Are institutional deliveries equitable in the southern states of India? A benefit incidence analysis.

BACKGROUND: Despite a commendable rise in the number of women seeking delivery care at public health institutions in South India, it is unclear if the benefit accrues to wealthier or poorer socio-economic groups. The study's aim was to investigate at how the public subsidy is distributed among Indian women who give birth in public hospitals in the southern regions. METHODS: Data from the Indian Demographic Health Survey's fifth wave (NFHS-5, 2019-21) was used in this study. A total of 22, 403 were institutional deliveries across all the southern states of India were included. Out-of-pocket expenditure (OOPE) on childbirth in health institutions was the outcome variable. We used summary statistics, Benefits Incidence Analysis (BIA), concentration index (CI), and concentration curve (CC) were used. RESULTS: Most women in the lowest, poorest, and medium quintiles of wealth opted to give birth in public facilities. In contrast, about 69% of mothers belonging to highest quintile gave birth in private health institutions. The magnitude of CI and CC of institutional delivery indicates that public sector usage was concentrated among poorer quintiles [CIX: - 0.178; SE: 0.005; p < 0.001] and private sector usage was concentrated among wealthier quintiles [CIX: 0.239; SE: 0.006; p < 0.001]. Benefit incidence analyses suggest that middle quintile of women received the maximum public subsidy in primary health centres (33.23%), followed by richer quintile (25.62%), and poorer wealth quintiles (24.84%). These pattern in the secondary health centres was similar. CONCLUSION: Poorer groups utilize the public sector for institutional delivery in greater proportions than the private sector. Middle quintiles seem to benefit the most from public subsidy in terms of the median cost of service and non-payment. Greater efforts must be made to understand how and why these groups are being left behind and what policy measures can enhance their inclusion and financial risk protection.

Prevalence and risk factors of physical violence against husbands: evidence from India.

As the proportion of women being victims of spousal violence in India is higher than men, laws are usually framed to safeguard women. However, men who have experienced physical spousal violence are not unheard of. The study aims to provide the nationwide prevalence of physical violence against husbands and the risk factors for such violence, using large-scale nationally representative 'National Family Health Survey' (NFHS 4) data. The study used descriptive, bivariate, logistic, and multilevel regression models with a random intercept clustering within states and households to explain the physical violence against husband. Sample size for the analysis was 62,716 currently married women aged 15-49 years. Findings revealed that in most of the states of India, physical spousal violence has increased over time. Behavioural characteristics like marital control, alcoholism, and childhood experience of parental violence have a consistent and strong role in explaining the experience of physical violence across states. With age, experience of violence against husbands increases. Differences in socio-economic characteristics do not have unidirectional effect on violence experienced by husbands across regions of India. Working women who are earning cash and having access to mobile phones perpetrate more physical violence in selected regions. Education shows a gradient on such violence perpetration, indicating that only after achieving a certain level of education, chances of violence reduce. Regionally contrasting social and economic risk factors in explaining violence strengthen the argument that violence is space and culture-specific, and development alone may not resolve violence unless the system is addressing the behavioural aspects. There is a need for supporting men experiencing domestic violence within the existing system facilities. Revisiting the present domestic violence laws and programmes for inclusivity is the need of the hour.

Assessing inequalities in publicly funded health insurance scheme coverage and out-of-pocket expenditure for hospitalization: findings from a household survey in Kerala.

BACKGROUND: Increasing financial risk protection is a key feature of Universal Health Coverage and the path towards health for all. Publicly Funded Health Insurance Schemes (PFHIS) have been considered as one of the pathways to safeguard against financial shocks and potentially reduce Out-of-Pocket Expenditure (OOPE). The south Indian state of Kerala has roughly a decade-long experience in implementing PFHIS. To date, there have been very few assessments of the coverage of these schemes and their impact on expenditure. Aiming to fill this gap, we explored the extent of and inequalities in insurance coverage, as well as choice of providers, and median cost of hospitalization in Kerala among insured and uninsured individuals. METHODS: A cross-sectional household survey was conducted in four districts of Kerala as part of a larger health systems research study from July-October 2019. We employed multistage random sampling to collect data from 13,064 individuals covering 3234 households in the catchment area of eight primary health care facilities. We used descriptive statistics, bivariate and multivariate analysis. We evaluated socioeconomic disparities using an absolute measure of inequality-the Slope Index of Inequality (SII) and a relative measure-the Relative Concentration Index (RCI). RESULTS: A substantial proportion of our study respondents reported that they were covered by PFHIS (45.8%). Respondents belonging to lowest and middle wealth quintiles of household had significantly greater odds of being covered by insurance than respondents belonging to the richest wealth quintile. The negative magnitude of RCI [-16.8% (95%CI: -25.3, -8.4)] and SII [-21.5% (95%CI: -36.1, -7.0)] suggest a higher concentration of PFHIS coverage among the poor. Median OOPE for hospitalisation at private health facilities was INR 9000 (approx. USD 108.70) among those covered by PFHIS, whereas it was INR 10500 (approx. USD 126.82) at private health facilities among those not covered by insurance. CONCLUSION: While PFHIS seems to be appropriately targeting poorer populations, among the insured, OOPE for hospitalization persists. Among the uninsured, population subgroups with advantage are spending the greatest amount, raising questions about whether those facing relative disadvantage are forgoing care altogether or seeking care using cheaper, public avenues. Further policy action to more effectively reduce financial burden among left behind eligible populations under PFHIS will be essential to UHC progress in the state.

Gender-specific inequalities in coverage of Publicly Funded Health Insurance Schemes in Southern States of India: evidence from National Family Health Surveys.

BACKGROUND: Publicly Funded Health Insurance Schemes (PFHIS) are intended to play a role in achieving Universal Health Coverage (UHC). In countries like India, PFHISs have low penetrance and provide limited coverage of services and of family members within households, which can mean that women lose out. Gender inequities in relation to financial risk protection are understudied. Given the emphasis being placed on achieving UHC for all in India, this paper examined intersecting gender inequalities and changes in PFHIS coverage in southern India, where its penetrance is greater and of longer duration. DATA AND METHODS: This study used the fourth (NFHS-4, 2015-16) and fifth (NFHS-5, 2019-21) rounds of India's National Family Health Survey for five southern states: namely, Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, and Telangana. The World Health Organization's Health Equity Assessment Toolkit (HEAT) Plus and Stata were used to analyse PFHIS coverage disaggregated by seven dimensions of inequality. Ratios and differences for binary dimensions; Between Group Variance and Theil Index for unordered dimensions; Absolute and Relative Concentration Index (RCI) for ordered dimensions were computed separately for women and men. RESULTS: Overall, PFHIS coverage increased significantly (p < 0.001) among women and men in Andhra Pradesh, and Kerala from NFHS-4 to NFHS-5. Overall, men had higher PFHIS coverage than women, especially in Andhra Pradesh, Tamil Nadu, and Telangana in both surveys. In both absolute and relative terms, PFHIS coverage was concentrated among older women and men across all states; age-related inequalities were higher among women than men in both surveys in Andhra Pradesh, Kerala, and Telengana. The magnitude of education-related inequalities was twice as high as among women in Telangana (RCINFHS-4: -12.23; RCINFHS-5: -9.98) and Andhra Pradesh (RCINFHS-4: -8.05; RCINFHS-5: -7.84) as compared to men in Telangana (RCINFHS-4: -5.58; RCINFHS-5: -2.30) and Andhra Pradesh (RCINFHS-4: -4.40; RCINFHS-5: -3.12) and these inequalities remained in NFHS-5, suggesting that lower education level women had greater coverage. In the latter survey, a high magnitude of wealth-related inequality was observed in women (RCINFHS-4: -15.78; RCINFHS-5: -14.36) and men (RCINFHS-4: -20.42; RCINFHS-5: -13.84) belonging to Kerala, whereas this inequality has decreased from NFHS-4 to NFHS-5., again suggestive of greater coverage among poorer populations. Caste-related inequalities were higher in women than men in both surveys, the magnitude of inequalities decreased between 2015-16 and 2019-20. CONCLUSIONS: We found gender inequalities in self-reported enrolment in southern states with long-standing PFHIS. Inequalities favoured the poor, uneducated and elderly, which is to some extend desirable when rolling out a PFHIS intended for harder to reach populations. However, religion and caste-based inequalities, while reducing, were still prevalent among women. If PFHIS are to truly offer financial risk protection, they must address the intersecting marginalization faced by women and men, while meeting eventual goals of risk pooling, indicated by high coverage and low inequality across population sub-groups.

Attitude towards negotiating safer sexual relations: Exploring power dynamics among married couples in India.

The study primarily focuses on analyzing married women's attitudes towards negotiating safer sex in two contexts. The first context is when a woman refuses to have sex with husband if she knows her husband has a sexually transmitted disease (STD) and the second is when she does so if she knows he has sex with other women. The study examined predictors of Indian women's attitude towards negotiating safer-sex using data on 92,306 ever married women from the state module of the 2015-16, National Family Health Survey 4. Descriptive and multilevel logistic regression was used to understand the interplay between the attitude towards negotiation of safer sexual relationships with husband and the selected background characteristics with a primary focus on controlling behaviour and power relations. About 17% of women did not believe in negotiating safer sexual relations with the husband. An approximately equal proportion of ever-married women (79% each) believed in doing so under the two specific conditions, that is, if they knew the husband had an STD and they knew he had sex with other women. Multilevel regression analysis showed that women who had household decision-making power [AOR=0.71; p<0.01] and those whose husbands displayed low control towards them [AOR=0.91; p<0.05] were more likely to believe in negotiating safer-sex. Our findings suggest that women who have controlling partners or those who live under the umbrella of the husband's authority lack the power to negotiate for safer sex. Interventions promoting sexual well-being must deal with negative male perceptions and expectations that perpetuate unhealthy sexual habits and marriage ties.

Decomposing socioeconomic inequality in blood pressure and blood glucose testing: evidence from four districts in Kerala, India.

BACKGROUND: Non-Communicable Diseases (NCDs) constitute a significant danger to the nation's public health system, both in terms of morbidity and mortality, as well as the financial burden they inflict. Kerala is undergoing an epidemiologic transition, which has significantly impacted the state's morbidity and mortality figures. For decades, the state has been putting in place myriad programs to reduce the burden of NCDs across population groups. Socioeconomic inequalities in NCD testing have been documented in India, although they are understudied in Kerala. The study aimed to estimate and characterize districtwise socioeconomic inequality in Blood Pressure (BP) and Blood Glucose (BG) testing. METHODS: A cross-sectional household survey was conducted between July-October 2019 in Kasaragod, Alappuzha, Kollam and Thiruvananthapuram districts of Kerala, India. A total of 6383 participants aged 30 years and above were interviewed using multistage random sampling. Descriptive statistics were derived district-wise. We computed ratios, differences, equiplots, and Erreygers concentration indices for each district to measure socioeconomic inequality in BP and BG testing. Erreygers decomposition techniques were used to estimate the relative contribution of covariates to socioeconomic inequality. RESULTS: There was a significant concentration of BP and BG testing favouring wealthier quintiles in Alappuzha, Kollam, and Thiruvananthapuram districts. The inequality in BP and BG testing was highest in Thiruvananthapuram (0.087 and 0.110), followed by Kollam (0.077 and 0.090), Alappuzha (0.083 and 0.073) and Kasaragod (0.026 and 0.056). Decomposition analysis revealed that wealth quintile and education contributed substantially to socioeconomic inequality in BP and BG testing in all four districts. It was also found that family history of NCDs significantly contributed to observed socioeconomic inequality in BP testing (29, 11, 16, and 27% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram, respectively). Similarly, in BG testing, family history of NCDs substantially contributed to observed socioeconomic inequality, explaining 16-17% in Kasaragod, Alappuzha, Kollam, and Thiruvananthapuram respectively of the total inequality. CONCLUSION: While the magnitude of socioeconomic inequality in NCD risk factor testing did not appear to be very high in four Kerala districts, although levels were statistically significant in three of them. Greater exploration is needed on how education and caste contribute to these inequalities and their relationship to NCD risk factors such as family history. From such analyses, we may be able to identify entry points to mitigate inequalities in testing access, as well as burden.

Socioeconomic inequalities in the HIV testing during antenatal care: evidence from Indian demographic health survey, 2015-16.

BACKGROUND: In India, there is currently a lack of data on socioeconomic inequalities in HIV testing on a national scale; thus, understanding socioeconomic inequalities in response to expanded HIV testing is critical for assessing and ensuring equity of HIV programmes in accordance with the Sustainable Development Goals. The specific objective of the study was to determine the factor associated with HIV testing during antenatal care and assess the socio-economic inequalities in HIV testing during antenatal care (ANC) among Indian women aged 15-49 years with a live birth in the two years preceding the survey. METHODS: The results drawn from the state module of women data file of fourth round of National Family Health Survey (NFHS-4, 2015-16), considering HIV testing during antenatal care among women aged 15-49 who gave live birth in the two years preceding the survey and received the result of HIV test as a matter of fact. Method, such as, descriptive statistics, binary ogistic regression, concentration index were used in the analysis. RESULTS: The findings of the study show that HIV testing during antenatal care was low (30%) among women in India. Our findings reveal that there were significant inequalities exist in HIV testing during ANC between richer and poorer quintile of women. Education, place of residence, comprehensive knowledge of HIV/AIDS, and regular exposure of mass media were substantially contributing to socioeconomic inequality in HIV testing during ANC among women in India. CONCLUSIONS: The socioeconomic inequities in HIV testing during pregnancy should be monitored and addressed in order to ensure an equitable distribution of the benefits specially among children and accomplishments of HIV programs in India.

Prevalence and determinants of nutritional status among women and children in Pakistan.

BACKGROUND: Nutrition has been a low-priority area in Pakistan, with low visibility from the political leadership. Despite various efforts, Pakistan has been reported to have one of the highest prevalences of child and women malnutrition compared to other developing counties. Therefore, this study intends to examine the prevalence and determinants of nutritional status of women and children in Pakistan. METHODS: The present study uses the Demographic Health Survey (DHS) data from Pakistan 2012-13 (PDHS-3). The nutritional status of women was examined through Body-Mass Index (Underweight, normal, overweight, & obese), and that of children was examined through stunting (severe and moderate), wasting (severe, moderate, overweight), and underweight (severe, moderate, overweight). Descriptive statistics and bivariate analysis have been used along with multinomial logistic regression. RESULTS: A higher proportion of children in rural areas were severely stunted (19.6% vs. 12.5%), severe wasted (2.4% vs. 2.2%), and severe underweight (9.4% vs. 6%) than their urban counterparts. A higher proportion of rural women (9.5% vs. 5.5%) were underweight than urban women, whereas a higher proportion of urban women were obese (24.3% vs. 19.0%) than rural women. The odds of severe stunting (OR = 0.24; C.I. = 0.15-0.37), severe underweight (OR = 0.11; C.I. = 0.05-0.22) were lower among children from the richest wealth quintile than their poorest counterparts. The Relative Risk Ratio (RRR) of being overweight (RRR = 3.7; C.I. = 2.47-5.54) and Obese (RRR = 4.35; C.I. = 2.67-7.07) than normal BMI were higher among women from richest wealth quintile than women belonged to poorest wealth quintile. CONCLUSION: This study has highlighted determinants associated with maternal and child nutritional status, whereby the child's nutritional status was measured by stunting, wasting, and underweight, and BMI measured the mother's nutritional status. The main risk factors for a child's poor nutritional status include low household wealth, urban residence, and mother's educational status. Similarly, the main risk factors for women's poor nutritional status include increasing the women's age, educational status, rural residence, and household wealth. Poor households should be provided special attention to improve the nutritional status among women and children in poor households.

Ultrastable Covalent Triazine Organic Framework Based on Anthracene Moiety as Platform for High-Performance Carbon Dioxide Adsorption and Supercapacitors.

Conductive and porous nitrogen-rich materials have great potential as supercapacitor electrode materials. The exceptional efficiency of such compounds, however, is dependent on their larger surface area and the level of nitrogen doping. To address these issues, we synthesized a porous covalent triazine framework (An-CTFs) based on 9,10-dicyanoanthracene (An-CN) units through an ionothermal reaction in the presence of different molar ratios of molten zinc chloride (ZnCl2) at 400 and 500 °C, yielding An-CTF-10-400, An-CTF-20-400, An-CTF-10-500, and An-CTF-20-500 microporous materials. According to N2 adsorption-desorption analyses (BET), these An-CTFs produced exceptionally high specific surface areas ranging from 406-751 m2·g-1. Furthermore, An-CTF-10-500 had a capacitance of 589 F·g-1, remarkable cycle stability up to 5000 cycles, up to 95% capacity retention, and strong CO2 adsorption capacity up to 5.65 mmol·g-1 at 273 K. As a result, our An-CTFs are a good alternative for both electrochemical energy storage and CO2 uptake.

An Ultrastable Porous Polyhedral Oligomeric Silsesquioxane/Tetraphenylthiophene Hybrid as a High-Performance Electrode for Supercapacitors.

In this study, we synthesized three hybrid microporous polymers through Heck couplings of octavinylsilsesquioxane (OVS) with 2,5-bis(4-bromophenyl)-1,3,4-oxadiazole (OXD-Br2), tetrabromothiophene (Th-Br4), and 2,5-bis(4-bromophenyl)-3,4-diphenylthiophene (TPTh-Br2), obtaining the porous organic-inorganic polymers (POIPs) POSS-OXD, POSS-Th, and POSS-TPTh, respectively. Fourier transform infrared spectroscopy and solid state 13C and 29Si NMR spectroscopy confirmed their chemical structures. Thermogravimetric analysis revealed that, among these three systems, the POSS-Th POIP possessed the highest thermal stability (T5: 586 °C; T10: 785 °C; char yield: 90 wt%), presumably because of a strongly crosslinked network formed between its OVS and Th moieties. Furthermore, the specific capacity of the POSS-TPTh POIP (354 F g-1) at 0.5 A g-1 was higher than those of the POSS-Th (213 F g-1) and POSS-OXD (119 F g-1) POIPs. We attribute the superior electrochemical properties of the POSS-TPTh POIP to its high surface area and the presence of electron-rich phenyl groups within its structure.

Change in the Prevalence and Determinants of Consanguineous Marriages in India Between National Family and Health Surveys of 1992-1993 and 2015-2016.

This study aimed to determine the changing prevalence of consanguineous marriage in India between two national-level surveys. The primary hypothesis was whether region of residence and religious affiliation continue to play a significant role in determining consanguineous marriage even after controlling other potentially significant confounding variables. Data from the 81,781 and 85,851 ever-married women during the National Family and Health Surveys (NFHS) survey periods 1992-1993 (NFHS-1) and 2015-2016 (NFHS-4), respectively, were used in the analysis. Multinomial and binary logistic regression analyses examined determinants of consanguineous marriage types and of paternal and maternal first-cousin marriages, respectively. In both analyses a systematic model-building procedure was adopted. Altogether, four models were estimated. In the final model (model 4) of both the analyses, all respondent background characteristics (region of residence, religious affiliation, sociodemographic, household wealth) and years of survey were included. Although the overall prevalence of consanguineous marriage in India declined significantly (16%), it was not uniform across respondent background characteristics. The northern region of India (154%) showed a significant increase in consanguineous marriage, whereas eastern (31%), central (2.3%), northeastern (40%), and southern (8%) regions showed a significant decline. Significant declines in consanguineous marriage were found for Hindus (16%) and Muslims (29%); for Muslims of eastern (48%), central (29%), western (31%), and southern (27%) regions; and for Hindus in the western region (37%). Relative risk ratios estimated using multinomial logistic regression models suggest those living in the southern region show 9.55 (p < 0.001), 5.96 (p < 0.001), and 38.16 (p < 0.001) times more likelihood in the prevalence of first-cousin, second-cousin, and uncle-niece marriages, respectively, compared to the northern region after controlling all other confounding variables. Muslims also showed 3.76 (p < 0.001) and 2.91 (p < 0.001) times more likelihood in first-cousin and second-cousin marriages, respectively, compared to Hindus. Adjusted odds ratios (AORs) estimated using binary logistic regression models suggest those living in southern and northeastern regions were 1.25 (p < 0.001) and 1.36 (p < 0.05) times more likely, respectively, to marry a maternal first cousin compared to the northern region. The AOR estimates also show that Muslims were 1.11 (p < 0.01) times more likely to marry a maternal first cousin compared to Hindus. The authors conclude that, despite significant development in the socioeconomic condition of India during the postglobalization era (beginning in 1992-1993), region of residence and religious affiliation continue to play significant role in determining consanguineous marriage.

Covariates of Multiplicity of High-Risk Sexual Behavior Among Men in India: Evidence from the Latest Indian Demographic and Health Survey.

Modern Indian society has witnessed rapid sociocultural transformation where loosening of cultural values is observed at all levels. In the era of transition, traditional norms and values are changing where young male individuals are found to be associated with high-risk multi-partner sexual behavior. Findings are based on a nationally representative sample of 45,231 and 65,704 men aged 15-54 during the period 2005-2006 and 2015-2016, respectively. The burden of high-risk sexual behaviors among men aged 15-54 years in India over the last decade remains disproportionately higher among younger, unmarried, and urban men, who are mainly from economically better-off households. Despite tremendous efforts of the government of India as well as various state governments in condom promotion as part of the HIV/AIDS prevention program, the improvements in condom use over the last decade are not impressive as it has not yet reached the desired threshold level. The disparities in high-risk sexual behavior among men aged 15-54 years, coming from rich and poor households, have narrowed. The findings of the study also underline an apparent paradox in the relationship between knowledge of HIV/AIDS and indulgence in high-risk sexual behavior and adopting safe sexual practices. It is recommended that all the HIV prevention programs in India should promote the concept of men as the responsible sexual partner. This concept may be promoted among young and unmarried men by reinforcing the shift from violence to respect and projecting the condom as a sexual stimulus rather than a means of disease prevention.

Prevalence and determinants of consanguineous marriage and its types in India: evidence from the National Family Health Survey, 2015-2016.

The aim of the present study was to estimate the prevalence and examine the determinants of consanguineous marriage types in India. Data for 456,646 ever-married women aged 15-49 years were analysed from the National Family Health Survey (NFHS)-4 conducted in 2015-16. The overall prevalence of consanguineous marriage was 9.9%; the South region (23%) and North-East region (3.1%) showed the highest and lowest prevalences, respectively. Muslims had a higher prevalence (15%) than Hindus (9%). The prevalence of first cousin marriage (8.7%) was more than that of second cousin (0.7%) and of uncle-niece marriages (0.6%). Women living in urban areas and in nuclear families, having a higher level of education and belonging to affluent families were less likely to marry their cousins (p < 0.01). Women living in the South region of the country were more likely to marry their cousins, as well as uncles (p < 0.001). Close scrutiny of the trends in the results (odds ratios) revealed no clear relationship between socioeconomic condition and consanguineous marriage. The study results suggest that religion and north-south regional dichotomy in culture largely determine consanguineous marriage rather than socioeconomic condition in India.

Transitions in adolescent boys and young Men's high-risk sexual behaviour in India.

BACKGROUND: The sexual behaviour of adolescents is of importance due to the engagement in risky sexual activity at a too early age, which may be associated with the adverse outcomes. The study aims to understand the transitions in adolescent boys and young men's high-risk sexual behaviour in India using two rounds of Indian demographic health survey, NFHS-3 (2005-06) and NFHS-4 (2015-16). METHODS: A total of 25,538 in NFHS-3 (2005-06) and 35,112 in NFHS-4 (2015-16) men were considered for the analysis. Men have been divided into two age groups as 15-19 years (adolescent) and 20-24 (young men) for comparison purposes. Descriptive and multivariate statistics have been used. RESULTS: Overall, high-risk sexual behaviour has increased among adolescent boys (64 to 70%) and young men (18 to 27%) from 2005-06 to 2015-16. The trend of live-in relationship has increased among adolescent boys of rural areas (0.6 to 6.0%) as well as in urban areas (3.1 to 10.9%) over the last 10 years. Adolescent boys having 10th and above years of schooling (AOR = 1.98; p < 0.01), residing in urban areas (AOR = 2.23; p < 0.01), and belonging to the affluent class of households (AOR = 1.41; p < 0.05) were more likely to engage in high-risk sexual activity than the young men in India. The odds of high-risk sexual behaviour was higher among alcohol-using adolescent boys (AOR = 1.82; p < 0.01) and young men (AOR = 2.38; p < 0.01) in 2015-16. CONCLUSIONS: The study concludes that early sexual debut, lower prevalence of condom use at first sexual experience, tendency of live-in-relationship, and alcohol consumption indicate the hazardous interconnection between such behaviours among adolescent boys over the last decade which placed them at higher-risky sexual behaviour as compared to young men. Adolescent' sexual behaviours have both short-term and long-term consequences, and interventions that focus on multiple domains of risk may be the most effective in helping to promote broad reproductive health among young adults.

Deciphering disparities in childhood stunting in an underdeveloped state of India: an investigation applying the unconditional quantile regression method.

BACKGROUND: Unacceptably high rate of childhood stunting for decades remained a puzzle in the eastern Indian state of Bihar. Despite various programmatic interventions, nearly half of the under-five children (numerically about 10 million) are still stunted in this resource-constrained state. DATA AND METHODS: Using four successive rounds of National Family Health Survey (NFHS) data spread over more than two decades and by employing unconditional quantile regressions and counterfactual decomposition (QR-CD), the present study aims to assess effects of various endowments as well as returns to those endowments in disparities in childhood stunting over the period. RESULTS: The results show that although the child's height-for-age Z-scores (HAZ) disparity largely accounted for differing levels of endowments during the earlier decades, in the later periods, inadequate access to the benefits from various development programmes was also found responsible for HAZ disparities. Moreover, effects of endowments and their returns varied across quantiles. We argue that apart from equalizing endowments, ensuring adequate access to different nutrition-centric programmes is essential to lessen the burden of childhood stunting. CONCLUSION: The state must focus on intersectoral convergence of different schemes in the form of state nutrition mission, and, strengthen nutrition-centric policy processes and their political underpinnings to harness better dividend.

Immuno-cytogenetic manifestation of epigenetic chromatin modification marks in plants.

Histone proteins and the nucleosomes along with DNA are the essential components of eukaryotic chromatin. Post-translational histone-DNA interactions and modifications eventually offer significant alteration in the chromatin environment and potentially influence diverse fundamental biological processes, some of which are known to be epigenetically inherited and constitute the "epigenetic code". Such chromatin modifications evidently uncover remarkable diversity and biological specificity associated with distinct patterns of covalent histone marks. The past few years have witnessed major breakthroughs in plant biology research by utilizing chromatin modification-specific antibodies through molecular cytogenetic tools to ascertain hallmark signatures of chromatin domains on the chromosomes. Here, we survey current information on chromosomal distribution patterns of chromatin modifications with special emphasis on histone methylation, acetylation, phosphorylation, and centromere-specific histone 3 (CENH3) marks in plants using immuno-FISH as a basic tool. Major available information has been classified under typical and comparative cytogenetic detection of chromatin modifications in plants. Further, spatial distribution of chromatin environment that exists between different cell types such as angiosperm/gymnosperm, monocot/dicot, diploid/polyploids, vegetative/generative cells, as well as different stages, i.e., mitosis versus meiosis has also been discussed in detail. Several challenges and future perspectives of molecular cytogenetics in the grooming field of plant chromatin dynamics have also been addressed.

The role(s) of community health workers in primary health care reform in Kerala, before and during the COVID 19 pandemic: a qualitative study.

Background: Accredited Social Health Activists (ASHA) are Community Health Workers (CHWs) employed by the National Health Mission of the Government of India to link the population to health facilities and improve maternal and child health outcomes in the country. The government of Kerala launched primary health reform measures in 2016 whereby Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The COVID-19 pandemic in 2020 impacted essential health service delivery, including primary care services. The CHWs network of Kerala played a crucial role in implementing the primary care reforms and COVID-19 management efforts that followed. We carried out a study to understand the perspectives of the CHWs in Kerala about their role in the recent primary healthcare reforms and during the COVID-19 pandemic management efforts. Methods: We conducted in-depth interviews (IDI) with 16 ASHAs from 8 primary care facilities in Kerala from July to October 2021. We further conducted Focus Group Discussions (FGDs) (N = 34) with population subgroups in these eight facility catchment areas and asked their opinion about the ASHAs working in their community. We obtained written informed consent from all the participants, and interview transcripts were thematically analysed by a team of four researchers using ATLAS.ti 9 software. Results: Our study participants were women aged about 45 years with over 10 years of work experience as CHWs. Their job responsibilities as a frontline health worker helped them build trust in the community and local self-governments. CHWs were assigned roles of outpatient crowd management, and registration duties in FHCs. The COVID-19 pandemic increased their job roles manifold. Community members positively mentioned the home visits, delivery of medicines, and emotional support offered by the CHWs during the pandemic. The CHWs noted that the honorarium of INR 6,000 (US$73) was inconsistent and very low for the volume of work done. Conclusion: The CHWs in Kerala play a crucial role in primary care reforms and COVID-19 management. Despite their strong work ethic and close relationship with local self-governments, low and irregular wages remain the biggest challenge.

Is pay for performance promoting inverse inequality in Irish general practice?

BACKGROUND: In 2020, the Chronic Disease Management (CDM) programme was introduced in Ireland. This programme resources GPs to review public (GMS) patients, diagnosed with eight named chronic diseases, twice yearly according to a structured protocol. This pay for performance initiative has been widely adopted by GPs. However, it is hypothesised that private patients (PPs) receive a poorer standard of care, as they may be reluctant to attend due to the cost involved. AIM: To assess whether the management of eight chronic diseases named in the CDM programme is to the same standard among both PPs and GMS patients. METHOD: A retrospective audit of GP practices in the Midwest of Ireland. Data relating to 25 GMS patients and 25 PPs, matched by age, gender, and clinical condition, is collected from each practice. Patients have at least 1 of the eight named chronic diseases. Parameters include vaccination status (influenza, pneumococcal, COVID); body mass index; blood pressure; smoking status; renal function; HbA1c; lipid profile; brain natriuretic peptide (BNP) in patients with heart failure; and lung function tests in patients with COPD or asthma. COVID vaccination status acts as a control because it is freely available for both PPs and GMS patients. RESULTS: Preliminary results from 2 GP practices show large consistent disparities in management between PPs and GMS patients in most parameters. CONCLUSION: Limiting Pay for Performance to the care of GMS patients only, based on age or income, promotes inverse inequality. We argue that CDM care should be offered to all patients.

Sex differences in non-communicable disease multimorbidity among adults aged 45 years or older in India.

OBJECTIVE: Older male and female adults differ in key characteristics such as disease-specific life expectancy, health behaviours and clinical presentations and non-communicable disease multimorbidity (NCD-MM). Therefore, examining the sex differences in NCD-MM among older adults is vital, as this issue is understudied in low-income and middle-income country (LMIC) contexts such as India, and has been growing in the past few decades. DESIGN: Large scale nationally representative cross-sectional study. SETTINGS AND PARTICIPANTS: Longitudinal Ageing Study in India (LASI 2017-2018) had data on 27 343 men and 31 730 women aged 45+, drawn from a sample of 59 073 individuals across India. PRIMARY AND SECONDARY OUTCOMES MEASURES: We operationalised NCD-MM based on prevalence of the presence of two or more long-term chronic NCD morbidities. Descriptive statistics and bivariate analysis along with multivariate statistics were used. RESULTS: Women aged 75+ had a higher prevalence of multimorbidity as compared with men (52.1% vs 45.17%). NCD-MM was more common among widows (48.5%) than widowers (44.8%). The female-to-male ratios of ORs (RORs) for NCD-MM associated with overweight/obesity and prior history of chewing tobacco were 1.10 (95% CI: 1.01 to 1.20) and 1.42 (95% CI: 1.12 to 1.80), respectively. The female-to-male RORs show that the odds of NCD-MM were greater in formerly working women (1.24 (95% CI: 1.06 to 1.44)) relative to formerly working men. The effect of increasing NCD-MM on limitations in activities of daily living and instrumental ADL was greater in men than women but reversed for the hospitalisation. CONCLUSIONS: We found significant sex differences in NCD-MM prevalence among older Indian adults, with various associated risk factors. The patterns underlying these differences warrant greater study, given existing evidence on differential longevity, health burdens and health-seeking patterns all of which operate in a larger structural context of patriarchy. Health systems in turn must respond to NCD-MM mindful of these patterns and aim to redress some of the larger inequities they reflect.