Compliance and Experience of Quarantine during the 1st Wave of COVID-19 Pandemic in Mumbai.

BACKGROUND: At the beginning of the pandemic, quarantine was thought to be the most effective way to contain the spread of the virus among international travelers and any potential carriers. OBJECTIVES: This study assessed the type of quarantine, compliance to quarantine measures (QM), mood, and any social stigma faced during that period. MATERIALS AND METHODS: After approval from the institutional ethics committee, a telephonic interview survey was conducted. Individuals above 18 years of age visiting the only functioning COVID-19 screening outpatient department at Kasturba Hospital between March 1, 2020, and March 10, 2020 were included in the study. A total of 263 individuals were interviewed. RESULTS: Out of 263 respondents, 71% and 34% of individuals had a history of international travel and contact history, respectively. Only 63% had read the guidelines on home QM. Among individuals quarantined, 127 that living alone in their apartments, 60 were in a single room with relatives outside, 37 were living with family members because they did not have another room, and 39 were staying in a facility quarantine center. On assessing the QM followed, wearing a mask was the least followed (46%). The average score of compliance to QM was 82.6%. Seventy-two per cent rated their mood as "5" on a scale of 1-10. Social stigma was reported by 7.6% of respondents. CONCLUSION: Among the early set of quarantined individuals in the city during the first wave of the pandemic, average score of compliance to QM was high even though lesser people recalled reading the guideline on home QM.

A cross-sectional study to assess the occupational health hazards among fisherwomen in a metropolitan city.

Context: Research on the working conditions and health hazards of fishing communities in developing countries is scarce. Aims: 1) To assess the occupational health hazards among women fish vendors. 2) To understand the morbidity profile in them. 3) To analyze various challenges faced by them at the workplace in this occupation. 4) To suggest various measures including ergonomic solutions that they can take to reduce these health hazards. Settings and Design: Community-based observational cross-sectional study. Methods and Material: Eight fish markets comprising women fish vendors working for more than one year (age > 30 years) in Mumbai were selected. A cluster sampling method was used. The sample size was 225. The period of the study was 2 years. Statistical Analysis Used: Chi-square test. Results: The majority of study subjects had diabetes mellitus (24%) and were overweight (54.7%). Of all participants, 55.1% had musculoskeletal pain of which low back pain (69; 30.7%) was most common. There was a significant association between musculoskeletal pain status and mode of carrying boxes, χ2 (1) =56.35 as well as with duration of occupation, χ2 (3) =89.67, P < 0.001. Of all participants, 90.2% got injured of which the majority had incisional wounds (124; 61.1%). Of all participants, 55.1% suffered from skin infections of which the majority (28; 12.4%) had itching and redness of hands and legs. There was a significant association between skin infections and duration of occupation, χ2 (3) =140.53 as well as with the use of gloves (63.2% participants), χ2 (1) =20.395, P < 0.001. Conclusions: Various measures including ergonomic solutions that women fish vendors can take to reduce these health hazards need to be addressed.

A Cross-sectional Study to Estimate the Proportion and Ascertain Risk Factors for Osteoarthritis Knee among Women above 45 Years of Age Attending a Tertiary Care Hospital.

Background: With aging, women face various health issues, the most common of which are musculoskeletal disorders. Osteoarthritis accounts for 15% of all musculoskeletal disorders in patients above the age of 45 years but receives little attention. This study aims to estimate the proportion of women above 45 years suffering from Osteoarthritis (OA) knee and to ascertain its risk determinants. Materials and Methods: A cross-sectional study was conducted among 380 women above 45 years of age attending the Orthopedic outpatient department of a tertiary care hospital over a period of 18 months. American College of Rheumatology clinicoradiological criteria were used for the diagnosis of OA knee. A predesigned case record form was used to collect information on sociodemographic profile and other risk factors. Results: Data were analyzed using SPSS version 16.0. Our study found the overall proportion of OA knee to be 69.2%. The Chi-square test was used to find the association of various factors with OA knee. On logistic regression, diabetes mellitus, hypertension, menopause, and increased body mass index were found to be significant for OA Knee. Conclusion: The study concludes the possibility of prevention of disabilities by early screening for OA Knee in those with risk factors as a part of wellness clinics.

Efficacy and safety of AP-Bio®(KalmCold®) in participants with uncomplicated upper respiratory tract viral infection (common cold) - A phase III, double-blind, parallel group, randomized placebo-controlled trial.

INTRODUCTION: Kalmegh (Andrographis paniculata) is commonly used for treating uncomplicated Upper Respiratory Tract Infection (URTI) in complementary and alternative system of medicine. AP-Bio®(KalmCold®) is a standardized extract derived from the leaves of A. paniculata. This study was proposed to evaluate its efficacy using validated scales and objective measures. METHODS: Participants were randomized in a ratio of 1:1:1 to receive either AP-Bio® 200 mg/day, AP-Bio® 400 mg/day or placebo for 7 days. The primary outcome measure was Wisconsin Upper Respiratory Symptom Survey (WURSS-21) score. The secondary outcome measures were nasal mucous weight, nasal muco-ciliary clearance function and Interleukin-8 in nasal wash, as well as safety and tolerability. RESULTS: A total of n = 331 participants were screened and N = 300 participants were enrolled. The absolute WURSS-21 global score [mean (Standard Deviation - SD)] in the AP-Bio® 400 mg group [5.70 (5.31)] was less than the AP-Bio® 200 mg group [5.81 (4.83)] on Day-3. However, it was much higher in the placebo group [9.55 (14.27)]. AP-Bio® 400 mg group (Mean Difference - MD [Standard Error - SE] = -3.85 [1.52]; 95% CI = -6.85, - 0.85; adjusted p = 0.034) and 200 mg group (MD [SE] = -3.74 [1.51]; 95% CI = -6.73, - 0.76; adjusted p = 0.038) had significantly lower score than placebo. Similarly, on Day-3, the change in global score from baseline was significantly better in the AP-Bio® 400 mg group (MD [SE] = -3.91; [1.82] 95% CI = -7.50, - 0.32; adjusted p = 0.038) and AP-Bio® 200 mg group (MD [SE] = -3.84 [1.97]; 95% CI = -7.72, - 0.04; adjusted p = 0.044) in comparison to the placebo group. Nasal mucous weight, tissue paper counts used, and interleukin-8 showed a trend towards AP-Bio® groups having a favourable outcome when compared with placebo but did not reach statistical significance due to a small sample size. None of the study participants complained of any adverse physical symptoms. However, incident eosinophilia was noted in n = 20 participants on day 3. (n = 6 in AP-Bio® 200 mg group, n = 7 in Ap-Bio® 400 mg group and n = 13 in placebo group; p = 0.181). CONCLUSIONS: Participants in both the AP-Bio® dose groups showed positive tendency towards resolution of URTI symptoms when compared with placebo on Day-3 but not on Day-5 and Day-7.

Normal Weight Obesity: Role of apoB and Insulin Sensitivity in Predicting Future Cardiovascular Risk.

Background: According to NFHS-4 survey, obesity has doubled in India. BMI cannot differentiate body fat from lean mass. Normal weight obesity was defined to distinguish people with normal BMI and increased body fat percentage (BF%). In contrast to conventional atherogenic prediction, Apolipoprotein B level is elevated before LDL cholesterol. Adiposity is also known for causing insulin resistance. Hence this study is an attempt to find the correlation of apo B and Insulin sensitivity in predicting future cardiovascular risk among normal weight obese. To study the role of apoB and insulin resistance in predicting cardio vascular risk. Methods: 269 participants of age group 18-24 in a medical teaching institute were selected for the first phase of the study through systematic random sampling. BF% was calculated with Harpenden skinfold callipers using Jackson Pollock's method. Second phase of the study involved biochemical investigation of 30 NWO participants. ApoB level and insulin sensitivity using HOMA model was estimated. Spearman correlations and simple linear regression were used. Analysis done using SPSSv16. Results: Male and Females were 56.4% and 43.6%, respectively. Out of 269, 44 were found to be having NWO. Hence Prevalence was 16.4%.There is a positive correlation found between apoB and insulin resistance with increasing body fat percentage. Conclusions: Elevated levels of apo B and insulin resistance are seen in NWO individuals as the BF% increases. NWO should be diagnosed early and thus apoB and insulin resistance can be screened for cardio vascular risk prediction.

Assessment of Preventable Risk Factors of Cardiovascular Diseases among Junior College Students: A Cross-Sectional Study.

CONTEXT: Lifestyle-associated risk factors may begin during childhood and result into cardiovascular diseases in adult life. Thus, a study was conducted among junior college students to assess these preventable risk factors among them. AIMS: To estimate (1) Prevalence of risk factors namely physical inactivity, unhealthy dietary habits, tobacco, and alcohol use among them and (2) The proportion of hypertension. SETTINGS AND DESIGN: A cross-sectional study was done among 416 11th and 12th standard students from a school of a metropolitan city. SUBJECTS AND METHODS: Two steps were conducted. Step 1 included an interview schedule and Step 2 involved anthropometry, pulse, and blood pressure of all the participants. Statistical analysis was done using SPSS 21. Chi-square test was applied. RESULTS: The prevalence of tobacco and alcohol consumption, physical inactivity, and unhealthy dietary habits were 5.5%, 5%, 74.5%, and 52.1%, respectively. The prevalence of overweight students was 13.9%. The prevalence of prehypertension and hypertension was 26.9% and 12.7%, respectively. CONCLUSIONS: It was concluded that these risk factors namely, physical inactivity, unhealthy dietary habits, tobacco, and alcohol consumption commence during adolescence.

Effect of Yoga Intervention in the Management of Hypertension: A Preventive Trial.

BACKGROUND: Noncommunicable diseases are on the rise in India. Hypertension is one of the major risk factors for cardiovascular diseases and also labeled as a chronic lifestyle disorder. Hence, non-pharmacological interventions leading to lifestyle modifications are of utmost importance to control and prevent hypertension. This trial aims to implement yoga intervention to the experimental group in addition to medicines, advice on diet and physical activity and to compare blood pressure and perceived stress scores with the control group. METHODS: It was an open-label, two-armed, non-randomized controlled trial, conducted at a tertiary care center on 145 patients with hypertension: 73 in the intervention group and 72 in the control group. The intervention group received yoga intervention for a period of 4 months on a weekly basis along with advice on physical activity, diet, and routine medicines. The control group did not receive yoga intervention. RESULTS: The mean age of the participants was 51.3 ± 9.4, females (58.2%) outnumbered males (41.3%). Following the intervention, perceived stress score and blood pressure showed a significant reduction between two groups (P < 0.001). Also, perceived stress and blood pressure were found to be reduced significantly within both groups (P < 0.001). CONCLUSIONS: Yoga proves to be an effective, safe, and less expensive adjunct therapy for hypertension management. Yoga was also found to be effective in reducing the level of stress. Diet modification and physical activity have got an important role to play in the control and prevention of hypertension.

Obesity Prevalence and Determinants among Young Adults, with Special Focus on Normal-Weight Obesity; A Cross-Sectional Study in Mumbai.

BACKGROUND: India has >135 million obese individuals at present. Body mass index (BMI) has been used to assess obesity until recent times. Later, studies have shown that central body fat (BF) measurements as a reliable predictor of metabolic diseases. Hence, normal-weight obesity (NWO) is defined. Those with a normal range of BMI but increased fat percentage are found to be having metabolic syndromes at a very early life. The young adult group is specifically focused on the study with diet and physical activity as potential determinants; as an intervention at the right time can prevent the development of many noncommunicable diseases. OBJECTIVES: The aim of this study is to estimate the prevalence of obesity and its determinants with special reference to NWO. MATERIALS AND METHODS: A cross-sectional study was conducted based on diet, physical activity, and other lifestyle factors on a sample of 269 young adults. Using Harpenden skinfold calipers, BF percentage was calculated based on Jackson and Pollock and Siri's equation. Binary logistic regression was also applied appropriately. RESULTS: The proportion of obesity was 42.01%, and that of NWO was 16.1%. Sex, high protein diet, number of restaurant visits, less homemade tiffin intake, heavy physical activity, alcohol intake were found to be significantly associated with obesity. Intake of fish, physical activity, protein diet, day-time sleep were found to be significantly associated with NWO. CONCLUSION: The study emphasizes the need for including BF percentage in addition to BMI in regular clinical practice. It may help in preventive and promotive efforts.

Assessment of adherence and factors contributing to non-adherence among patients on anti-retroviral therapy in a tertiary care hospital: A cross sectional study.

BACKGROUND: For the successful treatment of human immunodeficiency virus (HIV), it is important that drugs should be taken regularly. Non-adherence not only increases chances of failure of treatment but also leads to the development of resistance to drugs and hence more focus has been given to adherence in the treatment protocol of HIV. OBJECTIVES: To determine the level of adherence, its determinants, and to ascertain reasons for non-adherence of antiretroviral therapy (ART) in patients with HIV/acquired immunodeficiency syndrome (AIDS). METHODS: A cross-sectional study conducted at an adult ART clinic over a period of one year. The sample size was 320. A systematic random sampling technique was used. Semi-structured Adult AIDS Clinical Trials Group questionnaire was used. Beck Depression Inventory (BDI-II) for current depression and self-report of four days recall method and multi-method approach were used for adherence measurement. RESULTS: The mean age of respondents was 37.26 ± 8.3 years. About 60.3% were males, 34.1% females, and 5.6% were transgenders (TGs). High adherence was found in 87.2% by self-report and 72.5% by multi-method approach. History of opportunistic infection and depression were found to be the best predictors of adherence. Reasons for short term non-adherence were found to be simply forgot to take medications, being away from home, busy with other things, and ran out of pills. Reasons for long-term non-adherence were financial difficulty, side-effects, and shift to alternate therapy. CONCLUSIONS: Significant non-adherence to ART necessitates addressing adherence issues in pre-ART counseling, the involvement of family and social support.

A cross-sectional study of epidemiological factors related to road traffic accidents in a metropolitan city.

BACKGROUND: Traffic injuries are one of the major causes of morbidity in India. It involves human sufferings in terms of physical, emotional, and financial losses to the individual, family, and the country. A better insight into the epidemiological determinants will help prevent such injuries. OBJECTIVES: To estimate the proportion of fatal and nonfatal accidents and to determine the epidemiological factors related to nonfatal accidents. METHODS: It was a cross-sectional study carried out in a tertiary care hospital over a period of 6 months. A simple random sampling technique was used for the selection of sample size of 476. Nonfatal accident victims were interviewed. RESULTS: The proportion of nonfatal to fatal accidents was found to be 1.8:1. Around 72.9% of drivers did not use any safety measure while driving. Two-wheelers (39%) and light motor vehicles (28.3%) were mostly involved, 45% of drivers had speed more than 60 km/h. Obstacles in the road (41%), defective roads (36.5%), and poor street lighting (11.4%) were reported as contributing factors of the accident. Lower extremities and head neck and face were involved in 47.2% and 27.1% of cases, respectively. Around 40.4% of cases had a single-site fracture. CONCLUSION: Traffic injuries result from the interaction between agent, host, and environmental factors. Preventing these interactions is very well possible with little extra care given towards road safety and traffic behavior of individuals.

A cross-sectional study to screen community health volunteers for hip/knee-osteoarthritis and osteoporosis.

CONTEXT: Osteoarthritis (OA) is a degenerative disease mainly affecting hip and knee joints, and osteoporosis is characterized by diminution of bone mass. Both these diseases have a substantial economic impact on society. Community health volunteers (CHVs) being peripheral health workers are prone to such diseases owing to their sociodemographic and occupational profile. AIM: This study was conducted to estimate the proportion of hip/knee OA and osteoporosis among CHVs and understand determinants of their current bone health status. MATERIALS AND METHODS: Screening for OA was done using a tool adopted from a previous study after obtaining due permissions. Weight, height, blood pressure, and bone mineral density of all participants were recorded. Statistical tests such as Chi-square and multiple logistic regression were used for analysis of data. RESULTS: Out of 80 participants, 50 (62.5%) had increased body mass index (overweight + obese), 10 (12.5%) were hypertensive, 14 (17.5%) CHVs screened positive for hip OA, and 29 (36.3%) were positive for knee OA. Hip OA was associated with advancing age, parity, and obesity. Knee OA was associated with age and exercise. In total, 16.3% subjects were found to have osteoporosis and 61.2% had osteopenia. CONCLUSIONS: This study showed that a remarkable proportion of CHVs had bone and joint problems. CHVs must, therefore, receive preventive measures such as health education and screening for these diseases.

Awareness and acceptance of H1N1 vaccination among physicians: Experience of 2017 vaccination campaign.

CONTEXT: India experienced pandemic phase of H1N1 in May 2009 to December 2010. The postpandemic phase went on from January 2011 to December 2014. As per the WHO, all countries should immunize their health-care workers as a first priority to protect the essential health infrastructure. AIMS: The aim of the study is to assess the level of awareness and acceptance of influenza vaccine among physicians and also the perception of physicians regarding H1N1 infection. This study also examined time of vaccine administration in relation with efficacy concerns based on literature. SETTINGS AND DESIGN: A vaccination campaign was conducted for all health-care workers of Seth GSMC and KEM Hospital, Mumbai, in the month of July 2017 based on which a cross-sectional observational study was conducted among the physicians of the same institute. METHODS: After ethical clearance, a prevalidated pretested survey based on a pilot survey of 20 physicians was distributed among physicians, which was based on the awareness and acceptance of H1N1 vaccination among physicians and perception of H1N1 infection. Effective sample size was 272. STATISTICAL ANALYSIS USED: Descriptive statistics and Chi-square test were generated for the survey responses. All the continuous variables were reported as mean, median, and range. Categorical variables were reported as tables and pie charts. P < 0.05 was taken as significant. Data analysis was done with SPSS version 21. RESULTS: The overall vaccine compliance was 29.8%. This study has found that area of work, deficiency in knowledge about adverse effect of vaccine, misconceptions regarding vaccine, and concerns about efficacy and duration of vaccine are the important factors which lead to decreased vaccine compliance. Furthermore, it is found during the study that timing of vaccination was not given due importance as considering the epidemiological pattern. CONCLUSIONS: More emphasis should be given to education sessions and counseling of physicians regarding H1N1 vaccination and oseltamivir therapy. At administrative level, more focus should be given on timing of vaccination and other logistics. Vaccine campaigns should be conducted ideally 1 month before expected rise in cases. Quadrivalent vaccine would be more appropriate over trivalent based on epidemiology of infection in India.

Nutritional status of the student nurses of a tertiary health-care center - A mixed-method study.

CONTEXT: Nursing students are the future role model of health; so critical evaluation of their nutritional status is imperative for effective functioning of health sector. AIMS: The aim is to assess the nutritional status of nursing students using basal metabolic index and exploring the causes of malnutrition along with uncovering the causes behind these causes of malnutrition. SETTING AND DESIGN: Nutritional status of student's nurses was assessed by mixed-method study design in tertiary care center of Mumbai, India. MATERIALS AND METHODS: The method is to use the census method for sampling 280 nursing students of a tertiary care center interviewed using a semistructured interview schedule. Focus group discussions were held with student nurses, which were selected through purposive sampling technique to interpret the instigator causes behind causes of malnutrition. STATISTICAL ANALYSIS: Descriptive statistics was applied on qualitative data. Conceptual model framed on themes and subthemes based upon the codes from qualitative data. RESULTS: Students having BMI less than 18 and more than 24.9 were 189 and 11, respectively, out of 280 students. About 64.20% had acidity and 11.07% performed regular exercises evolving major themes: challenges, stress, attitude, knowledge, social barriers, and motivators. CONCLUSION: About 67.5% of nursing students had BMI less than 18. Inappropriate dietary pattern, frequent ailments, and improper personal habits ensued their malnourished status. Lack of proper knowledge on balanced diet, work place stress, and challenges such as financial constrain, peer pressure, and health ailments along with improper perception of body image of the student nurses are major triggering factors behind the causes of malnutrition.

Strategic implications of changing rule of halves in hypertension: A cross-sectional observational study.

CONTEXT: The burden of non-communicable diseases will sooner overwhelm the health system of the country and could curtail future economic development. Hypertension causes highest cardiovascular morbidities. To attain target Blood Pressure (BP), different strategies are required, which are area specific. The validity of rule of halves of hypertension in various settings needs to be studied for developing strategies for that particular geographical area. To utilize the resources in more efficient way, strategies need to differ in rural-urban and underserved- well-served areas. AIMS: The present study aims at exploring whether the rule of halves holds good in the city of Mumbai as the findings of such research may have implications on strategies to control hypertension in communities. Hence, the objectives of this study are to ascertain the proportion of persons with hypertension with respect to the status of diagnosis, treatment, adequate treatment, and validate it with existing rule of halves. SETTING AND DESIGN: Study was conducted in the urban field practice area of a teaching hospital and medical college of Mumbai that comprises 42 chawl (housing structures); study design- cross-sectional observational study. MATERIALS AND METHODS: This observational cross-sectional study was conducted over a period of 18 months in the field practice area of a teaching hospital and medical college of Mumbai with a total population of 43,069. Sample size was 667. After ethical clearance, participants were interviewed using pretested semi-structured interview schedule that included socio-demographic factors, risk factor evaluation, clinical examination, and anthropometry. Subjects with diagnosed hypertension were questioned thoroughly about hypertension adherence. STATISTICAL ANALYSIS: Descriptive statistics was applied on quantitative data. RESULTS: A total of 667 people from five chawls of age more than 35 years were included into the study. The mean age of study subjects was 50.84 ± 11.47 years. Out of total 667 respondents, 20.3% respondents were normotensive, 50.3% respondents were pre-hypertensive, 25.3% respondents were in stage 1 hypertension, and 4% respondents were in stage 2 hypertension. In contrary to the classical rule of halves, the present study shows only 31% of the diagnosed hypertensives are adequately treated. CONCLUSIONS: The strategies in the national programs are from the traditional understanding of rule of halves and emphasize increasing awareness and treatment. Family physician should actively involve in regular screening, treatment, and adherence of hypertension treatment. As a part of primary care, community participation is required for effectively achieving the target BP goal of the population.

A cross-sectional study to assess the awareness and practices related to adult immunization among nursing students in a metropolitan city.

INTRODUCTION: Immunization against vaccine-preventable diseases in adults is the need of the hour. The student nurses by virtue of training are the frontline health workers dealing with patient care. They are exposed to maximum risk of contracting the diseases. Vaccine awareness is not a part of their induction training program. It is necessary to plan preventive measure related to vaccination in their interest. AIM: This study aims to assess awareness and practices of nursing students related to adult immunization. MATERIALS AND METHODS: It is a cross-sectional study, conducted on nursing students of School of Nursing in Mumbai, over a period of 4 months. Universal sampling technique was used. Sample size was 271. A semi-structured interview schedule was used for data collection. Data were analyzed in Microsoft Excel. RESULTS: The awareness about the vaccines was as follows: hepatitis B (98.1%), hepatitis A (72.3%), rabies (90.4%), H1N1 (74.9%), dT (52%), meningococcal (33.6%), human papillomavirus (49.8%), vaccines during pregnancy (88.2%), varicella (76.4%), typhoid (54.6%), cholera (52.8%), rubella (79.7%), travel vaccines (63.5%), Japanese encephalitis (69%), haemophilus influenzae b (40.9%), and pneumococcal (43.5%). About 87.8% of students have received TT at 10 years of age and 83% have received TT at 16 years of age. Hepatitis B vaccine was taken by 64.5%, out of which only 35% students received complete three doses. Majority of them could not answer the correct doses, availability, and cost of these vaccines. CONCLUSIONS: The awareness and practices about adult immunization are found to be inadequate. Nurses should be appraised about theory and practical aspect of immunization as an immediate solution. Furthermore, considering the importance of this topic, the induction training program of nursing students should include awareness on adult immunization and emphasize their own vaccination. The annual health checkup of students should ensure the compliance of vaccines such as hepatitis B.

Catastrophic Health-care Expenditure and Willingness to Pay for Health Insurance in a Metropolitan City: A Cross-Sectional Study.

BACKGROUND: Health insurance can be a very useful strategy to mitigate the disabling effects of catastrophic health expenditure in India. OBJECTIVES: The aim of the study is to estimate catastrophic health expenditure incurred and the willingness to pay and ability to pay for health insurance among the unsubscribed. MATERIALS AND METHODS: A total of 201 principal earning members of households belonging to the 25-45 years age group were interviewed in a community-based household survey in a conveniently selected ward in Mumbai with the help of a pretested, semi-structured interview schedule. RESULTS: The proportion of households with catastrophic health expenditure was 22.4% (total expenditure estimate) and 17.4% (nonfood expenditure estimate). There was a statistically significant association between socioeconomic class and occurrence of catastrophic health expenditure. The average amount the respondents were willing to pay as premium for health insurance per month was ₹272 and the average amount they were able to pay was ₹259. CONCLUSION: Catastrophic health expenditure continues to be a disastrous problem in around 20% of Indian households. Targeted health insurance schemes with different premiums and coverages for different income and employment groups should be considered.