Out-of-pocket payment and financial risk protection for breast cancer treatment: a prospective study from India

Background

Available data on cost of cancer treatment, out-of-pocket payment and reimbursement are limited in India. We estimated the treatment costs, out-of-pocket payment, and reimbursement in a cohort of breast cancer patients who sought treatment at a publicly funded tertiary cancer care hospital in India.

Methods

A prospective longitudinal study was conducted from June 2019 to March 2022 at Tata Memorial Centre (TMC), Mumbai. Data on expenditure during each visit of treatment was collected by a team of trained medical social workers. The primary outcome variables were total cost (TC) of treatment, out-of-pocket payment (OOP), and reimbursement. TC included cost incurred by breast cancer patients during treatment at TMC. OOP was defined as the total cost incurred at TMC less of reimbursement. Reimbursement was any form of financial assistance (cashless or repayment), including social health insurance, private health insurance, employee health schemes, and assistance from charitable trusts, received by the patients for breast cancer treatment.

Findings

Of the 500 patients included in the study, 45 discontinued treatment (due to financial or other reasons) and 26 died during treatment. The mean TC of breast cancer treatment was ₹258,095/US$3531 (95% CI: 238,225, 277,934). Direct medical cost (MC) accounted for 56.3% of the TC. Systemic therapy costs (₹50,869/US$696) were higher than radiotherapy (₹33,483/US$458) and surgery costs (₹25,075/US$343). About 74.4% patients availed some form of financial assistance at TMC; 8% patients received full reimbursement. The mean OOP for breast cancer treatment was ₹186,461/US$2551 (95% CI: 167,666, 205,257), accounting for 72.2% of the TC. Social health insurance (SHI) had a reasonable coverage (33.1%), followed by charitable trusts (29.6%), employee health insurance (5.1%), private health insurance (4.4%) and 25.6% had no reimbursement. But SHI covered only 40.1% of the TC of treatment compared to private health insurance that covered as much as 57.1% of it. Both TC and OOP were higher for patients who were younger, belonged to rural areas, had a comorbidity, were diagnosed at an advanced stage, and were from outside Maharashtra.

Interpretation

In India, the cost and OOP for breast cancer treatment are high and reimbursement for the treatment flows from multiple sources. Though many of the patients receive some form of reimbursement, it is insufficient to prevent high OOP. Hence both wider insurance coverage as well as higher cap of the insurance packages in the health insurance schemes is suggested. Allowing for the automatic inclusion of cancer treatment in SHI can mitigate the financial burden of cancer patients in India.

Funding

This work was funded by an extramural grant from the Women's Cancer Initiative and the Nag Foundation and an intramural grant from the International Institute of Population Sciences, Mumbai.

Performance of wood waste biochar and food waste compost in a pilot-scale sustainable drainage system for stormwater treatment

Sustainable drainage system (SuDS) for stormwater reclamation has the potential to alleviate the water scarcity and environmental pollution issues. Laboratory studies have demonstrated that the capacity of SuDS to treat stormwater can be improved by integrating biochar and compost in the filter media, whereas their performance in scaled-up applications is less reported. This study examines the effectiveness of a pilot-scale SuDS, bioswale followed by bioretention, amended with wood waste biochar (1, 2, and 4 wt.%) and food waste compost (2 and 4 wt.%) to simultaneously remove multiple pollutants including nutrients, heavy metals, and trace organics from the simulated stormwater. Our results confirmed that SuDS modified with both biochar (2 wt.%) and compost (2 wt.%) displayed superior water quality improvement. The system exhibited high removal efficiency (> 70%) for total phosphorus and major metal species including Ni, Pb, Cd, Cr, Cu, and Zn. Total suspended solids concentration was approaching the detection limit in the effluent, thereby confirming its capability to reduce turbidity and particle-associated pollutants from stormwater. Co-application of biochar and compost also moderately immobilized trace organic contaminants such as 2,4-dichlorophenoxyacetic acid, diuron, and atrazine at field-relevant concentrations. Moreover, the soil amendments amplified the activities of enzymes including β-D-cellobiosidase and urease, suggesting that the improved soil conditions and health of microbial communities could possibly increase phyto and bioremediation of contaminants accumulated in the filter media. Overall, our pilot-scale demonstration confirmed that the co-application of biochar and compost in SuDS can provide a variety of benefits for soil/plant health and water quality.

Resilience of stormwater biofilters following the deposition of wildfire residues: Implication on downstream water quality management in wildfire-prone regions

Stormwater treatment systems such as biofilters could intercept and remove pollutants from contaminated runoff in wildfire-affected areas, ensuring the protection of water quality downstream. However, the deposition of wildfire residues such as ash and black carbon onto biofilters could potentially impair their stormwater treatment functions. Yet, whether and how wildfire residue deposition could affect biofilter functions is unknown. This study examines the impact of wildfire residue deposition on biofilter infiltration and pollutant removal capacities. Exposure to wildfire residues decreased the infiltration capacity based on the amount of wildfire deposited. Wildfire residues accumulated at the top layer of the biofilter, forming a cake layer, but scraping this layer restored the infiltration capacity. While the deposition of wildfire residues slightly changed the pore water geochemistry, it did not significantly alter the removal of metals and E. coli. Although wildfire residues leached some metals into pore water within the simulated root zone, the leached metals were effectively removed by the compost present in the filter media. Collectively, these results indicate that biofilters downstream of wildfire-prone areas could remain resilient or functional and protect downstream water quality if deposited ash is periodically scraped to restore any loss of infiltration capacity following wildfire residue deposition.

Socioeconomic variation in the prevalence of pain by anatomical sites among middle-aged and older adults in India: a cross-sectional study

BACKGROUND

Pain is a significant global public health concern, particularly among individuals aged 45 and above. Its impact on the overall lifestyle of the individuals varies depending on the affected anatomical parts. Despite its widespread impact, there is limited awareness of the attributes of pain, making effective pain management challenging, particularly in India. This study aims to estimate the prevalence and variation in pain in different anatomical sites among middle-aged and older adults in India.

METHODS

A cross-sectional design was employed, utilising data from the first wave of the Longitudinal Aging Study in India (LASI), 2017-2018. The age-sex adjusted prevalence of pain by anatomical sites (the back, joints, and ankles) was estimated using a multivariate logistic regression model.

RESULTS

47% of individuals aged 45 years and above reported joint pain, 31% reported back pain and 20% suffered from ankle or foot pain. The prevalence of pain at all the anatomical sites increased with age and was reported higher among females. Relative to respondents aged 45-59 years, those aged 75 years and older exhibited a 41% higher likelihood of experiencing back pain (AOR: 1.41, 95% CI: 1.19-1.67), a 67% higher likelihood of joint pain (AOR: 1.67, 95% CI: 1.49-1.89), and a 32% higher likelihood of ankle/foot pain (AOR: 1.32, 95% CI: 1.16-1.50). In comparison to males, females had a 56% higher likelihood of encountering back pain (AOR: 1.56, 95% CI: 1.40-1.74), a 38% higher likelihood of joint pain (AOR: 1.38, 95% CI: 1.27-1.50), and a 35% higher likelihood of ankle/foot pain (AOR: 1.35, 95% CI: 1.17-1.57). We also found significant regional variations in pain prevalence, with higher rates in the mountainous regions of India.

CONCLUSION

This research highlights the high burden of pain in major anatomical sites among middle-aged and older adults in India and emphasises the need for increased awareness and effective pain management strategies.

Socioeconomic and geographic variations of disabilities in India: evidence from the National Family Health Survey, 2019-21

BACKGROUND

Increasing disability is of global and national concern. Lack of evidence on disability across socioeconomic groups and geographic levels (especially small areas) impeded interventions for these disadvantaged subgroups. We aimed to examine the socioeconomic and geographic variations in disabilities, namely hearing, speech, visual, mental, and locomotor, in Indian participants using cross-sectional data from the National Family Health Survey 2019-2021.

METHODS

Using data from 27,93,971 individuals, we estimated age-sex-adjusted disability rates at the national and sub-national levels. The extent of socioeconomic variations in disabilities was explored using the Erreygers Concentration Index and presented graphically through a concentration curve. We adopted a four-level random intercept logit model to compute the variance partitioning coefficient (VPC) to assess the significance of each geographical unit in total variability. We also calculated precision-weighted disability estimates of individuals across 707 districts and showed their correlation with within-district or between-cluster standard deviation.

RESULTS

We estimated the prevalence of any disability of 10 per 1000 population. The locomotor disability was common, followed by mental, speech, hearing, and visual. The concentration index of each type of disability was highest in the poorest wealth quintile households and illiterate 18 + individuals, confirming higher socioeconomic variations in disability rates. Clusters share the largest source of geographic variation for any disability (6.5%), hearing (5.8%), visual (24.3%), and locomotor (17.4%). However, States/Union Territories (UTs) account for the highest variation in speech (3.7%) and mental (6.5%) disabilities, where the variation at the cluster level becomes negligible. Districts with the highest disability rates were clustered in Madhya Pradesh, Maharashtra, Karnataka, Tamil Nadu, Telangana, and Punjab. Further, we found positive correlations between the district rates and cluster standard deviations (SDs) for disabilities.

CONCLUSIONS

Though the growing disability condition in India is itself a concerning issue, wide variations across socioeconomic groups and geographic locations indicate the implementation of several policy-relevant implications focusing on these vulnerable chunks of the population. Further, the critical importance of small-area variations within districts suggests the design of strategies targeting these high-burden areas of disabilities.

PFAS release from the subsurface and capillary fringe during managed aquifer recharge

Managed aquifer recharge (MAR) is a sustainable way of harvesting groundwater in water-stressed urbanized areas, where reclaimed wastewater or stormwater is applied on a large basin to infiltrate water into the groundwater aquifer naturally. This process could rapidly fluctuate the water table and move the capillary fringe boundary, and the change in flow dynamic and associated geochemical changes could trigger the release of sequestered pollutants, including per- and polyfluoroalkyl substances (PFAS), also known as 'forever chemicals', from the subsurface and capillary fringe. Yet, the potential of PFAS release from the subsurface and capillary zone during recharge events when the water table rapidly fluctuates has not been evaluated. This study uses laboratory column experiments to simulate PFAS release from pre-contaminated subsurface and capillary fringe during groundwater table fluctuation. The results reveal that the groundwater level fluctuations during MAR increased the release of perfluorobutanesulfonic acid (PFBS) and perfluorooctanesulfonic acid (PFOS) from the capillary fringe, but the fraction released depended on PFAS type and their association with soil colloids. A higher proportion of PFOS in column effluent was found to be associated with particles, while a greater portion of released PFBS was in a free or dissolved state. The direction of water table fluctuation did not affect the release of PFAS in this study. A lack of change in the concentration of bromide, a conservative tracer, during flow interruption, indicates that diffusion of PFAS through reconnected pores during water table rise had an insignificant effect on PFAS release. Overall, this study provides insights into how PFAS can be released from the subsurface and capillary fringe during managed aquifer recharge when the groundwater level is expected to fluctuate quickly.

Iron-coated nutshell waste bioadsorbents: Synthesis, phosphate remediation, and subsequent fertilizer application

The increasing incidence of freshwater nutrient pollution worldwide has highlighted the need for improved phosphate capture technologies. Successful phosphate recovery from agricultural sources and commercial wastewater can help prevent freshwater algal bloom contamination, while also reducing the dependency on finite phosphate reserves. Biodegradable biosorbents have the potential to remove phosphate from water; however, their potential as slow-release fertilizers has not been tested. Novel biosorbents were developed by coating pistachio and walnut shells with iron oxides; batch and column experiments were conducted to investigate their adsorption capacities and performances. Surface characterization studies were also conducted to investigate changes in the surface area and morphology. The potential of using iron-coated shells loaded with phosphorus as slow-release fertilizers was also evaluated. Advanced characterization techniques (scanning electron microscopy, Brunauer-Emmett-Teller (BET) physisorption analysis, and x-ray diffraction) showed that hematite was successfully coated onto the surface, resulting in increased surface area and roughness. The iron-coated pistachio and walnut shell phosphate removal capacity was 12.63 mg g-1 and 9.25 mg g-1, respectively. The phosphate sorption data fitted well with the Freundlich isotherm model and pseudo-second-order kinetics. Inner sphere complex formation, coprecipitation, diffusion, and electrostatic attraction were the main uptake mechanisms. Results from sequential release experiments with simulated pore water suggested both fast and slow desorption components. The Mehlich-3 extraction revealed that more than 90% of the released phosphate was available for plant uptake. In addition, nutrient priming showed that corn seed shoot growth increased by more than 43% when pretreated with phosphate-loaded biosorbents, demonstrating that the released phosphate could be used for plant growth. This research provides a pathway for two important zero-waste, cyclical economic goals: (1) the beneficial use of agricultural waste, and (2) a low-cost technology that can recover phosphorus from waste streams while potentially adding an additional unconventional phosphate source to apatite mineral ores.

Do drinking water treatment residuals underperform in the presence of compost in stormwater media filters?

Drinking water treatment residuals (WTR), a waste-derived product, are often recommended to use as an amendment in stormwater biofilters to enhance their capacity to remove phosphate and microbial pollutants. However, their efficacy has been assumed to remain high in the presence of compost, one of the most common amendments used in biofilters. This study tests the validity of that assumption by comparing the removal capacities of WTR-amended biofilters with and without the presence of compost. Our results show that amending sand with WTR increased E. coli removal by at least 1-log, but the addition of compost in the sand-WTR media lowered the removal capacity by 13 %. Similarly, the addition of WTR to sand improved phosphate removal to nearly 1177 %, but the removal decreased slightly by 8 % when adding compost to the media. The results confirmed that dissolved organic carbon (DOC) leached from the compost could compete for adsorption sites for bacteria and phosphate, thereby lowering WTR's adsorption capacity based on the amount of DOC adsorbed on WTR. Collectively, these results indicate that the stormwater treatment industry should avoid mixing compost with WTR to get the maximum benefits of WTR for bacterial removal and improve the performance lifetime of WTR-amended biofilters.

Asynchronous Conferencing Through a Secure Messaging Application Increases Reporting of Medical Errors in a Mature Trauma Center

Background

Medical errors occur frequently, yet they are often under-reported and strategies to increase the reporting of medical errors are lacking. In this work, we detail how a level 1 trauma center used a secure messaging application to track medical errors and enhance its quality improvement initiatives.

Methods

We describe the formulation, implementation, evolution, and evaluation of a chatroom integrated into a secure texting system to identify performance improvement and patient safety (PIPS) concerns. For evaluation, we used descriptive statistics to examine PIPS reporting by the reporting method over time, the incidence of mortality and unplanned ICU readmissions tracked in the hospital trauma registry over the same, and time-to-loop closure over the study period to quantify the impact of the processes instituted by the PIPS team. We also categorized themes of reported events.

Results

With the implementation of a PIPS chatroom, the number of events reported each month increased and texting became the predominant way for users to report trauma PIPS events. This increase in PIPS reporting did not appear to be accompanied by an increase in mortality and unplanned ICU readmissions. The PIPS team also improved the tracking and timely resolution of PIPS events and observed a decrease in time-to-loop closure with the implementation of the PIPS chatroom.

Conclusions

The adoption of clinical texting as a way to report PIPS events was associated with increased reporting of such events and more timely resolution of concerns regarding patient safety and healthcare quality.

Out of pocket expenditure and distress financing on cesarean delivery in India: evidence from NFHS-5

BACKGROUND

Though over three-fourths of all births receive medical attention in India, the rate of cesarean delivery (22%) is twice higher than the WHO recommended level. Cesarean deliveries entail high costs and may lead to financial catastrophe for households. This paper examines the out-of-pocket expenditure (OOPE) and distress financing of cesarean deliveries in India.

METHODS

We used data from the latest round of the National Family Health Survey conducted during 2019-21. The survey covered 636,699 households, and 724,115 women in the age group 15-49 years. We have used 159,643 births those delivered three years preceding the survey for whom the question on cost was canvassed. Descriptive analysis, bivariate analysis, concentration index (CI), and concentration curve (CC) were used in the analysis.

RESULT

Cesarean deliveries in India was estimated at 14.08%, in private health centres and 9.96%  in public health centres. The prevalence of cesarean delivery increases with age, educational attainment, wealth quintile, BMI and high for those who had pregnancy complications, and previous birth as cesarean. The OOPE on cesarean births was US$133. It was US$498 in private health centres and US$99 in public health centres. The extent of distress financing of any cesarean delivery was 15.37%; 27% for those who delivered in private health centres compared to 16.61% for those who delivered in public health centres. The odds of financial distress arising due to OOPE on cesarean delivery increased with the increase of OOPE [AOR:10.00, 95% CI, 9.35-10.70]. Distress financing increased with birth order and was higher among those with low education and those who belonged to lower socioeconomic strata.

CONCLUSION

High OOPE on a cesarean delivery leads to distress financing in India. Timely monitoring of pregnancy and providing comprehensive pregnancy care, improving the quality of primary health centres to conduct cesarean deliveries, and regulating private health centres may reduce the high OOPE and financial distress due to cesarean deliveries in India.

Public health insurance coverage in India before and after PM-JAY: repeated cross-sectional analysis of nationally representative survey data

INTRODUCTION

The provision of non-contributory public health insurance (NPHI) to marginalised populations is a critical step along the path to universal health coverage. We aimed to assess the extent to which Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PM-JAY)-potentially, the world's largest NPHI programme-has succeeded in raising health insurance coverage of the poorest two-fifths of the population of India.

METHODS

We used nationally representative data from the National Family Health Survey on 633 699 and 601 509 households in 2015-2016 (pre-PM-JAY) and 2019-2021 (mostly, post PM-JAY), respectively. We stratified by urban/rural and estimated NPHI coverage nationally, and by state, district and socioeconomic categories. We decomposed coverage variance between states, districts, and households and measured socioeconomic inequality in coverage. For Uttar Pradesh, we tested whether coverage increased most in districts where PM-JAY had been implemented before the second survey and whether coverage increased most for targeted poorer households in these districts.

RESULTS

We estimated that NPHI coverage increased by 11.7 percentage points (pp) (95% CI 11.0% to 12.4%) and 8.0 pp (95% CI 7.3% to 8.7%) in rural and urban India, respectively. In rural areas, coverage increased most for targeted households and pro-rich inequality decreased. Geographical inequalities in coverage narrowed. Coverage did not increase more in states that implemented PM-JAY. In Uttar Pradesh, the coverage increase was larger by 3.4 pp (95% CI 0.9% to 6.0%) and 4.2 pp (95% CI 1.2% to 7.1%) in rural and urban areas, respectively, in districts exposed to PM-JAY and the increase was 3.5 pp (95% CI 0.9% to 6.1%) larger for targeted households in these districts.

CONCLUSION

The introduction of PM-JAY coincided with increased public health insurance coverage and decreased inequality in coverage. But the gains cannot all be plausibly attributed to PM-JAY, and they are insufficient to reach the goal of universal coverage of the poor.

Multi-Institutional Clinical Outcomes of Biopsy Gleason Grade Group 5 Prostate Cancers Treated With Contemporary High-Dose Radiation and Long-Term Androgen Deprivation Therapy

AIMS

This multicentric retrospective study reports long-term clinical outcomes of non-metastatic grade group 5 prostate cancers treated with external beam radiotherapy (EBRT) alone with long-term androgen deprivation therapy (ADT).

MATERIALS AND METHODS

Patients treated across 19 institutions were studied. The key endpoints that were evaluated were 5-year biochemical recurrence-free survival (bRFS), metastases-free survival (MFS), overall survival, together with EBRT-related acute and late toxicities. The impact of various prognostic factors on the studied endpoints was analysed using univariate and multivariate analyses.

RESULTS

Among the 462 patients, 88% (405) had Gleason 9 disease and 31% (142) had primary Gleason pattern 5. A prostate-specific membrane antigen positron emission tomography-computed tomography scan was used for staging in 33% (153), 80% (371) were staged as T3/T4 and 30% (142) with pelvic nodal disease. The median ADT duration was 24 months; 66% received hypofractionated EBRT and 71.4% (330) received pelvic nodal irradiation. With a median follow-up of 56 months, the 5-year bRFS, MFS and overall survival were 73.1%, 77.4% and 90.5%, respectively. Primary Gleason pattern 5 was associated with worse bRFS, MFS and overall survival with hazard ratios of 0.51 (95% confidence interval 0.35 to 0.73, P < 0.001), 0.64 (95% confidence interval 0.43 to 0.96, P = 0.031) and 0.52 (95% confidence interval 0.28 to 0.97, P = 0.040), respectively, whereas pelvic nodal disease was associated with worse bRFS (hazard ratio 0.67, 95% confidence interval 0.46 to 0.98, P = 0.039) and MFS (hazard ratio 0.56, 95% confidence interval 0.37 to 0.85, P = 0.006). The acute and late radiation-related toxicities were low overall and pelvic nodal irradiation was associated with higher toxicities.

CONCLUSION

Contemporary EBRT and long-term ADT led to excellent 5-year clinical outcomes and low rates of toxicity in this cohort of non-metastatic grade group 5 prostate cancers. Primary Gleason pattern 5 and pelvic node disease portends inferior clinical outcomes.

Electron donation of Fe-Mn biochar for chromium(VI) immobilization: Key roles of embedded zero-valent iron clusters within iron-manganese oxide

The dense surface passivation layer on zero-valent iron (ZVI) restricts its efficiency for water decontamination, causing a poor economy and waste of resources. Herein, we found that the ZVI on Fe-Mn biochar could afford a high electron-donating efficiency for the Cr(VI) reduction and immobilization. Over 78.0% of Fe in the Fe-Mn biochar was used for the Cr(VI) reduction and immobilization, i.e., 56.2 - 161.7 times higher than the commercial ZVI (0.5%) and modified ZVI (0.9 -1.3%), indicating that the unique ZVI species in Fe-Mn biochar offered an outstanding Fe utilization efficiency. We proposed that oxygen atoms in the FeO in the FeMnO₂ precursor were removed during pyrolysis with biochar while the MnO skeleton was preserved, forming the embedded ZVI clusters within Fe-Mn oxide. The unique structure inhibited the formation of the Fe-Cr complex on Fe(0), which would facilitate the electron transfer between core Fe(0) and Cr(VI). Moreover, the surface FeMnO₂ inhibited the diffusion of Fe and facilitated its affinity with pollutants, thus supporting higher efficiency for pollutant immobilization. The preserved performance of Fe-Mn biochar was proved in industrial wastewater and after long-term oxidation process, and the economic benefit was evaluated. This work provides a new approach for developing active ZVI-based materials with high Fe utilization efficiency and economics for water pollution control.

Examining chronic disease onset across varying age groups of Indian adults using competing risk analysis

In low-and-middle-income countries, people develop chronic diseases at a younger age, leading to health-and-economic loss. Estimates of the age of onset of chronic disease provide evidence for policy intervention, but in the Indian context, evidence is limited. The present study aims to explore the onset of seven chronic diseases across adults and the elderly, along with the prognostic factors of chronic disease onset. Using Wave 1 data of the Longitudinal Ageing Study in India (LASI), we estimated the statistical distributions, the median age at onset, and Loglogistic and Weibull accelerated failure time model to understand the onset of seven medically diagnosed self-reported chronic diseases across age groups. We also obtained the sub-distribution hazard ratio (SHR) from the Fine-Gray model to determine the risk of contracting selected chronic diseases in a competing risk setup. The seven chronic diseases- hypertension, diabetes, lung disease, heart disease/stroke, arthritis, neurological disease, and cancer- were developing early, especially in individuals aged 45-54 and 55-64. Arthritis risk was higher in rural areas, and physically active adults and elderly were 1.32 times (95% CI 1.12-1.56) more likely to develop heart disease/stroke. The emerging evidence of the early onset of neurological diseases in middle-aged adults (i.e., among the 45-54 age group) reminds us of the need to reinforce a balance between the physical and mental life of individuals. The early onset of chronic diseases in the independent and working-age category (45-54 years) can have many social and economic implications. For instance, it can create a greater healthcare burden when these individuals grow older with these diseases. Further, disease-specific interventions would be helpful in reducing future chronic disease burden.

Sociodemographic and geographic inequalities in diagnosis and treatment of older adults' chronic conditions in India: a nationally representative population-based study

CONTEXT

Expeditious diagnosis and treatment of chronic conditions are critical to control the burden of non-communicable disease in low- and middle-income countries. We aimed to estimate sociodemographic and geographic inequalities in diagnosis and treatment of chronic conditions among adults aged 45 + in India.

METHODS

We used 2017-18 nationally representative data to estimate prevalence of chronic conditions (hypertension, diabetes, lung disease, heart disease, stroke, arthritis, cholesterol, and neurological) reported as diagnosed and percentages of diagnosed conditions that were untreated by sociodemographic characteristics and state. We used concentration indices to measure socioeconomic inequalities in diagnosis and lack of treatment. Fully adjusted inequalities were estimated with multivariable probit and fractional regression models.

FINDINGS

About 46.1% (95% CI: 44.9 to 47.3) of adults aged 45 + reported a diagnosis of at least one chronic condition and 27.5% (95% CI: 26.2 to 28.7) of the reported conditions were untreated. The percentage untreated was highest for neurological conditions (53.2%; 95% CI: 50.1 to 59.6) and lowest for diabetes (10.1%; 95% CI: 8.4 to 11.5). Age- and sex-adjusted prevalence of any diagnosed condition was highest in the richest quartile (55.3%; 95% CI: 53.3 to 57.3) and lowest in the poorest (37.7%: 95% CI: 36.1 to 39.3). Conditional on reported diagnosis, the percentage of conditions untreated was highest in the poorest quartile (34.4%: 95% CI: 32.3 to 36.5) and lowest in the richest (21.1%: 95% CI: 19.2 to 23.1). Concentration indices confirmed these patterns. Multivariable models showed that the percentage of untreated conditions was 6.0 points higher (95% CI: 3.3 to 8.6) in the poorest quartile than in the richest. Between state variations in the prevalence of diagnosed conditions and their treatment were large.

CONCLUSIONS

Ensuring more equitable treatment of chronic conditions in India requires improved access for poorer, less educated, and rural older people who often remain untreated even once diagnosed.

Health-Related Quality of Life (HRQoL) Using EQ-5D-5L: Value Set Derived for Indian Breast Cancer Cohort

OBJECTIVE

The purpose of this study was to report quality of life of newly diagnosed breast cancer patients from India in a large cohort using the EQ-5D-5L instrument.

METHODS

The study used longitudinal data of 500 breast cancer and 200 non-cancer subjects registered at our centre, during June 2019 and March 2022. The EQ-5D-5L and EQ-VAS instruments were used to measure and compare utility scores among cancer and non-cancer subjects. Descriptive statistics were analyzed and Tobit regression model were used to confirm the predictors of the utility score.

RESULTS

The cancer subjects had a mean EQ-ED-5L utility score of 0.8703 (SD=0.121), 0.8745 (SD=0.094) and 0.8902 (SD=0.107) at the time of baseline, completion and follow up surveys respectively.  EQ-5D-5L values had significantly worsened after diagnosis of cancer as compared to the non-cancer cohort (0.87 vs. 0.93, p value 0.000). EQ-5D-5L utility scores as per stage for the cancer cohort were 0.88, 0.86 and 0.83 respectively for stage I-II, III and IV. Similarly, the EQ-VAS scores for stage I-II, III and IV were 74.9, 72.6 and 73.2 respectively. Multivariate analysis confirmed strong association of age, religion and income with the utility-values.

CONCLUSION

This is the first longitudinal study reporting the utility scores derived from a large cohort of breast cancer patients demonstrating lower utility scores compared to non-cancer cohort. The utility scores also improve post treatment completion for cancer patients and decrease with higher stage at diagnosis. This information will be useful for future health economic research in India pertaining to breast cancer.

Socio-economic variations of breast cancer treatment and discontinuation: a study from a public tertiary cancer hospital in Mumbai, India

BACKGROUND

The study examined the socio-economic variation of breast cancer treatment and treatment discontinuation due to deaths and financial crisis.

METHODS

We used primary data of 500 patients with breast cancer sought treatment at India's one of the largest cancer hospital in Mumbai, between June 2019 and March 2022. This study is registered on the Clinical Trial Registry of India (CTRI/2019/07/020142). Kaplan-Meier method and Cox-hazard regression model were used to calculate the probability of treatment discontinuation.

RESULTS

Of the 500 patients, three-fifths were under 50 years, with the median age being 46 years. More than half of the patients were from outside of the state and had travelled an average distance of 1,044 kms to get treatment. The majority of the patients were poor with an average household income of INR15,551. A total of 71 (14%) patients out of 500 had discontinued their treatment. About 5.2% of the patients died and 4.8% of them discontinued treatment due to financial crisis. Over one-fourth of all deaths were reported among stage IV patients (25%). Patients who did not have any health insurance, never attended school, cancer stage IV had a higher percentage of treatment discontinuation due to financial crisis. Hazard of discontinuation was lower for patients with secondary (HR:0.48; 95% CI: 0.27-0.84) and higher secondary education (HR: 0.42; 95% CI: 0.19-0.92), patients from rural area (HR: 0.79; 95% CI: 0.42-1.50), treated under general or non-chargeable category (HR: 0.60; 95% CI:0.22-1.60) while it was higher for the stage IV patients (HR: 3.61; 95% CI: 1.58-8.29).

CONCLUSION

Integrating breast cancer screening in maternal and child health programme can reduce delay in diagnosis and premature mortality. Provisioning of free treatment for poor patients may reduce discontinuation of treatment.

Socioeconomic inequality in awareness, treatment and control of diabetes among adults in India: Evidence from National Family Health Survey of India (NFHS), 2019-2021

Diabetes is a growing epidemic and a major threat to most of the households in India. Yet, there is little evidence on the extent of awareness, treatment, and control (ATC) among adults in the country. In this study, we estimate the prevalence and ATC of diabetes among adults across various sociodemographic groups and states of India. We used data on 2,078,315 individuals aged 15 years and over from the recent fifth round, the most recent one, of the National Family Health Survey (NFHS-5), 2019-2021, that was carried out across all the states of India. Diabetic individuals were identified as those who had random blood glucose above 140 mg/dL or were taking diabetes medication or has doctor-diagnosed diabetes. Diabetic individuals who reported diagnosis were labelled as aware, those who reported taking medication for controlling blood glucose levels were labelled as treated and those whose blood glucose levels were < 140 mg/dL were labelled as controlled. The estimates of prevalence of diabetes, and ATC were age-sex adjusted and disaggregated by household wealth quintile, education, age, sex, urban-rural residence, caste, religion, marital status, household size, and state. Concentration index was used to quantify socioeconomic inequalities and multivariable logistic regression was used to estimate the adjusted differences in those outcomes. We estimated diabetes prevalence to be 16.1% (15.9-16.1%). Among those with diabetes, 27.5% (27.1-27.9%) were aware, 21.5% (21.1-21.7%) were taking treatment and 7% (6.8-7.1%) had their diabetes under control. Across the states of India, the adjusted rates of awareness varied from 14.4% (12.1-16.8%) to 54.4% (40.3-68.4%), of treatment from 9.3% (7.5-11.1%) to 41.2% (39.9-42.6%), and of control from 2.7% (1.6-3.7%) to 11.9% (9.7-14.0%). The age-sex adjusted rates were lower (p < 0.001) among the poorer and less educated individuals as well as among males, residents of rural areas, and those from the socially backward groups Among individuals with diabetes, the richest fifth were respectively 12.4 percentage points (pp) (11.3-13.4; p < 0.001), 10.5 pp (9.7-11.4; p < 0.001), and 2.3 pp (1.6-3.0; p < 0.001) more likely to be aware, getting treated, and having diabetes under control, than the poorest fifth. The concentration indices of ATC were 0.089 (0.085-0.092), 0.083 (0.079-0.085) and 0.017 (0.015-0.018) respectively. Overall, the ATC of diabetes is low in India. It is especially low the poorer and the less educated individuals. Targeted interventions and management can reduce the diabetes burden in India.

A review of compaction effect on subsurface processes in soil: Implications on stormwater treatment in roadside compacted soil

Sustainable cities require spacious infrastructures such as roadways to serve multiple functions, including transportation and water treatment. This can be achieved by installing stormwater control measures (SCM) such as biofilters and swales on the roadside compacted soil, but compacted soil limits infiltration and other functions of SCM. Understanding the effect of compaction on subsurface processes could help design SCM that could alleviate the negative impacts of compaction. Therefore, we synthesize reported data on compaction effects on subsurface processes, including infiltration rate, plant health, root microbiome, and biochemical processes. The results show that compaction could reduce runoff infiltration rate, but adding sand to roadside soil could alleviate the negative impact of compaction. Compaction could decrease the oxygen diffusion rate in the root zone, thereby affecting plant root activities, vegetation establishment, and microbial functions in SCM. The impacts of compaction on carbon mineralization rate and root biomass vary widely based on soil type, aeration status, plant species, and inherent soil compaction level. As these processes are critical in maintaining the long-term functions of SCM, the analysis would help develop strategies to alleviate the negative impacts of compaction and turn road infrastructure into a water solution in sustainable cities.

Wildfire impacts on surface water quality parameters: Cause of data variability and reporting needs

Surface runoff mobilizes the burned residues and ashes produced during wildfires and deposits them in surface waters, thereby deteriorating water quality. A lack of a consistent reporting protocol precludes a quantitative understanding of how and to what extent wildfire may affect the water quality of surface waters. This study aims to analyze reported pre- and post-fire water quality data to inform the data reporting and highlight research opportunities. A comparison of the pre-and post-fire water quality data from 44 studies reveals that wildfire could increase the concentration of many pollutants by two orders of magnitude. However, the concentration increase is sensitive to when the sample was taken after the wildfire, the wildfire burned area, discharge rate in the surface water bodies where samples were collected, and pollutant type. Increases in burned areas disproportionally increased total suspended solids (TSS) concentration, indicating TSS concentration is dependent on the source area. Increases in surface water flow up to 10 m³ s^-1 increased TSS concentration but any further increase in flow rate decreased TSS concentration, potentially due to dilution. Nutrients and suspended solids concentrations increase within a year after the wildfire, whereas peaks for heavy metals occur after 1-2 years of wildfire, indicating a delay in the leaching of heavy metals compared to nutrients from wildfire-affected areas. The concentration of polycyclic aromatic hydrocarbons (PAHs) was greatest within a year post-fire but did not exceed the surface water quality limits. The analysis also revealed inconsistency in the existing sampling protocols and provides a guideline for a modified protocol along with highlighting new research opportunities. Overall, this study underlines the need for consistent reporting of post-fire water quality data along with environmental factors that could affect the data so that the post-fire water quality can be assessed or compared between studies.

Children's playgrounds contain more microplastics than other areas in urban parks

Children spend many hours in urban parks and playgrounds, where the tree canopy could filter microplastics released from the surrounding urban hotspots. However, the majority of children's playgrounds also contain plastic structures that could potentially release microplastics. To assess if the children's playgrounds pose a higher exposure risk than other places inside the park, we evaluate the extent of microplastic contamination in the sand, soil, and leaf samples from 19 playgrounds inside urban parks in Los Angeles, CA, USA. The average microplastic concentration in sand samples collected inside the playground was 72 p g-1, and >50 % of identified plastics were either polyethylene or polypropylene. Microplastic concentrations inside the playgrounds were on average >5 times greater than concentrations outside the playgrounds in the park, indicating that children playing within the playground may be exposed to more microplastics than children playing outside the playground in the same park. By comparing the microplastic composition found inside and outside the playgrounds with the plastic composition of the plastic structures in the playground, we show that plastic structures and other products used inside the playgrounds could contribute to elevated microplastic concentration. The population density was slightly correlated with a microplastic concentration in the park soil but did not correlate with microplastic concentration inside the playgrounds. Therefore, playgrounds in urban parks may have microplastic exposure risks via inhalation or ingestion via hand-to-mouth transfer.

Chronic diseases and productivity loss among middle-aged and elderly in India

CONTEXT

Chronic diseases are growing in India and largely affecting the middle-aged and elderly population; many of them are in working age. Though a large number of studies estimated the out-of-pocket payment and financial catastrophe due to this condition, there are no nationally representative studies on productivity loss due to health problems. This paper examined the pattern and prevalence of productivity loss, due to chronic diseases among middle-aged and elderly in India.

METHODS

We have used a total of 72,250 respondents from the first wave of Longitudinal Ageing Study in India (LASI), conducted in 2017-18. We have used two dependent variables, limiting paid work and ever stopped work due to ill health. We have estimated the age-sex adjusted prevalence of ever stopped working due to ill health and limiting paid work across MPCE quintile and socio- demographic characteristics. Propensity Score Matching (PSM) and logistic regression was used to examine the effect of chronic diseases on both these variables.

FINDINGS

We estimated that among middle aged adults in 45-64 years, 3,213 individuals accounting to 6.9% (95%CI:6.46-7.24) had ever-stopped work and 6,300 individuals accounting to 22.7% (95% CI: 21.49-23.95) had limiting paid work in India. The proportion of ever-stopped and limiting work due to health problem increased significantly with age and the number of chronic diseases. Limiting paid work is higher among females (25.1%), and in urban areas (24%) whereas ever-stopped is lower among female (5.7%) (95% CI:5.16-6.25 ) and in urban areas (4.9%) (95% CI: 4.20-5.69). The study also found that stroke (21.1%) and neurological or psychiatric problems (18%) were significantly associated with both ever stopped work and limiting paid work. PSM model shows that, those with chronic diseases are 4% and 11% more likely to stop and limit their work respectively. Regression model reveals that more than one chronic conditions had a consistent and significant positive impact on stopping work for over a year (increasing productivity loss) across all three models.

CONCLUSION

Individuals having any chronic disease has higher likelihood of ever stopped work and limiting paid work. Promoting awareness, screening and treatment at workplace is recommended to reduce adverse consequences of chronic disease in India.

Socio-economic and regional variation in breast and cervical cancer screening among Indian women of reproductive age: a study from National Family Health Survey, 2019-21

BACKGROUND

In India, breast and cervical cancers account for two-fifths of all cancers and are predominantly prevalent among women in the reproductive age group. The Government of India recommended screening of breast and cervical cancer among women aged 30 years and over. This study examines the socio-economic and regional variations of breast and cervical screening among Indian women in the reproductive age.

METHODS

A full sample of 707,119 women aged 15-49 and a sub-sample of 357,353 women aged 30-49 from National Family Health Survey-5 (2019-21) were used in the analysis. Self-reported ever screening for breast and cervical cancer for women aged 15-49 and women aged 30-49 were outcome variables. A set of socio-economic and risk factors associated with breast and cervical cancer screening were used as the predictors. Logistic regression was used to understand the significant correlates of cancer screening and, concentration index and concentration curve were used to assess the socio-economic inequality in breast and cervical cancer screening.

RESULTS

The proportion of breast and cervical cancer screening among women aged 30-49 were 877 and 1965 per 100,000 women respectively. Cancer screening was lower among women who were poor, young, had lower educational attainment and resided in rural areas. The concentration index was 0.2 for ever screening of breast cancer and 0.15 for cervical cancer among women aged 30-49 years. The concertation curve for screening of both breast and cervical cancers was pro-rich. Women with higher educational attainment [OR:1.46, 95% CI: 1.31-1.62], aged 40-49 years [OR:1.35; 95% CI: 1.28-1.43], resided in the western [OR:1.62; 95% CI:1.4-1.87] or southern [OR:6.66; 95% CI:5.93-7.49] region had significantly higher odds of up taking either of the screening. The pattern of breast and cervical cancer screening among women aged 15-49 was similar to that of women 30-49.

CONCLUSION

The overall proportion of cancer screening among women in 30-49 age group is low in India. Early screening and treatment can reduce the burden of these cancers. Creating awareness and providing knowledge on cancer could be a key strategy for reducing the burden of breast and cervical cancers among women in the reproductive age in India.

Association of pain and quality of life among middle-aged and older adults of India

BACKGROUND

India is passing through a phase of demographic and epidemiological transition where ageing and chronic morbidities are being more common. Though studies have examined the prevalence and risk factors of pain and other chronic morbidities, nationally representative research examining the association of pain and quality of life (QoL) is limited in India. This study examines the association between pain and QoL among middle-aged and older adults in India.

METHODS

This study uses the data from wave 1 of the Longitudinal Ageing Study in India (LASI) conducted in 2017-18. This study is restricted to 58,328 individuals from all states (except Sikkim), aged 45 years and above. The quality of life is measured in 6 domains (physical, psychological, social, environment, general health and life satisfaction) with 21 variables that range from 0 to 100. The principal component analysis was used to generate a composite score of QoL and the multiple linear regression was used to show the association between pain and quality of life.

RESULTS

It is estimated that approximately 37% of Indian middle-aged and older populations were often troubled with pain. Pain prevalence increase with age and is more common among older adults aged 75 + years (43.37%; 95% CI, 40.95-45.80), and female (41.38%; 95% CI, 39.36-43.39). The average QoL score among those with pain was 81.6 compared to 85.2 among those without pain. QoL was lower among elderly age 75 and above, females, rural residents and illiterates. Controlling for socio-demographic factors, pain reduces the QoL by 2.57 points (β= -2.57; 95% CI, -3.02 - -2.11).

CONCLUSION

Pain reduces the quality of life among middle-aged adults and older adults in India. This evidence could potentially help the policymakers to consider pain as a significant determinant of quality of life in India.

Quality of anthropometric data in India's National Family Health Survey: Disentangling interviewer and area effect using a cross-classified multilevel model

India has adopted a target-based approach to reduce the scourge of child malnourishment. Because the monitoring and evaluation required by this approach relies primarily on large-scale data, a data quality assessment is essential. As field teams are the primary mode of data collection in large-scale surveys, this study attempts to understand their contribution to variations in child anthropometric measures. This research can help disentangle the confounding effects of regions/districts and field teams on the quality of child anthropometric data. The anthropometric z-scores of 2,25,002 children below five years were obtained from the fourth round of India's National Family and Health Survey (NFHS-4), 2015–16. Unadjusted and adjusted standard deviations (SD) of the anthropometric measures were estimated to assess the variations in measurements. In addition, a cross-classified multilevel model (CCMM) approach was adopted to estimate the contribution of geographical regions/districts and teams to variations in anthropometric measures. The unadjusted SDs of the measures of stunting, wasting, and underweight were 1.7, 1.4, and 1.2, respectively. The SD of stunting was above the World Health Organisation threshold (0.8–1.2), as well as the Demographic and Health Survey mark. After adjusting for team-level characteristics, the SDs of all three measures reduced marginally, indicating that team-level workload had a marginal but significant role in explaining the variations in anthropometric z-scores. The CCMM showed that the maximum contribution to variations in anthropometric z-scores came from community-level (Primary Sampling Unit (PSU)) characteristics. Team-level characteristics had a higher contribution to variations in anthropometric z-scores than district-level attributes. Variations in measurement were higher for child height than weight. The present study decomposes the effects of district- and team-level factors and highlights the nuances of introducing teams as a level of analysis in multilevel modelling. Population size, density, and terrain variations between PSUs should be considered when allocating field teams in large-scale surveys.

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Unadjusted standard deviation for child malnourishment indicators are above the recommended level of DHS data quality standards.

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Variation in stunting is directly proportional to workload measured by number of eligible children in the PSUs.

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Cross-classified multilevel models show significant team-level contribution in explaining variations in anthropometric scores.

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Team-level contribution to explaining variations in child anthropometric measures is larger than district-level factors.

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The number of days assigned to gather anthropometric measurements should be dependent on the number of eligible respondents in a PSU, which may be identified at the time of mapping & listing, rather than being a fixed number of days across all the states of India.

Inconsistency in prevalence of hypertension based on self-reports and use of standard tests: Implications for large scale surveys

Objective

Biomarkers are increasingly integrated into population-based surveys to provide reliable estimates of the prevalence of specific diseases. The Demographic and Health Surveys have recently incorporated blood pressure measurements; however, little is known about the extent of agreement between measured and reported levels of hypertension in India. The objective of this study was to examine the extent of agreement between self-reported hypertension and the results of standard blood pressure measurements, as well as to explore the risk groups and factors associated with inconsistencies in self-reported and biomedically measured hypertension.

Methods

Reliability measures such as sensitivity, specificity, and kappa statistics were used to examine inconsistencies in self-reported and biomedically measured hypertension in the National Family Health Survey-4 data. Multilevel logistic models were adopted to analyse the respondent characteristics related to both false-positive and false-negative responses in the survey.

Results

Compared to biomedically measured hypertension, self-reported hypertension was inconsistent and disproportionate at disaggregated levels in India. While self-reports severely underestimated hypertension among men aged 15-54 years and women aged 35-49 years, it overestimated hypertension among women below the age of 35 years. The inconsistency in self-reported and biomedically examined hypertension had deviations from a sex standpoint. Women aged <35 years reported a false-positive prevalence of hypertension. False-negative responses were elucidated among women aged ≥35 years and men aged 15-54 years. The likelihood of false-positive responses was higher among pregnant and obese respondents, and those who consumed alcohol.

Conclusion

The significant deviance of self-reporting of hypertension from the prevalence derived based on standard tests further indicates the need for adopting standard tests in all emerging future large-scale surveys. A back-check survey is recommended to understand and differentiate the excessive false-positive reporting of hypertension among women aged 15-35 years.

Can water composition and weather factors predict fecal indicator bacteria removal in retention ponds in variable weather conditions?

Retention ponds provide benefits including flood control, groundwater recharge, and water quality improvement, but changes in weather conditions could limit the effectiveness in improving microbial water quality metrics. The concentration of fecal indicator bacteria (FIB), which is used as regulatory standards to assess microbial water quality in retention ponds, could vary widely based on many factors including local weather and influent water chemistry and composition. In this critical review, we analyzed 7421 data collected from 19 retention ponds across North America listed in the International Stormwater BMP Database to examine if variable FIB removal in the field conditions can be predicted based on changes in these weather and water composition factors. Our analysis confirms that FIB removal in retention ponds is sensitive to weather conditions or seasons, but temperature and precipitation data may not describe the variable FIB removal. These weather conditions affect suspended solid and nutrient concentrations, which in turn could affect FIB concentration in the ponds. Removal of total suspended solids and total P only explained 5% and 12% of FIB removal data, respectively, and TN removal had no correlation with FIB removal. These results indicate that regression-based modeling with a single parameter as input has limited use to predict FIB removal due to the interactive nature of their effects on FIB removal. In contrast, machine learning algorithms such as the random forest method were able to predict 65% of the data. The overall analysis indicates that the machine learning model could play a critical role in predicting microbial water quality of surface waters under complex conditions where the variation of both water composition and weather conditions could deem regression-based modeling less effective.

Transport of microplastics in stormwater treatment systems under freeze-thaw cycles: Critical role of plastic density

Stormwater treatment systems remove and accumulate microplastics from surface runoff, but some of them can be moved downward to groundwater by natural freeze-thaw cycles. Yet, it is unclear whether or how microplastic properties such as density could affect the extent to which freeze-thaw cycles would move microplastics in the subsurface. To examine the transport and redistribution of microplastics in the subsurface by freeze-thaw cycles, three types of microplastics, with density smaller than (polypropylene or PP), similar to (polystyrene or PS), or greater than (polyethylene terephthalate or PET) water, were first deposited on the top of packed sand-the most common filter media used in infiltration-based stormwater treatment systems. Then the columns were subjected to either 23 h of drying at 22 ⁰C (control) or freeze-thaw treatment (freezing at -20 ⁰C for 6 h and thawing at 22 ⁰C for 17 h) followed by a wetting event. The cycle was repeated 36 times, and the effluents were analyzed for microplastics. Microplastics were observed in effluents from the columns that were contaminated with PET and subjected to freeze-thaw cycles. Comparison of the distribution of microplastics in sand columns at the end of 36 cycles confirmed that freeze-thaw cycles could disproportionally accelerate the downward mobility of denser microplastics. Using a force balance model, we show that smaller microplastics (<50 µm) can be pushed at higher velocity by the ice-water interface, irrespective of the density of microplastics. However, plastic density becomes critical when the size of microplastics is larger than 50 µm. The coupled experimental studies and theoretical framework improved the understanding of why denser microplastics such as PET and PVC may move deeper into the subsurface in the stormwater treatment systems and consequently elevate groundwater pollution risk.

Old-age dependency and catastrophic health expenditure: Evidence from Longitudinal Ageing Study in India

BACKGROUND

Out-of-pocket (OOP) payments and catastrophic health expenditure (CHE) have a strong age gradient. Though studies have examined the socio-demographic and geographic inequality in OOP payments and CHE in India, the role of old-age dependency in financial catastrophe remains unclear. Disaggregated estimates of CHE by the level of old-age dependency of households may help identify the most vulnerable sub-group and provide evidence for specific policies for the financial protection and health care of the elderly. The present study aims to estimate the incidence and intensity of CHE by the old-age dependency of households among middle-aged adults and the elderly in India.

METHODS

A total of 42,949 households from the Longitudinal Aging Study in India (LASI), 2017-18, covering households with at least one-member aged 45+ years, were included in the analysis. Households were classified into three mutually exclusive groups: no old-age dependency, low old-age dependency, and high old-age dependency. The incidence and intensity of CHE were estimated using the capacity-to-pay (CTP) approach. Concentration indices and concentration curves examine the extent of socioeconomic inequality in CHE. Binary logistic regression helps to understand the potential predictors of CHE across each type of old-age-dependent household.

RESULTS

We estimated the overall incidence of CHE at 24.6% (95% CI: 23.3-25.8) among middle-aged adults and the elderly in India. The incidence was 33.2% (95% CI: 31.4-35.1) among households with high old-age dependency, 23.1% (95% CI: 20.8-25.5) among those with low old-age dependency, and 20.4% (95% CI: 19.0-21.7) among no old-age dependency households. CHE intensity was highest among households with low old-age dependency compared to those no old-age dependents. Catastrophic health expenditure was higher among the poorer households in each type of old-age dependency. Among all households, the odds of incurring CHE were higher among households with high old-age dependency (AOR: 1.52; 95% CI: 1.36-1.69) than those with no old-age dependency. Lower-income households, households with pensions as the main source of income, households belonging to scheduled castes, and households residing in rural areas had higher odds of incurring CHE. The co-variates of CHE varied significantly across the type of old-age dependency households. A household's enrolment into a health insurance scheme did not necessarily lower its CHE.

CONCLUSION

Households with high old-age dependency had a higher probability of incurring CHE in India. Providing preventive and curative geriatric care in primary health centres (PHC) is recommended.

Use of unclean cooking fuels and visual impairment of older adults in India: A nationally representative population-based study

Despite widespread use of unclean cooking fuels (UCF) in India, evidence from nationally representative data on its association with visual impairment was lacking. We used a population-based nationwide survey of adults aged 45 years and older that included reported UCF and measured visual impairment. We estimated that 44.8% (95% CI: 42.6, 47.1) of older adults in India lived in households that used UCF. Age- and sex-adjusted prevalence of visual impairment was estimated to be 33.0% (95% CI: 31.0, 34.9) in the older population that did not use UCF and 9.0 percentage points (pp) (95% CI: 8.9, 9.1) higher among those who did. Among those who used UCF, age- and sex-adjusted prevalence of low distance vision was 4.3 pp (95% CI: 4.2, 4.4) higher, prevalence of low near vision was 8.0 pp (95% CI: 7.9, 8.1) higher, and prevalence of blindness was 1.0 pp (95% CI: 0.9, 1.0) higher. After controlling for a rich array of sociodemographic characteristics and state fixed effects, we estimated that use of UCF was associated with higher prevalence of visual impairment by 3.2 pp (95% CI: 1.4, 5.0), low distance vision by 1.8 pp (95% CI: 0.7, 2.9), and low near vision by 3.2 pp (95% CI: 1.3, 5.0). Doubly robust estimates of these differences were slightly larger. Blindness was not significantly partially associated with use of UCF (95% CI: -0.4, 0.6). We did not find support for the hypotheses that the visual impairment risk associated with use of UCF was even larger for females and in households without a separate kitchen or ventilation. The older population of India is highly reliant on UCF that is very strongly associated with visual impairment. Impaired vision should not be overlooked among the harms associated with UCF.

Highly variable removal of pathogens, antibiotic resistance genes, conventional fecal indicators and human-associated fecal source markers in a pilot-scale stormwater biofilter operated under realistic stormflow conditions

Green stormwater infrastructure systems, such as biofilters, provide many water quality and other environmental benefits, but their ability to remove human pathogens and antibiotic resistance genes (ARGs) from stormwater runoff is not well documented. In this study, a field scale biofilter in Southern California (USA) was simultaneously evaluated for the breakthrough of a conservative tracer (bromide), conventional fecal indicators, bacterial and viral human-associated fecal source markers (HF183, crAssphage, and PMMoV), ARGs, and bacterial and viral pathogens. When challenged with a 50:50 mixture of untreated sewage and stormwater (to mimic highly contaminated storm flow) the biofilter significantly removed (p < 0.05) 14 of 17 microbial markers and ARGsin descending order of concentration reduction: ermB (2.5 log(base 10) reduction) > Salmonella (2.3) > adenovirus (1.9) > coliphage (1.5) > crAssphage (1.2) > E. coli (1.0) ∼ 16S rRNA genes (1.0) ∼ fecal coliform (1.0) ∼ intl1 (1.0) > Enterococcus (0.9) ∼ MRSA (0.9) ∼ sul1 (0.9) > PMMoV (0.7) > Entero1A (0.5). No significant removal was observed for GenBac3, Campylobacter, and HF183. From the bromide data, we infer that 0.5 log-units of attenuation can be attributed to the dilution of incoming stormwater with water stored in the biofilter; removal above this threshold is presumably associated with non-conservative processes, such as physicochemical filtration, die-off, and predation. Our study documents high variability (>100-fold) in the removal of different microbial contaminants and ARGs by a field-scale stormwater biofilter operated under transient flow and raises further questions about the utility of human-associated fecal source markers as surrogates for pathogen removal.

Are cesarean deliveries equitable in India: assessment using benefit incidence analysis

BACKGROUND

In the last two decades, cesarean section (CS) deliveries in India have increased by six-fold and created economic hardship for families and households. Although several schemes and policies under the National Health Mission (NHM) have reduced the inequality in the use of maternal care services in India, the distributive effect of public health subsidies on CS deliveries remains unclear. In this context, this paper examines the usage patterns of CS delivery and estimates the share of public health subsidies on CS deliveries among mothers by different background characteristics in India.

DATA

Data from the fourth round of the National Family Health Survey (NFHS-4) was used for the study. Out-of-pocket (OOP) payment for CS delivery was used as a dependent variable and was analyzed by level of care that is, primary (PHC, UHC, other) and secondary (government/municipal, rural hospital). Descriptive statistics, binary logistic regression, benefit incidence analysis, concentration curve and concentration index were used for the analysis.

RESULTS

A strong economic gradient was observed in the utilization of CS delivery from public health facilities. Among mothers using any public health facility, 23% from the richest quintile did not pay for CS delivery compared to 13% from the poorest quintile. The use of the public subsidy among mothers using any type of public health facility for CS delivery was pro-rich in nature; 9% in the poorest quintile, 16.1% in the poorer, 24.5% in the middle, 27.5% among richer and 23% in the richest quintile. The pattern of utilization and distribution of public subsidy was similar across the primary and secondary health facilities but the magnitude varied. The findings from the benefit-incidence analysis are supported by those obtained from the inequality analysis. The concentration index of CS was 0.124 for public health centers and 0.291 for private health centers. The extent of inequality in the use of CS delivery in public health centers was highest in the state of Mizoram (0.436), followed by Assam (0.336), and the lowest in Tamil Nadu (0.060), followed by Kerala (0.066).

CONCLUSION

The utilization of CS services from public health centers in India is pro-rich. Periodically monitoring and evaluating of the cash incentive schemes for CS delivery and generating awareness among the poor would increase the use of CS delivery services in public health centers and reduce the inequality in CS delivery in India.

Natural aging of expanded shale, clay, and slate (ESCS) amendment with heavy metals in stormwater increases its antibacterial properties: Implications on biofilter design

Aging is often expected to decrease the pathogen removal capacity of media because of exhaustion of attachment sites by adsorption of co-contaminants and dissolved organics. In contrast, the adsorption of metals naturally present in stormwater during aging could have a positive impact on pathogen removal. To examine the effect of adsorbed metals on pathogen removal, biofilter media amended with expanded clay, shale, and slate (ESCS) aggregates, a lightweight aggregate, were exposed to metals by intermittently injecting natural stormwater spiked with Cu, Pb, and Zn, and the capacity of aged and unaged media to remove Escherichia coli (E. coli), a pathogen indicator, were compared. Metal adsorption on ESCS media decreased their net negative surface charge and altered the surface properties as confirmed by zeta potential measurement and Fourier-Transform Infrared Spectroscopy (FTIR) analysis. These changes increased the E. coli adsorption capacity of aged media compared with unaged media and decreased overall remobilization of attached E. coli during intermittent infiltration of stormwater. A live-dead analysis confirmed that the adsorbed metals inactivated attached E. coli, thereby replenishing the adsorption capacity. Overall, the results confirmed that natural aging of biofilter media with adsorbed metals could indeed have a net positive effect on E. coli removal in biofilters and therefore should be included in the conceptual model predicting long-term removal of pathogens from stormwater containing mixed pollutants.

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.

Air quality monitoring and measurement in an urban airshed: Contextualizing datasets from the Detroit Michigan area from 1952 to 2020

With urban air quality being a pressing public health concern, community members are becoming increasingly engaged in determining the links between air quality and human health. Although new measurement tools such as low-cost sensors make local data more accessible, a better understanding of gaps in regional datasets is needed to develop effective metropolitan-scale solutions. Using scoping review methodology, we compiled 214 published journal articles and grey literature reports of air quality data from the Detroit, Michigan area from 1952 through 2020. This critical scoping review focuses on air quality datasets, but related topics such as health studies and community-based participatory science studies were examined from the included articles. Most of these publications were peer-reviewed journal articles published after 2001. Particulate matter, nitrous oxides, and sulfur dioxide were the most commonly studied air pollutants, and asthma was the most frequently associated health outcome paired with air pollution datasets. Few publications reported methods for community-based participatory science. This critical scoping review establishes a foundation of historical air quality data for the Detroit metropolitan area and a set of evaluation criteria that can be replicated in other urban centers. This foundation enables future detailed analysis of air quality datasets and showcases strategies for implementing effective community science programs and monitoring efforts.

Microplastics retained in stormwater control measures: Where do they come from and where do they go?

Stormwater control measures (SCM) can remove and accumulate microplastics and may serve as a long-term source of microplastics for groundwater pollution because of their potential for downward mobility in subsurface. Furthermore, the number of microplastics accumulated in SCM may have been underestimated as the calculation typically only accounts for microplastics accumulated via episodic stormwater loading and ignores microplastic accumuation via continuous atmospheric deposition. To evaluate the source pathways of accumulated microplastics and their potential for downward mobility to groundwater, we analyzed spatial distributions of microplastics above ground on the canopy around SCM and below ground in the subsurface in and outside the boundaries of fourteen SCM in Los Angeles. Using an exponential model, we link subsurface retardation of microplastics to the median particle size of soil (D₅₀) and land use. Despite receiving significantly more stormwater, microplastic concentrations in SCM at surface depth or subsurface depth were not significantly different from the concentration at the same depth outside the SCM. Similar concentration in and outside of SCM indicates that stormwater is not the sole source of microplastics accumulated in SCM. The high concentration of microplastics on leaves of vegetation in SCM confirms that the contribution of atmospheric deposition is significant. Within and outside the SCM boundary, microplastics are removed within the top 5 cm of the subsurface, and their concentration decreases exponentially with depth, indicating limited potential for groundwater pollution from the microplastics accumulated in SCM. Outside the SCM boundary, the subsurface retardation coefficient decreases with increases in D₅₀, indicating straining of microplastics as the dominant removal mechanism. Inside the boundary of SCM, however, the retardation coefficient was independent of D₅₀, implying that microplastics could have either moved deeper into the filter layer in SCM or that compost, mulch, or organic amendments used in the filter media were pre-contaminated with microplastics. Overall, these results provide insights on microplastics source, accumulation, and downward mobility in SCM.

Enhanced removal of per- and polyfluoroalkyl substances in complex matrices by polyDADMAC-coated regenerable granular activated carbon

Granular activated carbon (GAC) has been used to remove per- and polyfluoroalkyl substances (PFASs) from industrial or AFFF-impacted waters, but its effectiveness can be low because adsorption of short-chained PFASs is ineffective and its sites are exhausted rapidly by co-contaminants. To increase adsorption of anionic PFASs on GAC by electrostatic attractions, we modified GAC's surface with the cationic polymer poly diallyldimethylammonium chloride (polyDADMAC) and tested its capacity in complex water matrices containing dissolved salts and humic acid. Amending with concentrations of polyDADMAC as low as 0.00025% enhanced GAC's adsorption capacity for PFASs, even in the presence of competing ions. This suggests that electrostatic interactions with polyDADMAC's quaternary ammonium functional groups helped bind organic and inorganic ions as well as the headgroup of short-chain PFASs, allowing more overall PFAS removal by GAC. Evaluating the effect of polymer dose is important because excessive addition can block pores and reduce overall PFAS removal rather than increase it. To decrease the waste associated with this adsorption strategy by making the adsorbent viable for more than one saturation cycle, a regeneration method is proposed which uses low-power ultrasound to enhance the desorption of PFASs from the polyDADMAC-GAC with minimum disruption to the adsorbent's structure. Re-modification with the polymer after sonication resulted in a negligible decrease in the sorbent's capacity over four saturation rounds. These results support consideration of polyDADMAC-modified GAC as an effective regenerable adsorbent for ex-situ concentration step of both short and long-chain PFASs from real waters with high concentrations of competing ions and low PFAS loads.

Missed opportunities for hypertension screening: a cross-sectional study, India

Objective

To assess missed opportunities for hypertension screening at health facilities in India and describe systematic differences in these missed opportunities across states and sociodemographic groups.

Methods

We used nationally representative survey data from the 2017-2018 Longitudinal Ageing Study in India to estimate the proportion of adults aged 45 years or older identified with hypertension and who had not been diagnosed with hypertension despite having visited a health facility during the previous 12 months. We estimated age-sex adjusted proportions of missed opportunities to diagnose hypertension, as well as actual and potential proportions of diagnosis, by sociodemographic characteristics and for each state.

Findings

Among those identified as having hypertension, 22.6% (95% confidence interval, CI: 21.3 to 23.8) had not been diagnosed despite having recently visited a health facility. If these opportunities had been realized, the prevalence of diagnosed hypertension would have increased from 54.8% (95% CI: 53.5 to 56.1) to 77.3% (95% CI: 76.2 to 78.5). Missed opportunities for diagnosis were more common among individuals who were poorer (P = 0.001), less educated (P < 0.001), male (P < 0.001), rural (P < 0.001), Hindu (P = 0.001), living alone (P = 0.028) and working (P < 0.001). Missed opportunities for diagnosis were more common at private than at public health facilities (P < 0.001) and varied widely across states (P < 0.001).

Conclusion

Opportunistic screening for hypertension has the potential to significantly increase detection of the condition and reduce sociodemographic and geographic inequalities in its diagnosis. Such screening could be a first step towards more effective and equitable hypertension treatment and control.

Drudgery assessment and ergonomic evaluation of pedal operated Ragi (Eleusine Coracana) thresher

BACKGROUND

Ragi (Eleusine Coracana) is a major food crop for the tribal population of India.

OBJECTIVE

This study emphasizes the need to consider ergonomics aspects in the design and development of a pedal operated ragi thresher (PORT) for tribal people, and assesses the drudgery as well as ergonomic evaluation of a developed thresher against the conventional practice.

METHODS

Thirty subjects (male = 15 and female = 15) from the tribal region were evaluated ergonomically. The physiological responses of the subjects were studied and their performance was compared.

RESULTS

The results revealed that the working heart rate, oxygen consumption rate and overall discomfort rating were significantly higher in case of traditional threshing as compared to those in case of PORT. Postural analysis identified the traditional method as the most fatigue one as the person has to lift the hand above shoulder level repeatedly and has to sit in a squatting posture for long period.

CONCLUSION

The drudgery and occupational hazards to public health involved in the traditional method of threshing was reduced by using the PORT. Furthermore, the traditional method involved continuous stressed actions across the entire body, whereas the PORT involved only the lower limbs.

Association of multidimensional poverty and tuberculosis in India

Background

Reduction of multidimensional poverty and tuberculosis are priority development agenda worldwide. The SDGs aims to eradicate poverty in all forms (SDG 1.2) and to end tuberculosis (SDG 3.3.2) by 2030. While poverty is increasingly being measured across multiple domains, reduction of tuberculosis has been an integral part of public health programmes. Though literature suggests a higher prevalence of tuberculosis among the economically poor, no attempt has been made to understand the association between multidimensional poverty and tuberculosis in India. The objective of this paper is to examine the association of multidimensional poverty and tuberculosis in India.

Methods

The unit data from the National Family Health Survey-4, conducted in 2015–16 covering 628,900 households and 2,869,043 individuals across 36 states and union territories of India was used in the analysis. The survey collected information on the self-reported tuberculosis infection of each member of a sample household at the time of the survey. Multidimensional poverty was measured in the domains of education, health, and standard of living, with a set of 10 indicators. The prevalence of tuberculosis was estimated among the multidimensional poor and non-poor populations across the states of India. A binary logistic regression model was used to understand the association of tuberculosis and multidimensional poverty.

Results

Results suggest that about 29.3% population of India was multidimensional poor and that the multidimensional poverty index was 0.128. The prevalence of tuberculosis among the multidimensional poor was 480 (95% CI: 464–496) per 100,000 population compared to 250 (95% CI: 238–262) among the multidimensional non-poor. The prevalence of tuberculosis among the multidimensional poor was the highest in the state of Kerala (1590) and the lowest in the state of Himachal Pradesh (220). Our findings suggest a significantly higher prevalence of tuberculosis among the multidimensional poor compared to the multidimensional non-poor in most of the states in India. The odds of having tuberculosis among the multidimensional poor were 1.82 times higher (95% CI, 1.73–1.90) compared to the non-poor. Age, sex, smoking, crowded living conditions, caste, religion, and place of residence are significant socio-demographic risk factors of tuberculosis.

Conclusion

The prevalence of tuberculosis is significantly higher among the multidimensional poor compared to the multidimensional non-poor in India.

Release of soil colloids during flow interruption increases the pore-water PFAS concentration in saturated soil

Groundwater flow through aquifer soils or packed bed systems can fluctuate for various reasons, which could affect the concentration of natural colloids and per- and polyfluoroalkyl substances (PFAS) in the pore water. In such cases, PFAS concentration could either decrease due to matrix diffusion of PFAS or increase by the detachment of colloids carrying PFAS. Yet, the effect of flow fluctuation on PFAS transport or release in porous media has not been examined. To examine the relative importance of either process, we interrupted the flow during an injection of groundwater spiked with perfluorobutanoic acid (PFBA), perfluorooctanoic acid (PFOA), and bromide as conservative tracer through clay-rich soil, so that diffusive transport would be prominent during flow interruption. After flow interruption, the PFAS concentration did not decrease indicating an insignificant contribution of matrix diffusion. The concentration increased, potentially due to enhanced release of colloid-associated PFAS. Analysis of samples before and after flow interruption by particle size analysis and SEM confirmed an increase in soil colloid concentration after the flow interruption. XRD analysis of soil and the colloids proved that PFAS were associated with specific sites of the colloids. Due to a higher affinity of PFOA to soil colloids, the total PFOA concentration in the effluent samples increased more than PFBA after the flow interruption process. The results indicate that colloids may have a disproportionally higher role in the transport of PFAS in conditions that release colloids from porous media. Thus, fluctuations in groundwater flow can increase this colloid facilitated mobility of PFAS.

Perfluoroalkyl acids on suspended particles: Significant transport pathways in surface runoff, surface waters, and subsurface soils

Eroded particles from the source zone could transport a high concentration of perfluoroalkyl acids (PFAAs) to sediments and water bodies. Yet, the contribution of suspended particles has not been systematically reviewed. Analyzing reported studies, we quantitatively demonstrate that suspended particles in surface water can contain significantly higher concentrations of PFAAs than the sediment below, indicating the source of suspended particles are not the sediment but particles eroded and carried from the source zone upstream. The affinity of PFAAs to particles depends on the particle composition, including organic carbon fraction and iron or aluminum oxide content. In soils, most PFAAs are retained within the top 5 m below the ground surface. The distribution of PFAAs in the subsurface varies based on site properties and local weather conditions. The depth corresponding to the maximum concentration of PFAA in soil decreases with an increase in soil organic carbon or rainfall amount received in the catchment areas. We attribute a greater accumulation of PFAAs near the upper layer of the subsurface to an increase in the accumulation of particles eroded from source zones upstream receiving heavy rainfall. Precursor transformation in the aerobic zone is significantly higher than in the anaerobic zone, thereby making the aerobic subsurface zone serve as a long-term source of groundwater pollution. Collectively, these results suggest that suspended particles, often an overlooked vector for PFAAs, can be a dominant pathway for the transport of PFAAs in environments.

Awareness, treatment, and control of hypertension in adults aged 45 years and over and their spouses in India: A nationally representative cross-sectional study

BACKGROUND

Lack of nationwide evidence on awareness, treatment, and control (ATC) of hypertension among older adults in India impeded targeted management of this condition. We aimed to estimate rates of hypertension ATC in the older population and to assess differences in these rates across sociodemographic groups and states in India.

METHODS AND FINDINGS

We used a nationally representative survey of individuals aged 45 years and over and their spouses in all Indian states (except one) in 2017 to 2018. We identified hypertension by blood pressure (BP) measurement ≥140/90 mm Hg or self-reported diagnosis if also taking medication or observing salt/diet restriction to control BP. We distinguished those who (i) reported diagnosis ("aware"); (ii) reported taking medication or being under salt/diet restriction to control BP ("treated"); and (iii) had measured systolic BP <140 and diastolic BP <90 ("controlled"). We estimated age-sex adjusted hypertension prevalence and rates of ATC by consumption quintile, education, age, sex, urban-rural, caste, religion, marital status, living arrangement, employment status, health insurance, and state. We used concentration indices to measure socioeconomic inequalities and multivariable logistic regression to estimate fully adjusted differences in these outcomes. Study limitations included reliance on BP measurement on a single occasion, missing measurements of BP for some participants, and lack of data on nonadherence to medication. The 64,427 participants in the analysis sample had a median age of 57 years: 58% were female, and 70% were rural dwellers. We estimated hypertension prevalence to be 41.9% (95% CI 41.0 to 42.9). Among those with hypertension, we estimated that 54.4% (95% CI 53.1 to 55.7), 50.8% (95% CI 49.5 to 52.0), and 28.8% (95% CI 27.4 to 30.1) were aware, treated, and controlled, respectively. Across states, adjusted rates of ATC ranged from 27.5% (95% CI 22.2 to 32.8) to 75.9% (95% CI 70.8 to 81.1), from 23.8% (95% CI 17.6 to 30.1) to 74.9% (95% CI 69.8 to 79.9), and from 4.6% (95% CI 1.1 to 8.1) to 41.9% (95% CI 36.8 to 46.9), respectively. Age-sex adjusted rates were lower (p < 0.001) in poorer, less educated, and socially disadvantaged groups, as well as for males, rural residents, and the employed. Among individuals with hypertension, the richest fifth were 8.5 percentage points (pp) (95% CI 5.3 to 11.7; p < 0.001), 8.9 pp (95% CI 5.7 to 12.0; p < 0.001), and 7.1 pp (95% CI 4.2 to 10.1; p < 0.001) more likely to be aware, treated, and controlled, respectively, than the poorest fifth.

CONCLUSIONS

Hypertension prevalence was high, and ATC of the condition were low among older adults in India. Inequalities in these indicators pointed to opportunities to target hypertension management more effectively and equitably on socially disadvantaged groups.

Iron amendments minimize the first-flush release of pathogens from stormwater biofilters

First flush or the first pore volume of effluent eluted from biofilters at the start of rainfall contributes to most pollution downstream because it typically contains a high concentration of bacterial pathogens. Thus, it is critical to evaluate designs that could minimize the release of bacteria during a period of high risk. In this study, we test the hypothesis of whether an addition of iron-based media to biofilter could limit the leaching of Escherichia coli (E. coli), a pathogen indicator, during the first flush. We applied E. coli-contaminated stormwater intermittently in columns packed with a mixture of sand and compost (70:30 by volume, respectively) and iron filings at three concentrations: 0% (control), 3%, and 10% by weight. Columns packed with a mixture of sand and iron (3% or 10%) without compost were used to examine the maximum capacity of iron to remove E. coli. In columns with iron, particularly 10% by weight, the leaching of E. coli during the first flush was 32% lower than the leaching from compost columns, indicating that the addition of iron amendments could decrease first-flush leaching of E. coli. We attribute this result to the ability of iron to increase adsorption and decrease growth during antecedent drying periods. Although the addition of iron filings increased E. coli removal, the presence of compost decreased the adsorption capacity: exposure of 1 g of iron filings to 1 mg of DOC reduces E. coli removal by 8%. The result was attributed to the alteration of the surface charge of iron and blocking of adsorption sites shared by E. coli and DOC. Collectively, these results indicate that the addition of sufficient amounts of iron media could decrease pathogen leaching in the first flush effluent and increase the overall biofilter performance and protect downstream water quality.

Spatial heterogeneity in discontinuation of modern spacing method in districts of India

Background

Despite six decades of official family planning programme, the use of modern contraceptive method remained low in India. The discontinuation of modern spacing method (DMSM) has also increased from 42.3% in 2005−06 to 43.6% during 2015–16. Discontinuation rate is higher for Injectable (51%), followed by condom (47%), pill (42%) and lowest in IUD (26%).

Methods

Data from NFHS-4 (2015–16) comprising of 601,509 households, 699,686 women and a sample of 119,548 episode of modern spacing method was used for the analysis. Multiple decrement life table has used to estimate 12-month discontinuation rate of modern spacing methods (DMSM). Moran’s I statistics, Bivariate LISA cluster map has used to understand the spatial correlates and clustering the DMSM. OLS model and impact analysis has used to assess the significant associated covariates with discontinuation.

Result

The 12-month DMSM in India is 43.5%; largely due to desire for becoming pregnant and method failure. The high discontinuation rate was observed in most of the southern (62%) and central (46%) regions of India. DMSM has significantly and spatially associated with neighbouring districts of India (Moran’s I = 0.47, p-value = 0.00). The prevalence of modern spacing method is negatively associated with discontinuation in the neighbouring districts of India. The unmet need (β = 0.84, 95% CI 0.55–1.14), desire of children (β = 0.26, 95% CI − 0.05–0.57) and female sterilization (β = 0.54, 95% CI 0.14–0.95) were three main contributing factor to DMSM.

Conclusion

Districts of high DMSM need programmatic intervention. More attention for counselling to client, health worker outreach to user and better quality care services will stimulate non-user of contraception.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01185-w.

Contraceptive discontinuation is major issue of family planning of India. Without getting proper knowledge of modern spacing method, women facing serious health related issues so that they tend to discontinue their family planning method. We examine the spatial heterogeneity of discontinuation of modern spacing method in 640 district of India. Using secondary data of NFHS-4 (2015–16), we calculated 12-month discontinuation rate of any method and any modern spacing method by reason of discontinuation, also we presented discontinuation pattern by regions of India. To measure the spill over effect and associated factor of discontinuation of modern spacing method, we used OLS model and estimated Impact result. The findings of our study conveys that desire to become pregnant is the leading cause of discontinuation for both any method and any modern spacing method (12.43%), followed by other fertility related reasons and methods relates reason’s (4.40%). Method failure, side effect of method and method related reason together accounts 12% of contraceptive discontinuation in India. Very low use of modern spacing method of districts should be given more attention for policy maker and planner to increase the use of modern spacing method. The districts of high discontinuation of modern spacing method need programmatic intervention. More attention for counselling to client, health worker outreach to user and better quality care services will stimulate non-user of contraception.