Grappling with Morphine: A Local History of Painkiller Use in Kerala, India

In this article I argue that the scarcity of painkillers in the Global South is driven by a central asymmetry in which the health of developed countries is valued over that of the much poorer countries that comprise the rest of the world. To elucidate this point, I argue that by examining the history of various legal institutions and specific events, like the opioid crisis, that have shaped the global production of opium and production in India, one will be able to see the genealogy of the imbalance and inequality that has always affected care. I turn to the state of Kerala to explore instances in which these legal inflections live within the contemporary guidelines for palliative care, and thus constantly affect the supply and delivery of care. This also ties in with the much longer history of opium control for the growth of the global pharmaceutical industry, within which India has been uniquely placed.

Behavioural, emotional and rhythm-related disturbances in toddlers: Preliminary findings from a community-based study in Kerala, India

PURPOSE

The need to enhance mental health in primary care settings for infants and toddlers is increasingly becoming apparent. However, the lack of trained healthcare personnel and culturally appropriate measures makes it a challenge in low- and middle-income countries. A needs-based assessment of the extent of the problems in toddlers will help address the lacunae in providing mental health services.

METHODS

A needs-based assessment was carried out of a community sample of 9,287 mothers with toddlers aged between 13 and 25 months in Kerala, India. This assessment was conducted by junior public health nurses using an indigenously developed checklist titled 'Screening checklist for Behavioural, Emotional and Rhythm-related disturbances in Toddlers' (S-BERT).

RESULTS

According to the mothers surveyed, 30.4% of toddlers had concerning or distress causing behaviours. Three factors, namely behavioural, rhythm-related and emotional disturbances, were deemed significant when the item response theory was used to examine the factor structure of S-BERT.

CONCLUSION

This study suggests that behaviours that cause distress to mothers of toddlers are common, if queried specifically. Given the constraints in health resources as the cultural factors in operation, use of indigenous tools and principles of collaborative stepped care may be the way forward.

Systematic review and meta-analysis of the prevalence of smokeless tobacco consumption among adults in Bangladesh, India and Myanmar

OBJECTIVE

To estimate the pooled prevalence of smokeless tobacco consumption (STC) by gender and location in Bangladesh, India and Myanmar and to identify periodic changes in STC prevalence using data extracted from published studies.

METHODS

We searched for a combination of keywords in electronic databases and used a standard form to extract data from each article. We undertook a meta-analysis to estimate pooled prevalence and confidence intervals within these countries. To compare periodic changes in STC prevalence, we grouped studies into five-year periods (2000-2004, 2005-2009, 2010-2014 and 2015-2019).

RESULTS

The pooled estimates of STC prevalence were 25% (95% CI: 22-28%), 22% (95% CI: 15-28%) and 21% (95% CI: 14-28%) for Bangladesh, India and Myanmar, respectively. In pooled estimates across these countries, we found higher STC prevalence for men (30%; 95% CI: 24-35%) than women (16%; 95% CI: 10-23%) and for rural dwellings (24%; 95% CI: 18-31%) than urban dwellings (17%; 95% CI: 10-24%). We found significant decrease in STC in Bangladesh and India in the period 2010-2014 and 2015-2019, respectively. In Myanmar, STC prevalence increased significantly and substantially in 2010-2014, to levels higher than in Bangladesh and India.

CONCLUSIONS

The prevalence of STC in Bangladesh, India and Myanmar is highest in rural areas and among men. Public health prevention strategies are needed to maintain decrease in STC in Bangladesh and India, and to reverse the increased use in Myanmar.

Direct and indirect patient costs of tuberculosis care in India

OBJECTIVE

To synthesise the evidence for estimating the direct and indirect patient costs of drug-sensitive and drug-resistant tuberculosis care in India.

METHOD

PubMed, Embase, Web of Science, IndMED and Google Scholar were searched for studies conducted in India between 2000 and 2018 and published in English. The search terms were "tuberculosis" AND "costs" (cost Analysis, economics, cost of illness, health care costs, health expenditures, direct service costs, catastrophic cost) AND "India". The cost of TB care was from the patient's perspective. Data regarding costs were extracted, indexed to the year 2018 using cumulative inflation rate and converted to US dollars at the exchange rate of 2018.

RESULTS

Thirteen studies were included in this review. The mean (unweighted) total cost incurred by patients being treated for drug-sensitive TB in a public health facility was $ 235.00 (SD- 222.10), and the median of means was $ 170.60 (range - 43.70-718.40). The mean direct cost was 45.5% of the total cost. Only one study, which was conducted in a private facility, reported the mean total cost for drug-resistant TB as $ 7778.04. Catastrophic cost (total cost ≥ 20% of the total annual household income) was experienced by 7% to 32.4% of drug-sensitive TB patients and by 68% of drug-resistant TB patients.

CONCLUSION

Despite free diagnostic and treatment services provided under the Revised National Tuberculosis Control Programme, the patient cost of tuberculosis care is high. Relevant studies vary widely in methodology and cost reporting.

TB diagnostic cascade among patients registered under the Revised National TB Control Programme in Chennai, South India

OBJECTIVE

To discern and quantify the TB diagnostic cascade among patients registered under the Revised National TB Control Programme, Chennai city, Tamil Nadu, South India.

METHODS

This cross-sectional study was conducted in metropolitan Chennai from February 2017 to March 2018. We interviewed TB patients retrospectively on their diagnostic attempt in different health facilities.

RESULTS

Of 455 TB patients, only 4.4% received their diagnosis at their first health facility. Of 1250 visits to health facilities, the vast majority (79.4 vs. 20.6%) was in the public rather than the private sector. 56% of patients went to a public facility as the first point of care, of whom 1.6% shifted to private facilities subsequently. The remaining 54.4% shifted between up to five government health facilities. Male patients and those with a higher family income were more likely to shift from private to public.

CONCLUSION

Most shifts between diagnostic facilities occurred in the public sector. This necessitates interventions at public health facilities for strengthening and extending services to TB patients at their first point of care.

Determinants of transmission hotspots and filarial infection in households after eight rounds of mass drug administration in India

OBJECTIVES

Lymphatic filariasis (LF) elimination through mass drug administration (MDA) of DEC and albendazole have resulted in very low levels of infection in most endemic districts in India. But small pockets with residual microfilaraemia in the community and antigeneamia in children ('hotspots') are a cause of concern. We aimed to identify the determinants of such transmission hotspots and filarial infection in households using data from 33 communities.

METHODS

The filariasis vector Culex quinquefasciatus was collected from 627 randomly selected households using gravid traps. Parallel data on environmental, entomological, demographical, socio-economical and behavioural factors were analysed to identify the determinants of hotspots and household-level infection.

RESULTS

Hotspots and non-hotspots did not differ significantly in terms of socio-economical and behavioural aspects, but did differ in terms of demographical and environmental factors. Logistic regression revealed that tiled and concrete houses increased the risk of an area being a hotspot by 2.0 and 2.9 times respectively. Presence of Culex breeding habitats was significantly associated with elevated risk of being a hotspot. Proximity of U-drains to a house increased the risk of filarial infection 5.8 times.

CONCLUSIONS

An environment suitable to Culex breeding influences continued transmission despite eight rounds of MDA, particularly in hotspots. Proximity to U-drains increases the risk of infection in households. Implementing localised vector control measures may help interrupt low-level transmission, thereby reducing the risk of resurgence in the absence of MDA.

Household sanitation is associated with lower risk of bacterial and protozoal enteric infections, but not viral infections and diarrhoea, in a cohort study in a low-income urban neighbourhood in Vellore, India

Objective

This study examined associations between household sanitation and enteric infection – including diarrhoeal‐specific outcomes – in children 0–2 years of age in a low‐income, dense urban neighbourhood.

Methods

As part of the MAL‐ED study, 230 children in a low‐income, urban, Indian neighbourhood provided stool specimens at 14–17 scheduled time points and during diarrhoeal episodes in the first 2 years of life that were analysed for bacterial, parasitic (protozoa and helminths) and viral pathogens. From interviews with caregivers in 100 households, the relationship between the presence (and discharge) of household sanitation facilities and any, pathogen‐specific, and diarrhoea‐specific enteric infection was tested through mixed‐effects Poisson regression models.

Results

Few study households (33%) reported having toilets, most of which (82%) discharged into open drains. Controlling for season and household socio‐economic status, the presence of a household toilet was associated with lower risks of enteric infection (RR: 0.91, 95% CI: 0.79–1.06), bacterial infection (RR: 0.87, 95% CI: 0.75–1.02) and protozoal infection (RR: 0.64, 95% CI: 0.39–1.04), although not statistically significant, but had no association with diarrhoea (RR: 1.00, 95% CI: 0.68–1.45) or viral infections (RR: 1.12, 95% CI: 0.79–1.60). Models also suggested that the relationship between household toilets discharging to drains and enteric infection risk may vary by season.

Conclusions

The presence of a household toilet was associated with lower risk of bacterial and protozoal enteric infections, but not diarrhoea or viral infections, suggesting the health effects of sanitation may be more accurately estimated using outcome measures that account for aetiologic agents.

Costs of diarrhoea and acute respiratory infection attributable to not handwashing: the cases of India and China

OBJECTIVE

To estimate the national costs relating to diarrhoea and acute respiratory infections from not handwashing with soap after contact with excreta and the costs and benefits of handwashing behaviour change programmes in India and China.

METHODS

Data on the reduction in risk of diarrhoea and acute respiratory infection attributable to handwashing with soap were used, together with World Health Organization (WHO) estimates of disability-adjusted life years (DALYs) due to diarrhoea and acute respiratory infection, to estimate DALYs due to not handwashing in India and China. Costs and benefits of behaviour change handwashing programmes and the potential returns to investment are estimated valuing DALYs at per capita GDP for each country.

RESULTS

Annual net costs to India from not handwashing are estimated at US$ 23 billion (16-35) and to China at US$ 12 billion (7-23). Expected net returns to national behaviour change handwashing programmes would be US$ 5.6 billion (3.4-8.6) for India at US$ 23 (16-35) per DALY avoided, which represents a 92-fold return to investment, and US$ 2.64 billion (2.08-5.57) for China at US$ 22 (14-31) per DALY avoided - a 35-fold return on investment.

CONCLUSION

Our results suggest large economic gains relating to decreases in diarrhoea and acute respiratory infection for both India and China from behaviour change programmes to increase handwashing with soap in households.

Risk Factors associated with defaulting from visceral leishmaniasis treatment: analysis under routine programme conditions in Bihar, India

OBJECTIVE

To assess the rate of default from treatment in the visceral leishmaniasis (VL) elimination programme and to identify risk factors and its underlying causes.

METHODS

Case-control study conducted between December 2009 and June 2012 in three primary health centres (PHCs) of Muzaffarpur district, India. Patients who defaulted from treatment from the PHCs were considered as 'cases' and those who completed their treatment as 'controls'. Two controls were included in the study for each case. Respondents' opinion and satisfaction with the services provided at the PHCs were also elicited. Logistic regression was performed to assess the contribution of sociodemographic variables on patient status, and a discriminant analysis was used (after decomposing the original data) to identify factors that can predict the patient status as defaulter or not, based on factor scores of the components as predictor variables.

RESULTS

During the study period, 16.3% (89/544) of patients defaulted; 87 cases and 188 controls were interviewed through a semistructured questionnaire. Women tended to be more at risk for default (OR, 1.6, 95% CI (0.9 -2.9). Treatment received was miltefosine in 55.6% and sodium stibogluconate (SSG) in 44.4%. Most (86%) defaulters completed their treatment at other healthcare facilities; 70% of them preferred non-governmental institutions. Most cited reasons for default were seeking a second opinion for VL treatment and preferring to be treated in specialised VL centres. Discriminant analysis showed only one significant predictor: dissatisfaction with the medical care received in PHCs.

CONCLUSION

Efforts are needed to enhance the quality of VL care at PHC level, which will be beneficial in increasing treatment completion rates.

Spoligotyping of Mycobacterium tuberculosis isolates at a tertiary care hospital in India

OBJECTIVE

Spoligotyping is a valuable genotyping tool to study the genetic diversity and molecular epidemiology of Mycobacterium tuberculosis (M. tb). The aim of this study was to analyse different spoligotype patterns of M. tb strains isolated from patients with tuberculosis from different parts of India.

MATERIALS AND METHODS

A total of 163 M. tb isolates were spoligotyped between January 2014 and January 2015. About 47% (n = 77) were from patients with extrapulmonary tuberculosis; of these, 10 were MDR, and seven were Pre-XDR. Of the 86 M. tb isolates from patients with pulmonary tuberculosis, 25 were MDR, and 25 were Pre-XDR.

RESULTS

We found 61 spoligo patterns, 128 clusters in the spoligotype data base (spoldb4 data base) with spoligo international type (SIT) number and 35 true unique isolates. The most pre-dominant spoligotype was EAI lineage (56), followed by Beijing (28), CAS (20), T(9), U(7), X(3), H(3), BOVIS_1 BCG(1) and LAM(1).

CONCLUSION

Although our study identified EAI, CAS and Beijing strain lineages as pre-dominant, we also found a large number of orphan strains (20%) in our study. Beijing strains were more significantly associated with MDR TB than CAS and EAI lineages. Further studies on large sample sizes would help to clearly describe the epidemiology of M. tb in India.

HIV prevention and care-seeking behaviour among female sex workers in four cities in India, Kenya, Mozambique and South Africa

OBJECTIVE

To identify gaps in the use of HIV prevention and care services and commodities for female sex workers, we conducted a baseline cross-sectional survey in four cities, in the context of an implementation research project aiming to improve use of sexual and reproductive health services.

METHODS

Using respondent-driven sampling, 400 sex workers were recruited in Durban, 308 in Tete, 400 in Mombasa and 458 in Mysore and interviewed face-to-face. RDS-adjusted proportions were estimated by nonparametric bootstrapping and compared across cities using post hoc pairwise comparison.

RESULTS

Condom use with last client ranged from 88.3% to 96.8%, ever female condom use from 1.6% to 37.9%, HIV testing within the past 6 months from 40.5% to 70.9%, receiving HIV treatment and care from 35.5% to 92.7%, care seeking for last STI from 74.4% to 87.6% and having had at least 10 contacts with a peer educator in the past year from 5.7% to 98.1%. Many of the differences between cities remained statistically significant (P < 0.05) after adjusting for differences in FSWs' socio-demographic characteristics.

CONCLUSION

The use of HIV prevention and care by FSWs is often insufficient and differed greatly between cities. Differences could not be explained by variations in socio-demographic sex worker characteristics. Models to improve use of condoms and HIV prevention and care services should be tailored to the specific context of each site. Programmes at each site must focus on improving availability and uptake of those services that are currently least used.

Virological efficacy with first-line antiretroviral treatment in India: predictors of viral failure and evidence of viral resuppression

OBJECTIVE

Combination antiretroviral therapy (ART) has improved in efficacy, durability and tolerability. Virological efficacy studies in India are limited. We determined incidence and predictors of virological failure among patients initiating first-line ART and described virological resuppression after confirmed failure, with the goal of informing national policy.

METHODS

Therapy-naïve patients initiated on first-line ART as per national guidelines were monitored every 3 months for adherence and virological response over 2 years. Genotyping on baseline samples was performed to assess primary drug resistance. Multivariate Cox regression analysis was used to assess predictors of virological failure.

RESULTS

Virological failure rate among 599 eligible patients was 10.7 failures per 100 person-years. Cumulative failure incidence was 13.2% in the first year and 16.5% over 2 years. Patients initiated on tenofovir had a significantly lower rate of virological failure than those on stavudine or zidovudine (6.7 vs. 11.9 failures per 100 person-years, P = 0.013). Virological failure was independently associated with age <40 years, mean adherence <95%, non-tenofovir-containing regimens and presence of primary drug resistance. In a subset of 311 patients who were reassessed after treatment failure, 19% (11/58) patients resuppressed their viral load to <400 copies/ml after confirmed virological failure.

CONCLUSIONS

Our results support the inclusion of tenofovir as first-line ART in resource-limited settings and a role for regular adherence counselling and virological monitoring for enhanced treatment success. Detection of early virological failure should provide an opportunity to augment adherence counselling and repeat viral load testing before therapy switch is considered.

Traditional vs. non-traditional healing for minor and major morbidities in India: uses, cost and quality comparisons

OBJECTIVES

To examine the uses, cost and quality of care of traditional healing for short-term morbidities and major morbidities in India and to compare them with the non-traditional healing.

METHODS

We used data from a nationally representative survey, the India Human Development Survey (2004-2005) and descriptive as well as bivariate analyses for the examination.

RESULTS

Use of traditional healing is much less common than use of non-traditional healing in both rural and urban areas and across all socio-economic and demographic characteristics; it is slightly more common in rural than urban areas for short-term morbidities. Use of traditional healing is relatively more frequent for cataract (especially in rural areas), leprosy, asthma, polio, paralysis, epilepsy and mental illnesses; its total cost of care and mean waiting time (in the health facility) are substantially lower than for non-traditional healing. Among patients who use both traditional and non-traditional healing, a relatively higher proportion use traditional healing complemented by non-traditional healing for short-term illnesses, but vice versa for major morbidities.

CONCLUSION

This is the first study which has investigated at the national level the uses, complementarities, cost and quality aspects of traditional and non-traditional healing in India. Traditional healing is more affordable and pro-poor. Relatively higher use of traditional healing in patients from poorly educated as well as poor households and suffering from diseases, such as, epilepsy and mental illnesses; and higher demand for traditional healing for the above diseases highlight the need for research/policy reorientation in India.

Effectiveness of insecticide-treated and untreated nets to prevent malaria in India

OBJECTIVES

India is the most malaria-endemic country in South-East Asia, resulting in a high socio-economic burden. Insecticide-treated or untreated nets are effective interventions to prevent malaria. As part of an Indian first-aid guideline project, we aimed to investigate the magnitude of this effect in India.

METHODS

We searched MEDLINE, Embase and Central to systematically review Indian studies on the effectiveness of treated or untreated vs. no nets. Parasite prevalence and annual parasite incidence served as malaria outcomes. The overall effect was investigated by performing meta-analyses and calculating the pooled risk ratios (RR) and incidence rate ratios.

RESULTS

Of 479 articles, we finally retained 16 Indian studies. Untreated nets decreased the risk of parasite prevalence compared to no nets [RR 0.69 (95% CI; 0.55, 0.87) in high-endemic areas, RR 0.49 (95% CI; 0.28, 0.84) in low-endemic areas], as was the case but more pronounced for treated nets [RR 0.35 (95% CI; 0.26, 0.47) in high-endemic areas, risk ratio 0.16 (95% CI; 0.06, 0.44) in low-endemic areas]. Incidence rate ratios showed a similar observation: a significantly reduced rate of parasites in the blood for untreated nets vs. no nets, which was more pronounced in low-endemic areas and for those who used treated nets. The average effect of treated nets (vs. no nets) on parasite prevalence was higher in Indian studies (RR 0.16-0.35) than in non-Indian studies (data derived from a Cochrane systematic review; RR 0.58-0.87).

CONCLUSIONS

Both treated and untreated nets have a clear protective effect against malaria in the Indian context. This effect is more pronounced there than in other countries.

Determinants of common mental disorder, alcohol use disorder and cognitive morbidity among people coming for HIV testing in Goa, India

OBJECTIVE

To investigate associations between background characteristics (psychosocial adversity, risk behaviours/perception of risk and HIV-related knowledge, perceptions and beliefs) and psychological and cognitive morbidity among people coming for testing for HIV/AIDS in Goa, India.

METHODS

Analysis of cross-sectional baseline data (plus HIV status) from a prospective cohort study. Participants were recruited at the time of coming for HIV testing.

RESULTS

Consistent with associations found among general population samples, among our sample of 1934 participants, we found that indicators of psychosocial adversity were associated with CMD (common mental disorder - major depression, generalised anxiety and panic disorder) among people coming for testing for HIV. Similarly, perpetration of intimate partner violence was associated with AUD (alcohol use disorder). Two STI symptoms were associated with CMD, and sex with a non-primary partner was associated with AUD. Suboptimal knowledge about HIV transmission and prevention was associated with low cognitive test scores. In contrast with other studies, we found no evidence of any association between stigma and CMD. There was no evidence of modification of associations by HIV status.

CONCLUSIONS

Among people coming for testing for HIV/AIDS in Goa, India, we found that CMD occurred in the context of social and economic stressors (violence, symptoms of STI, poor education and food insecurity) and AUD was associated with violence and risky sexual behaviour. Further research is necessary to understand the role of gender, stigma and social norms in determining the relationship between sexual and mental health. Understanding associations between these background characteristics and psychological morbidity may help inform the design of appropriate early interventions for depression among people newly diagnosed HIV/AIDS.

Differential patterns, trends and hotspots of road traffic injuries on different road networks in Vellore district, southern India

OBJECTIVE

To describe spatial and temporal profiles of Road Traffic Injuries (RTIs) on different road networks in Vellore district of southern India.

METHODS

Using the information in the police maintained First Information Reports (FIRs), daily time series of RTI counts were created and temporal characteristics were analysed with respect to the vehicle, road types and time of the day for the period January 2005 to May 2007. Daily incidence and trend of RTIs were estimated using a Poisson regression analysis.

RESULTS

Of the reported 3262 RTIs, 52% had occurred on the National Highway (NH). The overall RTI rate on the NH was 8.8/100 000 vehicles per day with significantly higher pedestrian involvement. The mean numbers of RTIs were significantly higher on weekends. Thirteen percentage of all RTIs were associated with fatalities. Hotspots are major town junctions, and RTI rates differ over different stretches of the NH.

CONCLUSION

In India, FIRs form a valuable source of RTI information. Information on different vehicle profile, RTI patterns, and their spatial and temporal trends can be used by administrators to devise effective strategies for RTI prevention by concentrating on the high-risk areas, thereby optimising the use of available personnel and resources.

Isolation of keratinophilic fungi from selected soils of Sanjay Gandhi National Park, Mumbai (India)

One hundred and twenty-five samples were collected from eight different sites in the vicinity of Sanjay Gandhi National Park (SGNP) and screened for the presence of keratinophilic fungi using hair baiting technique for isolation. Seventy-three isolates were recovered and identified. The cultures were identified using macro- and micro-morphological features. Their identification was also confirmed by the BLAST search of sequences of the ITS1-5.8S-ITS2 rDNA region against the NCBI/Genbank data and compared with deposited sequences for identification purpose. Thirteen species of nine genera were isolated viz. Aphanoascus durus (2.4%), Arthroderma corniculatum (1.6%), Auxarthron umbrinum (0.8%), Chrysosporium evolceanui (1.6%), Chrysosporium indicum (16.0%), Chrysosporium tropicum (2.4%), Chrysosporium zonatum (4.0%), Chrysosporium states of Arthroderma tuberculatum (0.8%), Chrysosporium state of Ctenomyces serratus (11.2%), Gymnascella dankaliensis (3.2%), Microsporum gypseum (12.0%), Myriodontium keratinophilum (0.8%) and Trichophyton mentagrophytes (1.6%). Representative of all thirteen species can release the protein in the range of 152.2-322.4 μg/mL in liquid media when grown on human hair in shake flask culture and also decompose 18.4-40.2% of human hair after four weeks of incubation. This study indicates that the soils of SGNP, Mumbai may be significant reservoirs of certain keratinophilic fungi. The keratinolytic activity of these fungi may be playing significant role in superficial infections to man and animals and recycling of keratinic material of this environment.

Improving malaria treatment and prevention in India by aiding district managers to manage their programmes with local information: a trial assessing the impact of Lot Quality Assurance Sampling on programme outcomes

OBJECTIVES

This paper reports the first trial of Lot Quality Assurance Sampling (LQAS) assessing associations between access to LQAS data and subsequent improvements in district programming. This trial concerns India's approach to addressing an increase in malaria-attributable deaths by training community health workers to diagnose, treat and prevent malaria, while using LQAS to monitor sub-district performance and make programme improvements.

METHODS

The Ministry of Health introduced LQAS into four matched high malaria burden districts (Annual Parasite Incidence >5) (N > 5 million). In each sub-district, we sampled four populations in three 6-monthly surveys: households, children <5 years, people with fever in the last 2 weeks and community health workers. In three districts, trained local staff collected, analysed and used data for programme management; in one control district, non-local staff collected data and did not disseminate results. For eight indicators, we calculated the change in proportion from survey one to three and used a Difference-in-Differences test to compare the relative change between intervention and control districts.

RESULTS

Coverage increased from survey one to three for 24 of 32 comparisons. Difference-in-Differences tests revealed that intervention districts exhibited significantly greater change in four of six vertical strategies (insecticide treated bed-nets and indoor residual spraying), one of six treatment-seeking behaviours and four of 12 health worker capacity indicators. The control district displayed greater improvement than two intervention districts for one health worker capacity indicator. One district with poor management did not improve.

CONCLUSIONS

In this study, LQAS results appeared to support district managers to increase coverage in underperforming areas, especially for vertical strategies in the presence of diligent managers.

Reproductive risk factors assessment for anaemia among pregnant women in India using a multinomial logistic regression model

OBJECTIVE

To assess reproductive risk factors for anaemia among pregnant women in urban and rural areas of India.

METHOD

The International Institute of Population Sciences, India, carried out third National Family Health Survey in 2005-2006 to estimate a key indicator from a sample of ever-married women in the reproductive age group 15-49 years. Data on various dimensions were collected using a structured questionnaire, and anaemia was measured using a portable HemoCue instrument. Anaemia prevalence among pregnant women was compared between rural and urban areas using chi-square test and odds ratio. Multinomial logistic regression analysis was used to determine risk factors.

RESULTS

Anaemia prevalence was assessed among 3355 pregnant women from rural areas and 1962 pregnant women from urban areas. Moderate-to-severe anaemia in rural areas (32.4%) is significantly more common than in urban areas (27.3%) with an excess risk of 30%. Gestational age specific prevalence of anaemia significantly increases in rural areas after 6 months. Pregnancy duration is a significant risk factor in both urban and rural areas. In rural areas, increasing age at marriage and mass media exposure are significant protective factors of anaemia. However, more births in the last five years, alcohol consumption and smoking habits are significant risk factors.

CONCLUSION

In rural areas, various reproductive factors and lifestyle characteristics constitute significant risk factors for moderate-to-severe anaemia. Therefore, intensive health education on reproductive practices and the impact of lifestyle characteristics are warranted to reduce anaemia prevalence.

Can the rural poor in India afford to treat non-communicable diseases

OBJECTIVE

Non-communicable diseases (NCD) are on the increase in low-income countries, where healthcare costs are paid mostly out-of-pocket. We investigate the financial burden of NCD vs. communicable diseases (CD) among rural poor in India and assess whether they can afford to treat NCD.

METHODS

We used data from two household surveys undertaken in 2009-2010 among 7389 rural poor households (39 205 individuals) in Odisha and Bihar. All persons from the sampled households, irrespective of age and gender, were included in the analysis. We classify self-reported illnesses as NCD, CD or 'other morbidities' following the WHO classification.

RESULTS

Non-communicable diseases accounted for around 20% of the diseases in the month preceding the survey in Odisha and 30% in Bihar. The most prevalent NCD, representing the highest share in outpatient costs, were musculoskeletal, digestive and cardiovascular diseases. Cardiovascular and digestive problems also generated the highest inpatient costs. Women, older persons and less-poor households reported higher prevalence of NCD. Outpatient costs (consultations, medicines, laboratory tests and imaging) represented a bigger share of income for NCD than for CD. Patients with NCD were more likely to report a hospitalisation.

CONCLUSION

Patients with NCD in rural poor settings in India pay considerably more than patients with CD. For NCD cases that are chronic, with recurring costs, this would be aggravated. The cost of NCD care consumes a big part of the per person share of household income, obliging patients with NCD to rely on informal intra-family cross-subsidisation. An alternative solution to finance NCD care for rural poor patients is needed.