Many hops, many stops: care-seeking "loops" for diabetes and hypertension in three urban informal settlements in the Mumbai Metropolitan Region

Background

The burden of Non-Communicable Diseases (NCDs) in urban informal settlements across Lower and Middle Income Countries is increasing. In recognition, there has been interest in fine-tuning policies on NCDs to meet the unique needs of people living in these settlements. To inform such policy efforts, we studied the care-seeking journeys of people living in urban informal settlements for two NCDs-diabetes and hypertension. The study was done in the Mumbai Metropolitan Region, India.

Methods

This qualitative study was based on interviews with patients having diabetes and hypertension, supplemented by interactions with the general community, private doctors, and public sector staff. We conducted a total of 47 interviews and 6 Focus Group Discussions. We synthesized data thematically and used the qualitative software NVivo Version 10.3 to aid the process. In this paper, we report on themes that we, as a team, interpreted as striking and policy-relevant features of peoples' journeys.

Results

People recounted having long and convoluted care-seeking journeys for the two NCDs we studied. There were several delays in diagnosis and treatment initiation. Most people's first point of contact for medical care were local physicians with a non-allopathic degree, who were not always able to diagnose the two NCDs. People reported seeking care from a multitude of healthcare providers (public and private), and repeatedly switched providers. Their stories often comprised multiple points of diagnosis, re-diagnosis, treatment initiation, and treatment adjustments. Advice from neighbors, friends, and family played an essential role in shaping the care-seeking process. Trade-offs between saving costs and obtaining relief from symptoms were made constantly.

Conclusion

Our paper attempts to bring the voices of people to the forefront of policies on NCDs. People's convoluted journeys with numerous switches between providers indicate the need for trusted "first-contact" points for NCD care. Integrating care across providers-public and private-in urban informal settlements-can go a long way in streamlining the NCD care-seeking process and making care more affordable for people. Educating the community on NCD prevention, screening, and treatment adherence; and establishing local support mechanisms (such as patient groups) may also help optimize people's care-seeking pathways.

Quantum bath suppression in a superconducting circuit by immersion cooling

Quantum circuits interact with the environment via several temperature-dependent degrees of freedom. Multiple experiments to-date have shown that most properties of superconducting devices appear to plateau out at T ≈ 50 mK - far above the refrigerator base temperature. This is for example reflected in the thermal state population of qubits, in excess numbers of quasiparticles, and polarisation of surface spins - factors contributing to reduced coherence. We demonstrate how to remove this thermal constraint by operating a circuit immersed in liquid ³He. This allows to efficiently cool the decohering environment of a superconducting resonator, and we see a continuous change in measured physical quantities down to previously unexplored sub-mK temperatures. The ³He acts as a heat sink which increases the energy relaxation rate of the quantum bath coupled to the circuit a thousand times, yet the suppressed bath does not introduce additional circuit losses or noise. Such quantum bath suppression can reduce decoherence in quantum circuits and opens a route for both thermal and coherence management in quantum processors.

Role of civil society in health care: Mechanisms for realizing universal health coverage in vulnerable communities of India

The role of civil society as a partner in the delivery of primary health care is well-established. The pandemic placed a great burden on the existing public health system and civil society stepped forward not only to help the vulnerable population to mitigate challenges that subsequently arose but also to fill the gaps the pandemic exposed in India's health care system. The objective of this paper is to provide mechanisms for realizing universal health coverage by strengthening primary health care from the perspective of civil society. The paper uses examples of efforts of SNEHA, a non-profit organization working on the health of women and children in informal settlements of Mumbai and other civil society organizations working with vulnerable or hard-to-reach populations. We use existing literature, field data, reports and published work over the years. We find that civil society helps the health system to connect with difficult-to-reach populations and achieve wider coverage. They can also build the capacity of frontline staff in the public systems in formal and informal ways. They can recommend ways to change the attitudes and motivations of these workers. Civil society organizations with their close connection with the community can play the part of a "gap-filler" and data messenger. Finally, they can refer people to appropriate health facilities minimizing out-of-pocket expenditure on health.

To use or not to use: Exploring factors influencing the uptake of modern contraceptives in urban informal settlements of Mumbai

Rapid urbanization and a high unmet need for family planning in urban informal settlements point to the significance of identifying gaps that exist in the path of voluntary uptake of contraceptives. We undertook this study to better understand the perspectives related to family planning among women living in informal settlements of Mumbai. We used a mixed-methods approach, including a cross-sectional survey with 1407 married women of reproductive age and face-to-face in-depth interviews with 22 women, both users and non-users of modern contraceptives. 1070 (76%) of the participants were using modern contraceptives and women's age, education, parity, socioeconomic status and exposure to family planning interventions were the main determinants of contraceptive use. Poor contraceptive awareness before marriage coupled with social norms of early childbearing and completing family resulted in unplanned and less spaced pregnancies even among current users. In such cases, women either continued with the pregnancy or opted for abortion which sometimes could be unsafe. The decision to use contraceptives was taken in most cases after achieving the desired family size and was also influenced by belief in traditional methods, fear of side effects, spousal/family awareness and counselling by frontline workers. We recommend strengthening of sexual and reproductive health component of adolescent health programs. It is pertinent to inform women about their reproductive rights and most importantly empower them to practice these rights. This can be achieved by increasing women's age at marriage and continued promotion of formal education. Widespread misconceptions related to the side effects of modern methods need to be mitigated via counselling. Referral, follow-up, and suggestions on available choices of contraceptives should be given in case women face any side effects from the use of contraceptives. At the same time, improving spousal awareness and communication regarding family planning will allow couples to make informed decisions. Finally, roping in role models in the community will create an environment conducive to operationalizing rights-based family planning.

Emergency obstetric referrals in public health facilities: A descriptive study from urban Maharashtra, India

Background

An effective referral system is key to access timely emergency obstetric care. The criticality of referrals makes it necessary to understand its pattern at the health system level. This study aims to document the patterns and primary reasons of obstetric case referral and the maternal and perinatal outcome of the cases in public health institutions in select areas of urban Maharashtra, India.

Methods

The study is based on the health records of public health facilities in Mumbai and its adjoining three municipal corporations. The information on pregnant women referred for obstetric emergencies was collected from patient referral forms of municipal maternity homes and peripheral health facilities between 2016 and 2019. Maternal and child outcome data was obtained from "Received-In" peripheral and tertiary health facilities to track whether the referred woman reached the referral facility for delivery. Descriptive statistics were used to analyze demographic details, referral patterns, reasons of referrals, referral communication and documentation, time and mode of transfer and delivery outcomes.

Results

14% (28,020) women were referred to higher health facilities. The most common reasons for referral were pregnancy-induced hypertension or eclampsia (17%), previous caesarean section (12%), fetal distress (11%) and Oligohydramnios (11%). 19% of all referrals were entirely due to unavailability of human resources or health infrastructure. Non-availability of emergency Operation Theatre (47%) and Neonatal Intensive Care Unit (45%) were the major non-medical reasons for referrals. Absence of health personnel such as anaesthetist (24%), paediatrician (22%), physician (20%) or obstetrician (12%) was another non-medical reason for referrals. Referring facility had a phone-based communication about the referral with the receiving facility in less than half of the cases (47%). 60% of the referred women could be tracked in higher health facilities. Of the tracked cases, 45% women delivered via caesarean section. Most of the deliveries (96%) resulted in live birth outcomes. 34% of the newborns weighed less than 2,500 grams.

Conclusion

Improving referral processes are critical to enhance the overall performance of emergency obstetric care. Our findings emphasize the need for a formal communication and feedback system between referring and receiving facilities. Simultaneously, ensuring EmOC at different levels of health facilities by upgradation of health infrastructure is recommended.

Enabling Young People from Informal Urban Communities to Exercise Their Right to Sexual and Reproductive Health: A Practice-Based Study

This qualitative study explores how comprehensive sexuality education located within a broader positive youth development approach informed transformations among young people from informal urban communities in India. A thematic analysis of data obtained from the young people, their parents, and frontline workers revealed that securing the cooperation of families was possible for the program because sexual and reproductive health education was not a stand-alone intervention, but a part of a larger approach seeking to build capacities of young people. The strategic introduction of sexual and reproductive health communication helped the participants to overcome inhibitions about the topic. Enhanced awareness of gender, pubertal changes, gender-based violence, and child sexual abuse was evidenced post participation. Improved agency was manifest through decision making, critical thinking, confidence, mobility, and articulation, especially among girls. Program interventions to enhance sexual and reproductive health awareness of parents and communities and to improve health services and facilities were bolstered through youth engagement. Such contribution by the young reinforced their knowledge and skills, strengthened agency, and cemented family and community support. A holistic program situated within the positive youth development approach thus seemed a pragmatic vehicle to promote comprehensive sexuality education for young people in vulnerable urban communities.

Implementing a "convergent" framework of action against childhood malnutrition in urban informal settlements of Mumbai: Frontline perspectives

Context:

The National Nutrition Mission (POSHAN Abhiyaan) intends to “converge” nutrition-related program components across sectors (nutrition, health, water, and sanitation). In this study, we have examined the perspectives of Anganwadi workers (AWWs), the frontline workers of the Integrated Child Development Services, on working in convergence with the public health sector.

Methods:

This exploratory qualitative study was done between June 2018 and June 2019 in two urban informal settlements in Mumbai. We conducted in-depth interviews with 26 AWWs and their supervisors, purposively sampled and diversified in terms of age, education, and years of experience. We used the software NVivo version 12 to aid analysis.

Results:

Most AWWs acknowledged that a convergent framework of action between “nutrition” and “health” was likely to be beneficial to the community. However, they also shared that cross-sector convergence was currently limited due to technical unfamiliarity with “health-sector” issues in the frontline, discomfort with data sharing, and lack of meaningful incentives for joint work. Broader organizational challenges such as poor infrastructure and lack of supervision, as well as challenges in the urban context (migration and cultural barriers) further hindered joint activities.

Conclusions:

The findings indicate that critical structural gaps in the urban setup of ICDS need to be addressed and AWWs need to be better familiarized with the changing roles expected from them under POSHAN Abhiyaan. To work better with the health sector, the work timings of AWWs need to be aligned with those of the health sector and meaningful financial incentives need to be put in place for cross-sector activities.

Determinants of stunting among children under 2 years in urban informal settlements in Mumbai, India: evidence from a household census

BACKGROUND

There is limited evidence on the determinants of childhood stunting across urban India or specifically in slum settlements. This study aims to assess the extent of stunting among children under 2 years of age and examine its determinants in informal settlements of Mumbai.

METHODS

Data were collected in 2014-2015 in a post intervention census of a cluster randomized controlled trial to improve the health of women and children. Census covered 40 slum settlements of around 600 households each. A total of 3578 children were included in the study. Mixed effects logistic regression models were used to identify factors associated with stunting.

RESULTS

The prevalence of stunting among children aged 0-23 months was 38%. In the adjusted model, higher maternal education (AOR 0.59; 95% CI 0.42, 0.82), birth interval of at least 2 years (AOR 0.71; 95% CI 0.58, 0.87) and intended conception of the child (AOR 0.80; 95% CI 0.64, 0.99) were associated with lower odds of stunting. Maternal exposure to physical violence (AOR 1.83; 95% CI 1.21, 2.77) was associated with higher odds of being stunted. A child aged 18-23 months had 5.04 times greater odds (95% CI 3.91, 6.5) of being stunted than a child less than 6 months of age. Male child had higher odds of being stunted (AOR 1.33; 95% CI 1.14, 1.54).

CONCLUSIONS

Our findings support a multidimensional aetiology for stunting. The results of the study emphasize the importance of women's status and decision-making power in urban India, along with access to and uptake of family planning and services to provide support for survivors of domestic violence. Ultimately, a multilateral effort is needed to ensure the success of nutrition-specific interventions by focusing on the underlying health and social status of women living in urban slums.

TRIAL REGISTRATION

ISRCTN Register: ISRCTN56183183 , and Clinical Trials Registry of India: CTRI/2012/09/003004.

Effectiveness of NGO-government partnership to prevent and treat child wasting in urban India

This study reviews the performance of a community-based nutrition programme in preventing and treating wasting without complications among children under age three in urban informal settlements of India. Implemented by a non-profit organization, with national (Integrated Child Development Services [ICDS]) and city-level (Municipal Corporation of Greater Mumbai [MCGM]) government partners, the programme screened 7,759 children between May 2014 and April 2015. During this period, the programme admitted 705 moderately wasted and 189 severely wasted children into the treatment group and 6,820 not wasted children into the prevention group. Both prevention and treatment groups received growth monitoring, referrals to public health facilities, and home-based counselling (if <6 months) by community health workers. Treatment groups received additional home-based counselling and access to medical screenings. Severely wasted children also received access to ready-to-use therapeutic food. The study assessed default rates, wasting status, and average weight gain 3 months after admission. Factors associated with growth faltering in the prevention group were explored using logistic regression. Default rates for the severely wasted, moderately wasted, and prevention group were 12.7%, 20.4%, and 22.1%, respectively. Recovery rate was 42.4% for the severely wasted and 61.3% for the moderately wasted. For the moderately wasted, mean weight gain was 2.1 g/kg/day, 95% confidence interval (CI) [1.6, 2.6], and 4.5 g/kg/day for the severely wasted, 95% CI [3.1, 5.9]. Among prevention group children, 3.6% faltered into wasting-3.2% into moderate and 0.4% into severe. The paper gives insights into ways in which ICDS and MCGM can successfully integrate large-scale community-based acute malnutrition programming.

"Everybody breastfeeds if they have milk": factors that shape exclusive breastfeeding practices in informal settlements of Mumbai, India

Background

In India, though breastfeeding is universally practiced, exclusive breastfeeding (EBF) rates in urban informal settlements are low; and health programs face several challenges in promoting EBF. In this study, ensconced in one program area of a non-government organization, we focused on "positive deviant"- mothers who were able to practice EBF for six months and attempted to delineate factors that shaped their EBF practices. Typically, qualitative research from Lower and Middle Income countries on EBF has focused on understanding why women do not practice EBF; the converse perspective taken in this study has been less explored.

Methods

We employed the positive deviance approach which contends that important programmatic learnings can be attained from persons who adopt positive behaviours. We conducted twenty-five diverse, purposively sampled case-studies of "positive deviant" mothers from two urban informal settlements in Mumbai; and analysed these using a framework approach. The results were summarised using a socioecological framework (consisting of individual, interpersonal, organizational and environment levels).

Results

We found that mothers typically construed EBF as not giving breastmilk substitutes. Giving the infant minor supplements (water, honey) was not considered a violation of the EBF practice. The main themes that emerged as influencers of EBF included: at individual level, perceptions of having adequate milk; at interpersonal level, having role models who practiced EBF and having family support; at organizational level, advice from health workers (which was purported to play a secondary role); and at environmental level, financial constraints that limited access to supplements. One important finding was that women who practiced EBF could not always do it optimally; we encountered several instances of "poor EBF" practices, where mothers had breastfed infants inconsistently, allowing for long gaps between feeds, and had continued EBF even after six months.

Conclusions

There is an urgent need for health programs to clarify the meaning of EBF and counsel against "poor EBF" practices. Messages received by women from immediate family on EBF were powerful and families play an important role in the actualization of optimal EBF practices. Hence, it is imperative to counsel entire families on EBF rather than women alone.

Cost effectiveness of a community based prevention and treatment of acute malnutrition programme in Mumbai slums, India

Children in slums are at high risk of acute malnutrition and death. Cost-effectiveness of community-based management of severe acute malnutrition programmes has been demonstrated previously, but there is limited evidence in the context of urban slums where programme cost structure is likely to vary tremendously.

This study assessed the cost-utility of adding a community based prevention and treatment for acute malnutrition intervention to Government of India Integrated Child Development Services (ICDS) standard care for children in Mumbai slums. The intervention is delivered by community health workers in collaboration with ICDS Anganwadi community health workers. The analysis used a decision tree model to compare the costs and effects of the two options: standard ICDS services with the intervention and prevention versus standard ICDS services alone. The model used outcome and cost data from the Society for Nutrition, Education & Health Action’s Child Health and Nutrition programme in Mumbai slums, which delivered services to 12,362 children over one year from 2013 to 2014. An activity-based cost model was used, with calculated costs based on programme financial records and key informant interviews. Cost data were coupled with programme effectiveness data to estimate disability adjusted life years (DALYs) averted.

The community based prevention and treatment programme averted 15,016 DALYs (95% Uncertainty Interval [UI]: 12,246–17,843) at an estimated cost of $23 per DALY averted (95%UI:19–28) and was thus highly cost-effective. This study shows that ICDS Anganwadi community health workers can work efficiently with community health workers to increase the prevention and treatment coverage in slums in India and can lead to policy recommendations at the state, and potentially the national level, to promote such programmes in Indian slums as a cost-effective approach to tackling moderate and severe acute malnutrition.

Participation of pregnant women in a community-based nutrition program in Mumbai's informal settlements: Effect on exclusive breastfeeding practices

Background

In urban Maharashtra, India, approximately half of mothers exclusively breastfeed. For children residing in informal settlements of Mumbai, this study examines factors associated with exclusive breastfeeding, and whether exclusive breastfeeding, in a community-based nutrition program to prevent and treat wasting among children under age three, is associated with enrolment during the mother’s pregnancy.

Methods

The nutrition program conducted a cross-sectional endline survey (October-December 2015) of caregivers in intervention areas. Factors associated with exclusive breastfeeding for infants under six months of age were explored using multi-level logistic regressions. Additionally, program surveillance data collected during home-based counselling visits documented breastfeeding practices for children under six months of age. Using the surveillance data (January 2014-March 2016), exclusive breastfeeding status was regressed adjusting for child, maternal and socioeconomic characteristics, and whether the child was enrolled in the program in utero or after birth.

Results

The community-based endline survey included 888 mothers of infants. Mothers who received the nutrition program home visits or attended group counselling sessions were more likely to exclusively breastfeed (adjusted odds ratio 1.67, 95% CI 1.16, 2.41). Having a normal weight-for-height z-score (adjusted odds ratio 1.57, 95% CI 1.00, 2.45) was associated positively with exclusive breastfeeding. As expected, being an older infant aged three to five months (adjusted odds ratio 0.34, 95% CI 0.25, 0.48) and receiving a prelacteal feed after birth (adjusted odds ratio 0.57, 95% CI 0.41, 0.80) were associated with lower odds of exclusively breastfeeding. Surveillance data (N = 3420) indicate that infants enrolled in utero have significantly higher odds of being exclusively breastfed (adjusted odds ratio 1.55, 95% CI 1.30, 1.84) than infants enrolled after birth.

Conclusions

Prenatal enrolment in community-based programs working on child nutrition in urban informal settlements of India can improve exclusive breastfeeding practices.

Community-Based Management of Acute Malnutrition to Reduce Wasting in Urban Informal Settlements of Mumbai, India: A Mixed-Methods Evaluation

Under the NGO–government partnership, wasting among children under age 3 decreased by 28% in intervention areas and by only 5% in comparison areas. Success factors included persuading and engaging with communities including delivery of tailored information, close presence and supervision of field staff, and holistic management of other issues beyond acute malnutrition. This intensive approach may be challenging for the government to adapt effectively at large scale.

Background:

We evaluated an adaptation of a large-scale community-based management of acute malnutrition program run by an NGO with government partnerships, in informal settlements of Mumbai, India. The program aimed to reduce the prevalence of wasting among children under age 3 and covered a population of approximately 300,000.

Methods:

This study used a mixed-methods approach including a quasi-experimental design to compare prevalence estimates of wasting in intervention areas with neighboring informal settlements. Cross-sectional data were collected from March through November 2014 for the baseline and October through December 2015 for the endline. Endline data were analyzed using mixed-effects logistic regression models, adjusting for child, maternal, and household characteristics. In addition, we conducted in-depth interviews with 37 stakeholders (13 staff and 24 mothers) who reported on salient features that contributed to successful implementation of the program.

Results:

We interviewed 2,578 caregivers at baseline and 3,455 at endline in intervention areas. In comparison areas, we interviewed 2,082 caregivers at baseline and 2,122 at endline. At endline, the prevalence of wasting decreased by 28% (18% to 13%) in intervention areas and by 5% (16.9% to 16%) in comparison areas. Analysis of the endline data indicated that children in intervention areas were significantly less likely to be malnourished (adjusted odds ratio, 0.81; confidence interval, 0.67 to 0.99). Stakeholders identified 4 main features as contributing to the success of the program: (1) tailoring and reinforcement of information provided to caregivers in informal settings, (2) constant field presence of staff, (3) holistic case management of issues beyond immediate malnourishment, and (4) persistence of field staff in persuading reluctant families. Staff capabilities were enhanced through training, stringent monitoring mechanisms, and support from senior staff in tackling difficult cases.

Conclusion:

NGO–government partnerships can revitalize existing community-based programs in urban India. Critical to success are processes that include reinforced knowledge-building of caregivers, a high level of field support and encouragement to the community, and constant monitoring and follow-up of cases by all staff levels.

Historical and Projected Surface Temperature over India during the 20th and 21st century

Surface Temperature (ST) over India has increased by ~0.055 K/decade during 1860-2005 and follows the global warming trend. Here, the natural and external forcings (e.g., natural and anthropogenic) responsible for ST variability are studied from Coupled Model Inter-comparison phase 5 (CMIP5) models during the 20th century and projections during the 21st century along with seasonal variability. Greenhouse Gases (GHG) and Land Use (LU) are the major factors that gave rise to warming during the 20th century. Anthropogenic Aerosols (AA) have slowed down the warming rate. The CMIP5 projection over India shows a sharp increase in ST under Representative Concentration Pathways (RCP) 8.5 where it reaches a maximum of 5 K by the end of the 21st century. Under RCP2.6 emission scenarios, ST increases up to the year 2050 and decreases afterwards. The seasonal variability of ST during the 21st century shows significant increase during summer. Analysis of rare heat and cold events for 2080-2099 relative to a base period of 1986-2006 under RCP8.5 scenarios reveals that both are likely to increase substantially. However, by controlling the regional AA and LU change in India, a reduction in further warming over India region might be achieved.

"You Are a Part of the Solution": Negotiating Gender-Based Violence and Engendering Change in Urban Informal Settlements in Mumbai, India

This article explores how women front-line workers engage with domestic and gender-based violence in the urban informal settlements of Dharavi in Mumbai, India. We conducted in-depth interviews with 13 voluntary front-line workers, along with ethnographic fieldwork in Dharavi, as a part of a pilot study. Our findings contribute to literature on context-specific approaches to understanding gender-based violence and "models" to prevent domestic violence in urban micro-spaces. Furthermore, we also discuss notions of "change" ( badlaav) that the front-line workers experience. Finally, this article presents implications for socially engaged ethnographic research, as well as contextual and grounded insights on ways to reduce gender-based and domestic violence.

M-Health for Improving Screening Accuracy of Acute Malnutrition in a Community-Based Management of Acute Malnutrition Program in Mumbai Informal Settlements

BACKGROUND

Acute malnutrition is linked to child mortality and morbidity. Community-Based Management of Acute Malnutrition (CMAM) programs can be instrumental in large-scale detection and treatment of undernutrition. The World Health Organization (WHO) 2006 weight-for-height/length tables are diagnostic tools available to screen for acute malnutrition. Frontline workers (FWs) in a CMAM program in Dharavi, Mumbai, were using CommCare, a mobile application, for monitoring and case management of children in combination with the paper-based WHO simplified tables. A strategy was undertaken to digitize the WHO tables into the CommCare application.

OBJECTIVE

To measure differences in diagnostic accuracy in community-based screening for acute malnutrition, by FWs, using a mobile-based solution.

METHODS

Twenty-seven FWs initially used the paper-based tables and then switched to an updated mobile application that included a nutritional grade calculator. Human error rates specifically associated with grade classification were calculated by comparison of the grade assigned by the FW to the grade each child should have received based on the same WHO tables. Cohen kappa coefficient, sensitivity and specificity rates were also calculated and compared for paper-based grade assignments and calculator grade assignments.

RESULTS

Comparing FWs (N = 14) who completed at least 40 screenings without and 40 with the calculator, the error rates were 5.5% and 0.7%, respectively (p < .0001). Interrater reliability (κ) increased to an almost perfect level (>.90), from .79 to .97, after switching to the mobile calculator. Sensitivity and specificity also improved significantly.

CONCLUSION

The mobile calculator significantly reduces an important component of human error in using the WHO tables to assess acute malnutrition at the community level.

Sweat, Skepticism, and Uncharted Territory: A Qualitative Study of Opinions on Data Sharing Among Public Health Researchers and Research Participants in Mumbai, India

Efforts to internalize data sharing in research practice have been driven largely by developing international norms that have not incorporated opinions from researchers in low- and middle-income countries. We sought to identify the issues around ethical data sharing in the context of research involving women and children in urban India. We interviewed researchers, managers, and research participants associated with a Mumbai non-governmental organization, as well as researchers from other organizations and members of ethics committees. We conducted 22 individual semi-structured interviews and involved 44 research participants in focus group discussions. We used framework analysis to examine ideas about data and data sharing in general; its potential benefits or harms, barriers, obligations, and governance; and the requirements for consent. Both researchers and participants were generally in favor of data sharing, although limited experience amplified their reservations. We identified three themes: concerns that the work of data producers may not receive appropriate acknowledgment, skepticism about the process of sharing, and the fact that the terrain of data sharing was essentially uncharted and confusing. To increase data sharing in India, we need to provide guidelines, protocols, and examples of good practice in terms of consent, data preparation, screening of applications, and what individuals and organizations can expect in terms of validation, acknowledgment, and authorship.

Effect of wearable sensor dynamics on physical activity estimates: A comparison between SCI vs. healthy individuals

Accuracy of physical activity estimates predicted by activity monitoring technologies may be affected by device location, analysis algorithms, type of technology (i.e. wearable/stickable) and population demographics (disability) being studied. Consequently, the main purpose of this investigation was to study such sensor dynamics (i.e. effect of device location, type and population demographics on energy expenditure estimates) of two commercial activity monitors. It was hypothesized that device location, population studied (disability), choice of proprietary algorithm and type of technology used will significantly impact the accuracy of the predicted physical activity metrics. 10 healthy controls and eight individuals with spinal cord injury (SCI) performed structured activities in a laboratory environment. All participants wore, (i) three ActiGraph-G3TX's one each on their wrist, waist & ankle, (ii) a stickable activity monitor (Metria-IH1) on their upper-arm and (3) a Cosmed-K4B² metabolic unit, while performing sedentary (lying), low intensity (walk 50 steps at self-speed) and vigorous activity (a 6 minute walk test). To validate the hypothesis, the energy expenditures (EE) predicted by ActiGraph-GT3X and Metria-IH1 were benchmarked with estimated EE per Cosmed K4B² metabolic unit. To verify the step count accuracy predicted by ActiGraph-GT3X's and Metria-IH1, the manually calculated step count during the low intensity activity were compared to estimates from both devices. Results suggest that Metria-IH1 out-performed ActiGraph-GT3X in estimating EE during sedentary activity in both groups. The device location and population demographics, significantly affected the accuracy of predicted estimates. In conclusion, selecting activity monitor locations, analysis algorithm and choice of technology plays based on the movement threshold of population being studied can pave a better way for reliable healthcare decisions and data analytics in population with SCI.

Microbiota metabolite regulation of host immune homeostasis: a mechanistic missing link

Metazoans predominantly co-exist with symbiotic microorganisms called the microbiota. Metagenomic surveys of the microbiota reveal a diverse ecosystem of microbes particularly in the gastrointestinal (GI) tract. Perturbations in the GI microbiota in higher mammals (i.e., humans) are linked to diseases with variegated symptomology including inflammatory bowel disease, asthma, and auto-inflammatory disorders. Indeed, studies using germ-free mice (lacking a microbiota) confirm that host development and homeostasis are dependent on the microbiota. A long-known key feature of the GI tract microbiota is metabolizing host indigestible dietary matter for maximum energy extraction; however, host signaling pathways are greatly influenced by the microbiota as well. In line with these observations, recent research has revealed that metabolites produced strictly by select microbiota members are mechanistic regulators of host cell functions. In this review, we discuss two major classes of microbiota-produced metabolites: short-chain fatty acids and tryptophan metabolites. We describe the known important roles for these metabolites in shaping host immunity and comment on the current status and future directions for microbiota metabolomics research.

Urbanisation, poverty and sexual behaviour: the tale of five African cities

The question of how urbanisation and poverty are linked in sub-Saharan Africa is an increasingly pressing one. The urban character of the HIV epidemic in sub-Saharan Africa exacerbates concern about the urbanisation - poverty relationship. Recent empirical work has linked urban poverty, and particularly slum residence, to risky sexual behaviour in Kenya's capital city, Nairobi. This paper explores the generalisability of these assertions about the relationship between urban poverty and sexual behaviour using Demographic and Health Survey data from five African cities: Accra (Ghana), Dar-es-Salaam (Tanzania), Harare (Zimbabwe), Kampala (Uganda) and Nairobi (Kenya). The study affirms that, although risky behaviour varies across the five cities, slum residents demonstrate riskier sexual behaviour compared with non-slum residents. There is earlier sexual debut, lower condom usage and more multiple sexual partners among women residing in slum households regardless of setting, suggesting a relatively uniform effect of urban poverty on sexual risk behaviour.

Androgens selectively protect against apoptosis in hippocampal neurones

Androgens can protect neurones from injury, although androgen neuroprotection is not well characterised in terms of either specificity or mechanism. In the present study, we compared the ability of androgens to protect neurones against a panel of insults, empirically determined to induce cell death by apoptotic or non-apoptotic mechanisms. Three criteria defining but not inclusive of apoptosis are: protection by caspase inhibition, protection by protein synthesis inhibition and the presence of pyknotic nuclei. According to these criteria, beta-amyloid, staurosporine, and Apoptosis Activator II induced cell death involving apoptosis, whereas hydrogen peroxide (H(2)O(2)), iron, calcium ionophore and 3-nitropropionic acid induced cell death featuring non-apoptotic characteristics. Pretreatment of hippocampal neurones with testosterone or dihydrotestosterone attenuated cell death induced by beta-amyloid, staurosporine and Apoptosis Activator II, but none of the other insults. The anti-oxidant Trolox did not reduce cell death induced by beta-amyloid, staurosporine and Apoptosis Activator II, but did protect against H(2)O(2) and iron. Similarly, a supra-physiological concentration of oestrogen reduced cell death induced by H(2)O(2) and iron, an effect not observed with androgens. We also show that activation of oestrogen pathways was not necessary for androgen neuroprotection. These data suggest that androgens directly activate a neuroprotective mechanism specific to inhibition of cell death involving apoptosis. Determining the specificity of androgen neuroprotection may enable the development of androgen compounds for the treatment of neurodegenerative disorders.

The relationship of family size and composition to fertility desires, contraceptive adoption and method choice in South Asia

CONTEXT

Many countries in South Asia, including Nepal, India and Bangladesh, demonstrate a strong cultural preference for sons, which may influence fertility desires and contraceptive use.

METHODS

Demographic and Health Survey data from married, nonpregnant women aged 15-49 who had at least one child were used to examine the relationship of parity and number of sons to reproductive outcomes in Nepal, India and Bangladesh. Outcomes of interest were desire for another child, contraceptive use and type of contraceptive (modern vs. traditional, temporary vs. permanent). Odds ratios and relative risk ratios were calculated using binary and multinomial logistic regression.

RESULTS

In general, desire for another child decreased and contraceptive use increased as the number of children and number of sons increased. These associations were more prominent in Nepal and India than in Bangladesh. For example, compared with women who had three daughters and no sons, the odds of contraceptive use among women with two sons and one daughter were 4.8 in Nepal, 3.5 in India and 2.0 in Bangladesh. Within India, the associations of parity and number of sons with reproductive outcomes were generally stronger in northern states than in South India or West Bengal.

CONCLUSIONS

Son preference remains widespread in all three countries and has a major influence on reproductive behavior. Reducing such preference would require a change in social norms and attitudes of the people and an improvement of the status of women.

Progesterone attenuates oestrogen neuroprotection via downregulation of oestrogen receptor expression in cultured neurones

Recent findings indicate that progesterone can attenuate the beneficial neural effects of oestrogen. In the present study, we investigated the hypothesis that progesterone can modulate oestrogen actions by regulating the expression and activity of oestrogen receptors, ERalpha and ERbeta. Our studies in cultured neurones demonstrate that progesterone decreases the expression of both ERalpha and ERbeta and, as a consequence, also reduces both ER-dependent transcriptional activity and neuroprotection. These results identify a potential mechanism by which progesterone antagonises neural oestrogen actions, a finding that may have important implications for hormone therapy in postmenopausal women.

Parameter sensitivity analysis of IL-6 signalling pathways

Signal transduction pathways generally consist of a large number of individual components and have an even greater number of parameters describing their reaction kinetics. Although the structure of some signalling pathways can be found in the literature, many of the parameters are not well known and they would need to be re-estimated from experimental data for each specific case. However it is not feasible to estimate hundreds of parameters because of the cost of the experiments associated with generating data. Parameter sensitivity analysis can address this situation as it investigates how the system behaviour is changed by variations of parameters and the analysis identifies which parameters play a key role in signal transduction. Only these important parameters need then be re-estimated using data from further experiments. This article presents a detailed parameter sensitivity analysis of the JAK/STAT and MAPK signal transduction pathway that is used for signalling by the cytokine IL-6. As no parameter sensitivity analysis technique is known to work best for all situations, a comparison of the results returned by four techniques is presented: differential analysis, the Morris method, a sampling-based approach and the Fourier amplitude sensitivity test. The recruitment of the transcription factor STAT3 to the dimer of the phosphorylated receptor complex is determined as the most important step by the sensitivity analysis. Additionally, the desphosphorylation of the nuclear STAT3 dimer by PP2 as well as feedback inhibition by SOCS3 are found to play an important role for signal transduction.

Resistance training and locomotor recovery after incomplete spinal cord injury: a case series

STUDY DESIGN

Longitudinal intervention case series.

OBJECTIVE

To determine if a 12-week resistance and plyometric training program results in improved muscle function and locomotor speed after incomplete spinal cord injury (SCI).

SETTING

University research setting.

METHODS

Three ambulatory individuals with chronic (18.7+/-2.2 months post injury) motor incomplete SCI completed 12 weeks of lower extremity resistance training combined with plyometric training (RPT). Muscle maximum cross-sectional area (max-CSA) of the knee extensor (KE) and plantar flexor (PF) muscle groups was determined using magnetic resonance imaging (MRI). In addition, peak isometric torque, time to peak torque (T (20-80)), torque developed within the initial 220 ms of contraction (torque(220)) and average rate of torque development (ARTD) were calculated as indices of muscle function. Maximal as well as self-selected gait speeds were determined pre- and post-RPT during which the spatio-temporal characteristics, kinematics and kinetics of gait were measured.

RESULTS

RPT resulted in improved peak torque production in the KE (28.9+/-4.4%) and PF (35.0+/-9.1%) muscle groups, as well as a decrease in T(20-80), an increased torque(220) and an increase ARTD in both muscle groups. In addition, an increase in self-selected (pre-RPT=0.77 m/s; post-RPT=1.03 m/s) and maximum (pre-RPT=1.08 m/s; post-RPT=1.47 m/s) gait speed was realized. Increased gait speeds were accompanied by bilateral increases in propulsion and hip excursion as well as increased lower extremity joint powers.

CONCLUSIONS

The combination of lower extremity RPT can attenuate existing neuromuscular impairments and improve gait speed in persons after incomplete SCI.

Characterization of the domain chaos convection state by the largest Lyapunov exponent

Using numerical integrations of the Boussinesq equations in rotating cylindrical domains with realistic boundary conditions, we have computed the value of the largest Lyapunov exponent lambda1 for a variety of aspect ratios and driving strengths. We study in particular the domain chaos state, which bifurcates supercritically from the conducting fluid state and involves extended propagating fronts as well as point defects. We compare our results with those from Egolf, [Nature 404, 733 (2000)], who suggested that the value of lambda1 for the spiral defect chaos state of a convecting fluid was determined primarily by bursts of instability arising from short-lived, spatially localized dislocation nucleation events. We also show that the quantity lambda1 is not intensive for aspect ratios Gamma over the range 20<Gamma<40 and that the scaling exponent of lambda1 near onset is consistent with the value predicted by the amplitude equation formalism.

Lower extremity skeletal muscle function in persons with incomplete spinal cord injury

STUDY DESIGN

A cross-sectional study design.

OBJECTIVES

To characterize and specifically quantify impairments in muscle function after chronic incomplete spinal cord injury (SCI).

SETTING

University of Florida, Gainesville, FL, USA.

METHODS

Voluntary and electrically elicited contractile measurements were performed and voluntary activation deficits were quantitatively determined in the knee extensor and ankle plantar flexor muscle groups in 10 individuals with chronic incomplete SCI (C5-T8, ASIA C or D) and age-, gender-, height- and body weight matched healthy controls.

RESULTS

Persons with incomplete-SCI were able to produce only 36 and 24% of the knee extensor torque and 38 and 26% of the plantar flexor torque generated by noninjured controls in the self-reported less-involved and more-involved limbs, respectively (P<0.05). In addition, both indices of explosive or instantaneous muscle strength, torque200 (absolute torque reached at 200 ms) and the average rate of torque development (ARTD) were dramatically reduced in the ankle plantar flexor and knee extensor muscle groups in persons with incomplete-SCI. However, the deficit in instantaneous muscle strength was most pronounced in the ankle plantar flexor muscles, with an 11.7-fold difference between the torque200 measured in the self-reported more involved limb and a 5-fold difference in the less-involved limb compared to control muscles. Voluntary activation deficits ranged between 42 and 66% in both muscle groups. Interestingly, electrically elicited contractile properties did not differ between the groups.

CONCLUSION

The resultant impact of incomplete-SCI is that affected muscles not only become weak, but slow to develop voluntary torque. We speculate that the large deficit in torque200 and ARTD in the ankle plantar flexors muscles of persons with incomplete-SCI may limit locomotor function. The results presented in this study provide a quantitative and sensitive assessment of muscle function upon which future research examining rehabilitation programs aimed at restoring muscle function and promoting functional recovery after incomplete-SCI may be based.

Computer simulation study of pattern transfer in AB diblock copolymer film adsorbed on a heterogeneous surface

In this work we investigate how a pattern imposed in a copolymer film at a certain distance from the surface propagates through the film onto an adsorbing heterogeneous surface. We bias the copolymer film to adopt a specified target pattern and then use simulation to design a surface pattern that helps the adsorbed film to maintain that target pattern. We examine the effect of varying the copolymer chain length, the size of the target pattern, and the distance from the surface where the target pattern is applied, z', on the extent of pattern transfer. For each chain length, target pattern, and z' we compare the energy of the system when a pattern is applied in the bulk to the energy when no pattern is applied in order to understand why a certain pattern size is transferred to the surface with higher fidelity than the others. At constant chain length, pattern transfer is best when the pattern size brings the energy of the system close to the energy when no pattern is applied. At constant pattern size, pattern transfer is best in the systems with longer chains. This is because longer chains are more likely to adsorb as brushes and loops which then helps transfer the pattern through the adsorbed film down to the surface.

Adsorption of comb copolymers on weakly attractive solid surfaces

In this work continuum and lattice Monte Carlo simulation methods are used to study the adsorption of linear and comb polymers on flat surfaces. Selected polymer segments, located at the tips of the side chains in comb polymers or equally spaced along the linear polymers, are attracted to each other and to the surface via square-well potentials. The rest of the polymer segments are modeled as tangent hard spheres in the continuum model and as self-avoiding random walks in the lattice model. Results are presented in terms of segment-density profiles, distribution functions, and radii of gyration of the adsorbed polymers. At infinite dilution the presence of short side chains promotes the adsorption of polymers favoring both a decrease in the depletion-layer thickness and a spreading of the polymer molecule on the surface. The presence of long side chains favors the adsorption of polymers on the surface, but does not permit the spreading of the polymers. At finite concentration linear polymers and comb polymers with long side chains readily adsorb on the solid surface, while comb polymers with short side chains are unlikely to adsorb. The simple models of comb copolymers with short side chains used here show properties similar to those of associating polymers and of globular proteins in aqueous solutions, and can be used as a first approximation to investigate the mechanism of adsorption of proteins onto hydrophobic surfaces.

Expression profiling analysis of the metabolic and inflammatory changes following burn injury in rats

Burn injury initiates an inflammatory response as part of the healing process that is associated with extensive metabolic adjustments. While most studies have focused on understanding these changes from a biochemical perspective, not much work has been done to characterize these processes at the gene expression level. As a first step, we have comprehensively analyzed changes in gene expression in rat livers during the first 24 h after burn injury using Affymetrix GeneChips, which showed 339 genes to be differentially expressed at a statistical significance of P < 0.05 and changed at least twofold. Functional classification based on gene ontology terms indicated that two categories, metabolism (28%) and inflammation (14%), accounted for nearly 42%. Detailed analysis of the metabolism group of genes indicated that fatty acid (FA) and triglyceride (TG) biosynthesis in the liver were unchanged, whereas TG utilization, FA import, and beta-oxidation increased after burn injury. The increased FA pools after burn injury appear to serve as substrates for ATP production. Following burn injury, the cholesterol biosynthetic pathway was suppressed while cholesterol was increasingly imported and converted into bile acids. The inflammatory genes that were altered included several classic acute phase response markers, as well as genes involved in the complement, kinin, clotting, and fibrinolytic protein systems. These temporally coordinated changes in gene expression were also corroborated by biochemical measurements for FA, TG, cholesterol, and ATP. Together, these data indicate that FA are increasingly imported and oxidized in the liver to meet the enhanced energy demands arising from an inflammatory response during the first 24 h after burn injury.