The Impact of Alternate Methodological and Structural Assumptions on Results of Cost-effectiveness Analysis: Empirical Evidence using Three Indian Economic Evaluations.

BACKGROUND: Despite advancement in methods and application of economic evaluations (EEs), there are several uncertainties. OBJECTIVES: To assess the impact of alternate methodological and structural assumptions for four key principles of EE, on the results of cost-effectiveness analysis. MATERIALS AND METHODS: Three previously published model-based EEs were used: (1) Integrated Management of Neonatal and Childhood Illnesses (IMNCIs) intervention; (2) intervention for multiple myeloma, and (3) safety-engineered syringes (SES) intervention. A series of empirical analyses was undertaken to assess the impact of alternate assumptions for discount-rate, time-horizon, study perspective, and health outcome measure, on incremental cost-effectiveness ratio (ICER), and interpretation of cost-effectiveness. RESULTS: Increasing discount rate resulted in an increase in ICERs, for all three case-studies; however, there was no change in the conclusions. Using shorter time-horizons resulted in a significant increase in ICERs, the multiple myeloma intervention remained cost-ineffective, SES intervention became cost-ineffective, whereas IMNCI intervention remained cost-effective, despite a three-fold increase in ICER. On using disability adjusted life years instead of quality adjusted life years, ICERs increased to 0.04, 2 and 4 times for SES, IMNCI and multiple myeloma interventions, respectively. On analyzing results from a societal perspective, a decline in ICERs was observed. The decline was significant for IMNCI where the intervention turned dominant/cost-saving. In the other two case-studies decline in ICERs was modest, 32% for multiple myeloma, and 4% for SES. CONCLUSION: We observed a significant impact of using alternate assumptions on ICERs which can potentially impact resource-allocation decisions. Our findings provide strong argument in favor of standardization of processes and development of country-specific guidelines for conduct of EE.

Adherence to country-specific guidelines among economic evaluations undertaken in three high-income and middle-income countries: a systematic review.

OBJECTIVE: To assess the adherence of economic evaluations to the recommendations on principles of economic evaluation as stated in the country-specific guidelines for three countries across different income groups, namely, Canada, South Africa, and Egypt. METHODS: Searches were undertaken in three databases to identify economic evaluations meeting predefined inclusion criteria. Methodological and reporting standards listed in the country-specific guidelines were converted into discrete binary variables to calculate mean adherence scores. Quality appraisal was done using Drummond's checklist. Stratified analysis was undertaken to identify independent variables affecting adherence. RESULTS: We identified forty-four, seventy-nine, and sixteen economic evaluations for Canada, South Africa, and Egypt, respectively. The mean adherence score was the highest for Canada (71%), followed by South Africa (65%) and Egypt (60%). Adherence to guidelines was positively correlated with quality of studies, r = .72. Furthermore, the mean adherence score was significantly (p < .05) higher for studies using a cost-utility analysis design (72%), having local/national funding aid (72%), undertaken by a health economist (71%) and for pharmacoeconomic evaluations (70%). CONCLUSION: The quality of economic evaluations improves with adherence to country-specific guidelines. Locally funded and health-economist led health technology assessments (HTAs) should be encouraged for greater adherence to the guidelines. The HTA researchers and the HTA bodies should lay emphasis on adherence to the country-specific guidelines for improving the quality of HTA evidence.

Comprehensive measurement of health system performance at district level in India: Generation of a composite index.

There have been limited attempts at measurement of health system performance at decentralized levels in low- and middle-income countries. This study was undertaken to develop a composite indicator to measure health system performance at district level in India. Primary data were collected from 377 public health facilities in 21 districts of Haryana state in India using health facility surveys. In addition, 1700 health care providers and 800 clients visiting health facilities were interviewed. Routine health management information system data at district and state level were also analyzed. These data were used for computing 67 input and process indicators covering six health system building blocks. Indicators were normalized and aggregated to generate domain-specific and overall composite health system performance index (HSPI) for each district. Several sensitivity analyses were performed to assess robustness of results. Overall, Panchkula and Ambala districts were found to be the best performing in the state (with HSPI scores of 0.64 and 0.62 out of 1), while Mewat, Faridabad, and Palwal districts had the poorest performance (with HSPI scores of 0.46, 0.49, and 0.48 out of 1). Significant variation in performance was observed for each health system building block. Sensitivity analyses results showed that study findings were robust to variations in methods of aggregation of indicators. Our study provides a framework and methods to measure health system performance at district level in a comprehensive manner. The composite indicator provides a summary snapshot to benchmark performance, while building block and domain scores provide critical information for programmatic action.

Out-of-pocket expenditure for health care: District level estimates for Haryana state in India.

INTRODUCTION: In this paper, we present district level out-of-pocket (OOP) expenditures with respect to outpatient consultation within last 15 days and hospitalization in last 1 year for Haryana state. METHODS: The data from a large cross-sectional household survey covering all 21 districts of Haryana comprising of randomly selected 79 742 households were analyzed. Of the total sample, 56 056 households consisting of 314 639 individuals in 21 districts of Haryana state were surveyed to gather information on OOP expenditure incurred on outpatient consultation within last 15 days. Similarly, 59 901 households and 324 977 respondents were interviewed to elicit OOP expenditures for any hospitalization during the 1 year preceding the survey. Mean OOP expenditure per OP consultation, per hospitalization as well as per capita were computed. Mean OOP expenditure was also estimated by the type of provider, gender, and district. RESULTS: The mean OOP expenditure for OP consultation and hospitalization in Haryana was Indian National Rupees (INR) 1005 (US Dollar [USD] 16.1; 95% CI: INR 934-1076) and INR 22 489 (USD 360.0; 95% CI: INR 21 375-23 608), respectively. Mean per capita OOP expenditure for OP consultation, which was INR 85 (USD 1.3) in Haryana, varied from INR 595 (USD 9.5) in district Panipat to INR 29 (USD 0.5) in district Kaithal. CONCLUSION: This is the first study to comprehensively present district level estimates for OOP expenditure for health care. These estimates are useful for policy planning, and preparation for district and state health accounts.

Out-of-pocket expenditure for hospitalization in Haryana State of India: Extent, determinants & financial risk protection.

BACKGROUND & OBJECTIVES: India aspires to achieve universal health coverage, which requires ensuring financial risk protection (FRP). This study was done to assess the extent of out-of-pocket (OOP) expenditure and FRP for hospitalization in Haryana State, India. Further, the determinants for FRP were also evaluated. METHODS: Data collected as a part of a household level survey conducted in Haryana 'Concurrent Evaluation of National Rural Health Mission: Haryana Health Survey' were analyzed. Descriptive analysis was undertaken to assess socio-demographic characteristics, hospitalization rate, extent and determinants of OOP expenditure and FRP. Prevalence of catastrophic health expenditure (CHE) (more than 40% of non-food expenditure) and impoverishment (Int$ 1.25) were estimated. Multivariate logistic regression was used to assess determinants of FRP. RESULTS: Hospitalization rate was found to be 3106 persons or 3307 episodes per 100,000 population. Median OOP expenditure on hospitalization was ₹ 8000 (USD 133), which was predominantly attributed to medicines (37%). Prevalence of CHE was 25.2 per cent with higher prevalence amongst males [odds ratio (OR)=1.30], those belonging to scheduled caste and scheduled tribes (OR=1.35), poorest 20 per cent households (OR=3.05), having injuries (OR=4.03) and non-communicable diseases (OR=3.13) admitted in a private hospital (OR=2.69) and those who were insured (OR=1.74). There was a 12 per cent relative increase in poverty head count due to OOP payments on healthcare. INTERPRETATION & CONCLUSIONS: Our findings showed that hospitalization resulted in significant OOP expenditure, leading to CHEs and impoverishment of households. Impact of OOP expenditures was inequitably more on the vulnerable groups. OOP expenditure may be curtailed through provision of free medicines and diagnostics and removal of any form of user charges.

Cost analysis of a simulation-based training for health workforce in India.

BACKGROUND: Training of health-care workforce including doctors, staff nurses, and Auxiliary Nurse Midwives using simulation techniques for skill enhancement have been used in a variety of clinical settings to improve the quality of training. India adopted the skills laboratories model for capacity building of health workers in maternal and child health in Bihar state. OBJECTIVE: Current economic evaluation was performed with the objective of assessing the financial and economic cost of implementing skills laboratories. METHODS: Data on all resources spent for the development of skill laboratory and implementing training during financial year 2011 were collected from Patna district in Bihar state. We used standard methods to estimate the full financial and economic costs of implementing the skills laboratories from a health system perspective. RESULTS: Overall cost of implementing 20 permanent and 10 mobile skills laboratory training in Bihar was Indian Rupee (INR) 8849895 from a financial perspective. The cost was nearly two times higher when using an economic perspective to account for opportunity cost of all resources used. The unit cost of training a participant using permanent and mobile laboratory was INR 6856 and INR 7474, respectively assuming an annual volume of 90 training. The optimum number of training which should be operated annually in a skills laboratory to make it most efficient is about 70-80 training per annum. CONCLUSIONS: Economic implications of skills laboratory organization should be borne while planning scale up in Bihar and other states. Further research on the effectiveness of two models of skill laboratory, that is, permanent and mobile and their cost is recommended.

Impact of referral transport system on institutional deliveries in Haryana, India.

BACKGROUND & OBJECTIVES: Creation of a strong referral transport network across the country is necessary for improving physical access to public sector health facilities. In this study we evaluated the referral transport services in Haryana, i.e. Haryana Swasthya Vaahan Sewa (HSVS), now known as National Ambulance Service (NAS), to assess the extent and pattern of utilization, and to ascertain its effect on public sector institutional deliveries. METHODS: Secondary data on 116,562 patients transported during April to July 2011 in Haryana state were analysed to assess extent and pattern of NAS utilization. Exit interviews were conducted with 270 consecutively selected users and non- users of referral services respectively in Ambala (High NAS utilization), Hisar (medium utilization) and Narnaul (low utilization) districts. Month-wise data on institutional deliveries in public facilities during 2005-2012 were collected in these three districts, and analysed using interrupted time series analysis to assess the impact of NAS on institutional deliveries. RESULTS: Female gender (OR=77.7), rural place of residence (OR=5.96) and poor socio-economic status (poorest wealth quintile OR=2.64) were significantly associated with NAS ambulance service usage. Institutional deliveries in Haryana rose significantly after the introduction of NAS service in Ambala (OR=137.4, 95% CI=22.4-252.4) and Hisar (OR=215, 95% CI=88.5-341.3) districts. No significant increase was observed in Narnaul (OR=4.5, 95% CI=-137.4 to 146.4) district. INTERPRETATION & CONCLUSIONS: The findings of the present study showed a positive effect of referral transport service on increasing institutional deliveries. However, this needs to be backed up with adequate supply of basic and emergency obstetric care at hospitals and health centres.

Prevalence and sociodemographic determinants of common mental disorders (CMDs) symptoms in a rural adult population of Haryana, North India.

Objectives: Common mental disorders (CMDs), including depression, anxiety, and somatoform disorders, affect all stages of life and impact individuals, families, and communities. This study aimed to determine the magnitude of CMDs and their sociodemographic determinants in the adult population of a rural block in North India. Material and Methods: A cross-sectional, quantitative, community-based study was conducted among adult residents of a rural block in Haryana, North India, using a multistage random sampling technique. The Hindi version of the General Health Questionnaire (GHQ-12), a well-validated tool, was used to screen participants for CMDs. Scores of 4 or above denoted the presence of CMDs. Bivariate analyses were performed to determine the associations between CMDs and sociodemographic characteristics. Results: Of the 180 residents selected for the study, most were women (60.0%) and aged between 31 and 50 years (52.3%). The prevalence of CMDs symptoms in the study population was 20.0%. The presence of CMDs symptoms was significantly higher among those who were aged 60 years or older [OR=12.33, 95% CI 3.21-47.38], widowed, divorced or separated [OR=7.50, 95% CI 1.09-51.52], illiterate [OR= 6.25, 95% CI 2.84-13.77], had monthly family income below 10,000 INR [OR=3.33, 95% CI 1.54-7.20], had any chronic physical illness [OR=8.28, 95% CI 3.70-18.56] and had a family history of any psychiatric illness [OR=5.56, 95% CI 1.52-19.42]. Conclusion: The burden of CMDs was quite high among adults in rural North India. The presence of CMDs was closely associated with sociodemographic characteristics. Primary care and community-based settings need to screen for, diagnose, and manage CMDs to address this growing problem.

Cost & efficiency evaluation of a publicly financed & publicly delivered referral transport service model in three districts of Haryana State, India.

BACKGROUND & OBJECTIVES: Various models of referral transport services have been introduced in different States in India with an aim to reduce maternal and infant mortality. Most of the research on referral transport has focussed on coverage, quality and timeliness of the service with not much information on cost and efficiency. This study was undertaken to analyze the cost of a publicly financed and managed referral transport service model in three districts of Haryana State, and to assess its cost and technical efficiency. METHODS: Data on all resources spent for delivering referral transport service, during 2010, were collected from three districts of Haryana State. Costs incurred at State level were apportioned using appropriate methods. Data Envelopment Analysis (DEA) technique was used to assess the technical efficiency of ambulances. To estimate the efficient scale of operation for ambulance service, the average cost was regressed on kilometres travelled for each ambulance station using a quadratic regression equation. RESULTS: The cost of referral transport per year varied from [symbol: see text] 5.2 million in Narnaul to [symbol: see text] 9.8 million in Ambala. Salaries (36-50%) constituted the major cost. Referral transport was found to be operating at an average efficiency level of 76.8 per cent. Operating an ambulance with a patient load of 137 per month was found to reduce unit costs from an average [symbol: see text] 15.5 per km to [symbol: see text] 9.57 per km. INTERPRETATION & CONCLUSIONS: Our results showed that the publicly delivered referral transport services in Haryana were operating at an efficient level. Increasing the demand for referral transport services among the target population represents an opportunity for further improving the efficiency of the underutilized ambulances.

Human Resources for Health in Haryana, India: What can be Done Better?

Introduction: Health systems in developing countries suffers from both input and productivity issues. We examined the status of three domains of human resources for health, i.e., availability and distribution, capacity and productivity, and motivation and job-satisfaction, of the health-care workforce employed in the public health system of Haryana, a North Indian state. Methodology: The primary data were collected from 377 public health facilities and 1749 healthcare providers across 21 districts. The secondary data were obtained from government reports in the public domain. Bivariate and multivariate statistical techniques were used for evaluating district performances, making inter-district comparisons and identifying determinants of motivation and job-satisfaction of the clinical cadres. Results: We found 3.6 core health-care workers (doctors, staff nurses, and auxiliary nurses-midwives) employed in the public health-care system per 10,000 population, ranging from 1.35 in Faridabad district to 6.57 in Panchkula district. Around 78% of the sanctioned positions were occupied. A number of inpatient hospitalizations per doctor/nurses per month were 17 at the community health center level and 29 at the district hospital level; however, significant differences were observed among districts. Motivation levels of community health workers (85%) were higher than clinical workforce (78%), while health system administrators had lowest motivation and job satisfaction levels. Posting at primary healthcare facility, contractual employment, and co-habitation with family at the place of posting were found to be the significant motivating factors. Conclusions: A revamp of governance strategies is required to improve health-care worker availability and equitable distribution in the public health system to address the observed geographic variations. Efforts are also needed to improve the motivation levels of health system administrators, especially in poorly performing districts and reduce the wide gap with better-off districts.

Human rabies control in the era of post-COVID-19: a call for action.

Following the COVID-19 pandemic, there has been a sharp increase in rabies cases and deaths. Rabies outbreaks are being reported worldwide. Multiple disruptions in Rabies control occurred during the pandemic, significantly affecting lower-income countries. Countries need to develop specific action plans to become 'rabies free' by 2030.

Oral manifestation of the monkeypox virus: a systematic review and meta-analysis.

Background: Mpox (formerly known as monkeypox) is a global public health concern, given the recent outbreaks in non-endemic countries where little scientific evidence exists on the disease epidemiology. Oral lesions among mpox cases have been poorly reported. Our aim was to estimate the overall prevalence of oral manifestations among patients with mpox globally. Methods: In this systematic review and meta-analysis, an extensive literature search in PubMed, Scopus, Web of Science, Embase, Cochrane, and preprint servers (medRxiv, arXiv, bioRxiv, BioRN, ChiRxiv, ChiRN, and SSRN) and assessment of all published articles, conducted across the world, until Nov 15 2022 as per the PROSPERO registration protocol (CRD42022371249), was undertaken. Primary studies (case series, cross-sectional, retrospective, prospective designs) that reported the oral/oropharyngeal symptoms among laboratory-confirmed mpox cases were included. The characteristics of the study, information on the number of cases, and symptomatic status were extracted from the included studies. The quality of the included studies was assessed for bias. Random-effects meta-regression with DerSimonian & Laird estimator, and subgroup analyses were conducted using STATA (v17.0). The degree of funnel plot asymmetry was assessed using Egger's test when at least 10 estimates were available. The heterogeneity between studies was assessed using the I2 statistic. The primary outcome was the pooled prevalence of oral manifestations in the examined population. Findings: 19 studies were included with 4042 laboratory-confirmed patients with mpox for qualitative and quantitative synthesis. The pooled prevalence of oral manifestations in the investigated population was 36.75% (95% confidence interval [CI]: 23.77-50.65). Heterogeneity was found to be high in the current meta-analysis (I2 = 98.24%; p < 0.001). Subgroup analysis revealed a pooled prevalence of 39.96% (95% CI: 21.42-59.91) of sore throat, 24.80% (95% CI: 8.14-46.32) of mouth sore, 18.24% (95% CI: 0.34-52.54) of tonsillitis and 17.99% (95% CI: 15.66-20.43) of mouth rash from the included studies. Interpretation: Oral manifestations are common in patients with mpox, with variations in prevalence across the sites within the oral cavity, and geography of the studies. Healthcare workers should be wary of the oral signs and symptoms of mpox in endemic and high-risk areas. Funding: None.

Psychological distress and related factors regarding COVID-19 among the ancillary hospital staff: A cross-sectional study.

Background: Healthcare workers (HCWs) are at the front line of the Coronavirus disease (COVID-19) outbreak response. They have faced great risks to both physical and mental health. We aimed to assess the psychological effect of COVID-19 among ancillary hospital staff. Methods: A cross-sectional study was conducted among 267 on-duty ancillary hospital staff using a semi-structured questionnaire to assess their psychological status and risk perception. In addition, their knowledge, attitude, and practices (KAP) and risk perception were also assessed. The General Health Questionnaire (GHQ-12) was used to screen for psychological distress. Results: Among 267 participants, the mean (±SD) age was 33.5 (7.6) years. The majority knew about the symptoms of COVID-19 (88.4%), droplet spread (99.3%), and the importance of isolation (99.3%). About 35.2% were worried about infecting family members, while 26.2% were worried about colleagues at the frontline. Only 38.9% of them had a good knowledge score. Participants with high school and above education level had significantly good knowledge about COVID-19 (OR = 1.99; 95% CI = 1.17- 3.39) than those with primary school or below. Being female (OR 1.99; 95% CI 1.17-3.39) and working with COVID-19 patients (OR 3.88, 95% CI 1.77-8.47, P = 0.001) was associated with psychological distress. Conclusion: The ancillary hospital staff had insufficient knowledge regarding the risk factors of COVID-19 but possessed positive attitudes and practices. Continued health education and appropriate psychological interventions may improve understanding and reduce psychological distress.

A Novel Potential Treatment for Diabetic Foot Ulcers and Non-Healing Ulcers - Case Series.

INTRODUCTION: Appropriate care and treatment of a wound is the need of the hour whether it is an infected or a non-infected wound. If wound healing is delayed for some reason, it leads to serious complications and further increases the hospital stay and cost of treatment. Herein, we describe a novel antimicrobial wound dressing formulation (VG111), with an objective to generate the preliminary data showing the distinct advantages in various types of wounds. METHOD: This case series involved the treatment of acute cases of wounds or chronic wounds that did not respond well to conventional wound healing treatments with VG111 in patients with different etiologies. Thirteen cases of patients that included patients with diabetes, pressure ulcers, burns, trauma, and others treated with VG111 showed rapid wound healing in all the cases, even obviating the need for a graft when complete skin regeneration occurred RESULT: This was illustrated by clearing of the wound infections, reduction/disappearance of the exudate, appearance of intense granulation, epithelialization, and anti-biofilm activity followed by complete wound closure. This VG111 precludes the need for systemic antimicrobial agents in localized infections and therefore, this single agent is an attempt to address the limitations and the drawbacks of the available products. CONCLUSION: Despite patients belonging to the old age group and having comorbidities like diabetes, still VG111 showed effective rapid wound healing, and that too without any scar formation in hardto-heal, infected, and non-infected wounds

User charges in health care: evidence of effect on service utilization & equity from north India.

BACKGROUND & OBJECTIVES: User charges have been advocated on efficiency grounds despite the widespread criticism about their adverse effect on equity. We assessed the effect of user charges on inpatient hospitalizations rate and equity in Haryana State. METHODS: The inpatient department (IPD) statistics of the public sector facilities in Yamuna Nagar district where user charges had been introduced were analysed and compared with Rohtak district which did not have user charge between 2000 and 2006. National Sample Survey data of Haryana for the 2004-2005 period were analyzed to compare utilization of public sector facilities for hospitalization, cost of hospitalization, and prevalence of catastrophic out-of-pocket (OOP) expenditure by income quintiles in three districts which had user charges and 17 districts of Haryana which did not levy user charges. RESULTS: During 2000 and 2006, hospital admissions declined by 23.8 per cent in Yamuna Nagar district where user charges had been introduced compared to an almost static hospitalization rate in Rohtak district which did not have user charges (P<0.01). Public sector hospital utilization for inpatient services had a pro-rich (concentration index 0.144) distribution in the three districts with user charges and pro-poor (concentration index -0.047) in the 17 districts without user charges. Significantly higher prevalence of catastrophic health expenditure was observed in public sector institutions with user charges (48%) compared to those without user charges (35.4%) (P<0.001). INTERPRETATION & CONCLUSIONS: The findings of our study showed that user charges had a negative influence on hospitalizations in Haryana especially among the poor. Public policies for revenue generation should avoid user charges.

Harnessing machine learning models for non-invasive pre-diabetes screening in children and adolescents.

BACKGROUND AND OBJECTIVES: Pre-diabetes has been identified as an intermediate diagnosis and a sign of a relatively high chance of developing diabetes in the future. Diabetes has become one of the most frequent chronic disorders in children and adolescents around the world; therefore, predicting the onset of pre-diabetes allows a person at risk to make efforts to avoid or restrict disease progression. This research aims to create and implement a cross-validated machine learning model that can predict pre-diabetes using non-invasive methods. METHODS: We have analysed the national representative dataset of children and adolescents (5-19 years) to develop a machine learning model for non-invasive pre-diabetes screening. Based on HbA1c levels the data (n = 26,567) was segregated into normal (n = 23,777) and pre-diabetes (n = 2790). We have considered eight features, six hyper-tuned machine learning models and different metrics for model evaluation. The final model was selected based on the area under the receiver operator curve (AUC), Cohen's kappa and cross-validation score. The selected model was integrated into the screening tool for automated pre-diabetes prediction. RESULTS: The XG boost classifier was the best model, including all eight features. The 10-fold cross-validation score was highest for the XG boost model (90.13%) and least for the support vector machine (61.17%). The AUC was highest for RF (0.970), followed by GB (0.968), XGB (0.959), ETC (0.918), DT (0.908), and SVM (0.574) models. The XGB model was used to develop the screening tool. CONCLUSION: We have developed and deployed a machine learning model for automated real-time pre-diabetes screening. The screening tool can be used over computers and can be transformed into software for easy usage. The detection of pre-diabetes in the pediatric age may help avoid its enhancement. Machine learning can also show great competence in determining important features in pre-diabetes.

What is the out-of-pocket expenditure on medicines in India? An empirical assessment using a novel methodology.

The share of expenditure on medicines as part of the total out-of-pocket (OOP) expenditure on healthcare services has been reported to be much higher in India than in other countries. This study was conducted to ascertain the extent of this share of medicine expenditure using a novel methodology. OOP expenditure data were collected through exit interviews with 5252 out-patient department patients in three states of India. Follow-up interviews were conducted after Days 1 and 15 of the baseline to identify any additional expenditure incurred. In addition, medicine prescription data were collected from the patients through prescription audits. Self-reported expenditure on medicines was compared with the amount imputed using local market prices based on prescription data. The results were also compared with the mean expenditure on medicines per spell of ailment among non-hospitalized cases from the National Sample Survey (NSS) 75th round for the corresponding states and districts, which is based on household survey methodology. The share of medicines in OOP expenditure did not change significantly for organized private hospitals using the patient-reported vs imputation-based methods (30.74-29.61%). Large reductions were observed for single-doctor clinics, especially in the case of 'Ayurvedic' (64.51-36.51%) and homeopathic (57.53-42.74%) practitioners. After adjustment for socio-demographic factors and types of ailments, we found that household data collection as per NSS methodology leads to an increase of 25% and 26% in the reported share of medicines for public- and private-sector out-patient consultations respectively, as compared with facility-based exit interviews with the imputation of expenditure for medicines as per actual quantity and price data. The nature of healthcare transactions at single-doctor clinics in rural India leads to an over-reporting of expenditure on medicines by patients. While household surveys are valid to provide total expenditure, these are less likely to correctly estimate the share of medicine expenditure.

Potentially Asymptomatic Infection of Monkeypox Virus: A Systematic Review and Meta-Analysis.

Background: Monkeypox is a global public health concern, given the recent outbreaks in non-endemic countries where little scientific evidence exists on the disease. Specifically, there is a lack of data on asymptomatic monkeypox virus infection. This study aims to evaluate the overall prevalence of asymptomatic monkeypox virus infection. Methods: In this systematic review and meta-analysis, we performed an extensive literature search in PubMed, Scopus, Web of Science, ProQuest, EMBASE, EBSCOHost, Cochrane, and preprint servers (medRxiv, arXiv, bioRxiv, BioRN, ChiRxiv, ChiRN, and SSRN) and assessed all published articles till September 2022. Primary studies reporting monkeypox infections among asymptomatic participants were included after quality assessment. The characteristics of the study and information on the number of cases and symptomatic status were extracted from the included studies. The heterogeneity between studies was assessed using the I2 statistic. Publication bias was analyzed using funnel plots and Egger regression tests. The primary outcome was the pooled prevalence of asymptomatic infections within the examined population. Results: A total of 16 studies were included for qualitative synthesis, while five studies, including 645 individuals, were included for quantitative synthesis. There was substantial heterogeneity between studies (I2 = 94.86%; p < 0.01), with a pooled percentage of asymptomatic infections in the studied population of 10.2% (95%CI, 2.5−17.9%). Conclusion: This meta-analysis suggests that many people infected with the monkeypox virus are asymptomatic and difficult to detect. Therefore, prompt detection of these cases of monkeypox virus and appropriate subsequent management is of utmost importance to global public health.

Parents' Perceptions and Intention to Vaccinate Their Children Against COVID-19: Results From a Cross-Sectional National Survey in India.

Background: Despite the success of adult vaccination against COVID-19, providing vaccines to children remains a challenge for policymakers globally. As parents are primary decision-makers for their children, we aimed to assess parents' perceptions and intentions regarding COVID-19 vaccination in India. Methods: A cross-sectional web-based study was designed, parents or caregivers (N = 770) were recruited through snowball sampling using Google form. Cross-tabulation was performed by parents' intention to vaccinate their children against COVID-19 virus with sociodemographic characteristics and their risk perception toward COVID-19, trust in the healthcare system, and their history of vaccine hesitancy behavior. Multivariable logistic regression analysis was performed to compute the predictors of child vaccination intention among Indian parents. Results: Seven hundred and seventy parents across the country have completed the survey. Of the 770 participants, 258 (33.5%) have shown intent to vaccinate their children. The stated likelihood of child vaccination was greater among parents who had a bachelor's degree or higher education (aOR: 1.98, 95% CI: 1.15-3.51); as well as among parents who intended to vaccinate themselves (aOR: 2.35, 95% CI: 1.30-4.67). Parental concerns centered around vaccine safety and side effects. Conclusion: Indian parents reported high knowledge of the COVID-19 virus and were aware of the development of a vaccine. However, about one-third of parents intended to vaccinate their children, and about half of them were not sure whether to vaccinate their children or not against the COVID-19 virus. The study highlighted the need for health promotion strategies that promote vaccine uptake among parents.

Sociodemographic Determinants of Willingness and Extent to Pay for COVID-19 Vaccine in India.

Background: Responding to the fast transmission rates and increasing fatality rates, countries across the world expedited the development and deployment of the vaccine for coronavirus disease 2019 (COVID-19). Evaluation of individuals' willingness to pay (WTP) would provide pertinent information regarding future demand and financing preferences, which shall help to devise the effective payment strategy for COVID-19 vaccination. Methods: A nationwide, cross-sectional, and self-administered online survey using a structured questionnaire was conducted to identify the sociodemographic determinants of willingness and extent to pay for COVID-19 vaccine in India. A non-probability convenience sampling followed by snowball sampling was employed to recruit participants (n = 3,341). The likelihood of sociodemographic determinants to predict willingness and extent to pay was modeled using the multivariate binary logistic regression analysis. Results: Out of 3,341 participants, 68% (n = 2,271) were willingness to pay for COVID-19 vaccine. Results showed significantly higher odds for willingness to pay among participants who were single [adjusted odds ratio (aOR) = 1.394, p < 0.01] and having a family size of 4 members (aOR = 1.346, p < 0.01). The adjusted odds ratio sizably increased from 1.396 for participants whose monthly income was between INR 10,000 and 20,000/month to 2.240 for participants whose monthly income was above INR 50,000/month. Further, out of 2,271 of those participants who were willingness to pay for COVID-19 vaccine, majority (n = 1,246, 54.9%) of participants were willingness to pay below 50% of COVID-19 vaccine cost. This study found that those who are single (aOR = 0.688, p < 0.01), having an income between INR 20,000 and 50,000/month (aOR = 0.686, p < 0.05), and those who belonged to socially disadvantaged category (aOR = 0.450, p < 0.01) were estimated to have significantly lower odds of willingness to pay more than 50% of COVID-19 vaccine cost. Conclusion: This study observed that majority of those participants who willingness to pay for COVID-19 vaccine were willingness to pay only up to 50% of COVID-19 vaccine and income was observed as a precursor predictor of the willingness and extent to pay for COVID-19 vaccine. The understanding on the willingness and extent to pay for COVID-19 vaccine and its sociodemographic determinants will be helpful for making the strategic decisions related to the financing of COVID vaccine in India.