Maternal depressiveness and infant growth outcomes: Findings from the MAASTHI cohort study in India.

OBJECTIVE: The study aims to examine the association between depressiveness in mothers on infant obesity and stunting at one year of age. METHODS: We enrolled 4829 pregnant women, followed them up at public health facilities in Bengaluru for one year after birth. We collected information on women's sociodemographic characteristics, obstetric history, depressive symptoms during pregnancy and delivery within 48 h. We took infant anthropometric measurements at birth and one year. We used chi-square tests, and calculated an unadjusted odds ratio using univariate logistic regression. We used multivariate logistic regression to examine the association between maternal depressiveness, childhood adiposity, and stunting. RESULTS: We found that the prevalence of depressiveness was 31.8% in mothers who delivered in public health facilities in Bengaluru. Infants born to mothers with depressiveness at birth had 3.9 times higher odds of having larger waist circumference than infants born to mothers with no depressiveness (AOR: 3.96, 95% Confidence Interval: 1.24,12.58) and 1.9 times higher odds of having a larger sum of skinfold thickness (AOR: 1.99, 95% CI: 1.18,3.38). Additionally, we found that infants born to mothers with depressiveness at birth had 1.7 times higher odds of stunting than infants born to mothers with no depressiveness (AOR: 1.72; 95%CI: 1.22,2.43) after adjusting for confounders. CONCLUSION: Our study highlights a high prevalence of depressiveness among mothers seeking antenatal care at a public hospital is associated with an increased risk of infant adiposity and stunting at one year. Further research is needed to understand the underlying mechanisms and identify effective interventions.

Vitamin B6 Levels and Impaired Folate Status but Not Vitamin B12 Associated with Low Birth Weight: Results from the MAASTHI Birth Cohort in South India.

Vitamins B12 and B6 and folate are known to have implications for pregnancy outcomes. We aimed to describe B6, B12, and folate status in pregnancy and investigate their associations with low birth weight and preterm delivery in mothers recruited from public hospitals in urban Bengaluru. Pregnant women between 18 and 45 years were included in the MAASTHI prospective cohort study. Each participant's age, socioeconomic status, and anthropometry were recorded during baseline and followed up after delivery. Blood samples were collected between the 24th and 32nd weeks of gestation and stored at -80° for analysis. B6, B12, folate, homocysteine, and methylmalonic acid (MMA) levels were analyzed in the stored samples. We found low plasma vitamin B12, folate, and B6 levels in 48.5%, 42.0%, and 10.4% of the women (n = 230), respectively. Elevated MMA and homocysteine were observed among 73.6% and 6.1% of the women, respectively. We found B6 levels were significantly associated with birth weight (ß(SE) -0.002(0.0), p = 0.001) after adjusting for age, parity, adiposity, gestational diabetes, and socioeconomic status of the mother. Those with impaired folate deficiency were twice at risk (AOR 1.95 (1.29, 3.07), p = 0.002) of low birth weight. Vitamin B6 levels and impaired folate status were associated with low birth weight in the MAASTHI birth cohort.

Population Preferences for Primary Care Models for Hypertension in Karnataka, India.

Importance: Hypertension contributes to more than 1.6 million deaths annually in India, with many individuals being unaware they have the condition or receiving inadequate treatment. Policy initiatives to strengthen disease detection and management through primary care services in India are not currently informed by population preferences. Objective: To quantify population preferences for attributes of public primary care services for hypertension. Design, Setting, and Participants: This cross-sectional study involved administration of a household survey to a population-based sample of adults with hypertension in the Bengaluru Nagara district (Bengaluru City; urban setting) and the Kolar district (rural setting) in the state of Karnataka, India, from June 22 to July 27, 2021. A discrete choice experiment was designed in which participants selected preferred primary care clinic attributes from hypothetical alternatives. Eligible participants were 30 years or older with a previous diagnosis of hypertension or with measured diastolic blood pressure of 90 mm Hg or higher or systolic blood pressure of 140 mm Hg or higher. A total of 1422 of 1927 individuals (73.8%) consented to receive initial screening, and 1150 (80.9%) were eligible for participation, with 1085 (94.3%) of those eligible completing the survey. Main Outcomes and Measures: Relative preference for health care service attributes and preference class derived from respondents selecting a preferred clinic scenario from 8 sets of hypothetical comparisons based on wait time, staff courtesy, clinician type, carefulness of clinical assessment, and availability of free medication. Results: Among 1085 adult respondents with hypertension, the mean (SD) age was 54.4 (11.2) years; 573 participants (52.8%) identified as female, and 918 (84.6%) had a previous diagnosis of hypertension. Overall preferences were for careful clinical assessment and consistent availability of free medication; 3 of 5 latent classes prioritized 1 or both of these attributes, accounting for 85.1% of all respondents. However, the largest class (52.4% of respondents) had weak preferences distributed across all attributes (largest relative utility for careful clinical assessment: ß = 0.13; 95% CI, 0.06-0.20; 36.4% preference share). Two small classes had strong preferences; 1 class (5.4% of respondents) prioritized shorter wait time (85.1% preference share; utility, ß = -3.04; 95% CI, -4.94 to -1.14); the posterior probability of membership in this class was higher among urban vs rural respondents (mean [SD], 0.09 [0.26] vs 0.02 [0.13]). The other class (9.5% of respondents) prioritized seeing a physician (the term doctor was used in the survey) rather than a nurse (66.2% preference share; utility, ß = 4.01; 95% CI, 2.76-5.25); the posterior probability of membership in this class was greater among rural vs urban respondents (mean [SD], 0.17 [0.35] vs 0.02 [0.10]). Conclusions and Relevance: In this study, stated population preferences suggested that consistent medication availability and quality of clinical assessment should be prioritized in primary care services in Karnataka, India. The heterogeneity observed in population preferences supports considering additional models of care, such as fast-track medication dispensing to reduce wait times in urban settings and physician-led services in rural areas.

How do tobacco control policies work in low-income and middle-income countries? A realist synthesis.

BACKGROUND: The burden of tobacco use is disproportionately high in low- and middle-income countries (LMICs). There is scarce theorisation on what works with respect to implementation of tobacco control policies in these settings. Given the complex nature of tobacco control policy implementation, diversity in outcomes of widely implemented policies and the defining role of the context, we conducted a realist synthesis to examine tobacco control policy implementation in LMICs. METHODS: We conducted a systematic realist literature review to test an initial programme theory developed by the research team. We searched EBSCOHost and Web of Science, containing 19 databases. We included studies on implementation of government tobacco control policies in LMICs. RESULTS: We included 47 studies that described several contextual factors, mechanisms and outcomes related to implementing tobacco control policies to varying depth. Our initial programme theory identified three overarching strategies: awareness, enforcement, and review systems involved in implementation. The refined programme theory identifies the plausible mechanisms through which these strategies could work. We found 30 mechanisms that could lead to varying implementation outcomes including normalisation of smoking in public places, stigmatisation of the smoker, citizen participation in the programme, fear of public opposition, feeling of kinship among violators and the rest of the community, empowerment of authorised officials, friction among different agencies, group identity among staff, shared learning, manipulation, intimidation and feeling left out in the policy-making process. CONCLUSIONS: The synthesis provides an overview of the interplay of several contextual factors and mechanisms leading to varied implementation outcomes in LMICs. Decision-makers and other actors may benefit from examining the role of one or more of these mechanisms in their particular contexts to improve programme implementation. Further research into specific tobacco control policies and testing particular mechanisms will help deepen our understanding of tobacco control implementation in LMICs. PROSPERO REGISTRATION NUMBER: CRD42020191541.

Cohort profile: maternal antecedents of adiposity and studying the transgenerational role of hyperglycaemia and insulin (MAASTHI).

PURPOSE: The Maternal Antecedents of Adiposity and Studying the transgenerational role of Hyperglycaemia and Insulin cohort in Bengaluru, South India, aims to understand the transgenerational role of increased circulating glucose levels or hyperglycaemia and other nutrients and psychosocial environment, on the risk of childhood obesity, as an early marker of chronic diseases. PARTICIPANTS: Through this paper, we describe the baseline characteristics of the cohort participants and their children, along with plans and challenges. A total of 5694 pregnant women were screened, with 4862 (85.4%) eligible pregnant women recruited at baseline. We assessed anthropometry, Haemoglobin status, Oral Glucose Tolerance Test (OGTT), dietary practices, depressive symptoms using the Edinburgh Postnatal Depression Scale and social support in all women. Follow-up visits involved assessing anthropometry and the health profile of mothers and children. FINDINGS TO DATE: Among 4862 eligible participants recruited, 3260 (67%) underwent OGTT, while 2962 participants completed OGTT (90.9%). During the pregnancy, 9.7% of women were obese (>90th percentile of skinfold thickness), and 14.3% had gestational diabetesmellitus. Moreover, 6.2% and 16.8% of women had symptoms suggestive of depression during pregnancy and the immediate postnatal period, respectively. We found that 3.3% of children were small for gestational age, 10.8% were large for gestational age and 9.7% of children were obese at birth. FUTURE PLANS: We have completed recruitment and baseline data collection in 2019, and are conducting annual follow-ups until age 4 of the participant's children. For delineating causal pathways of childhood obesity, blood aliquots are stored in the biorepository. The study will inform policy formulation and community awareness in the prevention and control of non-communicable diseases and health promotion.

Contact tracing of COVID-19 in Karnataka, India: Superspreading and determinants of infectiousness and symptomatic infection.

BACKGROUND: India has experienced the second largest outbreak of COVID-19 globally, yet there is a paucity of studies analysing contact tracing data in the region which can optimise public health interventions (PHI's). METHODS: We analysed contact tracing data from Karnataka, India between 9 March and 21 July 2020. We estimated metrics of transmission including the reproduction number (R), overdispersion (k), secondary attack rate (SAR), and serial interval. R and k were jointly estimated using a Bayesian Markov Chain Monte Carlo approach. We studied determinants of risk of further transmission and risk of being symptomatic using Poisson regression models. FINDINGS: Up to 21 July 2020, we found 111 index cases that crossed the super-spreading threshold of ≥8 secondary cases. Among 956 confirmed traced cases, 8.7% of index cases had 14.4% of contacts but caused 80% of all secondary cases. Among 16715 contacts, overall SAR was 3.6% [95% CI, 3.4-3.9] and symptomatic cases were more infectious than asymptomatic cases (SAR 7.7% vs 2.0%; aRR 3.63 [3.04-4.34]). As compared to infectors aged 19-44 years, children were less infectious (aRR 0.21 [0.07-0.66] for 0-5 years and 0.47 [0.32-0.68] for 6-18 years). Infectors who were confirmed ≥4 days after symptom onset were associated with higher infectiousness (aRR 3.01 [2.11-4.31]). As compared to asymptomatic cases, symptomatic cases were 8.16 [3.29-20.24] times more likely to cause symptomatic infection in their secondary cases. Serial interval had a mean of 5.4 [4.4-6.4] days, and case fatality rate was 2.5% [2.4-2.7] which increased with age. CONCLUSION: We found significant heterogeneity in the individual-level transmissibility of SARS-CoV-2 which could not be explained by the degree of heterogeneity in the underlying number of contacts. To strengthen contact tracing in over-dispersed outbreaks, testing and tracing delays should be minimised and retrospective contact tracing should be implemented. Targeted measures to reduce potential superspreading events should be implemented. Interventions aimed at children might have a relatively small impact on reducing transmission owing to their low symptomaticity and infectivity. We propose that symptomatic cases could cause a snowballing effect on clinical severity and infectiousness across transmission generations; further studies are needed to confirm this finding.

Factors associated with differential COVID-19 mortality rates in the SEAR nations: a narrative review.

Objectives: Since December 2019, the world has been grappling with the COVID-19 pandemic, which has caused severe loss of lives, the breakdown of health infrastructure, and disruption of the global economy. There is growing evidence on mortality patterns in high-income countries. However, similar evidence from low/middle-income nations is lacking. Our review aimed to describe COVID-19 mortality patterns in the WHO-SEAR nations, and explore the associated factors in order to explain such trends. Methods: A systematic and comprehensive search was undertaken in PubMed and Google Scholar to obtain maximum hits on COVID-19 mortality and its determinants in the SEAR, using a combination of MeSH terms and Boolean operators. The data were narratively synthesized in detail under appropriate themes. Results: Our search identified 6411 unique records. Mortality patterns were described in terms of important demographical and epidemiological indicators. Gaps in available evidence and paucity of adequate research in this area were also highlighted. Conclusions: This review examined significant contributors to COVID-19 mortality across SEAR nations, while emphasizing issues relating to insufficient studies and data quality, and reporting challenges and other concerns in resource-constrained settings. There is a compelling need for more work in this area, to help inform decision making and improve public-health response.

What is the Modern Human Eating? Dietary Transition of the Age-Old to the Modern Man of India.

Objectives: The objective of this review is to examine the changes in food consumption pattern of Indians over the years and to recommend evidence-based policy making regarding all the factors affecting food consumption. Methods: We have reviewed the articles from major databases such as PubMed and Google Scholar. The keywords used for the search included dietary pattern, dietary trend, dietary intake, food system, nutrition system, prehistoric food systems, drought, famine, whole grains, diets, prices, income, environment, urban food consumption, processed foods, food security, food preferences, demographic transition, fat intake, food production, public distribution system, food consumption pattern, Indian agriculture, and India. Results: There is no facilitating environment for the production and cultivation of healthy and sustainable food. Conclusion: Policymakers should make major amendments to food and agricultural policies, and demotivate the consumption of junk food.

COVID-19: Optimal Design of Serosurveys for Disease Burden Estimation.

We provide a methodology by which an epidemiologist may arrive at an optimal design for a survey whose goal is to estimate the disease burden in a population. For serosurveys with a given budget of C rupees, a specified set of tests with costs, sensitivities, and specificities, we show the existence of optimal designs in four different contexts, including the well known c-optimal design. Usefulness of the results are illustrated via numerical examples. Our results are applicable to a wide range of epidemiological surveys under the assumptions that the estimate's Fisher-information matrix satisfies a uniform positive definite criterion.

Screening and management options for severe thinness during pregnancy in India.

This paper answers research questions on screening and management of severe thinness in pregnancy, approaches that may potentially work in India, and what more is needed for implementing these approaches at scale. A desk review of studies in the last decade in South Asian countries was carried out collating evidence on six sets of strategies like balanced energy supplementation (BEP) alone and in combination with other interventions like nutrition education. Policies and guidelines from South Asian countries were reviewed to understand the approaches being used. A 10-point grid covering public health dimensions covered by World Health Organization and others was created for discussion with policymakers and implementers, and review of government documents sourced from Ministry of Health and Family Welfare. Eighteen studies were shortlisted covering Bangladesh, India, Nepal, and Pakistan. BEP for longer duration, preconception initiation of supplementation, and better pre-supplementation body mass index (BMI) positively influenced birthweight. Multiple micronutrient supplementation was more effective in improving gestational weight gain among women with better pre-supplementation BMI. Behavior change communication and nutrition education showed positive outcomes on dietary practices like higher dietary diversity. Among South Asian countries, Sri Lanka and Nepal are the only two countries to have management of maternal thinness in their country guidelines. India has at least nine variations of supplementary foods and three variations of full meals for pregnant women, which can be modified to meet additional nutritional needs of those severely thin. Under the National Nutrition Mission, almost all of the globally recommended maternal nutrition interventions are covered, but the challenge of reaching, identifying, and managing cases of maternal severe thinness persists. This paper provides four actions for addressing maternal severe thinness through available public health programs, infrastructure, and human resources.

Population estimates and determinants of severe maternal thinness in India.

OBJECTIVE: To examine prevalence, risk factors, and consequences of maternal severe thinness in India. METHODS: This mixed methods study analyzed data from the Indian National Family Health Survey (NFHS)-4 (2015-2016) to estimate the prevalence of and risk factors for severe thinness, followed by a desk review of literature from India. RESULTS: Prevalence of severe thinness (defined by World Health Organization as body mass index [BMI] <16 in adult and BMI for age Z score < -2 SD in adolescents) was higher among pregnant adolescents (4.3%) compared with pregnant adult women (1.9%) and among postpartum adolescent women (6.3%) than postpartum adult women (2.4%) 2-6 months after delivery. Identified research studies showed prevalence of 4%-12% in pregnant women. Only 13/640 districts had at least three cases of severely thin pregnant women; others had lower numbers. Three or more postpartum women aged ≥20 years were severely thin in 32 districts. Among pregnant adolescents, earlier parity increased odds (OR 1.96; 95% CI, 1.18-3.27) of severe thinness. Access to household toilet facility reduced odds (OR 0.72; 95% CI, 0.52-0.99]. Among mothers aged ≥20 years, increasing education level was associated with decreasing odds of severe thinness (secondary: OR 0.74; 95% CI, 0.57-0.96 and Higher: OR 0.54; 95% CI, 0.32-0.91, compared with no education); household wealth and caste were also associated with severe thinness. CONCLUSION: This paper reveals the geographic pockets that need priority focus for managing severe thinness among pregnant women and mothers in India to limit the immediate and intergenerational adverse consequences emanating from these deprivations.

Emerging and Public Health Challenges Existing in Gestational Diabetes Mellitus and Diabetes in Pregnancy.

We review the evidence available worldwide on the various challenges in the screening, management, prevention of gestational diabetes mellitus and diabetes in pregnancy. The use of multiple screening and diagnostic tests prescribed by numerous guidelines is challenging for practitioners. Also, sociocultural, demographic and economic challenges affect the prevention and care. Life-course perspectives need to be adopted, as well as an integrated approach in public health care is essential. Tackling these challenges at each phase of life-course, with development and adherence to the country-specific guidelines by practitioners can decrease the burden of gestational diabetes mellitus and diabetes in pregnancy.

Lessons From the Aftermaths of Green Revolution on Food System and Health.

Food production has seen various advancements globally in developing countries, such as India. One such advancement was the green revolution. Notably, the World Bank applauds the introduction of the green revolution as it reduced the rural poverty in India for a certain time. Despite the success of the green revolution, the World Bank reported that health outcomes have not been improved. During the post-green revolution period, several notable negative impacts arose. Exclusive studies were not conducted on the benefits and harms before the introduction of the green revolution. Some of such interventions deviate from the natural laws of balance and functioning and are unsustainable practices. To avoid the adverse effects of some of these developments, a review of these interventions is necessary.

Mid-upper arm circumference in pregnant women and birth weight in newborns as substitute for skinfold thickness: findings from the MAASTHI cohort study, India.

BACKGROUND: Estimating total body fat in public hospitals using gold-standard measurements such as air displacement plethysmography (ADP), deuterium oxide dilution, or dual-energy X-ray absorptiometry (DXA) is unaffordable, and it is challenging to use skinfold thickness. We aimed to identify the appropriate substitute marker for skinfold thickness to estimate total body fat in pregnant women and infants. METHODS: The study is part of a prospective cohort study titled MAASTHI in Bengaluru, from 2016 to 19. Anthropometric measurements such as body weight, head circumference, mid-upper arm circumference (MUAC), and skinfold thickness were measured in pregnant women between 14 and 36 weeks of gestational age; while measurements such as birth weight, head, chest, waist, hip, mid-upper arm circumference, and skinfold thickness were recorded for newborns. We calculated Kappa statistics to assess agreement between these anthropometric markers with skinfold thickness. RESULTS: We found the highest amount of agreement between total skinfold thickness and MUAC (Kappa statistic, 0.42; 95 % CI 0.38-0.46) in pregnant women. For newborns, the highest agreement with total skinfold thickness was with birth weight (0.57; 95 % CI 0.52-0.60). Our results indicate that MUAC higher than 29.2 cm can serve as a suitable alternative to total skinfolds-based assessments for obesity screening in pregnancy in public facilities. Similarly, a birth weight cut-off of 3.45 kg can be considered for classifying obesity among newborns. CONCLUSION: Mid-upper arm circumference and birth weight can be used as markers of skinfold thickness, reflecting total body fat in pregnant women and the infant, respectively. These two anthropometric measurements could substitute for skinfold thickness in low- and middle-income urban India settings.

The burden of active infection and anti-SARS-CoV-2 IgG antibodies in the general population: Results from a statewide sentinel-based population survey in Karnataka, India.

OBJECTIVE: To estimate the burden of active infection and anti-SARS-CoV-2 IgG antibodies in Karnataka, India, and to assess variation across geographical regions and risk groups. METHODS: A cross-sectional survey of 16,416 people covering three risk groups was conducted between 3-16 September 2020 using the state of Karnataka's infrastructure of 290 healthcare facilities across all 30 districts. Participants were further classified into risk subgroups and sampled using stratified sampling. All participants were subjected to simultaneous detection of SARS-CoV-2 IgG using a commercial ELISA kit, SARS-CoV-2 antigen using a rapid antigen detection test (RAT) and reverse transcription-polymerase chain reaction (RT-PCR) for RNA detection. Maximum-likelihood estimation was used for joint estimation of the adjusted IgG, active and total prevalence (either IgG or active or both), while multinomial regression identified predictors. RESULTS: The overall adjusted total prevalence of COVID-19 in Karnataka was 27.7% (95% CI 26.1-29.3), IgG 16.8% (15.5-18.1) and active infection fraction 12.6% (11.5-13.8). The case-to-infection ratio was 1:40 and the infection fatality rate was 0.05%. Influenza-like symptoms or contact with a COVID-19-positive patient were good predictors of active infection. RAT kits had higher sensitivity (68%) in symptomatic people compared with 47% in asymptomatic people. CONCLUSION: This sentinel-based population survey was the first comprehensive survey in India to provide accurate estimates of the COVID-19 burden. The findings provide a reasonable approximation of the population immunity threshold levels. Using existing surveillance platforms coupled with a syndromic approach and sampling framework enabled this model to be replicable.

Implementation research for taking tobacco control policies to scale in India: a realist evaluation study protocol.

INTRODUCTION: There are ongoing policies and programs to reduce tobacco use and minimise the associated health burden in India. However, there are several challenges in practice leading to different outcomes across Indian states. Inadequate understanding of how national tobacco control policies achieve their results under varied circumstances obstruct the implementation and scaling up of effective strategies. This study is a realist evaluation using largely qualitative methods to understand the implementation process of India's tobacco control policies. It will do so by evaluating India's Cigarettes and Other Tobacco Products Act (COTPA) and the National Tobacco Control Program (NTCP). The study aims to examine how, why, for whom and under which circumstances COTPA and NTCP are implemented in India. METHODS AND ANALYSIS: A realist synthesis on implementation of tobacco control policies in low-income and middle-income countries is conducted. This is followed by qualitative data collection and analysis in three Indian states selected based on data from two rounds of the Global Adult Tobacco Survey. The study comprises of three steps (1): development of initial programme theories, (2) testing and refinement of initial programme theories and (3) testing and validation of refined programme theories. We will interview policy-makers, programme managers and implementers to identify facilitators and barriers of implementation. The purpose is to identify context-specific evidence-based strategies to gain insights into the implementation process of COTPA and NTCP. Further we aim to contribute to tobacco control research by establishing communities of practice to engage with cross-cutting issues. ETHICS AND DISSEMINATION: The Institutional Ethics Committee, at the Institute of Public Health (Bengaluru), has approved the protocol. Written informed consent forms will be obtained from all the participants. Dissemination has been planned for researchers, policy-makers and implementers as well as the public through peer-reviewed publications, conference presentation, webinars and social media updates. PROSPERO REGISTRATION NUMBER: CRD42020191541.