Use of online food delivery services among adults in five countries from the International Food Policy Study 2018-2021.

Aim: Online food delivery services (OFDS) are popular for purchasing meals prepared outside home, increasing access to energy-dense and nutrient-poor foods. This adversely impacts dietary choices and health outcomes. Our study examined trends in OFDS use in Australia, Canada, Mexico, the United Kingdom (UK), and the United States (US) from 2018 to 2021. Methods: Repeated annual cross-sectional data was sourced from the International Food Policy Study for five countries among adults over 18 years (N = 83,337). Weighted estimates for trends in i) the proportion of the respondent's purchasing meals per week using OFDS, and ii) average number (and standard deviation (SD)) of meals purchased per week using OFDS were assessed. Logistic regression models were fitted. Findings: OFDS use increased among adults between 2018-2021 (Australia: 17 % of respondents purchased at least one meal in the last 7 days using OFDS in 2018 to 25 % in 2021, Canada: 12 % to 19 %, Mexico: 28 % to 38 %, UK: 19 % to 28 %, and US: 17 % to 21 %). Average number of meals purchased per week outside home remained consistent for all countries over time (e.g., in Australia, 2.70 (SD 0.06) meals in 2018 and 2.63 (SD 0.06) in 2021). However, average number of meals purchased using OFDS nearly doubled between 2018 and 2021 (e.g., in Australia, 0.45 (SD 0.03) meals in 2018 to 0.81 (SD 0.04) in 2021). Conclusion: OFDS use is increasing and are substituting the conventional forms of purchasing meals outside home. Nutritional quality of foods sold, marketing practices and purchasing patterns on OFDS deserve further attention.

'Healthier options tend to get lost in the noise of online' - Australian shoppers' experiences with online grocery platforms.

OBJECTIVE: We aimed to understand what influences parents' purchasing behaviours when shopping for groceries online and potential ways to improve the healthiness of online grocery platforms. DESIGN: We conducted semi-structured interviews, guided by the Marketing Mix framework. Reflexive thematic analysis was used to analyse data. SETTING: Online interviews were conducted with primary grocery shoppers. PARTICIPANTS: Parents (n 14) or caregivers (n 2) using online grocery platforms at least every 2 weeks. RESULTS: Most participants perceived purchasing healthy food when shopping for groceries online to be more challenging compared to in physical stores. They expressed concerns about the prominence of online marketing for unhealthy food. Participants from lower socio-economic backgrounds often depended on online supermarket catalogues to find price promotions, but healthy options at discounted prices were limited. Across socio-economic groups, fresh items like meat and fruit were preferred to be purchased instore due to concerns about online food quality.Participants believed online grocery platforms should make healthy foods more affordable and supported regulations on supermarket retailers to promote healthy options and limit unhealthy food promotion online. CONCLUSIONS: Participants had varied experiences with online grocery shopping, with both positive and negative aspects. Efforts to improve population diets need to include mechanisms to create health-enabling online grocery retail platforms. Government interventions to restrict marketing of unhealthy foods and promote marketing of healthy options on these platforms warrant investigation.

Convenience as a dimension of food environments: A systematic scoping review of its definition and measurement.

Convenience is a major driver of food choice throughout the world, yet it is often inconsistently conceptualised, defined and measured. This limits the scope for food systems policy and interventions to leverage convenience to improve diet and nutrition outcomes. We conducted a systematic literature review to determine how convenience is both defined and measured in food environment and nutrition research. Six databases were systematically searched and studies were screened by two independent reviewers based on pre-defined eligibility criteria, yielding 243 studies for inclusion in the final review. 77% of studies did not explicitly define convenience. Among those that did, the dimensions and components within definitions varied. 83% of studies used perceived measures of convenience rather than objective measures. Convenience was most commonly measured in high income countries (64%) and in relation to the home food environment (53%), followed by formal retail (40%). Very few studies measured convenience in relation to the informal retail or cultivated food environments, and no studies considered convenience in relation to wild food environments. The vast majority of studies did not consider the validity or reliability of the measures of convenience. Based on our findings we propose a definition of convenience as a characteristic that results in reduced requirement for resources including time, physical effort, mental effort and skills by the consumer in relation to the planning, acquisition, preparation, storage, transport, consumption or clean-up of food. This definition can be used to help guide the development of measurement tools that can be used to assess convenience across different dimensions and contexts in a more comprehensive way. We also propose a framework for considering convenience as an entry point in food systems to improve diets and nutrition outcomes.

Australians support for policy initiatives addressing unhealthy diet: a population-based study.

To inform public health policy implementation in Australia, our study investigated the level of public support for six policy initiatives addressing unhealthy diet. The policy initiatives included taxing soft drinks and energy drinks, taxing less healthy food and beverage purchases, zoning to restrict the supply of junk foods near schools, prohibiting advertising and promotion of less healthy food and beverages to children under the age of 16 and restricting sugar-sweetened beverages from vending machines in schools, and public places. Data from a cross-sectional population-based study for 4040 Australians aged 15+ years, were analysed. A high overall support across all policy initiatives was observed. Nearly three-quarter of public support was observed for policy initiatives targeting children (zoning to restrict the supply of junk food near schools, prohibiting advertising and promotion of less healthy food and beverages to children under the age of 16 and restricting sugars-sweetened beverages from vending machines in schools), and half of Australians supported policy initiatives of taxing soft drinks and energy drinks and taxing less healthy food and beverage purchases. Australian women and those with tertiary level of education were more likely to support public health initiatives targeting children and all policy initiatives respectively. Interestingly, young adults expressed low level of support for all policy initiatives. The study demonstrated considerable public support for policy initiatives focussed on protecting children from unhealthy diet in Australia. Framing, designing and implementing policies targeting children is potentially a good starting point for policymakers to create a health promoting food environment.

Virtual Care Initiatives for Older Adults in Australia: Scoping Review.

BACKGROUND: There has been a rapid shift toward the adoption of virtual health care services in Australia. It is unknown how widely virtual care has been implemented or evaluated for the care of older adults in Australia. OBJECTIVE: We aimed to review the literature evaluating virtual care initiatives for older adults across a wide range of health conditions and modalities and identify key challenges and opportunities for wider adoption at both patient and system levels in Australia. METHODS: A scoping review of the literature was conducted. We searched MEDLINE, Embase, PsycINFO, CINAHL, AgeLine, and gray literature (January 1, 2011, to March 8, 2021) to identify virtual care initiatives for older Australians (aged ≥65 years). The results were reported according to the World Health Organization's digital health evaluation framework. RESULTS: Among the 6296 documents in the search results, we identified 94 that reported 80 unique virtual care initiatives. Most (69/80, 89%) were at the pilot stage and targeted community-dwelling older adults (64/79, 81%) with chronic diseases (52/80, 65%). The modes of delivery included videoconference, telephone, apps, device or monitoring systems, and web-based technologies. Most initiatives showed either similar or better health and behavioral outcomes compared with in-person care. The key barriers for wider adoption were physical, cognitive, or sensory impairment in older adults and staffing issues, legislative issues, and a lack of motivation among providers. CONCLUSIONS: Virtual care is a viable model of care to address a wide range of health conditions among older adults in Australia. More embedded and integrative evaluations are needed to ensure that virtually enabled care can be used more widely by older Australians and health care providers.

Association between cash transfer programs and oral health-A scoping review.

OBJECTIVES: The aims of this scoping review are to assess the literature investigating the association between cash transfer programs and oral health; and to identify the theoretical frameworks applied to guide this literature. METHODS: A search strategy to identify studies published until December 2020 was applied to a range of databases. Observational and interventional studies that had cash transfer programs as exposure/intervention and oral health as outcome were considered. Dental health services utilization, as well as access to dental health services, were considered secondary outcomes. Cash transfer programs were considered programs based on conditional or unconditional cash transfer carried out as part of national social protection schemes, and interventional studies on the impact of cash transfer on oral health were also considered eligible. Data charting was performed in two steps and a narrative synthesis was conducted. RESULTS: Of 6344 articles identified, four articles were included. These articles investigated three different conditional cash transfer programs, Universal Child Allowance (Argentina), Bolsa Família (Brazil) and Family Rewards (USA). Inconsistencies were identified in findings on the effect of conditional cash transfer programs on the prevalence of dental caries and these differences may be due to the comparison group selected for each study. Concerning dental visits, the results point in different directions, which makes these findings still inconclusive. No explicit theoretical framework was reported in the articles to guide the expected association. CONCLUSION: Although cash transfers play an important role in improving certain health outcomes, there is limited evidence to suggest an association between cash transfers and oral health.

Factors Influencing Implementation, Sustainability and Scalability of Healthy Food Retail Interventions: A Systematic Review of Reviews.

The aim of this systematic review of reviews was to synthesise the evidence on factors influencing the implementation, sustainability and scalability of food retail interventions to improve the healthiness of food purchased by consumers. A search strategy to identify reviews published up until June 2020 was applied to four databases. The Risk of Bias in Systematic Review tool was used. Review findings were synthesised narratively using the socio-ecological model. A total of 25 reviews met the inclusion criteria. A number of factors influenced implementation; these included retailers' and consumers' knowledge and preferences regarding healthy food; establishing trust and relationships; perceived consumer demand for healthy food; profitability; store infrastructure; organizational support, including resources; and enabling policies that promote health. Few reviews reported on factors influencing sustainability or scalability of the interventions. While there is a large and rapidly growing body of evidence on factors influencing implementation of interventions, more work is needed to identify factors associated with their sustainability and scalability. These findings can be used to develop implementation strategies that consider the multiple levels of influence (individual, intrapersonal and environmental) to better support implementation of healthy food retail interventions.

The association between sugar intake during pregnancy and allergies in offspring: a systematic review and a meta-analysis of cohort studies.

CONTEXT: It has been hypothesized that a mother's diet during pregnancy may modulate her offspring's immune system development and lead to development of allergic diseases among offspring. However, the evidence for this is unclear and inconclusive. OBJECTIVE: This systematic review was undertaken to examine the weight of evidence for causality from cohort studies on the association between maternal free sugar intake during pregnancy and development of allergies in offspring. DATA SOURCES: Using a systematic search strategy, PubMed, SCOPUS, and Web of Science databases were searched from inception to May 2020. DATA EXTRACTION: For the reporting of this systematic review, the PRISMA guideline was followed. Studies examining maternal sugar consumption during pregnancy (using self-reported data) and the development of allergic diseases among offspring (infancy to 5 years) were included. DATA ANALYSIS: The Newcastle-Ottawa Scale quality assessment tool was used to assess the study quality. Meta-analysis was conducted using a random-effects model to synthesize the findings. Of 159 publications identified from the search, 5 articles with 4 unique cohort studies were included in this systematic review. The limited meta-analysis showed that a mother's increased free sugar intake during pregnancy was associated with an increased risk of developing asthma in offspring (odds ratio 1.07 [95% CI, 1.00 to 1.14; I2 = 0%]). High free sugar intake by the mother during pregnancy was also associated with increased odds of offspring (to age 7.7 years) developing other common allergies, including allergic rhinitis, atopy and eczema, wheeze, and food allergies . CONCLUSION: From the limited evidence, this review suggests that high free sugar consumption during pregnancy may be associated with the development of allergies in offspring. Clinical guidelines and public health policy recommendations for maternal diet in pregnancy should include advice about reducing free sugar intake due to a possible association with allergies in offspring. However, recommendations should be made with caution considering other maternal and fetal risk factors.

The Impact of and Government Planning and Responses to Pandemics for People with Disability: A Rapid Review.

Objective-To collate evidence on (1) the risk of infection for people with disability during infectious disease outbreaks and/or pandemics and (2) government responses and pandemic plans for people with disability. Methods-Through two rapid reviews, relevant peer-reviewed studies and grey literature published from 2002 onwards in the English language were identified. Data were synthesised narratively. Results-Aim 1: Of the 680 studies, two studies were included in the review. No grey literature was eligible for inclusion. The evidence regarding risk was inconclusive. Aim 2: Of the 50 studies, three peer-review studies, along with four government reports were included. The literature largely reported on measures being taken to maximise the prevention of transmission of COVID-19 for the general population, with only a few programs including people with disability. Conclusion-Overall, there is inconclusive evidence on the risk of infection for people with disability during infectious disease outbreaks and/or pandemics and the government preparedness and planning for disease outbreaks and/or pandemics largely exclude people with disability. From a population health perspective, during disease outbreaks and pandemics, including the COVID-19 pandemic, along with the general population, it is important for governments to include people with disability in their pandemic planning and response.

A state-wide audit of unhealthy sponsorship within junior sporting clubs in Victoria, Australia.

OBJECTIVE: To systematically audit the extent of unhealthy sponsorship within junior community sporting clubs and ascertain whether differences exist across geographical areas and sport types. DESIGN: Club sponsorship data were assessed to determine the extent of unhealthy food/beverage, alcohol and gambling sponsorship using a cross-sectional design. Differences across geographical areas were assessed using logistic regressions. SETTING: A stratified random sampling procedure was used to select thirty communities across the state of Victoria, Australia. Within each community, local clubs across the top eight participating junior sports were selected for audit. PARTICIPANTS: Sponsorship data were collected from 191 club websites and Facebook pages in September-November 2019. RESULTS: Unhealthy sponsorships represented 8·9 % of all identified sponsorship arrangements. A quarter of all clubs accepted alcohol (25·6 %) and unhealthy food sponsors (25·9 %), and one-fifth of all clubs accepted high-risk food (unhealthy brands with large market share) (18·1 %) and gambling sponsors (20·4 %). Acceptance of unhealthy sponsorship differed across sport types with football, netball, cricket and soccer clubs having the greatest numbers. Compared with metro areas, a significantly greater proportion of sporting clubs in regional areas were affiliated with unhealthy food (32·7 % v. 19·6 %) and high-risk food sponsors (26·9 % v. 9·8 %). A higher proportion of clubs in low socio-economic status (SES), compared with the high SES areas, were affiliated with alcohol (33·9 % v. 16·5 %) and gambling sponsors (27·4 % v. 12·6 %). CONCLUSION: Victorian children participating in community junior sports are being exposed to marketing of unhealthy brands and products. Public health intervention is necessary to protect children from this exposure.

Differential exposure to, and potential impact of, unhealthy advertising to children by socio-economic and ethnic groups: A systematic review of the evidence.

Children's exposure to advertising of unhealthy food and nonalcoholic beverages that are high in saturated fats, salt and/or sugar is extensive and increases children's preferences for, and intake of, targeted products. This systematic review examines the differential potential exposure and impact of unhealthy food advertising to children according to socio-economic position (SEP) and/or ethnicity. Nine databases (health, business, marketing) and grey literature were searched in November 2019 using terms relating to 'food or drink', 'advertising' and 'socioeconomic position or ethnicity'. Studies published since 2007 were included. Article screening and data extraction were conducted by two independent reviewers. Quality of studies was assessed using the Newcastle-Ottawa quality scale. Of the 25 articles included, 14 focused on exposure to unhealthy food advertising via television, nine via outdoor mediums and two via multiple mediums. Most studies (n = 19) revealed a higher potential exposure or a greater potential impact of unhealthy food advertising among ethnic minority or lower SEP children. Few studies reported no difference (n = 3) or mixed findings (n = 3). Children from minority and socio-economically disadvantaged backgrounds are disproportionately exposed to unhealthy food advertising. Regulations to restrict unhealthy food advertising to children should be implemented to improve children's diets and reduce inequities in dietary intake.

The effect of front-of-package labels or point-of-sale signage on consumer knowledge, attitudes and behavior regarding sugar-sweetened beverages: a systematic review.

CONTEXT: Globally, the use of labels or signage targeting SSBs remains in its infancy and there is limited evidence available regarding its ability to decrease purchase and consumption of SSBs. OBJECTIVE: This systematic review aimed to synthesize the evidence on the effect of sugar- or health-related sugar-sweetened beverage (SSB) warning labels or signage on knowledge, attitudes, and beliefs, and SSB purchase and consumption. DATA SOURCES: Nine databases - Ovid Medline, Emerald Insight, Scopus, Informit, Business Source Complete, CINAHL, Global Health, PsychINFO, and SocIndex - were searched along with grey literature from inception to December 2019. The PRISMA guidelines were applied for reporting this systematic review. STUDY SELECTION: Studies examining the impact of front of pack (FOP) labels and/or point of sale (POS) signage highlighting added sugar content or its health risks were included. DATA EXTRACTION: Two authors independently extracted data on items, including study details, study design, population characteristics, intervention label details (type, duration, and settings), and outcomes measures. The Effective Public Health Practice Project tool was used to assess the study quality. DATA ANALYSIS: Findings were synthesized narratively. RESULTS: Twenty-one studies published between 1992 and 2019 were included. Of these, 16 studies examined the impact of FOP labels and 5 studies examined the impact of POS signage. Both FOP labels and POS signage were associated with improved health knowledge, attitudes, and beliefs regarding SSBs and reduced SSB purchases. Warning labels with diet-related health consequences were found to be particularly effective. Overall quality of studies was assessed as mixed. CONCLUSION: Health- or sugar-related FOP labels and POS signage for SSBs are promising public health measures and may improve consumers' health behaviors toward reduced SSB purchase and consumption.

Australia's sugar tale.

OBJECTIVE: To establish high intake of free sugars and its related disease burden as a significant public health challenge in Australia. DESIGN: We discuss five key actions to reduce intake of free sugars tailored to the Australian context. These strategies are informed by reviewing the global scientific evidence on the effectiveness of a range of policy responses to reduce intake of free sugars at the population level. SETTING: Australia. PARTICIPANTS: Australian population. RESULTS: The five key actions to reduce population levels for intake of free sugars tailored to the Australian context include prioritising health in trade agreements and policy; introducing a fiscal policy supporting health and promoting food reformulation; regulating advertising and improving labelling; strengthening the current dietary guidelines; and encouraging healthy choices. CONCLUSIONS: The adoption and implementation of the strategies discussed in the current commentary would aid in tackling the rising health burden from the intake of free sugars in Australia.

How much free sugar do Australians consume? Findings from a national survey.

OBJECTIVE: To identify the characteristics of Australian adults exceeding the World Health Organization's free sugar (FS) intake recommendations of <10% and compare the sources of FS among those exceeding (high FS consumers) and complying (low FS consumers) with the recommendations. METHOD: Nationally weighted data from the Australian National Nutrition and Physical Activity Survey 2011-12 was used to describe the proportions of FS consumption and sources of FS among adults aged ≥18 years (n=9,435) across demographic, socioeconomic and health behavioural subgroups. Six categories of food groups likely to contain FS were generated and analysed. RESULTS: Almost half of all adults (47%) were high FS consumers. More than one-third of adults in each demographic, socioeconomic and health behaviour subgroup were high FS consumers. Of the food groups containing FS, beverages contributed the most FS (37%), particularly for young adults (48%). High FS consumers obtained twice as much FS from beverages (42%) than low FS consumers (21%). A reverse age gradient was observed for the FS sourced from beverages. CONCLUSIONS: Almost half the Australians surveyed exceeded the FS intake recommendations. Sugary beverages were the largest source of FS, with young adults being the highest consumers. Implications for public health: Whole population strategies targeting beverages could possibly reduce Australia's high sugar intake.

Determinants of knowledge and attitudes about sugar and the association of knowledge and attitudes with sugar intake among adults: A systematic review.

Efforts to reduce sugar intake levels have been primarily limited to increasing knowledge and changing attitudes. We conducted a systematic review to (1) identify factors influencing adults' knowledge and attitudes about sugar, and (2) determine if there is an association between knowledge and attitudes about sugar and sugar intake. We searched 15 electronic databases from inception to December 2016 for English language publications including adults with relevant exposure and outcome measures. Findings were summarised meta-narratively. Of 3287 studies, 22 studies (14 for objective one and 8 for objective two) were included. Individual (liking of sugary food), interpersonal (attitudes of peers) and environmental factors (media, health professionals and food labelling) influenced adults' knowledge and attitudes about sugar, at least to some extent. Overall, quality of the studies included in our review was weak, and evidence for the application of the Knowledge-Attitude-Behavior model for understanding sugar intake is limited. Protocol registered in the PROSPERO International prospective register of systematic reviews (registration number CRD42015027540).

Barriers and prospects of India's conditional cash transfer program to promote institutional delivery care: a qualitative analysis of the supply-side perspectives.

BACKGROUND: Under the National Health Mission (NHM) of India, Janani Suraksha Yojana (JSY) offers conditional cash transfer and support services to pregnant women to use institutional delivery care facilities. This study aims to understand community health workers' (ASHAs) and program officials' perceptions regarding barriers to and prospects for the uptake of facilities offered under the JSY. METHODS: Fifty in-depth interviews of a purposively selected sample of ASHAs (n = 12), members of Village Health and Sanitation Committees (n = 11), and officials at different tiers of healthcare facilities (n = 27) were conducted in three Indian states. The data were analyzed thematically using ATLAS.ti software. RESULTS: Although the JSY has triggered considerable advancement on the Indian maternal and child health front, there are several barriers to be resolved pertaining to i) delivering quality care at health-facility; ii) linkages between home and health-facility; and iii) the community/household context. At the facility level, respondents cited an inability to treat birth complications as a barrier to JSY uptake, resulting in referrals to other (mostly private) facilities. Despite increased investment in health infrastructure under the program, shortages in emergency obstetric-care facilities, specialists and staff, essential drugs, diagnostics, and necessary equipment persisted. Weaker linkages between various vertical (standalone) elements of maternal and primary healthcare programs, and nearly uniform resource allocation to all facilities irrespective of caseloads and actual need also constrained the provision of quality healthcare. Barriers affecting the linkages between home and facility arose mainly due to the mismatch between the multiple demands and the availability of transport facilities, especially in emergency situations. Regarding community/household context, several socio-cultural issues such as resistance towards the ASHA's efforts of counselling, particularly from elderly family members, often adversely affected people's decision to seek healthcare. CONCLUSION: Adequate interventions at the community level, capacity building for healthcare providers, and measures to address underlying structural and systemic barriers are needed to improve the uptake of institutional maternal healthcare.

A qualitative study of factors impacting accessing of institutional delivery care in the context of India's cash incentive program.

Not all eligible women use the available services under India's Janani Suraksha Yojana (JSY), which provides cash incentives to encourage pregnant women to use institutional care for childbirth; limited evidence exists on demand-side factors associated with low program uptake. This study explores the views of women and ASHAs (community health workers) on the use of the JSY and institutional delivery care facilities. In-depth qualitative interviews, carried out in September-November 2013, were completed in the local language by trained interviewers with 112 participants consisting of JSY users/non-users and ASHAs in Jharkhand, Madhya Pradesh and Uttar Pradesh. The interaction of impeding and enabling factors on the use of institutional care for delivery was explored. We found that ASHAs' support services (e.g., arrangement of transport, escort to and support at healthcare facilities) and awareness generation of the benefits of institutional healthcare emerged as major enabling factors. The JSY cash incentive played a lesser role as an enabling factor because of higher opportunity costs in the use of healthcare facilities versus home for childbirth. Trust in the skills of traditional birth-attendants and the notion of childbirth as a 'natural event' that requires no healthcare were the most prevalent impeding factors. The belief that a healthcare facility would be needed only in cases of birth complications was also highly prevalent. This often resulted in waiting until the last moments of childbirth to seek institutional healthcare, leading to delay/non-availability of transportation services and inability to reach a delivery facility in time. ASHAs opined that interpersonal communication for awareness generation has a greater influence on use of institutional healthcare, and complementary cash incentives further encourage use. Improving health workers' support services focused on marginalized populations along with better public healthcare facilities are likely to promote the uptake of institutional delivery care in resource-poor settings.

Has India's national rural health mission reduced inequities in maternal health services? A pre-post repeated cross-sectional study.

BACKGROUND: In 2005, India launched the National Rural Health Mission (NRHM) to strengthen the primary healthcare system. NRHM also aims to encourage pregnant women, particularly of low socioeconomic backgrounds, to use institutional maternal healthcare. We evaluated the impacts of NRHM on socioeconomic inequities in the uptake of institutional delivery and antenatal care (ANC) across high-focus (deprived) Indian states. METHODS: Data from District Level Household and Facility Surveys (DLHS) Rounds 1 (1995-99) and 2 (2000-04) from the pre-NRHM period, and Round 3 (2007-08), Round 4 and Annual Health Survey (2011-12) from post-NRHM period were used. Wealth-related and education-related relative indexes of inequality, and pre-post difference-in-differences models for wealth and education tertiles, adjusted for maternal age, rural-urban, caste, parity and state-level fixed effects, were estimated. RESULTS: Inequities in institutional delivery declined between pre-NRHM Period 1 (1995-99) and pre-NRHM Period 2 (2000-04), but thereafter demonstrated steeper decline in post-NRHM periods. Uptake of institutional delivery increased among all socioeconomic groups, with (1) greater effects among the lowest and middle wealth and education tertiles than highest tertile, and (2) larger equity impacts in the late post-NRHM period 2011-12 than in the early post-NRHM period 2007-08. No positive impact on the uptake of ANC was found in the early post-NRHM period 2007-08; however, there was considerable increase in the uptake of, and decline in inequity, in uptake of ANC in most states in the late post-NRHM period 2011-12. CONCLUSION: In high-focus states, NRHM resulted in increased uptake of maternal healthcare, and decline in its socioeconomic inequity. Our study suggests that public health programs in developing country settings will have larger equity impacts after its almost full implementation and widest outreach. Targeting deprived populations and designing public health programs by linking maternal and child healthcare components are critical for universal access to healthcare.

Association between tooth loss and hypertension among a primarily rural middle aged and older Indian adult population.

BACKGROUND: Studies in high-income countries have reported associations between tooth loss and hypertension. There is however a lack of evidence on this association from South Asian countries especially India. The current study aimed to assess the association between self-reported tooth loss and hypertension in a primarily rural middle-aged and older Indian population. METHODS: A secondary analysis of cross-sectional data from the Longitudinal Ageing Study of India - pilot survey was conducted on 1,486 adults aged 45 years and above from four states of India. The primary outcome was self-reported hypertension and the main explanatory variable was self-reported tooth loss. Multivariable logistic regression models estimated the association between hypertension and tooth loss after controlling for confounders including age, sex, marital status, area of residence, educational attainment, tobacco use, alcohol use, physical activity, and self-reported diabetes. RESULTS: Compared to those without any tooth loss, individuals with partial tooth loss had 1.62 times (95% CI: 1.12-2.35) higher odds of being hypertensive after adjustment of confounders including age, sex, marital status, area of residence, educational attainment, tobacco use, alcohol use, physical activity, and self-reported diabetes. The crude significant association (OR: 2.54; 95% CI: 1.50-4.29) between edentulousness and hypertension became nonsignificant and attenuated after adjustment of potential confounders (fully adjusted model OR: 1.33; 95% CI: 0.72-2.44). CONCLUSION: Partial tooth loss was associated with a higher probability of hypertension among dentate middle-aged and older adults in four states of India.

Examining Implementation of Tobacco Control Policy at the District Level: A Case Study Analysis from a High Burden State in India.

Introduction. While extensive scientific evidence exists on the tobacco epidemic, a lack of understanding of both policies and their appropriate way of implementation continues to hinder effective tobacco control. This is especially so in the developing countries such as India. The present study aims to understand current implementation practices and the challenges faced in mainstreaming tobacco control policy and program. Methods. We chose a qualitative study design to conduct the case analysis. A total of 42 in-depth interviews were undertaken with seven district officials in six districts of Andhra Pradesh. A conceptual framework was developed by applying grounded theory for analysis. Analysis was undertaken using case analysis approach. Results and Discussion. Our study revealed that most program managers were unfamiliar with the comprehensive tobacco control policy. Respondents have an ambiguous opinion regarding integration of tobacco control program into existing health and development programs. Respondents perceive lack of resources, low prioritization of tobacco control, and lack of monitoring and evaluation of smoke-free laws as limiting factors affecting implementation of tobacco control policy. Conclusion. The findings of this study highlighted the need for a systematic, organized action plan for effective implementation of tobacco control policy and program.