Patient satisfaction and value based purchasing in hospitals, Odisha, India.

Objective: To examine how a general inpatient satisfaction survey functions as a hospital performance measure. Methods: We conducted a mixed-methods pilot study of the Hospital Consumer Assessment of Health Providers and Systems survey in Odisha, India. We divided the study into three steps: cognitive testing of the survey, item testing with exploratory factor analysis and content validity indexing. Cognitive testing involved 50 participants discussing their interpretation of survey items. The survey was then administered to 507 inpatients across five public hospitals in Odisha, followed by exploratory factor analysis. Finally, we interviewed 15 individuals to evaluate the content validity of the survey items. Findings: Cognitive testing revealed that six out of 18 survey questions were not consistently understood within the Odisha inpatient setting, highlighting issues around responsibilities for care. Exploratory factor analysis identified a six-factor structure explaining 66.7% of the variance. Regression models showed that interpersonal care from doctors and nurses had the strongest association with overall satisfaction. An assessment of differential item functioning revealed that patients with a socially marginalized caste reported higher disrespectful care, though this did not translate into differences in reported satisfaction. Content validity indexing suggested that discordance between experiences of disrespectful care and satisfaction ratings might be due to low patient expectations. Conclusion: Using satisfaction ratings without nuanced approaches in value-based purchasing programmes may mask poor-quality interpersonal services, particularly for historically marginalized patients. Surveys should be designed to accurately capture true levels of dissatisfaction, ensuring that patient concerns are not hidden.

Formulation of Resveratrol-Loaded Polycaprolactone Inhalable Microspheres Using Tween 80 as an Emulsifier: Factorial Design and Optimization.

Resveratrol (RSV) is a bioactive phytoconstituent that has potential applications in respiratory diseases. However, poor oral bioavailability is the major hurdle to its clinical use. In the present work, resveratrol-loaded polycaprolactone (PCL) inhalable microspheres (MSs) were formulated to improve their therapeutic potential. The inhalable microspheres were formulated using the emulsion-solvent evaporation method. In this research, inhalable resveratrol microspheres were prepared using Tween 80 in place of polyvinyl alcohol which formed insoluble lumps. A 32 factorial design was applied taking polymer (PCL) and emulsifier (Tween 80) as independent variables and drug loading (DL) and encapsulation efficiency (EE) as dependent variables. The DL and EE of the optimized formulation were found to be 30.6% and 63.84% respectively. The in vitro aerosolization study performed using the Anderson cascade impactor showed that the fine particle fraction (FPF) of optimized resveratrol polycaprolactone microspheres (RSV-PCL-MSs) blended with lactose, and RSV-PCL-MSs were significantly higher than those of the pure drugs. The MMADT (theoretical mass median aerodynamic diameter) of optimized RSV-PCL-MSs was found to be 3.25 ± 1.15. The particle size of microspheres was within the inhalable range, i.e., between 1 and 5 µm. The morphological analysis showed spherical-shaped particles with smooth surfaces. The in vitro release study showed sustained drug release from the microspheres for up to 12 h. The study concluded that resveratrol-loaded inhalable microspheres may be an efficient delivery system to treat COPD.

Application of PLGA as a Biodegradable and Biocompatible Polymer for Pulmonary Delivery of Drugs.

Pulmonary administration of biodegradable polymeric formulation is beneficial in the treatment of various respiratory diseases. For respiratory delivery, the polymer must be non-toxic, biodegradable, biocompatible, and stable. Poly D, L-lactic-co-glycolic acid (PLGA) is a widely used polymer for inhalable formulations because of its attractive mechanical and processing characteristics which give great opportunities to pharmaceutical industries to formulate novel inhalable products. PLGA has many pharmaceutical applications and its biocompatible nature produces non-toxic degradation products. The degradation of PLGA takes place through the non-enzymatic hydrolytic breakdown of ester bonds to produce free lactic acid and glycolic acid. The biodegradation products of PLGA are eliminated in the form of carbon dioxide (CO2) and water (H2O) by the Krebs cycle. The biocompatible properties of PLGA are investigated in various in vivo and in vitro studies. The high structural integrity of PLGA particles provides better stability, excellent drug loading, and sustained drug release. This review provides detailed information about PLGA as an inhalable grade polymer, its synthesis, advantages, physicochemical properties, biodegradability, and biocompatible characteristics. The important formulation aspects that must be considered during the manufacturing of inhalable PLGA formulations and the toxicity of PLGA in the lungs are also discussed in this paper. Additionally, a thorough overview is given on the application of PLGA as a particulate carrier in the treatment of major respiratory diseases, such as cystic fibrosis, lung cancer, tuberculosis, asthma, and pulmonary hypertension.

Unlocking the Real Potential of Black Soldier Fly (Hermetia illucens) Larvae Protein Derivatives in Pet Diets.

Black soldier fly larvae (BSFL)-derived proteins are gaining popularity as sustainable pet food ingredients. According to the literature, these ingredients have strong antioxidant and antimicrobial activities. Due to the ability of BSFL protein derivatives to donate hydrogen atoms and/or electrons to counterpoise unstable molecules, they could possibly help in the prevention of osteoarthritis. During this study, the antiarthritic potential of BSFL protein derivatives was evaluated using the following assays: (1) proteinase inhibition, (2) erythrocyte membrane stability, (3) reactive oxygen species (ROS) production by activated macrophages, (4) ROS production by monocytes, and (5) cellular toxicity. Additionally, the glucosamine content of these ingredients was also evaluated. Chicken meal is commonly used in pet food formulations and was used as an industrial benchmark. The results obtained during this study demonstrated the strong antiarthritic potential of BSFL protein derivatives. We found that BSFL protein derivatives are not only useful in preventing the development of arthritis but could also help to cure it due to the presence of glucosamine. We also found that chicken meal could contribute to the development of arthritis by increasing ROS production by monocytes.

Palatability Enhancement Potential of Hermetia illucens Larvae Protein Hydrolysate in Litopenaeus vannamei Diets.

Marine feed ingredients derived from cephalopods (e.g., squid) and crustaceans (e.g., krill) are commercially used to improve the palatability of shrimp diets. Increase in global demand for shrimps has resulted in overfishing of these marine organisms and is a matter of concern. Insect protein hydrolysate could be a sustainable alternative for the possible replacement of these marine feed ingredients. During this study, four formulations: diet A (control: not containing any palatability enhancer), diet B (containing squid meal and krill oil), diet C (containing 1% insect protein hydrolysate), and diet D (containing 2% insect protein hydrolysate) were tested for (1) time required by first subject to begin feeding (time to strike) and (2) palatability in Litopenaeus vannamei. Additionally, the chemical composition of all four diet formulations was also analyzed. Results indicate that all diets had similar crude composition. The major essential amino acids in all diets were leucine and lysine, whereas eicosapentaenoic acid was the major omega-3 fatty acid in all diets. There were no significant differences between the mean time to strike for all the tested formulations. Palatability of tested formulations was found in the following order: diet D > diet C > diet B = diet A (p < 0.05), indicating that addition of squid meal and krill oil has no effect on palatability in comparison to control, whereas inclusion of insect protein hydrolysates significantly improves the palatability of formulations. Palatability enhancement potential of insect protein hydrolysate could be attributed to the high free amino acid content and water solubility in comparison to squid meal.

Impact of community-based health insurance in rural India on self-medication & financial protection of the insured.

BACKGROUND & OBJECTIVES: The evidence-base of the impact of community-based health insurance (CBHI) on access to healthcare and financial protection in India is weak. We investigated the impact of CBHI in rural Uttar Pradesh and Bihar s0 tates of India on insured households' self-medication and financial position. METHODS: Data originated from (i) household surveys, and (ii) the Management Information System of each CBHI. Study design was "staggered implementation" cluster randomized controlled trial with enrollment of one-third of the treatment group in each of the years 2011, 2012 and 2013. Around 40-50 per cent of the households that were offered to enroll joined. The benefits-packages covered outpatient care in all three locations and in-patient care in two locations. To overcome self-selection enrollment bias, we constructed comparable control and treatment groups using Kernel Propensity Score Matching (K-PSM). To quantify impact, both difference-in-difference (DiD), and conditional-DiD (combined K-PSM with DiD) were used to assess robustness of results. RESULTS: Post-intervention (2013), self-medication was less practiced by insured HHs. Fewer insured households than uninsured households reported borrowing to finance care for non-hospitalization events. Being insured for two years also improved the HH's location along the income distribution, namely insured HHs were more likely to experience income quintile-upgrade in one location, and less likely to experience a quintile-downgrade in two locations. INTERPRETATION & CONCLUSIONS: The realized benefits of insurance included better access to healthcare, reduced financial risks and improved economic mobility, suggesting that in our context health insurance creates welfare gains. These findings have implications for theoretical, ethical, policy and practice considerations.

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.

Spatiotemporal analysis of bacterial diversity in sediments of Sundarbans using parallel 16S rRNA gene tag sequencing.

The influence of temporal and spatial variations on the microbial community composition was assessed in the unique coastal mangrove of Sundarbans using parallel 16S rRNA gene pyrosequencing. The total sediment DNA was extracted and subjected to the 16S rRNA gene pyrosequencing, which resulted in 117 Mbp of data from three experimental stations. The taxonomic analysis of the pyrosequencing data was grouped into 24 different phyla. In general, Proteobacteria were the most dominant phyla with predominance of Deltaproteobacteria, Alphaproteobacteria, and Gammaproteobacteria within the sediments. Besides Proteobacteria, there are a number of sequences affiliated to the following major phyla detected in all three stations in both the sampling seasons: Actinobacteria, Bacteroidetes, Planctomycetes, Acidobacteria, Chloroflexi, Cyanobacteria, Nitrospira, and Firmicutes. Further taxonomic analysis revealed abundance of micro-aerophilic and anaerobic microbial population in the surface layers, suggesting anaerobic nature of the sediments in Sundarbans. The results of this study add valuable information about the composition of microbial communities in Sundarbans mangrove and shed light on possible transformations promoted by bacterial communities in the sediments.

Mobilizing community-based health insurance to enhance awareness & prevention of airborne, vector-borne & waterborne diseases in rural India.

BACKGROUND & OBJECTIVES: Despite remarkable progress in airborne, vector-borne and waterborne diseases in India, the morbidity associated with these diseases is still high. Many of these diseases are controllable through awareness and preventive practice. This study was an attempt to evaluate the effectiveness of a preventive care awareness campaign in enhancing knowledge related with airborne, vector-borne and waterborne diseases, carried out in 2011 in three rural communities in India (Pratapgarh and Kanpur-Dehat in Uttar Pradesh and Vaishali in Bihar). METHODS: Data for this analysis were collected from two surveys, one done before the campaign and the other after it, each of 300 randomly selected households drawn from a larger sample of Self-Help Groups (SHGs) members invited to join community-based health insurance (CBHI) schemes. RESULTS: The results showed a significant increase both in awareness (34%, p<0.001) and in preventive practices (48%, P=0.001), suggesting that the awareness campaign was effective. However, average practice scores (0.31) were substantially lower than average awareness scores (0.47), even in post-campaign. Awareness and preventive practices were less prevalent in vector-borne diseases than in airborne and waterborne diseases. Education was positively associated with both awareness and practice scores. The awareness scores were positive and significant determinants of the practice scores, both in the pre- and in the post-campaign results. Affiliation to CBHI had significant positive influence on awareness and on practice scores in the post-campaign period. INTERPRETATION & CONCLUSIONS: The results suggest that well-crafted health educational campaigns can be effective in raising awareness and promoting health-enhancing practices in resource-poor settings. It also confirms that CBHI can serve as a platform to enhance awareness to risks of exposure to airborne, vector-borne and waterborne diseases, and encourage preventive practices.

Changing bacterial profile of Sundarbans, the world heritage mangrove: impact of anthropogenic interventions.

Mangrove microbial communities and their associated activities have profound impact on biogeochemical cycles. Although microbial composition and structure are known to be influenced by biotic and abiotic factors in the mangrove sediments, finding direct correlations between them remains a challenge. In this study we have explored sediment bacterial diversity of the Sundarbans, a world heritage site using a culture-independent molecular approach. Bacterial diversity was analyzed from three different locations with a history of exposure to differential anthropogenic activities. 16S rRNA gene libraries were constructed and partial sequencing of the clones was performed to identify the microbial strains. We identified bacterial strains known to be involved in a variety of biodegradation/biotransformation processes including hydrocarbon degradation, and heavy metal resistance. Canonical Correspondence Analysis of the environmental and exploratory datasets revealed correlations between the ecological indices associated with pollutant levels and bacterial diversity across the sites. Our results indicate that sites with similar exposure of anthropogenic intervention reflect similar patterns of microbial diversity besides spatial commonalities.

Optimizing the formulation variables for encapsulation of linezolid into polycaprolactone inhalable microspheres using double emulsion solvent evaporation.

Inhaled antibiotics delivered through dry powder inhalers (DPIs) effectively treat severe bacterial infections by directly targeting the lungs. Our study focused on developing inhalable dry powder microspheres of linezolid (LNZ) using biodegradable polycaprolactone (PCL) polymer. The LNZ-PCL microspheres were fabricated using a double emulsification solvent evaporation method. Optimization of formulation parameters was performed using a factorial design. Evaluation of the microspheres included size, shape, drug loading, entrapment efficiency, aerosolization, and drug release. The morphological analysis confirmed spherical-shaped rough particles within the inhalable size range. The encapsulation efficiency was determined to be 52.84%, indicating successful drug incorporation. Aerosolization efficiency was significantly enhanced when LNZ-PCL microspheres were combined with lactose as a carrier, achieving a fine particle fraction (FPF) value of 70.90%. In-vitro dissolution studies demonstrated sustained drug release for over 24 h under lung pH conditions. Overall, our study highlights the potential of inhalable LNZ-PCL microspheres as a targeted approach for treating pulmonary tuberculosis. Further research and in-vivo studies are needed to validate their effectiveness in life-threatening bacterial infections.

Cost-effectiveness of a direct to beneficiary mobile communication programme in improving reproductive and child health outcomes in India.

INTRODUCTION: Kilkari is the largest maternal messaging programme of its kind globally. Between its initiation in 2012 in Bihar and its transition to the government in 2019, Kilkari was scaled to 13 states across India and reached over 10 million new and expectant mothers and their families. This study aims to determine the cost-effectiveness of exposure to Kilkari as compared with no exposure across 13 states in India. METHODS: The study was conducted from a programme perspective using an analytic time horizon aligned with national scale-up efforts from December 2014 to April 2019. Economic costs were derived from the financial records of implementing partners. Data on incremental changes in the practice of reproductive maternal newborn and child health (RMNCH) outcomes were drawn from an individually randomised controlled trial in Madhya Pradesh and inputted into the Lives Saved Tool to yield estimates of maternal and child lives saved. One-way and probabilistic sensitivity analyses were carried out to assess uncertainty. RESULTS: Inflation adjusted programme costs were US$8.4 million for the period of December 2014-April 2019, corresponding to an average cost of US$264 298 per year of implementation in each state. An estimated 13 842 lives were saved across 13 states, 96% among children and 4% among mothers. The cost per life saved ranged by year of implementation and with the addition of new states from US$392 ($385-$393) to US$953 ($889-$1092). Key drivers included call costs and incremental changes in coverage for key RMNCH practices. CONCLUSION: Kilkari is highly cost-effective using a threshold of India's national gross domestic product of US$1998. Study findings provide important evidence on the cost-effectiveness of a national maternal messaging programme in India. TRIAL REGISTRATION: NCT03576157.

Electromagnetic field stimulation facilitates motor neuron excitability, myogenesis and muscle contractility in spinal cord transected rats.

Spinal cord injury (SCI) is one of the most devastating injuries which causes either complete or partial loss of movement, balance, muscular coordination and endurance. Electromagnetic field (EMF) stimulation has been shown to reduce muscle atrophy and fiber-type switching and improves muscle function in a hindlimb suspension model. The present study aims to elucidate the therapeutic potential of EMF stimulation on motor neuron excitability, soleus muscle morphology and function in complete SCI rats. Thirty-six adult male Wistar rats were randomly divided into Sham, SCI and SCI+EMF groups. Complete transection was done at the T13 spinal level, followed by whole-body EMF exposure for 7 or 14 days. Hyper-reflexia, muscle atrophy, reduction in twitch and tetanic force with earlier onset of fatigue was evident in the SCI group. EMF stimulation showed significant improvement in H and M wave parameters, H/M ratio, muscle twitch and tetanic force, fusion frequency and fatigability. A significant increase in regenerating myofibers and reduction in muscle degeneration following EMF was evident on histopathological examination. Further, EMF significantly increased myogenic protein levels responsible for muscle regeneration. Our study demonstrates for the first time the potential of EMF to modulate motor neuron excitability and muscle contractile function in SCI rats through activity-dependent mechanisms.

Low high density lipoprotein cholesterol levels and acute coronary syndrome in young patients admitted at a tertiary care facility.

Background: Coronary artery disease (CAD) is a cardiovascular disease which is related to mortality and morbidity among the Indians predominantly in the older age group. But, recently CAD has been found more often in young population. Hence, our study aims to observe the outcomes based on various categories of high density lipoprotein (HDL) cholesterol levels estimated during admission at the hospital and correlate the levels of HDL cholesterol with severity of CAD as measured by Gensini score. Methods: A cross-sectional study was conducted in 151 young patients (18-45 years) who were admitted at the hospital with newly diagnosed acute coronary syndrome (ACS). Tests such as electrocardiogram, cardiac enzyme assay, hematologic and biochemical tests including fasting lipid profile levels were taken into account. Results: There was an inverse relation observed between the number of vessels involvedand HDL cholesterol levels. Those with lower levels of HDL cholesterol were more vulnerable to multi-vessel CAD. However, no association was observed between HDL cholesterol and severity of CAD as measured by Gensini score. Conclusion: In young patients with acute coronary syndrome and diminished HDL cholesterol levels had a greater number of vessels involved when compared with elevated HDL cholesterol levels group. However, low HDL cholesterol levels had no association with severity of CAD as measured by Gensini score. No statistically significant association was noticed between levels of HDL cholesterol and in hospital mortality /morbidity.

The impact of a direct to beneficiary mobile communication program on reproductive and child health outcomes: a randomised controlled trial in India.

BACKGROUND: Direct-to-beneficiary communication mobile programmes are among the few examples of digital health programmes to have scaled widely in low-resource settings. Yet, evidence on their impact at scale is limited. This study aims to assess whether exposure to mobile health information calls during pregnancy and postpartum improved infant feeding and family planning practices. METHODS: We conducted an individually randomised controlled trial in four districts of Madhya Pradesh, India. Study participants included Hindi speaking women 4-7 months pregnant (n=5095) with access to a mobile phone and their husbands (n=3842). Women were randomised to either an intervention group where they received up to 72 Kilkari messages or a control group where they received none. Intention-to-treat (ITT) and instrumental variable (IV) analyses are presented. RESULTS: An average of 65% of the 2695 women randomised to receive Kilkari listened to ≥50% of the cumulative content of calls answered. Kilkari was not observed to have a significant impact on the primary outcome of exclusive breast feeding (ITT, relative risk (RR): 1.04, 95% CI 0.88 to 1.23, p=0.64; IV, RR: 1.10, 95% CI 0.67 to 1.81, p=0.71). Across study arms, Kilkari was associated with a 3.7% higher use of modern reversible contraceptives (RR: 1.12, 95% CI 1.03 to 1.21, p=0.007), and a 2.0% lower proportion of men or women sterilised since the birth of the child (RR: 0.85, 95% CI 0.74 to 0.97, p=0.016). Higher reversible method use was driven by increases in condom use and greatest among those women exposed to Kilkari with any male child (9.9% increase), in the poorest socioeconomic strata (15.8% increase), and in disadvantaged castes (12.0% increase). Immunisation at 10 weeks was higher among the children of Kilkari listeners (2.8% higher; RR: 1.03, 95% CI 1.00 to 1.06, p=0.048). Significant differences were not observed for other maternal, newborn and child health outcomes assessed. CONCLUSION: Study findings provide evidence to date on the effectiveness of the largest mobile health messaging programme in the world. TRIAL REGISTRATION NUMBER: Trial registration clinicaltrials.gov; ID 90075552, NCT03576157.

Connecting the dots: Kerala's use of digital technology during the COVID-19 response.

Digital tools are increasingly being applied to support the response to the ongoing COVID-19 pandemic in India and elsewhere globally. This article draws from global frameworks to explore the use of digital tools in the state of Kerala across the domains of communication, surveillance, clinical management, non-clinical support, and core health system readiness and response. Kerala is considered India's first digital state, with the highest percentage of households with computers (24%) and the internet (51%) in India, 95% mobile phone penetration, 62% smartphone penetration and 75% digital literacy. Kerala has long been a model for the early adoption of digital technology for education and health. As part of the pandemic response, technology has been used across private and public sectors, including law enforcement, health, information technology and education. Efforts have sought to ensure timely access to health information, facilitate access to entitlements, monitor those under quarantine and track contacts, and provide healthcare services though telemedicine. Kerala's COVID-19 pandemic response showcases the diverse potential of digital technology, the importance of building on a strong health system foundation, the value of collaboration, and the ongoing challenges of data privacy and equity in digital access.

SMS feedback system as a quality assurance mechanism: experience from a household survey in rural India.

The increasing use of digital health solutions to support data capture both as part of routine delivery of health services and through special surveys presents unique opportunities to enhance quality assurance measures. This study aims to demonstrate the feasibility and acceptability of using back-end data analytics and machine learning to identify impediments in data quality and feedback issues requiring follow-up to field teams using automated short messaging service (SMS) text messages. Data were collected as part of a postpartum women's survey (n=5095) in four districts of Madhya Pradesh, India, from October 2019 to February 2020. SMSs on common errors found in the data were sent to supervisors and coordinators. Before/after differences in time to correction of errors were examined, and qualitative interviews conducted with supervisors, coordinators, and enumerators. Study activities resulted in declines in the average number of errors per week after the implementation of automated feedback loops. Supervisors and coordinators found the direct format, complete information, and automated nature of feedback convenient to work with and valued the more rapid notification of errors. However, coordinators and supervisors reported preferring group WhatsApp messages as compared with individual SMSs to each supervisor/coordinator. In contrast, enumerators preferred the SMS system over in-person group meetings where data quality impediments were discussed. This study demonstrates that automated SMS feedback loops can be used to enhance survey data quality at minimal cost. Testing is needed among data capture applications in use by frontline health workers in India and elsewhere globally.

Examining the reach and exposure of a mobile phone-based training programme for frontline health workers (ASHAs) in 13 states across India.

Mobile phones are increasingly used to facilitate in-service training for frontline health workers (FLHWs). Mobile learning (mLearning) programmes have the potential to provide FLHWs with high quality, inexpensive, standardised learning at scale, and at the time and location of their choosing. However, further research is needed into FLHW engagement with mLearning content at scale, a factor which could influence knowledge and service delivery. Mobile Academy is an interactive voice response training course for FLHWs in India, which aims to improve interpersonal communication skills and refresh knowledge of preventative reproductive, maternal, neonatal and child health. FLHWs dial in to an audio course consisting of 11 chapters, each with a 4-question true/false quiz, resulting in a cumulative pass/fail score. In this paper, we analyse call data records from the national version of Mobile Academy to explore coverage, user engagement and completion. Over 158 596 Accredited Social Health Activists (ASHAs) initiated the national version, while 111 994 initiated the course on state-based platforms. Together, this represents 41% of the estimated total number of ASHAs registered in the government database across 13 states. Of those who initiated the national version, 81% completed it; and of those, over 99% passed. The initiation and completion rates varied by state, with Rajasthan having the highest initiation rate. Many ASHAs made multiple calls in the afternoons and evenings but called in for longer durations earlier in the day. Findings from this analysis provide important insights into the differential reach and uptake of the programme across states.

Does exposure to health information through mobile phones increase immunisation knowledge, completeness and timeliness in rural India?

INTRODUCTION: Immunisation plays a vital role in reducing child mortality and morbidity against preventable diseases. As part of a randomised controlled trial in rural Madhya Pradesh, India to assess the impact of Kilkari, a maternal messaging programme, we explored determinants of parental immunisation knowledge and immunisation practice (completeness and timeliness) for children 0-12 months of age from four districts in Madhya Pradesh. METHODS: Data were drawn from a cross-sectional survey of women (n=4423) with access to a mobile phone and their spouses (n=3781). Parental knowledge about immunisation and their child's receipt of vaccines, including timeliness and completeness, was assessed using self-reports and vaccination cards. Ordered logistic regressions were used to analyse the factors associated with parental immunisation knowledge. A Heckman two-stage probit model was used to analyse completeness and timeliness of immunisation after correcting for selection bias from being able to produce the immunisation card. RESULTS: One-third (33%) of women and men knew the timing for the start of vaccinations, diseases linked to immunisations and the benefits of Vitamin-A. Less than half of children had received the basic package of 8 vaccines (47%) and the comprehensive package of 19 vaccines (44%). Wealth was the most significant determinant of men's knowledge and of the child receiving complete and timely immunisation for both basic and comprehensive packages. Exposure to Kilkari content on immunisation was significantly associated with an increase in men's knowledge (but not women's) about child immunisation (OR: 1.23, 95% CI 1.02 to1.48) and an increase in the timeliness of the child receiving vaccination at birth (Probit coefficient: 0.08, 95% CI 0.08 to 0.24). CONCLUSION: Gaps in complete and timely immunisation for infants persist in rural India. Mobile messaging programmes, supported by mass media messages, may provide one important source for bolstering awareness, uptake and timeliness of immunisation services. TRIAL REGISTRATION NUMBER: NCT03576157.

Can health information through mobile phones close the divide in health behaviours among the marginalised? An equity analysis of Kilkari in Madhya Pradesh, India.

Kilkari is one of the largest maternal mobile messaging programmes in the world. It makes weekly prerecorded calls to new and expectant mothers and their families from the fourth month of pregnancy until 1-year post partum. The programme delivers reproductive, maternal, neonatal and child health information directly to subscribers' phones. However, little is known about the reach of Kilkari among different subgroups in the population, or the differentiated benefits of the programme among these subgroups. In this analysis, we assess differentials in eligibility, enrolment, reach, exposure and impact across well-known proxies of socioeconomic position-that is, education, caste and wealth. Data are drawn from a randomised controlled trial (RCT) in Madhya Pradesh, India, including call data records from Kilkari subscribers in the RCT intervention arm, and the National Family Health Survey-4, 2015. The analysis identifies that disparities in household phone ownership and women's access to phones create inequities in the population eligible to receive Kilkari, and that among enrolled Kilkari subscribers, marginalised caste groups and those without education are under-represented. An analysis of who is left behind by such interventions and how to reach those groups through alternative communication channels and platforms should be undertaken at the intervention design phase to set reasonable expectations of impact. Results suggest that exposure to Kilkari has improved levels of some health behaviours across marginalised groups but has not completely closed pre-existing gaps in indicators such as wealth and education.