High prevalence of multi-drug resistant organisms in the gut flora of healthy rural individuals in northern India.

Background & objectives Presence of resistant gut flora in the community is associated with increasing multi-drug resistance (MDR) infections. In this study, the prevalence of MDR organisms in the gut flora of a healthy rural population residing in northern India was determined. Methods Healthy individuals aged 18-45 yr from Nuh district, Haryana, India were included in this study. Risk factors associated with dysbiosis, diet, lifestyle and exposure to animals was assessed. Qualitative food frequency questionnaire and inflammatory diet score was calculated. Pathogens in stool sample were detected by MALDI-TOF. Evaluation of antimicrobial susceptibility was done by automated Vitek-2 System. The presence of antimicrobial resistance (AMR) genes was evaluated using PCR. An isolate having resistance to at least one antibiotic out of the three or more classes of antibiotics tested was labelled as MDR. Results Among 153 individuals included in this study (mean age-32.5±8.6 yr, females-58.2%, vegetarian-68.6%), the most frequent organism isolated was E. coli (n=137, 89.5%) followed by K. pneumoniae (n=19, 12.4%) and Enterobacter species (n=23, 15%). Forty seven (30.7%) individuals had sensitive and 42 (27.4%) had MDR organisms. Fifty one (33.3%) were positive for ESBL, 5 (3.3%) were positive for carbapenems, and 18 (11.8%) were positive for both genes. Age, gender, body mass index, diet pattern, or diet score were similar between participants with sensitive and resistant organisms. Resistance against fluoroquinolones was highest [92(48.7%)] among all isolates. Forty nine (25.9%), 25 (13.2%), 24 (12.7%) and 21 (11.1%) isolates, respectively were positive for blaTEM, blaSHV, blaCTXM-1 and OXA-48 genes. Interpretation & conclusions Overall the study findings suggest that 27 per cent individuals from rural northern India carry MDR organisms in their fecal flora, with an ESBL carriage rate of 44 per cent.

Comparison of risk factors for dementia among rural and urban elderly adults-data from two cohort studies in India.

INTRODUCTION: Studies on risk factors for dementia in India, especially rural India, are sparse and therefore we aimed to assess risk factors in a rural cohort on aging and compare it with an urban cohort. METHODS: We are presenting baseline data on proportion of hypertension, diabetes, obesity, physical inactivity, and Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) scores in both cohorts. RESULTS: The rural cohort is younger and less educated than the urban cohort. The chi-square test showed that the proportion of participants with hypertension, diabetes, and obesity was lower in the rural cohort, whereas physical inactivity was higher in comparison with the urban cohort; however, the proportion of high-risk CAIDE scores was higher in the rural cohort. DISCUSSION: Despite the rural cohort having a smaller proportion of participants with hypertension, diabetes, and obesity, the overall CAIDE score was higher-the main reason for this is low educational level.

COGNITO (Computerized assessment of adult information processing): Normative scores for a rural Indian population from the SANSCOG study.

INTRODUCTION: Neuropsychological assessments are inexpensive and efficient methods to understand the cognitive abilities of individuals in research studies and clinical settings. Normative scores for such measures are crucial in serving as a reference standard for identifying cognitively healthy and impaired individuals belonging to similar sociodemographic characteristics. METHODS: Study subjects in rural India recruited into the Srinivaspura Aging, Neuro Senescence and Cognition (SANSCOG) study were administered the COGNITO battery of tests, which traverse cognitive domains of attention, memory, language, and visuospatial abilities. Percentile norms based on age and education stratification were derived for the above cohort. RESULTS: Percentile norms are commensurate with literacy levels in this population. The percentile scores for the cognitive tests show a decline for the individuals aged 75 years and above indicating lower cognitive functioning in this age group. DISCUSSION: This is the first-ever study reporting norms for diverse cognitive domains for illiterate, literate, low-literate individuals enrolled in a large-scale community-based cohort study in rural India.

Approaches to engage an aging, rural cohort in southern India during the COVID-19 crisis and the psychological impact of COVID-19 in this cohort.

INTRODUCTION: The COVID-19 pandemic produced an unprecedented crisis across the world. Long-term cohort studies were stalled, including our longitudinal aging cohort study in rural India. METHODS: We describe approaches undertaken to engage with our cohort (n = 1830) through multiple rounds of calls and how we provided useful services to our subjects during the lockdown period. Consenting subjects also underwent telephonic assessments for depression and anxiety using validated, self-report questionnaires. RESULTS: Subjects reported benefitting from our telephonic engagement strategies, including the COVID-related safety awareness and counselling service. The proportion of subjects with depression increased from 7.42% pre-COVID to 28.97% post-COVID. DISCUSSION: We envisage that such engagement strategies would improve subject rapport and cohort retention, and thus, could be adopted by similar cohort studies across the world. This marginalized, rural Indian community had severe, adverse psychological impact in this pandemic. Urgent public health measures are needed to mitigate this impact and develop appropriate preventive strategies.

Menstrual hygiene practices among adolescent women in rural India: a cross-sectional study.

BACKGROUND: Exclusive use of hygienic methods (sanitary napkins, locally prepared napkins, tampons, and menstrual cups) to prevent the visibility of bloodstains during menstruation is still considerably low among adolescent women in rural India. However, no prior research has explored the prevalence and determinants of exclusive hygienic methods among rural Indian adolescent women. To address this gap, this study examines the factors affecting adolescent women's exclusive use of hygienic methods in rural India. Additionally, this study explores state- and district-level geographical disparities in the exclusive use of hygienic methods among adolescent women in rural India. METHODS: Information on 95,551 adolescent women from rural India from the latest round of National Family Health Survey (NFHS-5) was analyzed. Bivariate statistics and multilevel logistic regression analysis were used to assess the Individual- and community-level factors associated with exclusive use of hygienic methods among adolescent women in rural India. Choropleth maps were used to discern the geographical disparities in the exclusive use of hygienic methods. RESULTS: In rural India, only 42% of adolescent women exclusively used hygienic methods, with substantial geographic disparities at the state and district levels. At the state level, the exclusive use of hygienic methods varied from 23% in Uttar Pradesh to 85% in Tamil Nadu. Even greater variation was observed at the district level. There was a clear north-south divide in the exclusive use of hygienic methods among adolescent women in rural India. The results of multilevel logistic regression indicated a considerable amount of variation in the exclusive use of hygienic methods at community level which further reduced when controlled for individual and community-level factors. Rural Indian adolescent women with higher education (AOR:3.20, 95% CI: 2.81-3.64), from general category (AOR: 1.14, 95% CI: 1.07-1.21), with medium mass media exposure (AOR: 1.43, 95% CI: 1.35-1.51), and from richest wealth quintile (AOR: 3.98, 95% CI: 3.69-4.30) were more likely to use hygienic methods exclusively. CONCLUSION: Wide differential across biodemographic and socioeconomic groups, and substantial geographic disparities at state- and district-level in the exclusive use of hygienic methods suggests a need to adopt context-specific interventions for adolescent women in rural India. Distribution of subsidized or free menstrual hygiene methods to disadvantaged adolescent women, and in the low-prevalence districts may increase the level of exclusive use of hygienic methods remarkably.

What shapes adolescents' diet and physical activity habits in rural Konkan, India? Adolescents' and caregivers' perspectives.

OBJECTIVE: To explore, adolescents' and caregivers' perspectives, about shaping of diet and physical activity habits in rural Konkan, India. DESIGN: Five focus group discussions (FGD) were conducted with adolescents and two with caregivers. Data were analysed using thematic analysis. SETTING: FGD were conducted in secondary schools located in remote rural villages in the Ratnagiri district, Konkan region, Maharashtra, India. PARTICIPANTS: Forty-eight adolescents were recruited including twenty younger (10-12 years) and twenty-eight older (15-17 years) adolescents. Sixteen caregivers (all mothers) were also recruited. RESULTS: Three themes emerged from discussion: (i) adolescents' and caregivers' perceptions of the barriers to healthy diet and physical activity, (ii) acceptance of the status quo and (iii) salience of social and economic transition. Adolescents' basic dietary and physical activity needs were rarely met by the resources available and infrastructure of the villages. There were few opportunities for physical activity, other than performing household chores and walking long distances to school. Adolescents and their caregivers accepted these limitations and their inability to change them. Increased use of digital media and availability of junk foods marked the beginning of a social and economic transition. CONCLUSION: FGD with adolescents and their caregivers provided insights into factors influencing adolescent diet and physical activity in rural India. Scarcity of basic resources limited adolescent diet and opportunities for physical activity. To achieve current nutritional and physical activity recommendations for adolescents requires improved infrastructure in these settings, changes which may accompany the current Indian social and economic transition.

Adolescent diet and physical activity in the context of economic, social and nutrition transition in rural Maharashtra, India: a qualitative study.

OBJECTIVE: To explore the perceptions of adolescents and their caregivers on drivers of diet and physical activity in rural India in the context of ongoing economic, social and nutrition transition. DESIGN: A qualitative study comprising eight focus group discussions (FGD) on factors affecting eating and physical activity patterns, perceptions of health and decision-making on food preparation. SETTING: Villages approximately 40-60 km from the city of Pune in the state of Maharashtra, India. PARTICIPANTS: Two FGD with adolescents aged 10-12 years (n 20), two with 15- to 17- year-olds (n 18) and four with their mothers (n 38). RESULTS: Dietary behaviour and physical activity of adolescents were perceived to be influenced by individual and interpersonal factors including adolescent autonomy, parental influence and negotiations between adolescents and caregivers. The home food environment, street food availability, household food security and exposure to television and digital media were described as influencing behaviour. The lack of facilities and infrastructure was regarded as barriers to physical activity as were insufficient resources for public transport, safe routes for walking and need for cycles, particularly for girls. It was suggested that schools take a lead role in providing healthy foods and that governments invest in facilities for physical activity. CONCLUSIONS: In this transitioning environment, that is representative of many parts of India and other Lower Middle Income Countries (LMIC), people perceive a need for interventions to improve adolescent diet and physical activity. Caregivers clearly felt that they had a stake in adolescent health, and so we would recommend the involvement of both adolescents and caregivers in intervention design.

Layering of a health, nutrition and sanitation programme onto microfinance-oriented self-help groups in rural India: results from a process evaluation.

BACKGROUND: The state of Bihar has been lagging behind Indian national averages on indicators related to maternal and child health, primarily due to lack of knowledge among mothers of young children on lifesaving practices and on where to seek services when healthcare is needed. Hence, the JEEViKA Technical Support Programme was established in 101 blocks to support the state rural livelihood entity, JEEViKA, in order to increase demand for and link rural families to existing health, nutrition and sanitation services. Programme activities were geared to those engaged in JEEViKA's microfinance-oriented self-help groups. These groups were facilitated by a village-based community mobilizer who was trained on health, nutrition and sanitation-related topics which she later shared in self-help group meetings monthly and during ad hoc home visits. Further, a block-level health, nutrition and sanitation integrator was introduced within JEEViKA to support community mobilizers. Also, indicators were added into the existing monitoring system to routinely capture the layering of health, nutrition and sanitation activities. METHODS: A process evaluation was conducted from August-November 2017 which comprised of conducting 594 quantitative surveys with community mobilizers, from program and non-programme intervention blocks. Linear and logistic regressions were done to capture the association of at least one training that the community mobilizers received on knowledge of the topics learned and related activities they carried out. RESULTS: Community mobilizers who had received at least one training were more likely to have higher levels of knowledge on the topics they learned and were also more likely to carry out related activities, such as interacting with block-level integrators for guidance and support, routinely collect data on health, nutrition and sanitation indicators and spend time weekly on related activities. CONCLUSIONS: Successful integration of health, nutrition and sanitation programming within a non-health programme such as JEEViKA is possible through trainings provided to dedicated staff in decentralized positions, such as community mobilizers. The findings of this evaluation hold great promise for engaging existing non-health, nutrition and sanitation systems that are serving vulnerable communities to become partners in working towards ensuring stronger health, nutrition and sanitation outcomes for all.

Towards transformative WASH: an integrated case study exploring environmental, sociocultural, economic and institutional risk factors contributing to infant enteric infections in rural tribal India.

BACKGROUND: Despite clear linkages between poor Water, Sanitation, Hygiene (WASH) and enteric disease, the design of effective WASH interventions that reduce child enteric infections and stunting rates has proved challenging. WASH factors as currently defined do not capture the overall exposure factors to faecal pathogens through the numerous infection transmission pathways. Understanding the multiple and multifaceted factors contributing to enteric infections and their interconnectedness is key to inform future interventions. This study aimed to perform an in-depth holistic exploration of the environmental, socio-cultural, economic and institutional context surrounding infants to develop an integrated understanding of enteric infection drivers in rural tribal Banswara, in Rajasthan State, India. METHODS: This study relied on the triangulation of mixed-methods to capture critical influences contributing to infant enteric infection transmission. We conducted structured observations and exploratory qualitative research across 9 rural tribal villages, including transect walks, household observations, interviews with frontline health workers and group discussions with mothers. The emergent social themes and identified factors were mapped based on the scale of agency (individual, family or community-level factor) and on their nature (environmental, socio-cultural, economic and institutional factors). RESULTS: Infants aged 5 to 24 months were seen to have constant exposures to dirt via mouthing of soil, soiled hands, soiled objects and food. Rudimentary household environments with dirt floors and domestic animals lacked a hygiene-enabling environment that hindered hygienic behaviour adoption. Several unsafe behaviours failing to interrupt infants' exposures to pathogens were captured, but caregivers reported a lack of self-efficacy skills to separate children from faecal exposures due to the rural farming environments where they lived. Conceptual mapping helped understand how wider-level societal factors such as socio-economic limitations, caste inequalities, and political corruption may have trickle-down effects on the caregivers' motivation and perceived self-efficacy for improving hygiene levels around children, highlighting the influence of interconnected broader factors. CONCLUSIONS: Conceptual mapping proved useful to develop an integrated understanding of the interlinked factors across socio-ecological levels and domains, highlighting the role of wider sociocultural, economic and institutional factors contributing to infant's enteric infection risks. Future WASH interventions are likely to require similar integrated approaches that account for the complex factors at all levels.

Lack of access to clean fuel and piped water and children's educational outcomes in rural India.

Investments in clean fuel and piped water are often recommended in developing countries on health grounds. This paper examines an alternative channel, the relationship between piped water and access to liquefied petroleum gas (LPG) and children's educational outcomes. Results based on the second round of the India Human Development Survey (2011-12) for rural India show that children aged 6-14 years, living in households that rely on free collection of water and cooking fuel, have lower mathematics scores and benefit from lower educational expenditures than children living in households that do not collect water and fuel. Moreover, gender inequality in this unpaid work burden also matters. In households where the burden of collection is disproportionately borne by women, child outcomes are significantly lower, particularly for boys. The endogeneity of choice to collect or purchase water and cooking fuel are modeled via Heckman selection and the entropy balancing method.

Adult convulsive status epileptic us: clinical, etiological, and predictors of outcome study from rural population of North India.

AIM: To determine the clinical profile, etiologies and predictors of mortality in patients with convulsive status epilepticus (CSE) among rural population of North India in view of limited published data on epidemiology and etiology of status epilepticus (SE) from developing countries. METHODS: One hundred sixty-two consecutive adult patients with CSE were evaluated from 2016 to 2018 for demographic profile, etiologies and predictors of poor outcome. RESULTS: The mean age was 41.71 ± 19.72 years. Most of the CSE cases were acute symptomatic (48.8%) type with central nervous system (CNS) infections (24.1%) being the predominant precipitating factor. Antiepileptic drugs (AEDs) noncompliance accounted for 34.9% of the cases with pre-existing epilepsy. The median duration of CSE was 5.5 h (IQR-3-10 h). 82.1% cases responded to the first line drugs and their response was related with duration of CSE (p = .0045). Case fatality was 16.0% and the predictors of the mortality were; low Glasgow Coma Scale (GCS) (OR =9.64, 95% CI= 2.064-45.02; p = .0001), lack of response to first line drugs (OR =0.019, 95% CI= 0.003-0.11; p = .0001) and absence of past history of epilepsy (OR =0.525, 95%CI =0.104-2.66; p = .004). CONCLUSIONS: CNS infection and AEDs noncompliance were identified to be the major cause of CSE which can be potentially preventable. Present study signifies that prompt and successful control of infections appears to be the most efficient preventive approach. Level of consciousness as a potential predictor of poor outcome can be quickly accessible to the treating clinician in optimizing treatment strategies.

How "Elderly Staying Alone" Cope Up with their Age and Deteriorating Health: A Qualitative Exploration from Rural Wardha, Central India.

BACKGROUND: This study is done to explore the various changes and problems faced by the "elderly people staying alone" and how they cope up to maintain their life amidst the physical, familial, social, and financial crisis in their lives. MATERIALS AND METHODS: This qualitative study was carried out in the villages surrounding Bhidi Rural Health and Training Center, located in the Vidarbha region of Maharashtra. A triangulation of free listing and pile sorting exercise was used. Elderly >65 years of age of either sex, living alone in their own houses, for at least 2 years were included in the study. Twenty-four such individuals were selected purposively who could figure out the different words and concepts regarding the three domains of our study for the purpose of line listing, namely, change of life since staying alone, problems faced while staying alone, and how they cope up with the problem of living alone. The data were analyzed using Anthropac software. The study findings were presented to the participants, who later pointed out few recommendations to be made. RESULTS: The "elderly staying alone" face the problems of lack of family, social, and financial support in their day-to-day life. They cope with these problems by a number of ways. Although there are a number of government schemes to protect the elderly, none of these policies are dedicated to this special group of elderlies. CONCLUSION: There is no social structure that can take care of this vulnerable group of elderlies in rural India. It is high time for the government to step in to bring some societal and familial reforms that will safeguard the elderly staying alone from the ongoing familial, social, and financial hardship.

Probable psychiatric disorder in a rural community of West Bengal, India.

PURPOSE: India faces multiple challenges to mitigate a high burden of psychiatric disorders. The risk of developing psychiatric disorder among the rural Indian population is poorly investigated. This study aims to understand the factors associated with probable psychiatric disorder (PPD) among a select rural Indian population. METHODS: Data from the Birbhum population project of the society for health and demographic surveillance, West Bengal, India, were utilized. Cross-sectional data covering a sample of 31,135 respondents (male 15,384 and female 15,751) aged ≥ 16 years were used. The General Health Questionnaire-28 was administered and the responses were computed into three categories: psychological case, psychological caseness, and normal. Bivariate and multivariate ordered logit regression analyses were applied to attain the study objective. RESULTS: Of the total population, 26% of respondents were identified with PPD. People aged ≥ 60 years, females, divorced/separated/widowed individuals, the unemployed and people with no formal education, individuals from the poorest economic group, and people with a history of selling or mortgaging assets towards their healthcare expenditure had a higher prevalence of psychiatric case within their respective group. CONCLUSIONS: A high burden of PPD was estimated in the select rural community. While designing an intervention for measuring and addressing psychiatric disorders, the socioeconomic gradient of PPD could be helpful.

Negotiating Collective and Individual Agency: A Qualitative Study of Young Women's Reproductive Health in Rural India.

The societal changes in India and the available variety of reproductive health services call for evidence to inform health systems how to satisfy young women's reproductive health needs. Inspired by Foucault's power idiom and Bandura's agency framework, we explore young women's opportunities to practice reproductive agency in the context of collective social expectations. We carried out in-depth interviews with 19 young women in rural Rajasthan. Our findings highlight how changes in notions of agency across generations enable young women's reproductive intentions and desires, and call for effective means of reproductive control. However, the taboo around sex without the intention to reproduce made contraceptive use unfeasible. Instead, abortions were the preferred method for reproductive control. In conclusion, safe abortion is key, along with the need to address the taboo around sex to enable use of "modern" contraception. This approach could prevent unintended pregnancies and expand young women's agency.

Emission reduction potentials of improved cookstoves and their issues in adoption: An Indian outlook.

Biomass as a fuel for cooking is a common practice in rural India, and about 700 million people use traditional stoves to meet their energy demand. However, the thermal and the combustion efficiencies of these stoves are very low, leading to an inefficient use of biomass, and also, resulting in significant indoor air pollution. Research development has however led to the development of some improved stoves viz., natural draft and forced draft for both domestic as well as large scale cooking applications and government is trying to promote them. Forced draft stoves using processed biomass fuels (pellets) have received more prominence due to their superior performance, however, higher initial cost and limited fuel distribution networks have remained the key challenges. Improved natural draft stoves too have gained attention for being relatively inexpensive, and they are more likely to hit the rural households. In this paper, we have examined the environmental benefits obtained by the use of improved stoves for two important scenarios: traditional stoves are replaced by (i)improved natural draft stoves and, (ii) by improved natural draft as well as forced draft stoves. In the best case scenario (case ii), i.e., by shifting 111 million households who currently use wood to the forced draft stoves, and another 45 million households who are dependent on dung cake and agro residues to the improved natural draft stoves, the emission reduction that can be achieved are as follows: particulate matter (PM) 875 kT, black carbon (BC) 229 kT, organic carbon (OC) 525 kT, methane (CH4)1178 kT and non methane hydrocarbon (NMHC) of 564 kT. With the promotion of only natural draft improved stoves, the total reductions would be ∼12% lower than the combinational promotion. The CO2 equivalent reduction is estimated to be ∼70-80 MT per year.

Benefits of an Android Based Tablet Application in Primary Screening for Eye Diseases in a Rural Population, India.

To investigate the effectiveness, efficiency and cost gains in collecting patient eye health information from remote rural villages of India by trained field investigators through an Android Based Tablet Application namely 'Sankara Electronic Remote Vision Information System (SERVIS)". During January and March 2016, a population based cross-sectional study was conducted in three Indian states employing SERVIS and manual method. The SERVIS application has a 48-items survey instrument programed into the application. Data on 281 individuals were collected for each of these methods as part of screening. The demographic details of individuals between both screening methods were comparable (P>0.05). The mean time (in minutes) to screen an individual by SERVIS was significantly less when compared to manual method (6.57±1.46 versus 11.93±1.53) (P<0.0001). The efficiency of SERVIS in screening was significantly evident as 26% (n = 73) of the patients screened have been referred to campsite and 69.8% (n = 51) of those referred were visited the campsite for a detailed eye examination by an ophthalmologist. The cost of screening through SERVIS is significantly less when compared to manual method; INR 7,633 (USD 113.9) Versus INR 24,780 (USD 370). SERVIS is an effective and efficient tool in terms of patients' referral conversion to the camp site leading to timely detection of potential blinding eye conditions and their appropriate treatment. This ensures timely prevention of avoidable blindness and visual impairment. In addition, the storage and access of eye health epidemiological quality data is helpful to plan appropriate blindness prevention initiatives in rural India.

Impact of Health Awareness Campaign in Improving the Perception of the Community about Palliative Care: A Pre- and Post-intervention Study in Rural Tamil Nadu.

BACKGROUND AND OBJECTIVE: The only way to provide palliative care to a huge number of people in need in India is through community participation, which can be achieved by improving the awareness of the people about palliative care. We conducted a study to assess the impact of health awareness campaign in improving the awareness of people about palliative care. MATERIALS AND METHODS: This was a pre- and post-intervention study conducted in Kadaperikuppam village of Vanur Taluk in Villupuram district, Tamil Nadu. One respondent each from 145 households in the village was interviewed regarding the knowledge and attitude on palliative care before and after the health awareness campaign using a pretested questionnaire. Health awareness campaign consisted of skit, pamphlet distribution, poster presentation, giving door-to-door information, and general interaction with palliative team in the village. RESULTS: The awareness regarding palliative care during the preintervention was nil. After the intervention, it increased to 62.8%. However, there was a decline in the attitude and the interest of the people toward palliative care. INTERPRETATION AND CONCLUSIONS: Health awareness campaigns can increase the awareness of people in the rural parts of the country about palliative care. However, to improve the attitude of the community about delivery of palliative care services, more sustained efforts are required to make them believe that palliative care can be provided by community volunteers also and not necessarily only by professionals.

Prevalence and Predictors of Unmet Needs among the Elderly Residents of the Rural Field Practice Area of a Tertiary Care Centre from Northern India.

BACKGROUND: Surrogate markers simple enough to be used by primary care workers have not been closely investigated by the community experts in rural Uttar Pradesh. We assessed the physical disabilities in activities of daily living (ADL) and unmet need in physical disabilities among rural elderly. Predictors of unmet needs in physical disabilities among the elderly were also identified. METHODS: A community based cross-sectional study was conducted among elderly residents of the rural field practice area of a tertiary care centre in rural Uttar Pradesh. Three hundred and thirty five (335) participants aged 60 years and above from 9 villages were selected using the Probability Proportional to Size (PPS) sampling technique. Study tools were the proforma regarding socio-demographic details, socio-economic status and Stanford Health Assessment Questionnaire. Multivariate logistic regression analysis was performed to identify predictors of unmet needs. RESULTS: 185 (55.2%) had physical disability in one or more activity limitation. Gender wise elderly females had more physical disability in one or more ADL categories than elderly males (66.8% vs. 42.0%). Almost one third (32.5%) of subjects had unmet need for one or more physical disabilities. the predictors of unmet needs that were identified in the study were female gender (P = 0.046), elderly aged 70 years and above (P = 0.032), those living alone (P = 0.035), low monthly family income (P = 0.044), financially fully dependent elderly (P = 0.0002), and those having 3 or more physical disabilities (P = 0.033). CONCLUSIONS: The findings of the study highlight that large number of needs of the disabled are still unmet. Greater, targeted efforts are needed to identify at-risk elderly people living in the community. These predictors would act as surrogate markers and can be easily used by primary care workers to plan and provide services to the elderly people in rural communities.

Suicide deaths in rural Andhra Pradesh--a cause for global health action.

OBJECTIVES: To determine the proportion of deaths attributable to suicides in rural Andhra Pradesh, India over a 4-year period using a verbal autopsy method. METHODS: Deaths occurring in 45 villages (population 185,629) were documented over a 4-year period from 2003 to 2007 by non-physician healthcare workers trained in the use of a verbal autopsy tool. Causes of death were assigned by physicians trained in the International Classification of Diseases, version 10. All data were entered and processed electronically using a secure study website. RESULTS: Verbal autopsies were completed for 98.2% (5786) of the deaths (5895) recorded. The crude death rate was 8.0/1000. 4.8% (95% CI 4.3-5.4) of all deaths were suicides, giving a suicide rate of 37.5/100,000 population. Forty-three percent of suicides occurred in the age group 15-29 years, and 62% were in men. In the younger age groups (10-29 years), suicides by women (56%) were more common than by men (44%). Poisoning (40%) was the most common method of self-harm followed by hanging (12%). CONCLUSION: The suicide rate in this part of rural Andhra Pradesh is three times higher than the national average of 11.2/100,000, but is in line with that reported in the Million Death Study. There is an urgent need to develop strategies targeted at young individuals to prevent deaths by suicide in India.

Building awareness to health insurance among the target population of community-based health insurance schemes in rural India.

OBJECTIVE: To evaluate an insurance awareness campaign carried out before the launch of three community-based health insurance (CBHI) schemes in rural India, answering the questions: Has the awareness campaign been successful in enhancing participants' understanding of health insurance? What awareness tools were most useful from the participants' point of view? Has enhanced awareness resulted in higher enrolment? METHODS: Data for this analysis originates from a baseline survey (2010) and a follow-up survey (2011) of more than 800 households in the pre- and post-campaign periods. We used the difference-in-differences method to evaluate the impact of awareness activities on insurance understanding. Assessment of usefulness of various tools was carried out based on respondents' replies regarding the tool(s) they enjoyed and found most useful. An ordinary least square regression analysis was conducted to understand whether insurance knowledge and CBHI understanding are related with enrolment in CBHI. RESULTS: The intervention cohort demonstrated substantially higher understanding of insurance concepts than the control group, and CBHI understanding was a positive determinant for enrolment. Respondents considered the 'Treasure-Pot' tool (an interactive game) as most useful in enhancing awareness to the effects of insurance. CONCLUSIONS: We conclude that awareness-raising is an important prerequisite for voluntary uptake of CBHI schemes and that interactive, contextualised awareness tools are useful in enhancing insurance understanding.