be not generalizable to agricultural communities other than the one studied, it is expected that the study will generate baseline evidence that might be beneficial in developing and implementing an appropriate intervention strategy.

Medical schools in India: pattern of establishment and impact on public health - a Geographic Information System (GIS) based exploratory study.

BACKGROUND: Indian medical education system is on the brink of a massive reform. The government of India has recently passed the National Medical Commission Bill (NMC Bill). It seeks to eliminate the existing shortage and maldistribution of health professionals in India. It also encourages establishment of medical schools in underserved areas. Hence this study explores the geographic distribution of medical schools in India to identify such under and over served areas. Special emphasis has been given to the mapping of new medical schools opened in the last decade to identify the ongoing pattern of expansion of medical education sector in India. METHODS: All medical schools retrieved from the online database of Medical Council of India were plotted on the map of India using geographic information system. Their pattern of establishment was identified. Medical school density was calculated to analyse the effect of medical school distribution on health care indicators. RESULTS: Presence of medical schools had a positive influence on the public health profile. But medical schools were not evenly distributed in the country. The national average medical school density in India amounted to 4.08 per 10 million population. Medical school density of provinces revealed a wide range from 0 (Nagaland, Dadra and Nagar Haveli, Daman and Diu and Lakshadweep) to 72.12 (Puducherry). Medical schools were seen to be clustered in the vicinity of major cities as well as provincial capitals. Distance matrix revealed that the median distance of a new medical school from its nearest old medical school was just 22.81 Km with an IQR of 6.29 to 56.86 Km. CONCLUSIONS: This study revealed the mal-distribution of medical schools in India. The problem is further compounded by selective opening of new medical schools within the catchment area of already established medical schools. Considering that medical schools showed a positive influence on public health, further research is needed to guide formulation of rules for medical school establishment in India.

Identifying the know-do gap in evidence-based neonatal care practices among informal health care providers-a cross-sectional study from Ujjain, India.

BACKGROUND: More than a quarter of global neonatal deaths are reported from India, and a large proportion of these deaths are preventable. However, in the absence of robust public health care systems in several states in India, informal health care providers (IHCPs) with no formal medical education are the first contact service providers. The aim of this study was to assess the knowledge of IHCPs in basic evidence-based practices in neonatal care in Ujjain district and investigated factors associated with differences in levels of knowledge. METHODS: A cross-sectional survey was conducted using a questionnaire with multiple-choice questions covering the basic elements of neonatal care. The total score of the IHCPs was calculated. Multivariate quantile regression model was used to look for association of IHCPs knowledge score with: the practitioners' age, years of experience, number of patients treated per day, and whether they attended children in their practice. RESULTS: Of the 945 IHCPs approached, 830 (88%) participated in the study. The mean ± SD score achieved was 22.3 ± 7.7, with a median score of 21 out of maximum score of 48. Although IHCPs could identify key tenets of enhancing survival chances of neonates, they scored low on the specifics of cord care, breastfeeding, vitamin K use to prevent neonatal hemorrhage, and identification and care of low-birth-weight babies. The practitioners particularly lacked knowledge about neonatal resuscitation, and only a small proportion reported following up on immunizations. Results of quantile regression analysis showed that more than 5 years of practice experience and treating more than 20 patients per day had a statistically significant positive association with the knowledge score at higher quantiles (q75th and q90th) only. IHCPs treating children had significantly better scores across quantiles accept at the highest quantile (90th). CONCLUSIONS: The present study highlighted that know-do gap exists in evidence-based practices for all key areas of neonatal care tested among the IHCPs. The study provides the evidence that some IHCPs do possess knowledge in basic evidence-based practices in neonatal care, which could be built upon by future educational interventions. Targeting IHCPs can be an innovative way to reach a large rural population in the study setting and to improve neonatal care services.

Participation in the state led 'Janani Sahayogi Yojana' public private partnership program to promote facility births in Madhya Pradesh, India: views from private obstetrician partners.

BACKGROUND: In Madhya Pradesh, India, the government invited private obstetric hospitals for partnership to provide intrapartum care to poor women, paid for by the state. This statewide program, the Janani Sahayogi Yojana (JShY or maternal support scheme), ran from 2006 to 2012. The partnership was an uneasy one with many private obstetricians choosing to leave the partnership. This paper explores the motives of private obstetricians in the state for participating in the JShY, their experiences within the partnership, their interactions with the state and motives for withdrawal among those who withdrew from the scheme. This study sheds light on the dynamics of a public-private partnership for obstetric care from the perspective of private sector obstetricians. METHOD: Fifteen in-depth interviews were conducted with private obstetricians and hospital administrators from eight districts of Madhya Pradesh who had participated in the JShY. A Framework approach was used to analyze the data. RESULTS: Private obstetricians reported entering the JShY partnership for altruistic reasons but also as way of expanding their practices and reputations. They perceived that although their facilities provided better quality of care than state facilities, participation was risky because beneficiaries were often unbooked and seen as 'high risk' cases. The need to arrange for blood transfusions for these high risk women was perceived as particularly difficult. Cumbersome paper work and delays in receiving payments from the state also dissuaded participation. Some participants felt that there was inadequate engagement by the state, and better monitoring and supervision would have helped. The state changed the financial reimbursement arrangements due to a high proportion of Cesarean births in the early years of the partnership, as these were perversely incentivized. This change resulted in a large exodus of private obstetricians from the partnership. CONCLUSION: This study highlights the contribution of cumbersome processes, trust deficits and a lack of dialogue between public and private partners. Input from both public and private sectors into the design of a carefully thought through financial reimbursement package for private partners was highlighted as a necessary component for future success of such schemes.

Postpartum quality of life in Indian women after vaginal birth and cesarean section: a pilot study using the EQ-5D-5L descriptive system.

BACKGROUND: There has been little evaluation of the postpartum quality of life (QOL) of women in India and its association with the mode of birth. This study piloted the use of the generic EQ-5D-5L questionnaire to assess postpartum QOL experienced by rural Indian women. METHODS: A convenience sample of rural women who gave birth in a health facility in Gujarat or Madhya Pradesh was recruited into this pilot study. QOL was measured during three interviews within 30 days of birth using the EQ-5D-5L questionnaire. Patient-level quality-adjusted life days (QALDs) were estimated. Multivariate regression was used to adjust for selected baseline characteristics. RESULTS: Forty-six women with cesarean section and 178 with vaginal birth from 17 public and private health facilities were studied. Postpartum QOL in both groups improved between interviews 1 and 3. Comparing between vaginal and cesarean births indicated that the vaginal birth group had a higher QOL (0-3 days postpartum: 0.28 vs. 0.57, 3-7 days postpartum: 0.59 vs. 0.81; P < 0.001) and was more likely to report no or slight problems in 4 of 5 health dimensions (mobility, self-care, usual activities, pain or discomfort; P ≤ 0.04) during interviews 1 and 2. Postpartum QOL converged, but still differed between groups by the time of interview 3 (21-30 days postpartum: 0.85 vs. 0.93; P < 0.001). While most women reported no problems by the end of the first postpartum month, the difference in the ability to perform usual activities persisted (P = 0.001). In result, fewer QALDs were attained by women in the cesarean section group between day 1 and day 21 postpartum (13.1 vs. 16.6 QALDs; P < 0.001). Subgroup analysis showed that having had an episiotomy during vaginal birth was also associated with reduced QOL postpartum, but to a lesser extent than cesarean section. Similar results were obtained when adjusting for socioeconomic, pregnancy and birth characteristics, but postpartum QOL already ceased to be statistically different between groups before interview 3. CONCLUSIONS: Vaginal births, even with episiotomy, were associated with a higher postpartum QOL than cesarean births among the Indian women in our pilot study. Finding these expected results suggests that the EQ-5D-5L questionnaire is a suitable instrument to assess postpartum QOL in Indian women.

Adenine-induced chronic kidney disease in rats.

Many animal models have been developed to study the causes and treatments of chronic kidney disease (CKD) in humans, an insidious disease resulting from kidney injury and characterized by persistent functional decline for more than 3 months, with or without evidence of structural deficit. The eventual outcome of CKD may be end-stage kidney disease (ESKD), where patients need dialysis or transplantation to survive. Cardiovascular disease is accelerated in patients with CKD and contributes to increased mortality, with the relationship between CKD and cardiovascular disease being bi-directional. Most animal models do not mimic the complexity of the human disease as many do not develop CKD-associated cardiovascular disease. The adenine diet model of CKD in rodents is an exception. The original adenine diet model produced rapid-onset kidney disease with extensive tubulointerstitial fibrosis, tubular atrophy, crystal formation and marked vessel calcification. Since then, lower adenine intake in rats has been found to induce slowly progressive kidney damage and cardiovascular disease. These chronic adenine diet models allow the characterization of relatively stable kidney and cardiovascular disease, similar to CKD in humans. In addition, interventions for reversal can be tested. Here the key features of the adenine diet model of CKD are noted, along with some limitations of other available models. In summary, the data presented here support the use of chronic low-dose adenine diet in rats as an easy and effective model for understanding human CKD, especially the links with cardiovascular disease, and developing potential therapeutic interventions.

Nicotinamide reverses behavioral impairments and provides neuroprotection in 3-nitropropionic acid induced animal model ofHuntington's disease: implication of oxidative stress- poly(ADP- ribose) polymerase pathway.

Huntington's disease (HD) is characterized by cognitive and psychiatric impairment caused by neuronal degeneration in the brain. Several studies have supported the hypothesis that oxidative stress is the main pathogenic factor in HD. The current study aims to determine the possible neuroprotective effects of nicotinamide on 3-nitropropionic acid (3-NP) induced HD. Male Wistar albino rats were divided into six groups. Group I was the vehicle-treated control, group II received 3-NP (20 mg/kg, intraperitoneally (i.p.) for 4 days, group III received nicotinamide (500 mg/kg, i.p.). The remaining groups received a combination of 3-NP plus nicotinamide 100, 300 or 500 mg/kg, i.p. respectively for 8 days. Afterward, the motor function and hind paw activity in the limb withdrawal were tested; rats were then euthanized for biochemical and histopathological analyses. Treatment of rats with 3-NP altered the motor function, elevated oxidative stress and caused significant histopathological changes in the brain. The treatment of rats with nicotinamide (100, 300 and 500 mg/kg) improved the motor function tested by locomotor activity test, movement analysis, and limb withdrawal test, which was associated with decreased oxidative stress markers (malondialdehyde, nitrites) and increased antioxidant enzyme (glutathione) levels. In addition, nicotinamide treatment decreased lactate dehydrogenase and prevented neuronal death in the striatal region. Our study, therefore, concludes that antioxidant drugs like nicotinamide might slow progression of clinical HD and may improve the motor functions in HD patients. To the best of our knowledge, this study is the first to explore the neuroprotective effects of nicotinamide on 3-NP-induced HD.

Out-of-pocket expenditures for childbirth in the context of the Janani Suraksha Yojana (JSY) cash transfer program to promote facility births: who pays and how much? Studies from Madhya Pradesh, India.

BACKGROUND: High out-of-pocket expenditures (OOPE) make delivery care difficult to access for a large proportion of India's population. Given that home deliveries increase the risk of maternal mortality, in 2005 the Indian Government implemented the Janani Suraksha Yojana (JSY) program to incentivize poor women to deliver in public health facilities by providing a cash transfer upon discharge. We study the OOPE among JSY beneficiaries and women who deliver at home, and predictors of OOPE in two districts of Madhya Pradesh. METHODS: September 2013 to April 2015 a cross-sectional community-based survey was performed. All recently delivered women were interviewed to elicit delivery costs, socio-demographic characteristics and delivery related information. RESULTS: Most women (n = 1995, 84 %) delivered in JSY public health facility, the remaining 16 % (n = 386) delivered at home. Women who delivered under JSY program had a higher median, IQR OOPE ($8, 3-18) compared to home ($6, 2-13). Among JSY beneficiaries, poorest women had twice net gain ($20) versus wealthiest ($10) post cash transfer. Informal payments (64 %) and food/baby items (77 %) were the two most common sources of OOPE. OOPE made among JSY beneficiaries was pro-poor: poorer women made proportionally less expenditures compared to wealthier women. In an adjusted model, delivering in a JSY public facility increased odds of incurring expenditures (OR: 1.58, 95 % CI: 1.11-2.25) but at the same time to a 16 % (95 % CI: 0.73-0.96) decrease in the amount paid compared to home deliveries. CONCLUSIONS: OOPE is prevalent among JSY beneficiaries as well in home deliveries. In JSY, OOPE varies by income quintile: wealthier quintiles pay more OOPE. However the cash incentive is adequate enough to provide a net gain for all quintiles. OOPE was largely due to indirect costs and not direct medical payments. The program seems to be effective in providing financial protection for the most vulnerable groups.

'The money is important but all women anyway go to hospital for childbirth nowadays' - a qualitative exploration of why women participate in a conditional cash transfer program to promote institutional deliveries in Madhya Pradesh, India.

BACKGROUND: In 2005-06, only 39 % of Indian women delivered in a health facility. Given that deliveries at home increase the risk of maternal mortality, it was in this context in 2005, that the Indian Government implemented the Janani Suraksha Yojana program that incentivizes poor women to give birth in a health facility by providing them with a cash transfer upon discharge. JSY helped raise institutional delivery to 74 % in the eight years since its implementation. Despite the success of the JSY in raising institutional delivery proportions, the large number of beneficiaries (105 million), and the cost of the program, there have been few qualitative studies exploring why women participate (or not) in the program. The objective of this paper was to explore this. METHODS: In March 2013, we conducted 24 individual in-depth interviews with women who delivered within the previous 12 months in two districts of Madhya Pradesh, India. Qualitative framework analysis was used to analyze the data. RESULTS: Our findings suggest that women's increased participation in the program reflect a shift in the social norm. Drivers of the shift include social pressure from the Accredited Social Health Activist (ASHA) to deliver in a health facility, and a growing individual perception of the importance for 'safe' and 'easy' delivery which was most likely an expression of the new social norm. While the incentive was an important influence on many women's choices, others did not perceive it as an important consideration in their decision to deliver in a health facility. Many women reported procedural difficulties to receive the benefit. Retaining the cash incentive was also an issue due to out-of-pocket expenditures incurred at the facility. Non-participation was often unintentional and caused by personal circumstances, poor geographic access or driven by a perception of poor quality of care provided in program facilities. CONCLUSIONS: In summary, while the cash incentive was important for some women in facilitating an institutional birth, the shift in social norm (possibly in part facilitated by the program) and therefore their own perceptions has played a major role in them giving birth in facilities.

The availability of emergency obstetric care in the context of the JSY cash transfer programme in Madhya Pradesh, India.

BACKGROUND: Since 2005, India has implemented a national cash transfer programme, the Janani Suraksha Yojana (JSY), which provides women a cash transfer upon giving birth in an existing public facility. This has resulted in a steep rise in facility births across the country. The early years of the programme saw efforts being made to strengthen the ability of facilities to provide obstetric care. Given that the JSY has been able to draw millions of women into facilities to give birth (there have been more than 50 million beneficiaries thus far), it is important to study the ability of these facilities to provide emergency obstetric care (EmOC), as the functionality of these facilities is critical to improved maternal and neonatal outcomes. We studied the availability and level of provision of EmOC signal functions in public facilities implementing the JSY programme in three districts of Madhya Pradesh (MP) state, central India. These are measured against the World Health Report (WHR) 2005benchmarks. As a comparison, we also study the functionality and contribution of private sector facilities to the provision of EmOC in these districts. METHODS: A cross-sectional survey of all healthcare facilities offering intrapartum care was conducted between February 2012 and April 2013. The EmOC signal functions performed in each facility were recorded, as were human resource data and birth numbers for each facility. RESULTS: A total of 152 facilities were surveyed of which 118 were JSY programme facilities. Eighty-six percent of childbirths occurred at programme facilities, two thirds of which occurred at facilities that did not meet standards for the provision basic emergency obstetric care. Of the 29 facilities that could perform caesareans, none could perform all the basic EmOC functions. Programme facilities provided few EmOC signal functions apart from parenteral antibiotic or oxytocic administration. Complicated EmOC provision was found predominantly in non-programme (private) facilities; only one of six facilities able to provide such care was in the public sector and therefore in the JSY programme. Only 13 % of all qualified obstetricians practiced at programme facilities. CONCLUSIONS: Given the high proportion of births in public facilities in the state, the JSY programme has an opportunity to contribute to the reduction in maternal and perinatal mortality However, for the programme to have a greater impact on outcomes; EmOC provision must be significantly improved.. While private, non-programme facilities have better human resources and perform caesareans, most women in the state give birth under the JSY programme in the public sector. A demand-side programme such as the JSY will only be effective alongside an adequate supply side (i.e., a facility able to provide EmOC).

Impact of Alternative Maternal Demand-Side Financial Support Programs in India on the Caesarean Section Rates: Indications of Supplier-Induced Demand.

BACKGROUND: This paper examines two state-led public-private demand-side financial support programs aiming to raise hospital delivery rates in two neighbouring Indian states-Gujarat and Madhya Pradesh. The national Janani Suraksha Yojana (JSY) was complemented with a public-private partnership program Janani Sahayogi Yojana (JSaY) in Madhya Pradesh in which private obstetricians were paid to deliver poor women. A higher amount was paid for caesarean sections (CS) than for vaginal deliveries (VD). In Gujarat state, the state program Chiranjeevi Yojana (CY) paid private obstetricians a fixed amount for a block 100 deliveries irrespective of delivery mode. The two systems thus offered an opportunity to observe the influence of supplier-induced demand (SID) from opposite incentives related to delivery mode. METHODS: The data from the two programs was sourced from the Departments of Health and Family Welfare, Governments of Gujarat and Madhya Pradesh, India. RESULTS: In JSaY program the CS rate increased from 26.6% (2007-2008) to 40.7% (2010-2011), against the background rate for CS in Madhya Pradesh, of only 4.9% (2004-2006). Meanwhile in CY program in Gujarat, the CS rate decreased to 4.3% (2010-2011) against a background CS rate of 8.1% (2004-2006). CONCLUSIONS: The findings from India are unique in that they not only point to a significant impact from the introduction of the financial incentives but also how disincentives have an inverse impact on the choice of delivery method.

Understanding collaboration in a multi-national research capacity-building partnership: a qualitative study.

BACKGROUND: Research capacity building and its impact on policy and international research partnership is increasingly seen as important. High income and low- and middle-income countries frequently engage in research collaborations. These can have a positive impact on research capacity building, provided such partnerships are long-term collaborations with a unified aim, but they can also have challenges. What are these challenges, which often result in a short term/ non viable collaboration? Does such collaboration results in capacity building? What are the requirements to make any collaboration sustainable? This study aimed to answer these and other research questions through examining an international collaboration in one multi-country research capacity building project ARCADE RSDH (Asian Regional Capacity Development for Research on Social Determinants of Health). METHOD: A qualitative study was conducted that focused on the reasons for the collaboration, collaboration patterns involved, processes of exchanging information, barriers faced and perceived growth in research capacity. In-depth interviews were conducted with the principal investigators (n = 12), research assistants (n = 2) and a scientific coordinator (n = 1) of the collaborating institutes. Data were analysed using thematic framework analysis. RESULTS: The initial contact between institutes was through previous collaborations. The collaboration was affected by the organisational structure of the partner institutes, political influences and the collaboration design. Communication was usually conducted online, which was affected by differences in time and language and inefficient infrastructure. Limited funding resulted in restricted engagement by some partners. CONCLUSION: This study explored work in a large, North-South collaboration project focusing on building research capacity in partner institutes. The project helped strengthen research capacity, though differences in organization types, existing research capacity, culture, time, and language acted as obstacles to the success of the project. Managing these differences requires preplanned strategies to develop functional communication channels among the partners, maintaining transparency, and sharing the rewards and benefits at all stages of collaboration.

Protocol: a 'One health' two year follow-up, mixed methods study on antibiotic resistance, focusing children under 5 and their environment in rural India.

BACKGROUND: Antibiotic resistance has been referred to as 'the greatest malice of the 21st century' and a global action plan was adopted by the World Health Assembly in 2015. There is a wealth of independent studies regarding antibiotics and resistant bacteria in humans, animals and their environment, however, integrated studies are lacking, particularly ones that simultaneously also take into consideration the health related behaviour of participants and healthcare providers. Such, 'One health' studies are difficult to implement, because of the complex teamwork that they entail. This paper describes the protocol of a study that investigates 'One health' issues regarding antibiotic use and antibiotic resistance in children and their environment in Indian villages. METHODS/DESIGN: Both quantitative and qualitative studies are planned for a cohort of children, from 6 villages, and their surrounding environment. Repeated or continues data collection is planned over 2 years for quantitative studies. Qualitative studies will be conducted once. Studies include parents' health seeking behavior for their children (1-3 years of age at the onset), prescribing pattern of formal and informal healthcare providers, analysis of phenotypic antibiotic resistance of Escherichia coli from samples of stool from children and village animals, household drinking water, village source water and waste water, and investigation on molecular mechanisms governing resistance. Analysis of interrelationship of these with each other will also be done as basis for future interventions. Ethics approval has been obtained from the Institutional Ethics Committee R.D. Gardi Medical College, Ujjain, India (No: 2013/07/17-311). DISCUSSION: The findings of the study presented in this protocol will add to our knowledge about the multi-factorial nature of causes governing antibiotic use and antibiotic resistance from a 'One health' perspective. Our study will be the first of its kind addressing antibiotic use and resistance issues related to children in a One-health approach, particularly for rural India.