Utilisation of public healthcare services by an indigenous group: a mixed-method study among Santals of West Bengal, India

A barrier to meeting the goal of universal health coverage in India is the inequality in utilisation of health services between indigenous and non-indigenous people. This study aimed to explore the determinants of utilisation, or non-utilisation, of public healthcare services among the Santals, an indigenous community living in West Bengal, India. The study holistically explored the utilisation of public healthcare facilities using a framework that conceptualised service coverage to be dependent on a set of determinants - viz. the nature and severity of the ailment, availability, accessibility (geographical and financial), and acceptability of the healthcare options and decision-making around these further depends on background characteristics of the individual or their family/household. This cross-sectional study adopts ethnographic approach for detailed insight into the issue and interviewed 422 adult members of Santals living in both rural (Bankura) and urban (Howrah) areas of West Bengal for demographic, socio-economic characteristics and healthcare utilisation behaviour using pre-tested data collection schedule. The findings revealed that utilisation of the public healthcare facilities was low, especially in urban areas. Residence in urban areas, being female, having higher education, engaging in salaried occupation and having availability of private allopathic and homoeopathic doctors in the locality had higher odds of not utilising public healthcare services. Issues like misbehaviour from the health personnel, unavailability of medicine, poor quality of care, and high patient load were reported as the major reasons for non-utilisation of public health services. The finding highlights the importance of improving the availability and quality of care of healthcare services for marginalised populations because these communities live in geographically isolated places and have low affordability of private healthcare. The health programme needs to address these issues to improve the utilisation and reduce the inequality in healthcare utilisation, which would be beneficial for all segments of Indian population.

Differences in Quality of Care of Family Planning Services Received by Age and Contraceptive Continuation Among Young Mothers in India

PURPOSE

Youth face barriers that affect their use of family planning (FP) services, including low quality of care and provider bias. Although young women have the highest unmet need for FP in India, little is known about the effect of age on quality of care received. Additionally, although youth have higher contraceptive discontinuation than older women, the factors associated with continuation, including the effect of quality of care, are not well known. This study aims to assess differences in quality of care received by young mothers aged 15-24 and mothers aged 25-48, and to examine factors associated with modern contraceptive continuation 6 months after initiation among young mothers.

METHODS

Data come from a 12-month longitudinal study of married reversible contraceptive users in India. Multinomial logistic regression was conducted to examine adjusted associations of age and reported receipt of low, medium, or high quality of care. Logistic regression was used to assess factors associated with modern contraceptive continuation after 6 months.

RESULTS

Results showed that young mothers were less likely to receive high quality of care than older mothers, and that among young mothers, motivation to prevent pregnancy was significantly associated with continued use after 6 months.

DISCUSSION

As India aims to improve quality of care and increase access to services for youth, special attention should be paid to care received by young mothers, as well as options to support them in continuing to use contraceptive methods as long as they desire to prevent pregnancy.

Comparative analysis of contraceptive use in Punjab and Manipur: exploring beyond women's education and empowerment

Background

Women’s education and empowerment are important predictors of contraceptive use across countries. However, two of the Indian states, namely, Punjab and Manipur, showed large variations in contraceptive use, despite the similar level of women’s educational attainment and empowerment. Therefore, this paper attempts to understand variation in contraceptive use between these states, despite having similar level of educational attainment and empowerment among the married women.

Methods

This study primarily used cross-sectional data of the National Family Health Survey (NFHS) 2015–16 and to some extent the District Level Household Survey (DLHS) 2012–13 data. The analytical sample includes 13,730 currently married women in Punjab and 8,872 in Manipur. Modern contraceptive prevalence rate (mCPR) is the key outcome variable of this study. Bivariate, multivariate, and multilevel regression analysis are applied to understand the differences in mCPR between these states and its determinants.

Results

Mean years of schooling was about 8 years among women of both the states, and about 34% of the women in Punjab and 27% of the women in Manipur have high level of autonomy. Despite this, use of modern method was 66% in Punjab and only 13% in Manipur. Coverage of family planning program indicators were significantly lower in Manipur than Punjab – frontline workers’ (FLWs) outreach for family planning was only 18% in Manipur compared to 52% in Punjab. Similarly, only 11% of the public health facilities in Manipur compared to 50% of the health facilities in Punjab were ready to provide at least one clinical method of family planning.

Conclusion

Despite the similar level of individual level characteristics across the two states, poor coverage of family planning programs – low outreach of FLWs, low level of facility readiness, as well as sociocultural norms discouraging contraceptive use – might be responsible for lower contraceptive use in Manipur than Punjab. This implies for strengthening the health system for family planning in Manipur to meet the contraception needs of women by addressing sociocultural barriers in the state.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13147-3.

Spousal Violence Against Women in India: A Social-Ecological Analysis Using Data From the National Family Health Survey 2015 to 2016

Even after enactment of the Protection of Women From Domestic Violence Act 2005, over the last 10 years, the rate of decline of prevalence of spousal violence against women has remained low in India. This study attempts to explain the experience of spousal violence using a social-ecological framework. We analyzed the National Family Health Survey 2015 to 2016 (NFHS-4) data of 66,013 ever-married women aged 15 to 49 years. Participants in the domestic violence module of the NFHS-4 reported their experience of violence committed by their husband within the 12 months preceding the survey. Multilevel logistic regression analyses were done to determine the association between spousal violence and different explanatory variables of various levels of social ecology including variables on women's empowerment. About one fourth of ever-married women reported experiencing any form of violence during the last year. The experience of spousal violence was significantly associated with social ecology at multiple levels. At the individual level, the odds of experiencing physical violence were higher among younger women, who married at a younger age, had an age gap of 3 to 4 years with her husband, and had more children. Women in vulnerable groups, with poor economic status, and members of marginalized communities had higher odds of experiencing spousal violence. Women had high odds of experiencing spousal violence if living in a social ecology with unfavorable social norms, higher rates of domestic crimes, and a higher prevalence of underage marriage. The association of spousal violence with women's empowerment remained inconclusive. The results argue for manipulating contextual factors to empower women to challenge gender-related equations and investing in education for gender sensitization at the higher level social ecologies.

Mass media exposure and use of reversible modern contraceptives among married women in India: An analysis of the NFHS 2015-16 data

Since the inception of the National Programme for Family Planning, messages on family planning (FP) have been promoted across India using different mass media platforms. Mass media plays an important role in disseminating important information among the masses, such as how reversible modern methods give women more reproductive choices than opting for permanent methods that limit their child-bearing capacity. Mass media can provide a continuous flow of information and motivation to deter women from discontinuing the methods they have opted for. However, very few studies have been conducted on this issue, especially using recently available data. This study particularly focuses on exposure to mass media and the use of reversible modern methods of family planning among married women in India. The data for this study was obtained from the National Family Health Survey (2015–16) on currently married women aged 15–49 years. The association of reversible modern method use with media exposure variables was examined, controlling for a set of independent variables from multiple levels—individual, district, state, and region. The findings from this study showed that television was the most important medium for disseminating information on FP among married women in India. Spatial analysis revealed that some districts in the north, parts of the northeast, and Kerala in South India lacked any television exposure. The results from the decomposition analysis showed that mass media exposure was associated with a 14% increase in the use of reversible modern methods. Results from the multilevel analyses showed that exposure to TV along with other media (AOR 1.57 95% CI 1.49–1.65) and exposure to FP messages through different media (AOR 1.22 95% CI 1.12–1.32) had a significant positive effect on the use of reversible modern methods even when various individual, district, state, and regional-level factors were controlled. The findings of this paper provide evidence supporting the use of mass media to promote and increase awareness of voluntary contraceptive use in India. An increase in mass media exposure coupled with improvement in coverage and services of the FP program can significantly increase the use of reversible modern methods in a cost-effective yet efficient manner among women in need of FP services.

Not All Women Who Experience Side Effects Discontinue Their Contraceptive Method: Insights from a Longitudinal Study in India

Side effects are a primary reason why women stop using contraception, even though they may still want to avoid a pregnancy. The Demographic and Health Surveys (DHS), the largest source of nationally representative data on contraceptive discontinuation, only asks women who discontinued a method their reasons for discontinuation, for which side effects is an option. Yet, side effects are also experienced by continued users. Using longitudinal data collected from a cohort of contraceptive users in Odisha and Haryana, India, this study explores the effect of side effect severity and frequency on six-month discontinuation. Among women who experienced side effects of their enrollment method, 49.7 percent continued to use it by the six-month interview. Women who experienced moderate/severe side effects infrequently were 67 percent (adjusted odds ratio [AOR]: 0.33; 95 percent confidence interval [CI]: 0.16-0.64) less likely to discontinue the enrollment method compared to women who experienced moderate/severe side effects always. Women who experienced mild side effects were even less likely to discontinue (AOR: 0.15; 95 percent CI: 0.06-0.37). Study results suggest side effect severity and frequency are more important factors than simply the experience of a side effect in understanding contraceptive discontinuation. DHS and other national surveys should expand their exploration of side effects to include questions asked of current users.

Client-provider interaction: understanding client experience with family planning service providers through the mystery client approach in India

The benefits of employing a rights-based approach in family planning (FP) programmes have made the client's rights to informed choices and quality care an essential part of any such programme. client-provider interaction is one of the critical components of the quality of care (QoC) framework of FP. While several studies have assessed QoC in FP services in India, very few have focused on the in-depth assessment of the interaction between the client and the provider during service delivery. The present study used the mystery client approach to assess the quality of interactions between clients and FP service providers in two of the most populous states of India: Bihar and Uttar Pradesh (UP). Findings highlighted that the providers spent very little time with the clients, gave them information on only one or two FP methods, and rarely talked about possible side-effects of the methods. Furthermore, the providers seemed hesitant to suggest any FP method other than condoms to newly married women. This study concluded that despite being a government priority, the quality of client-provider interaction in these two states was extremely poor.

Quality of care in sterilization services at the public health facilities in India: A multilevel analysis

Female sterilization is the most popular contraceptive method among Indian couples, and the public sector is the major source of sterilization services in the country. However, concerns remain on the quality of services provided, deaths, failures, and complications following sterilization. In this paper, we study the complexities around the quality of care in female sterilization services at public health facilities and identify strategies for improving the measurement of such quality. A better understanding of these issues could inform pragmatic strategies for enhancing quality. This study uses data from the National Family Health Survey (NFHS) 2015–16 and District Level Household and Facility Survey (DLHS) 2012–13. The study is limited to only districts whose data are available in both DLHS 2012–13 and NFHS 2015–16. The methods of analysis include bivariate statistics, Pearson’s chi-square test, and two-level mixed-effects logistic regression. We found that the quality of care (QoC) in sterilization service at the public health facilities in India is associated with facility readiness and the socio-economic characteristics of the clients. There is a significant association between household wealth and the QoC received. Our study provides empirical shreds of evidence on the role of structural attributes in delivering quality sterilization services. The spatial analyses revealed the geographies in the country where the QoC and facility readiness are low. Quality should be an overriding priority to establish the credibility of any health care delivery system. It is essential to provide safeguards against adverse events to develop the client’s confidence in the services, which is the key to success for any voluntary family planning program like in India.

Association between modern contraceptive use and child mortality in India: A calendar data analysis of the National Family Health Survey (2015-16)

Background

Influence of contraceptive use on increased gap between successive births and attributed reduced risk of child deaths is well documented in developing countries. However, there is scarcity of evidence on direct contribution of contraceptive use on child survival especially in Indian context.

Methods

Using information given in the reproductive calendar history of the National Family Health Survey of India conducted in 2015–16, this study examines the effect of modern contraceptive use on childhood mortality – infant mortality rate (IMR) and under-five mortality rate (U5MR). Bivariate analysis and cox proportional hazard model is applied in the study.

Results

Finding reveals that use of reversible contraceptives prior to birth resulted in low childhood mortality rates. IMR is 35 per 1000 live births among births with preceding use of modern reversible contraceptives as compared to 44 per 1000 live births among births with no use. Similarly, U5MR is 41 per 1000 live births as compared to 61 per 1000 live births among births with preceding use of contraceptive and no use respectively. The use of reversible modern contraceptives prior to birth is protective against child mortality even among births with preceding birth interval of less than 24 months.

Conclusions

This study provides evidence of dual benefit of contraceptive use. Such information is important for promoting evidence-based advocacy to expand use of family planning services. This will help the country to achieve Sustainable Development Goal 3.2 which calls for end of preventable deaths during childhood.

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First paper providing evidence of direct effect of modern contraceptive use on child mortality in India.

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Contraceptive use increases birth intervals, and births with large preceding birth intervals have higher chances of survival.

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Use of modern contraceptive prior to birth reduces risk of child mortality even in the absence of large birth intervals.

Health workers' outreach and intention to use contraceptives among married women in India

Background

The influence of health workers on uptake of maternal healthcare services is well documented; however, their outreach for family planning (FP) services and influence on the intention to use contraceptives is less explored in the Indian context. This study examined the extent of health worker outreach for FP service and its effects on intention to use contraceptives among currently married women aged 15–49 years.

Methods

This study used data from two rounds of the National Family Health Survey (NFHS) of India, conducted during 2005–06 and 2015–16 respectively. Bivariate analysis and multivariate logistic regression were used to understand the level of and change in health worker outreach for FP services over time, and its association with intention to use contraceptives among currently married women.

Results

In the past 10 years, health workers’ outreach for FP service has significantly increased by about 10 percentage points, although the level is not optimal and only 28% of non-users were reached by health workers in 2015–16. Increase in the outreach to younger and low parity women was higher than their respective counterparts. Intention to use contraceptive among women who were not using any method was 41% when health workers contacted and discussed FP, compared to only 20% when there was no such contact with health workers. Multivariable analysis suggests that contact with health workers has significant positive effects on intention to use contraceptive (AOR = 3.05; p < 0.001; 95% CI 2.85–3.27).

Conclusion

Increased scope of outreach of frontline health workers to provide FP communication and services will not only help in building knowledge of contraceptive methods but will also increase women’s intention to use a method. For India, this may be the most promising way to achieve the Sustainable Development Goals 3.7, which calls for universal access to reproductive health services.

Intrahousehold influence on contraceptive use among married Indian women: Evidence from the National Family Health Survey 2015-16

Background

India, where more than one married woman of reproductive age often live in the same household, provides an ideal setting to promote family planning through intrahousehold influence.

Objectives

This study examined the association between use of modern contraceptives by young married women, and other married women live in the same household.

Methods

We included 31,361 currently married women of 15–24 years from women data of the National Family Health Survey 2015–16. Each of these women was living with another married woman within the same household, who was also interviewed. From each household, we labeled the woman with the shortest marital duration as the Index Woman. The second woman in each household was either labeled as Peer or Other or Elderly (had married within 5 years or 5–19 years after or 20 or more years after the marriage of Index women, respectively). The association between use of modern contraceptives by Index Women and the second woman in household was examined using logistic regressions—controlled for the background characteristics of Index Women.

Results

Index Women had 2.9 times adjusted odds (95%CI 2.5–3.3) of using modern contraceptives if living with Peers, who were also using modern contraceptives. Similarly, when the second women using modern contraceptives, an Index Woman had 1.7 times adjusted odds for using modern contraceptives (95%CI 1.5–1.9) if living with Elderly, and about 2.5 times adjusted odds if living with Other women (95%CI 2.1–2.8). The association between contraceptive use by an Index Woman and the second woman in the household remained significant even after controlling for background characteristics, showing the independent effect of intrahousehold influence on contraceptive use.

Conclusion

The conclusive evidence of positive intrahousehold influence on contraceptive use of Index Women will encourage program managers to promote intrahousehold communication to increase use of family planning.

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Strong intrahousehold influence on contraceptive use among young women.

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Young women get more influence on contraceptive use from peers than other women.

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Results will encourage voluntary contraceptive use through intrafamily communication.

The relationship between attitudes towards pregnancy and contraceptive continuation: Results from a longitudinal study of married women in India

To understand the relationship between pregnancy intentions and contraceptive use, a growing body of research has begun to examine various domains of women's attitudes towards pregnancy, acknowledging that these attitudes may contradict one another, and women may be ambivalent. This study examines pregnancy ambivalence and assesses the relationship between attitudes towards pregnancy and contraceptive continuation after nine months among a sample of women in Odisha and Haryana, India. Data come from a longitudinal study of married women age 15–49 who began using a modern reversible method of contraception at the time of study enrollment. To assess their cognitive attitudes (beliefs/knowledge) towards pregnancy, women were asked “how important is it you to avoid a pregnancy now?” To assess their affective attitudes (feelings/emotions), women were asked about their agreement with the statement: “If I found out I was pregnant in the next several weeks, I would be happy.” A joint, 4-category measure combining these cognitive and affective attitudes towards pregnancy was created to measure concordance and ambivalence in attitudes towards pregnancy. Multivariate random-effects logistic regression models were employed to examine the relationship of these two measures with method-specific contraceptive continuation nine months later. Two models were conducted, one with the two attitude variables included independently and the second with the joint, 4-category measure included. Results showed that affective and cognitive attitudes were both significantly associated with continuation, but that there were no significant differences between those that were ambivalent and those whose attitudes were concordantly anti-pregnancy. This study suggests that attitudes towards pregnancy are multifaceted and both cognitive and affective attitudes towards pregnancy may play an important role in contraceptive use in India.

Infection prevention preparedness and practices for female sterilization services within primary care facilities in Northern India

Background

In 2014, 16 women died following female sterilization operations in Bilaspur, a district in central India. In addition to those 16 deaths, 70 women were hospitalized for critical conditions (Sharma, Lancet 384,2014). Although the government of India’s guidelines for female sterilization mandate infection prevention practices, little is known about the extent of infection prevention preparedness and practice during sterilization procedures that are part of the country’s primary health care services. This study assesses facility readiness for infection prevention and adherence to infection prevention practices during female sterilization procedures in rural northern India.

Method

The data for this study were collected in 2016–2017 as part of a family planning quality of care survey in selected public health facilities in Bihar (n = 100), and public (n = 120) and private health facilities (n = 97) in Uttar Pradesh. Descriptive analysis examined the extent of facility readiness for infection prevention (availability of handwashing facilities, new or sterilized gloves, antiseptic lotion, and equipment for sterilization). Correlation and multivariate statistical methods were used to examine the role of facility readiness and provider behaviors on infection prevention practices during female sterilization.

Result

Across the three health sectors, 62% of facilities featured all four infection prevention components. Sterilized equipment was lacking in all three health sectors. In facilities with all four components, provider adherence to infection prevention practices occurred in only 68% of female sterilization procedures. In Bihar, 76% of public health facilities evinced all four components of infection prevention, and in those facilities provider’s adherence to infection prevention practices was almost universal. In Uttar Pradesh, where only 55% of public health facilities had all four components, provider adherence to infection prevention practices occurred in only 43% of female sterilization procedures.

Conclusion

The findings suggest that facility preparedness for infection prevention does play an important role in provider adherence to infection prevention practices. This phenomenon is not universal, however. Not all doctors from facilities prepared for infection prevention adhere to the practices, highlighting the need to change provider attitudes. Unprepared facilities need to procure required equipment and supplies to ensure the universal practice of infection prevention.

Determinants of low birth weight in India: An investigation from the National Family Health Survey

OBJECTIVE

This study aimed to estimate the change in prevalence of low birth weight (LBW) over the last decade in India and to identify its associated factors-biological, demographic, socio-economic, and programmatic.

METHODS

We used the data from the National Family Health Survey of 2005-2006 (NFHS-3) and 2015-2016 (NFHS-4). The sample of this study included 11 300 children from NFHS-3 and 99 894 from NFHS-4 data; all these children were the last full-term singleton live-births, born within the last 3 years prior to the survey.

RESULTS

In India, the prevalence of LBW has significantly declined from 20.4% (95%CI 19.4-21.4) to 16.4% (95% CI 16.1-16.8) in the last decade. The prevalence of LBW remained high in girl children (OR = 1.2, 95% CI 1.2-1.3; P < .001), whose mothers were adolescent (OR = 1.2, 95% CI 1.1-1.3; P < .001), and were stunted (OR = 1.3, 95% CI 1.3-1.3; P < .001). Prevalence of LBW declined among second or higher birth order child (OR = 0.8, 95% CI 0.8-0.9; P < .001), whose mothers educated up to secondary level and above (OR = 0.6 to 0.8), belonged to rich wealth quintiles (OR = 0.9 to 0.8), were from rural area (OR = 0.9, 95% CI 0.9-1.0; P < .001), received better nutrition and adequate antenatal care (OR = 0.8, 95% CI 0.8-0.8; P < .001), and were from eastern, northeastern, and southern regions of India (OR = 0.9 to 0.5).

CONCLUSION

Although the prevalence of LBW in India has declined over the past decade, the extent of the decline is modest. In the coming years, health programs in India need to gear up with greater convergence between maternal health services and maternal nutrition to reduce LBW.

Dietary Adequacy Among Young Children in India: Improvement or Stagnation? An Investigation From the National Family Health Survey

BACKGROUND

This study assessed the trend of minimum acceptable dietary practices among children aged 6 to 23 months in India in the past decade.

METHODS

Data collected in the National Family Health Survey during 2005 to 2006 (NFHS-3) and 2015 to 2016 (NFHS-4) were used. The sample size for this study was 11 727 children for NFHS-3 and 61 158 children for NFHS-4. Bivariate and multivariate analyses were done to identify the predictors of feeding practices. We analyzed data of last-born singleton children aged 6 to 23 months who were living with their mother (ever-married women aged 15-49 years).

RESULTS

In India, a low proportion (10%) of children aged 6 to 23 months received a minimum acceptable diet, and its estimate remained the same in the past 10 years. Older mothers, educated mothers, antenatal care, high economic status, and place of residence were the most consistent predictors of minimum acceptable dietary intake. Over the past decade, however, the minimum acceptable dietary intake has declined among older children (odds ratio [OR] = 0.57, 95% confidence interval [CI], 0.47-0.70; P < .001), children with overweight mothers (OR = 0.40, 95% CI, 0.31-0·50; P <.001), and children of well-off families (OR = 0.29, 95% CI, 0.23-0.37; P < .001). The odds for minimum acceptable dietary intake were significantly higher among children of high (4+) birth order (OR = 1.74, 95% CI, 1.41-2.15; P < .001), rural areas, and children living in the central, eastern, and north-eastern region.

CONCLUSION

Results indicate the need for further investigations of poor dietary intake among children living in well-off families and in the northern region. This study suggests policymakers and program managers to address contextual barriers against minimum acceptable dietary intake among children and to reconsider existing strategies in India.

Adding a Question About Method Switching to the Method Information Index Is a Better Predictor of Contraceptive Continuation

Adding the question “Were you told about the possibility of switching to another method if the method you selected was not suitable?” to the Method Information Index (MII) was associated with better contraceptive continuation. This MIIplus variable includes another domain of quality of care, and thus better reflects voluntary contraceptive use and continuation.

Introduction:

The Method Information Index (MII) is 1 of 18 core indicators used to monitor progress toward achieving Family Planning 2020's goal of 120 million more women using a modern method of family planning by 2020. The 3 questions of the MII are intended to measure informed choice at method initiation. Although routinely used in the Demographic and Health Surveys and the Performance Monitoring and Accountability 2020 project in cross-sectional household surveys, the MII may not adequately reflect all key aspects of quality of care or predict contraceptive continuation. In the current study, a question was added to the MII regarding the possibility of switching to a different contraceptive method if the current method is not suitable. The revised MII is referred to as MIIplus.

Methods:

A total of 2,699 married women aged 15–49 who started a new episode of use of intrauterine device, injectable, or oral contraceptive pills between December 2016 and October 2017 were followed for 1 year in India and interviewed at method start and 3, 6, and 12 months later. Of these women, 2,267 were interviewed 3 months later and included in the analysis. Using 3 Cox proportional hazard models, we estimated hazard ratios for risk of discontinuation, based on the MII, MIIplus, and a recategorization of MIIplus into a 3-category variable.

Results:

The modern method continuation rate 100 days (∼3 months) later was 91% overall. Women who received the information in MIIplus were more likely to continue using a method at 100 days (95%) compared to those who received information covered in the MII (82%) or less than 3 components of the MII (89%) (P<.001). Women who received all components in the MIIplus were 69% (adjusted hazard ratio, 0.31; 95% confidence interval: 0.17 to 0.61) less likely than those who received information in the MII to discontinue using a modern method 100 days later. Discontinuation was not significantly different between women who received information on less than the 3 components of the MII compared to the complete MII.

Conclusion:

We recommend including the question about the possibility of switching to another family planning method in routine measurement because it better predicts contraceptive continuation than the MII alone and ensures that another domain of quality of care is reflected in the measurement. When programs provide information on the possibility of switching, women are better informed about voluntary family planning choice and their options to continue family planning when a method is not suitable.

Choice of contraceptive methods in public and private facilities in rural India

Background

Client-centric quality of care (QoC) in family planning (FP) services are imperative for contraceptive method adoption and continuation. Less is known about the choice of contraceptive method in India beyond responses to the three common questions regarding method information, asked in demographic and health surveys. This study argues for appropriate measurement of method choice and assesses its levels and correlates in rural India.

Methods

A cross-sectional study was conducted with new acceptors of family planning method (N = 454) recruited from public and private health facilities in rural Bihar and Uttar Pradesh, the two most populous states in India. The key quality of care indicator ‘method choice’ was assessed using four key questions from client-provider interactions that help in making a choice about a particular method: (1) whether the provider asked the client about their preferred method, (2) whether the provider told the client about at least one additional method, (3) whether the client received information without any single method being promoted by the provider, and (4) client’s perception about receipt of method choice. The definition of method choice in this study included women who responded “yes” to all four questions in the survey. The relationship between contraceptive communication and receipt of method choice was assessed using logistic regression analyses, after adjusting for socio-demographic characteristics of the respondents.

Results

Although 62% of clients responded to a global question and reported that they received the method of their choice, only 28% received it based on responses about client-provider interactions. Receipt of the information on side-effects of the selected method (Adjusted Odds Ratio [AOR]: 7.4, 95% Confidence Interval [CI]: 3.96–13.86) and facility readiness to provide a range of contraceptive choice (AOR: 2.67, 95% CI: 1.48–4.83) were significantly associated with receipt of method choice.

Conclusions

Findings demonstrated that women’s choice of contraceptive could be improved in rural India if providers give full information prior to and during the acceptance of a method and if facilities are equipped to provide a range of choice of contraceptive methods.

Validation of Two Quality of Care Measures: Results from a Longitudinal Study of Reversible Contraceptive Users in India

Bruce's quality of care framework, developed nearly three decades ago, brought needed international attention to family planning services. Various data collection efforts exist to measure the quality of contraceptive services. Our study validates two process quality measures and tests their predictive validity related to contraceptive continuation among 2,699 married women who started to use a reversible contraceptive method in India. We assessed four process quality domains with 22 items, which were reduced to 10 items using exploratory factor analysis. Weighted additive indices were calculated for the 22- and 10-item measures. Scores were trichotomized into high, medium, and low process quality received. The predictive validity of the two measures was assessed related to modern contraceptive continuation three months later. The adjusted odds of continuing a modern contraceptive three months later was nearly three times greater (AOR: 2.78; 95% CI: 1.83-4.03) for women who received high process quality at enrollment compared with low quality with the 22-item measure, and 2.2 times greater (95% CI: 1.46-3.26) with the 10-item measure. Results suggest that the 22- and 10-item measures are valid, and while the larger 22-item measure can be used in special studies, the 10-item measure is more suited for routine data collection and monitoring.

India's family planning market and opportunities for the private sector: An analysis using the total market approach

The private (commercial) sector in India can complement public sector for family planning services, but the roadmap to engage these two sectors remains a challenge. The total market approach (TMA) offers a strategy by understanding the comparative advantage of public, commercial, and nonprofit sectors. We estimated TMA indicators using data of four rounds of the National Family Health Surveys: 1992‐93, 1998‐99, 2005‐06, and 2015‐16. The contraceptive prevalence of modern methods in India did not increase in recent years, but the number of users increased, and so did the market size for the commercial sector. In rural areas, the current market size in 2015‐16 (75 million) failed to reach its potential size in 1992‐93 (84 million). In urban areas, the market of modern contraceptives is mostly composed of the users from higher wealth, and a high percentage of users obtain contraceptives from subsidized sources. The family planning market of northern part of Bihar and Uttar Pradesh and of Northeast India are in the “early” stage and need more demand generation; “matured” markets are mostly concentrated in and around big metros. Subsidization in urban areas should be offered to the targeted population who need family planning products and services at low cost.

Increasing knowledge of home based maternal and newborn care using self-help groups: Evidence from rural Uttar Pradesh, India

BACKGROUND

In India, pregnant women and recently delivered mothers of marginalized communities in Uttar Pradesh (UP) remain un-reached by frontline-health-workers. In these communities, self-help groups (SHGs) have the potential to reach these women with knowledge of home-based maternal and newborn care (HBMNC).

OBJECTIVE

The study examines the feasibility of SHGs to improve knowledge of HBMNC. The study identifies the facilitating factors and barriers to knowledge change.

METHODS

A panel study with a quasi-experimental design was conducted in Jhansi, UP. Peer educators, called Swasthya Sakhi, of the SHGs of the experimental area were trained on how to conduct discussions on HBMNC topics. Both at baseline and endline 233 women from the experimental area and 237 women from the comparison area were interviewed to measure their knowledge change in HBMNC topics. The net-effect of the intervention was examined using difference-in-difference (DID) analysis with propensity-score-matching (PSM) controlling for the effect of background characteristics of the participants from two study areas. Generalized-estimating-equation (GEE) was used to identify the facilitating factors and barriers to the knowledge change.

RESULTS

The findings show significant net-increases in women's knowledge for most of the HBMNC topics including danger signs for a pregnant mother and a newborn child, even after controlling for the background characteristics of the participants. The most significant determinant of the increase of knowledge was the women's education.

CONCLUSION

Findings from the study showed SHGs can increase HBMNC knowledge among women. However, studies with longer duration are required to examine the scalability and sustainability of the intervention.

Understanding the use of India's National Health Insurance Scheme for family planning and reproductive health services in Uttar Pradesh

India's National Health Insurance Scheme, Rashtriya Swasthya Bima Yojana (RSBY), expands health services to families living below the poverty line by enrolling them into the scheme through selected health facilities. Use and reasons for nonuse of RSBY for family planning (FP) and reproductive health (RH) services have not been explored previously. This cross-sectional study explored the use of RSBY for FP/RH services at private health facilities, knowledge of FP/RH service availability, and factors influencing knowledge among RSBY enrolled families. A total of 726 women and 640 men from enrolled families living in 3 cities of Uttar Pradesh, India, were interviewed. Use of FP/RH services at private hospitals enrolled in the RSBY was 2%. Nearly 20% of respondents used FP or delivery services from unenrolled private hospitals but could have accessed these services through the scheme. Over 75% of respondents were unaware of FP/RH service availability through RSBY. Respondents with some education were more likely to have this knowledge, while poorer families were less likely to have this knowledge. Findings suggest that for RSBY to reach the most vulnerable families, efforts need to be made to better educate enrolled families about their entitlements and benefits of the scheme.

Gender-Based Violence in Rural Uttar Pradesh, India: Prevalence and Association With Reproductive Health Behaviors

This study explores the prevalence of different forms of domestic violence and their impact on women's reproductive health behavior in rural Uttar Pradesh (UP), India. Data were collected as a part of a large household survey carried out in 2009-2010. A multistage stratified systematic sampling design was used. A total of 4,223 married women aged 15 to 49 years and 2,274 husbands of these women were interviewed. Data were analyzed using bivariate and multivariate analyses. More than one third of married women in rural UP had experienced one or more forms of violence, such as verbal abuse, physical manhandling, and sexual abuse by their spouse. Nearly 47% of the women had experienced some form of violence during their last pregnancy. Significant associations were found between violence and incorrect reproductive health behaviors, pregnancy complications, poor birth preparedness, poor likelihood of institutional delivery, limited postnatal care, and limited spousal communication for family planning. After controlling for socio-economic variables in multivariate analysis, only pregnancy complications (odds ratio [OR] = 1.62, 95% confidence interval [CI] = [1.40, 1.85]) and lack of delivery preparedness (OR = 0.79, 95% CI = [0.68, 0.93]) were found to be significantly associated with violence. Husband's attitude and reporting of violence by their wives in different situations were not significantly associated. This study provides evidence of the association of violence on the reproductive health behavior of married women in rural India. The results argue for frontline health workers to identify and counsel pregnant women experiencing violence during antenatal check-up to reduce maternal morbidity and mortality.

Corrective Equations to Self-Reported Height and Weight for Obesity Estimates Among U.S. Adults: NHANES 1999-2008

PURPOSE

Estimating obesity prevalence using self-reported height and weight is an economic and effective method and is often used in national surveys. However, self-reporting of height and weight can involve misreporting of those variables and has been found to be associated to the size of the individual. This study investigated the biases in self-reporting of height and weight in the U.S. adult population and generated age-adjusted correction equations for self-reported height and weight separately for each ethnic group's specific height and weight quartile sample. Validity of the body mass index (BMI) classification calculated from corrected self-reported height and weight was also examined.

METHOD

Data on self-reporting and direct measurement of height and weight from National Health and Nutrition Examination Survey 1999-2008 were analyzed. The final sample included 11,521 men and 10,905 nonpregnant women who were all U.S. citizens aged 20 years or older.

RESULTS

A variation in misreporting of self-reported height and weight depended on the gender, ethnicity, age, and size of the individual. The results from sensitivity and specificity analyses showed that the BMI calculated from corrected values of self-reported height and weight provided more accurate estimations of overweight and obesity than did BMI calculated from self-reported height and weight.

CONCLUSION

In spite of some methodological concerns, the correction equation of self-reported height and weight generated in this study can be utilized as a method for quick assessment of estimating the obesity and overweight prevalence in the U.S. adult population.

Prevalence, trends, and determinants of menopause in India: NFHS 1992-93 to NFHS 2005-06

OBJECTIVES

The purpose of this study was to estimate the prevalence of menopause in three rounds of the National Family Health Survey (NFHS), determine correlates of menopause, and estimate the age of start of menopause in Indian women.

METHODS

Three rounds of NFHS data collected during 1992-93, 1998-99, and 2005-06 were analyzed. The NFHS was carried out using a uniform sample design all over the country. Age adjusted complex sample analyses, multivariate logistic regression, and probit analysis were carried out.

RESULTS

The prevalence of menopause (natural and surgical) remained similar from 1992-93 to 2005-06 among Indian women. A higher prevalence and earlier onset of menopause was associated with farming, no education, belonging to a scheduled caste or scheduled tribe, underweight, higher parity, and motherhood before 16 years of age. The age of the start of menopause did not increase much from the first to third round of NFHS.

CONCLUSIONS

Women of poor socio-economic status have an earlier age at menopause and may be unable to utilize their full reproductive potential.

Changes in metabolic syndrome in American and Korean youth, 1997-2008

BACKGROUND

Metabolic syndrome (MetSyn) in children and adolescence is increasing worldwide; however, its pattern may be different between Asians and Americans. We compare the prevalence and patterns of MetSyn between American and Korean children and adolescents between roughly 1998 and 2007.

METHODS

Data from the American and Korean versions of the NHANES (NHANES and KNHANES) were used for this study. The main outcome is prevalence and pattern of MetSyn among participants separately in each country. In each survey, stratified multistage probability sampling designs and weighting adjustments were conducted to represent the entire population. The revised National Cholesterol Education Program criteria were used to define MetSyn.

RESULTS

Totals of 934, 1781, and 1690 Americans aged 12 to 19 participated in NHANES 1988-1994, NHANES 1999-2002, and NHANES 2003-2006, respectively; and 1225, 976, 705, and 456 Koreans aged 12 to 19 have participated in KNHANES 1998, 2001, 2005, and 2007. The age-adjusted prevalence of MetSyn in American NHANES decreased from 7.3% to 6.7% and 6.5%, whereas in Korean NHANES there was an increase from 4.0% to 5.9%, 6.6%, and 7.8% in each country's respective study. Increases in dyslipidemia and abdominal obesity contributed to the increased prevalence in Korea, whereas in the United States, decreases in low high-density lipoprotein cholesterolemia and high blood pressure contributed to a decreased prevalence.

CONCLUSIONS

Considering different phenotype changes, different approaches should be conducted at the national level to reduce the burden and consequences of MetSyn between Korea and the United States.

Occupational physical activity and risk of coronary heart disease among active and non-active working-women of North Dakota: a Go Red North Dakota Study

Currently less than half of the US adults meet physical activity (PA) recommendations, yet many more are sedentary in their occupations. Sedentary workers may therefore be at elevated risk for coronary heart disease (CHD). Therefore, the objective of the study is to examine the relationship of CHD risk with occupational PA (OCPA) and leisure time PA (LTPA) among working-women. The 10-year CHD risk and relative risk scores were calculated for 642 working-women. Self-report questionnaire determined levels of OCPA and LTPA. Biometric data were directly collected on all women. No direct relationship for OCPA and 'high risk' of CHD was determined. Insufficient LTPA was significantly associated with greater prevalence of 'high risk' of CHD. No dose response relationship was determined with PA and CHD risk. The odds of being 'high risk' were significantly greater for sedentary workers with insufficient LTPA compared to sufficient LTPA. The odds for being 'high risk' were similar among moderately active or heavy working women completing insufficient LTPA compared to women doing sufficient LTPA. For women with sedentary occupations, a sufficient amount of LTPA is essential to reduce CHD risk. Women in moderate to heavy working occupations may be acquiring adequate amounts of PA to minimize CHD risk.

Correction equations to adjust self-reported height and weight for obesity estimates among college students

The purposes of this study were to generate correction equations for self-reported height and weight quartiles and to test the accuracy of the body mass index (BMI) classification based on corrected self-reported height and weight among 739 male and 434 female college students. The BMIqc (from height and weight quartile-specific, corrected self-reported measurements) provided a more accurate estimation of BMI classification than BMIc (from corrected self-reported measurements) and BMIs (from self-reported measurements) by showing a greater ability to predict cases with either a high or a low BMI category while still maintaining a high specificity. However, the equations are applicable only to Caucasian college student populations, so cross-validation in similar populations is needed before they are used more broadly.

Persistent increase of prevalence of metabolic syndrome among U.S. adults: NHANES III to NHANES 1999-2006

OBJECTIVE

To compare the prevalence in metabolic syndrome (MetSyn) between 1988-1994 and 1999-2006 among U.S. adults of different races or ethnicities.

RESEARCH DESIGN AND METHODS

Analysis of data on 6,423 adult men and nonpregnant women aged ≥20 years from Third National Health and Nutrition Examination Survey (NHANES III) and 6,962 participants from the combined NHANES 1999-2006 were done. The revised National Cholesterol Education Program Adult Treatment Panel III definition was used to calculate MetSyn.

RESULTS

Both the unadjusted prevalence (27.9 ± 1.1% to 34.1 ± 0.8%, P < 0.001) and age-adjusted prevalence (29.2 ± 1.0% to 34.2 ± 0.7%, P < 0.001) increased from NHANES III to NHANES 1999-2006, respectively. Although MetSyn prevalence was highest in Mexican Americans, significant increases in prevalence occurred among non-Hispanic whites and non-Hispanic blacks, especially among younger women.

CONCLUSIONS

The persistent increase of MetSyn among U.S. adults is a serious public health concern because it raises the likelihood of increased prevalence of type 2 diabetes.

Statewide awareness study on personal risks of cardiovascular disease in women: a go red North Dakota study

General awareness of cardiovascular disease (CVD) as the leading cause of death for women and knowledge of CVD risk factors have increased in the last 10 years. Whether this greater general awareness and knowledge leads to improved risk assessment on a personal level remains uncertain. Therefore, the purpose of this study was to measure the knowledge of CVD risk factors and determine the level of personal CVD risk-factor awareness among female public employees of North Dakota, ND, USA. A 30-item, pretested, standardized questionnaire was adapted from previous American Heart Association (AHA) nationwide surveys to measure awareness of the AHA's Go Red For Women movement and cardiovascular health. The online survey was completed by 1044 women, with most of the participants ( approximately 90%) reported as being aware that heart disease was the leading cause of death for women in the USA, which is much higher than the national average. Nearly all the participants (97.3%) correctly recognized the Go Red 'Red Dress' symbol, and knew that it relates to women and heart disease. The prevalence of individual CVD risk awareness was high for blood pressure (82.2%) and moderately high for cholesterol (67%). Much lower rates of CVD awareness were reported for blood glucose (40.8%) and BMI (29.4%). Along with age and certain socioeconomic factors, awareness of any one CVD risk factor was strongly associated with awareness of other CVD risk factors. It is worth mentioning that the participants with favorable demographics and background characteristics and with a high general awareness may also have low personal awareness of certain CVD risk factors. This low personal awareness lessens one's perceived susceptibility to CVD, which in turn reduces the likelihood of adopting preventive action to decrease personal risk of CVD. Future awareness programs should concentrate on improving individual risk awareness, particularly of blood glucose and BMI, as a means of improving behavior towards better cardiovascular health.

Somatotype of the individuals with lower extremity amputation and its association with cardiovascular risk

Anthropometric somatotyping is one of the methods to describe the shape of the human body, which shows some associations with an individual's health and disease condition, especially with cardiovascular diseases (CVD). Individuals with lower extremity amputation (LEA) are known to be more vulnerable to the cardiovascular risk. The objectives of the present study are to report the somatotype of the individuals having lower extremity amputation, to study the possible variation in somatotype between two groups of amputated individuals, and to study the association between cardiovascular disease risk factor and somatotype components among individuals with locomotor disability. 102 adult male individuals with unilateral lower-extremity amputation residing in Calcutta and adjoining areas were investigated. The anthropometric data for somatotyping and data on cardiovascular risk traits (such as body mass index, blood pressure measurements, blood lipids) have been collected. The somatotyping technique of Carter & Heath (1990) has been followed. The result shows high mean values of endomorphy and mesomorphy components and a low mean value of the ectomorphy component among the amputated individuals having cardiovascular risks. The results of both discriminant analysis and logistic regression analysis show a significant relationship between somatotype components and CVD risk among the individuals with LEA. The findings of the present study support the findings of similar studies conducted on the normal population. Diagnosis of CVD risk condition through somatotyping can be utilized in prevention/treatment management for the individuals with LEA.

Validity of an alternative anthropometric trait as cardiovascular diseases risk factor: example from individuals with traumatic lower extremity amputation

BACKGROUND

Published studies reveal that individuals with lower extremity amputation are vulnerable to cardiovascular diseases (CVD) because of poor physical activity level. Many cardiovascular risk assessment studies have utilized anthropometric traits (primarily body mass index and waist circumference) as cardiovascular risk factor. However, some studies emphasized the technical limitations of measuring waist circumference for studying cardiovascular risk, and so it is difficult to obtain correct measurement from the individuals with lower extremity amputation.

OBJECTIVES

The objectives of the present article are to study the prevalence of CVD risk factors among the individuals with traumatic lower extremity amputation and to test the validity of upper arm circumference (UAC) as an alternative anthropometric measurement for screening the CVD risk condition.

SUBJECTS AND SETTING

Anthropometric data and other cardiovascular traits data have been collected from unilateral traumatic lower extremity amputated adult males (n = 85) residing in Calcutta and adjoining areas.

RESULTS

Results show higher prevalence of cardiovascular risk factor among individuals with above-knee amputation than below-knee amputation. The receiver operating characteristics curve analysis shows significant ability of upper arm circumference to diagnose cardiovascular risk condition. The cutoff value of UAC > 26.6 cm show maximum sensitivity and specificity for the diagnosis of cardiovascular risk condition. Although, binomial tests for equality of proportion does not show any significant difference, however, agreement statistics reveal better diagnostic ability of cutoff value of UAC than the existing cutoff value of waist circumference.

CONCLUSIONS

Therefore, UAC provides a better assessment of cardiovascular risk condition than does waist circumference especially for individuals with lower extremity amputation.

SPONSORSHIP

Indian Statistical Institute, Kolkata.

Effect of skill on work productivity and physical body dimensions of the Oraon tea garden labourers of the Jalpaiguri district, West Bengal, India

Skill is one of the factors influencing labour productivity of manual labour. The present study aims to find out the possible relationship between skill and productivity and between skill and physical body dimension among the tea garden labourers of Northern West Bengal, India. Skill was measured by indigenously devised test protocols developed only for this purpose. Productivity or labour output was measured in terms of amount of tea leaves (in weight) plucked in a day by an individual. Physical body dimension was recorded in terms of a list of anthropometric traits. The results show an inconsistent relationship between skill and productive output and a non-significant relationship between skill and physical body dimensions. However, there are some trends that skill is high in younger individuals and low skill in females is associated with relatively high fat accumulation in the body.

Method for estimating body weight in persons with lower-limb amputation and its implication for their nutritional assessment

BACKGROUND

Body weight is a good indicator of a person's size and is widely used in clinical assessment. However, health-status assessment based on observed body weight (W(O)) is incorrect for persons with limb amputation.

OBJECTIVES

The objectives were 1) to develop a more accurate and generalized method for estimating body weight in persons with limb amputation, 2) to determine whether corrected body weight can be used to assess nutritional status in persons with limb amputation, and 3) to test the validity of the estimation by using empirical data.

DESIGN

Anthropometric data were collected from men from Calcutta and adjoining areas with unilateral lower-extremity amputation (n = 102). Mathematic formulas were developed for determining estimated body weight (W(E)) and body mass index (BMI) calculated from both W(O) and W(E) (ie, BMI(O) and BMI(E), respectively). We assessed nutritional status by using BMI(O) and BMI(E) and tested the validity of each by considering the result of nutritional assessment from midupper arm circumference as the gold standard. We also compared the nutritional status results for the subjects with limb amputation with those for a similar sample size of healthy control subjects.

RESULTS

BMI(E) had a stronger association with midupper arm circumference and a higher efficiency (ie, proportion of correct results given by any test method) than did BMI(O). Moreover, the results obtained with BMI(E) were similar to those obtained with BMI in healthy control subjects. However, the nutritional assessments made with BMI(O) and BMI(E) did not differ significantly from one another.

CONCLUSION

For persons with limb amputation, W(E) provides a better basis for appropriate nutritional evaluation than does W(O).