Cultural and Contextual Drivers of Triple Burden of Malnutrition among Children in India.

This study examines malnutrition's triple burden, including anaemia, overweight, and stunting, among children aged 6-59 months. Using data from the National Family Health Survey-5 (2019-2021), the study identifies risk factors and assesses their contribution at different levels to existing malnutrition burden. A random intercept multilevel logistic regression model and spatial analysis are employed to identify child, maternal, and household level risk factors for stunting, overweight, and anaemia. The study finds that 34% of children were stunted, 4% were overweight, and 66% were anaemic. Stunting and anaemia prevalence were higher in central and eastern regions, while overweight was more prevalent in the north-eastern and northern regions. At the macro-level, the coexistence of stunting, overweight, and anaemia circumstantiates the triple burden of childhood malnutrition with substantial spatial variation (Moran's I: stunting-0.53, overweight-0.41, and anaemia-0.53). Multilevel analysis reveals that child, maternal, and household variables play a substantial role in determining malnutrition burden in India. The nutritional health is significantly influenced by a wide range of determinants, necessitating multilevel treatments targeting households to address this diverse group of coexisting factors. Given the intra-country spatial heterogeneity, the treatment also needs to be tailor-made for various disaggregated levels.

Utilisation of ANC services before and after the COVID-19 pandemic in selected resource-poor blocks of India: role of community health workers in Swabhimaan programme area.

INTRODUCTION: COVID-19 has disrupted maternal and child health services. Community Health Workers (CHWs) supported the women by visiting pregnant women's homes and providing the MCH services as required. This study attempts to understand the role of CHW and its impact on the Ante-Natal Care (ANC) services pre-pandemic and post-Pandemic in the poor resource setting. METHODS: The Swabhimaan programme interventions were carried out in the selected blocks in the Indian States of Bihar, Odisha and Chhattisgarh with the objective to improve the nutritional status of mothers, pregnant women and adolescents living in resource-poor blocks of three selected states during 2016-2022. Cross-sectional surveys, namely pre-pandemic (2018-19) and post-pandemic (2021-22) of pregnant and mothers of under two children, utilised to fulfil the objectives of this study. These surveys are part of Swabhimaan evaluation, a community-based non-randomised controlled study. RESULTS: The ANC services received by women have increased over time from 2015 to 2022. Our findings confirm that the ground-level community and health systems were active during the pandemic, and the results show significant improvement. Additionally, the women supported by the CHW have substantially improved pregnancy registration, first ANC, Tetanus injection, consumption of Iron Folic Acid, Calcium and deworming tablets than those who did not. Propesnsity Score Matching analysis shows that the average treatment effect on the various ANC services of having the support of CHW is significant. CONCLUSION: This study shows the vital role of CHWs in utilising various Maternal and Child Health services. Better linkage and networking of the CHWs with the community will ensure health service delivery regularly and in an emergency like a pandemic and develop resilience.

Prevalence of pain and its treatment among older adults in India: a nationally representative population-based study.

ABSTRACT: There were no estimates of the prevalence of pain and its treatment in the older population of India obtained from face-to-face interviews with a nationally representative sample. We addressed this evidence gap by using data on 63,931 individuals aged 45 years and older from the 2017/2018 Longitudinal Ageing Study in India. We identified pain from an affirmative response to the question: Are you often troubled by pain? We also identified those who reported pain that limited usual activities and who received treatment for pain. We estimated age- and sex-adjusted prevalence of pain, pain limiting usual activity and treatment, and compared these estimates across states and sociodemographic groups. We used a multivariable probit model to estimate full adjusted differences in the probability of each outcome across states and sociodemographic groups. We estimated that 36.6% (95% confidence interval [CI]: 35.3-37.8) of older adults in India were often troubled by pain and 25.2% (95% CI: 24.2-26.1) experienced pain limiting usual activity. We estimated that 73.3% (95% CI: 71.9-74.6) of those often troubled by pain and 76.4% (95% CI: 74.9-78.0) of those with pain that limited usual activity received treatment. There was large variation in each outcome across states. Fully adjusted prevalence of pain and pain limiting usual activity were higher among individuals who were female, older, less educated, rural residents, and poorer. Prevalence of treatment among those troubled by pain was lower among socially disadvantaged groups.

Prevalence of dementia in India: National and state estimates from a nationwide study.

INTRODUCTION: Prior estimates of dementia prevalence in India were based on samples from selected communities, inadequately representing the national and state populations. METHODS: From the Longitudinal Aging Study in India (LASI) we recruited a sample of adults ages 60+ and administered a rich battery of neuropsychological tests and an informant interview in 2018 through 2020. We obtained a clinical consensus rating of dementia status for a subsample (N = 2528), fitted a logistic model for dementia status on this subsample, and then imputed dementia status for all other LASI respondents aged 60+ (N = 28,949). RESULTS: The estimated dementia prevalence for adults ages 60+ in India is 7.4%, with significant age and education gradients, sex and urban/rural differences, and cross-state variation. DISCUSSION: An estimated 8.8 million Indians older than 60 years have dementia. The burden of dementia cases is unevenly distributed across states and subpopulations and may therefore require different levels of local planning and support. HIGHLIGHTS: The estimated dementia prevalence for adults ages 60+ in India is 7.4%. About 8.8 million Indians older than 60 years live with dementia. Dementia is more prevalent among females than males and in rural than urban areas. Significant cross-state variation exists in dementia prevalence.

Use of unclean cooking fuels and visual impairment of older adults in India: A nationally representative population-based study.

Despite widespread use of unclean cooking fuels (UCF) in India, evidence from nationally representative data on its association with visual impairment was lacking. We used a population-based nationwide survey of adults aged 45 years and older that included reported UCF and measured visual impairment. We estimated that 44.8% (95% CI: 42.6, 47.1) of older adults in India lived in households that used UCF. Age- and sex-adjusted prevalence of visual impairment was estimated to be 33.0% (95% CI: 31.0, 34.9) in the older population that did not use UCF and 9.0 percentage points (pp) (95% CI: 8.9, 9.1) higher among those who did. Among those who used UCF, age- and sex-adjusted prevalence of low distance vision was 4.3 pp (95% CI: 4.2, 4.4) higher, prevalence of low near vision was 8.0 pp (95% CI: 7.9, 8.1) higher, and prevalence of blindness was 1.0 pp (95% CI: 0.9, 1.0) higher. After controlling for a rich array of sociodemographic characteristics and state fixed effects, we estimated that use of UCF was associated with higher prevalence of visual impairment by 3.2 pp (95% CI: 1.4, 5.0), low distance vision by 1.8 pp (95% CI: 0.7, 2.9), and low near vision by 3.2 pp (95% CI: 1.3, 5.0). Doubly robust estimates of these differences were slightly larger. Blindness was not significantly partially associated with use of UCF (95% CI: -0.4, 0.6). We did not find support for the hypotheses that the visual impairment risk associated with use of UCF was even larger for females and in households without a separate kitchen or ventilation. The older population of India is highly reliant on UCF that is very strongly associated with visual impairment. Impaired vision should not be overlooked among the harms associated with UCF.

Awareness, treatment, and control of hypertension in adults aged 45 years and over and their spouses in India: A nationally representative cross-sectional study.

BACKGROUND: Lack of nationwide evidence on awareness, treatment, and control (ATC) of hypertension among older adults in India impeded targeted management of this condition. We aimed to estimate rates of hypertension ATC in the older population and to assess differences in these rates across sociodemographic groups and states in India. METHODS AND FINDINGS: We used a nationally representative survey of individuals aged 45 years and over and their spouses in all Indian states (except one) in 2017 to 2018. We identified hypertension by blood pressure (BP) measurement ≥140/90 mm Hg or self-reported diagnosis if also taking medication or observing salt/diet restriction to control BP. We distinguished those who (i) reported diagnosis ("aware"); (ii) reported taking medication or being under salt/diet restriction to control BP ("treated"); and (iii) had measured systolic BP <140 and diastolic BP <90 ("controlled"). We estimated age-sex adjusted hypertension prevalence and rates of ATC by consumption quintile, education, age, sex, urban-rural, caste, religion, marital status, living arrangement, employment status, health insurance, and state. We used concentration indices to measure socioeconomic inequalities and multivariable logistic regression to estimate fully adjusted differences in these outcomes. Study limitations included reliance on BP measurement on a single occasion, missing measurements of BP for some participants, and lack of data on nonadherence to medication. The 64,427 participants in the analysis sample had a median age of 57 years: 58% were female, and 70% were rural dwellers. We estimated hypertension prevalence to be 41.9% (95% CI 41.0 to 42.9). Among those with hypertension, we estimated that 54.4% (95% CI 53.1 to 55.7), 50.8% (95% CI 49.5 to 52.0), and 28.8% (95% CI 27.4 to 30.1) were aware, treated, and controlled, respectively. Across states, adjusted rates of ATC ranged from 27.5% (95% CI 22.2 to 32.8) to 75.9% (95% CI 70.8 to 81.1), from 23.8% (95% CI 17.6 to 30.1) to 74.9% (95% CI 69.8 to 79.9), and from 4.6% (95% CI 1.1 to 8.1) to 41.9% (95% CI 36.8 to 46.9), respectively. Age-sex adjusted rates were lower (p < 0.001) in poorer, less educated, and socially disadvantaged groups, as well as for males, rural residents, and the employed. Among individuals with hypertension, the richest fifth were 8.5 percentage points (pp) (95% CI 5.3 to 11.7; p < 0.001), 8.9 pp (95% CI 5.7 to 12.0; p < 0.001), and 7.1 pp (95% CI 4.2 to 10.1; p < 0.001) more likely to be aware, treated, and controlled, respectively, than the poorest fifth. CONCLUSIONS: Hypertension prevalence was high, and ATC of the condition were low among older adults in India. Inequalities in these indicators pointed to opportunities to target hypertension management more effectively and equitably on socially disadvantaged groups.

Seroprevalence of anti-SARS-CoV-2 of IgG antibody by ELISA: Community-based, cross-sectional study from urban area of Malegaon, Maharashtra.

BACKGROUND: Given the high incidence of asymptomatic or subclinical SARS-CoV-2 infection, reported cases likely underestimate the overall prevalence and infectivity of COVID-19. Serological test for IgG can provide a better measure of disease activity by identifying asymptomatic or subclinical infection. This study was conducted to estimate the seroprevalence of SARS-CoV-2 infection and to the determinants of SARS-CoV-2 infection in the hotspot area of COVID-19. METHOD: It was a community-based, cross-sectional study using multistage sampling with a sample size of 360. After informed consent, the demographic information, past history of SARI/ILI, contact, COVID-19 status were collected. The blood samples were taken from one family member for anti-SARS-CoV-2 IgG antibody by ELISA testing kit. RESULTS: Majority of the study subjects had no history of SARI (86%) or any contact with COVID-19 case (98%). Overall seroprevalence of anti-SARS-CoV-2 of IgG antibody was 40% (95% CI 35-45%), infection fatality rate (IFR) was 0.7%. Seroprevalence varied significantly depending on religious background; with Muslims (53%) seroprevalence compared to other religious groups. Seroprevalence of homemaker/unemployed (49%) and laborer (55%) was significantly higher compared to business (30%) and service occupation (21%). Subjects with overcrowding conditions and poor ventilation was significantly associated with higher seroprevalence with odds ratio of 2.5 and 2.3, respectively. CONCLUSION: The antibody testing detects a large number of asymptomatic cases or previously infected cases which would have been missed by clinical history. Thus, the number of undiagnosed cases was found significantly higher even with rigorous implementation of lockdown.

Methodological considerations in designing and implementing the harmonized diagnostic assessment of dementia for longitudinal aging study in India (LASI-DAD).

The Harmonized Diagnostic Assessment of Dementia for Longitudinal Aging Study in India (LASI-DAD) is a population-representative, prospective cohort study of late-life cognition and dementia. It is part of an ongoing international research collaboration that aims to measure and understand cognitive impairment and dementia risk by collecting a set of cognitive and neuropsychological assessments and informant reports, referred to as the Harmonized Cognitive Assessment Protocol (HCAP). LASI-DAD provides nationally representative data drawn from a subsample of the ongoing Longitudinal Aging Study in India (LASI). One of LASI-DAD's distinctive features is its rich geriatric assessment, including the collection of venous blood samples and brain imaging data for a subsample of respondents. In this paper, we discuss the methodological considerations of developing and implementing the HCAP protocol in India. The lessons we learned from translating and applying the HCAP protocol in an environment where illiteracy and innumeracy are high will provide important insights to researchers interested in measuring and collecting data on late-life cognition and dementia in developing countries. We further developed an innovative blood management system that enables us to follow the collection, transportation, assay, and storage of samples. Such innovation can benefit other population surveys collecting biomarker data.

Socio-economic Correlates and Spatial Heterogeneity in the Prevalence of Asthma among Young Women in India.

BACKGROUND: Asthma is one of the leading causes of disease burden when measured in terms of disability adjusted life years, despite low prevalence of self-reported cases among young women. This paper deals with the meso-scale correlates and spatial heterogeneity in the prevalence of self-reported Asthma across 640 districts in India, using a nationally representative sample of 699,686 women aged 15-49 years from all 36 States/UTs under NFHS-4 (2015-16). METHODS: Analytical methods used in this paper include multivariate logistic regression to examine the adjusted effects of various independent variables on self-reported Asthma and poor-rich ratios (PRR) and concentration index (CI) to understand the economic inequalities in the prevalence of Asthma. For the spatial analysis in the prevalence of Asthma, univariate and bivariate local Moran's I statistic have been computed in addition to measure of spatial autocorrelation and auto regression using spatial error and spatial lag models. RESULTS: Results highlight that women's education was an important marker to the prevalence of Asthma. Smoking tobacco in any form among women were significantly more likely to suffer from Asthma. The prevalence of Asthma was further aggravated among women from the households without a separate room for kitchen, as well as those using unclean fuel for cooking. The poor-rich ratio in the prevalence of Asthma across various States/UTs in India depict inherent inequality. An analysis of spatial clustering in the prevalence of Asthma based on spatial autocorrelation portrays that Moran's I values were significant for improved source of drinking water, clean fuel used for cooking, and household environment. When spatial weights are taken into consideration, the autoregression model noticeably becomes stronger in predicting the prevalence of Asthma. CONCLUSIONS: Any programmatic effort to curb the prevalence of Asthma through vertical interventions may hinge around the use of clean fuel, poverty, and lifestyle of subjects, irrespective of urban-rural place of their residence, environmental and ecological factors.

Integrated multisectoral strategy to improve girls' and women's nutrition before conception, during pregnancy and after birth in India (Swabhimaan): protocol for a prospective, non-randomised controlled evaluation.

INTRODUCTION: Swabhimaan is a community-based programme to improve adolescent girls' and women's nutrition in the rural areas of three Indian states-Bihar, Chhattisgarh and Odisha with high prevalence of undernutrition. METHODS AND ANALYSIS: Swabhimaan has a nested prospective, non-randomised controlled evaluation. Since 2017, five intervention sites receive community-led interventions through national government's livelihood mission supported women's self-help group federations and five control sites will initiate these activities 36 months later, in 2020. Community-led activities aim to improve coverage of 18 interventions including adequacy of food consumed, prevention of micronutrient deficiencies, access to basic health services and special care of nutritionally 'at risk' girls and women, improving hygiene and access to water and sanitation services and access to family planning services. The evaluation includes baseline (2016-2017), midline (2018-2019) and endline (2020-2021) surveys covering 6638 adolescent girls, 2992 pregnant women and 8755 mothers of children under 2. The final impact analysis will be by intention to treat, comparing primary and secondary outcomes in five intervention areas and five control areas. The primary outcomes are: (1) a 15% reduction in the proportion of adolescent girls with a body mass index (BMI) <18.5 kg/m2; (2) a 15% reduction in the proportion of mothers of children under two with a BMI <18.5 kg/m2 and (3) and a 0.4 cm improvement in mean mid-upper arm circumference among pregnant women. ETHICS AND DISSEMINATION: All procedures involving human subjects were approved by the Institutional Ethics Committee of the All India Institute of Medical Sciences, Bihar, Chhattisgarh and Odisha and in compliance with guidelines laid down in the Declaration of Helsinki. Evidence will inform maternal and preconception nutrition policy at national and state level. TRIAL REGISTRATION NUMBER: 58261b2f46876 and CTRI/2016/11/007482; Pre-results.

Oral problems and associated risk indicators in adults in the Russian Federation, India, and China.

BACKGROUND: Oral problems, known as a neglected epidemic, have become prevalent in Brazil, the Russian Federation, India, China, and South Africa (BRICS) countries in last decade. The objective of the study is to examine the prevalence and associated risk indicators of oral problems in adults in the Russian Federation, India, and China in BRICS countries. METHODS: We used data from the first round of the Study of Global AGEing and Adult Health (SAGE), conducted by WHO in 2007-10 in selected BRICS countries. Oral problems are defined as if an adult had any mouth and/or teeth related problems including swallowing problems in last 1 year of the survey. We estimated the mean age of adults who had oral problems and used a t-test for comparing it by sex of adults. We determined the prevalence of oral problems in adults. We designed a hierarchical conceptual model to identify associated risk indicators with oral problems. Finally, we applied a multivariable binary logistic regression model based on a conceptual model to examine associated socioeconomic and demographic, behavioral and nutritional risk indicators and systemic diseases - diabetes, hypertension, and angina pectoris/angina with oral problems in adults. RESULTS: The mean age of adults who had oral problems is lowest in India (57 years; SD: 15) and highest in China (65 years; SD: 11). However, it does not vary by sex of adults except India. The prevalence of oral problems is highest in the Russian Federation (35%) and lowest in China (9%). Adults with body mass index (BMI) less than 25 kg/m2, age 45 years or more, diabetes, hypertension, and angina pectoris/angina have a higher risk of oral problems. Females and adults using alcohol are also more likely to have oral problems in selected countries. CONCLUSIONS: The study concludes that females, adults using alcohol and those having any systemic disease are at higher risk of oral problems in the Russian Federation, India, and China. A one-third of adults had oral problems in particularly, in the Russian Federation; thus there is an urgent need to formulate oral policy and program, which the country currently lacks in.

Mid-upper arm circumference cut-offs for screening thinness and severe thinness in Indian adolescent girls aged 10-19 years in field settings.

OBJECTIVE: (i) To assess diagnostic accuracy of mid-upper arm circumference (MUAC) for screening thinness and severe thinness in Indian adolescent girls aged 10-14 and 15-19 years compared with BMI-for-age Z-score (BAZ) <-2 and <-3 as the gold standard and (ii) to identify appropriate MUAC cut-offs for screening thinness and severe thinness in Indian girls aged 10-14 and 15-19 years. DESIGN: Cross-sectional, conducted October 2016-April 2017. SETTING: Four tribal blocks of two eastern India states, Chhattisgarh and Odisha. PARTICIPANTS: Girls (n 4628) aged 10-19 years. Measurements included height, weight and MUAC to calculate BAZ. Standard diagnostic accuracy tests, receiver-operating characteristic curves and Youden index helped arrive at MUAC cut-offs at BAZ < -2 and <-3, as gold standard. RESULTS: Mean MUAC and BMI correlation was positive (0·78, P = 0·001 and r 2 = 0·61). Among 10-14 years, MUAC cut-off corresponding to BAZ < -2 and BAZ < -3 was ≤19·4 and ≤18·9 cm. Among 15-19 years, corresponding values were ≤21·6 and ≤20·7 cm. For both BAZ < -2 and BAZ < -3, specificity was higher in 15-19 v. 10-14 years. State-wise variations existed. MUAC cut-offs ranged from 17·7 cm (10 years) to 22·5 cm (19 years) for BAZ < -2, and from 17·0 cm (10 years) to 21·5 cm (19 years) for BAZ < -3. Single-age area under the curve range was 0·82-0·97. CONCLUSIONS: Study provides a case for use of year-wise and sex-wise context-specific MUAC-cut-offs for screening thinness/severe thinness in adolescents, rather than one MUAC cut-off across 10-19 years, depending on purpose and logistic constraints.

Assessing Knowledge, Attitudes, and Preventive Practices Related to Kala-A: A Study of Rural Madhepura, Bihar, India.

To assess the knowledge, attitude, and preventive practices related to kala-azar in Madhepura district of Bihar, a community-based cross-sectional study was carried out in November 2014. A total of 353 households were interviewed from 24 villages of four blocks of Madhepura district. Data were collected using structured interview schedule. For knowledge, attitude, and preventive practice indexes, scores were assigned to individual questions based on the accuracy of responses. Univariate and binary logistic regressions were applied for the analysis. Eighty-four percent households had heard of kala-azar disease, but only 15.9% could recognize that sand flies were responsible for transmitting the disease. Overall, only 43.9% had fair knowledge on kala-azar disease (e.g., mode of transmission, signs and symptoms, and the outcome if left untreated) and the vector (breeding place, season, and biting time). Almost 48.6% had a favorable attitude toward treatability and management of kala-azar and 37.7% practiced proper mechanism to prevent and control kala-azar. Occupation emerged as a significant predictor for all three indexes. Other important predictors for the attitude index were literacy, household type, households ever had a kala-azar case, and knowledge index. Despite 61.8% of the households ever reported to have a member diagnosed with kala-azar, the overall knowledge of the disease and vector, attitude, and practices about prevention and control of kala-azar was found to be lagging. Therefore, our investigation suggests that further strengthening of comprehensive knowledge about kala-azar and preventive practices is needed.

Disposal of children's stools and its association with childhood diarrhea in India.

BACKGROUND: Children's stool disposal is often overlooked in sanitation programs of any country. Unsafe disposal of children's stool makes children susceptible to many diseases that transmit through faecal-oral route. Therefore, the study aims to examine the magnitude of unsafe disposal of children's stools in India, the factors associated with it and finally its association with childhood diarrhea. METHODS: Data from the third round of the National Family Health Survey (NFHS-3) conducted in 2005-06 is used to carry out the analysis. The binary logistic regression model is used to examine the factors associated with unsafe disposal of children's stool. Binary logistic regression is also used to examine the association between unsafe disposal of children's stool and childhood diarrhea. RESULT: Overall, stools of 79% of children in India were disposed of unsafely. The urban-rural gap in the unsafe disposal of children's stool was wide. Mother's illiteracy and lack of exposure to media, the age of the child, religion and caste/tribe of the household head, wealth index, access to toilet facility and urban-rural residence were statistically associated with unsafe disposal of stool. The odds of diarrhea in children whose stools were disposed of unsafely was estimated to be 11% higher (95% CI: 1.01-1.21) than that of children whose stools were disposed of safely. An increase in the unsafe disposal of children's stool in the community also increased the risk of diarrhea in children. CONCLUSION: We found significant statistical association between children's stool disposal and diarrhea. Therefore, gains in reduction of childhood diarrhea can be achieved in India through the complete elimination of unsafe disposal of children's stools. The sanitation programmes currently being run in India must also focus on safe disposal of children's stool.