Child marriage in South Asia : a systematic review

Background: Child marriage is a serious public health issue with dire implications at the individual and societal level. Almost half of all child marriages globally originate from South Asia. The aim of this study is to identify consistent factors associated with and resulting from child marriage in South Asia through a review of available evidence. Methods: This systematic review adhered to the 2015 Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines. Six computerized bibliographic databases, namely PsycINFO, CINAHL, EMBASE, Ovid Medline, PUBMED, and Scopus were searched. Retrieved studies were exported to EndNote and screened for eligibility using pre-determined criteria. The quality of the included studies was rated using 14 quality appraisal criteria derived from the National Institutes of Health (NIH) Tool. Results: A total of 520 articles were retrieved from six databases. Of these, 13 articles met the eligibility criteria and were included in this study. Factors consistently associated with child marriage in South Asia were rural residence, low level of education, poor economic background, low exposure to mass media and religion (Hindu and Muslim in particular countries). Maternal health care factors resulting from child marriage included: low utilization of antenatal care services, low institutional delivery, and low delivery assistance by a skilled birth attendant. Conclusions: Child marriage results from an interplay of economic and social forces. Therefore, to address the complex nature of child marriage, efforts targeting improvement in education, employment, exposure to health information via mass media, and gender egalitarianism are required

"Getting the water-carrier to light the lamps": Discrepant role perceptions of traditional, complementary, and alternative medical practitioners in government health facilities in India.

The government of India has, over the past decade, implemented the "integration" of traditional, complementary and alternative medical (TCAM) practitioners, specifically practitioners of Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-rigpa, and Homoeopathy (collectively known by the acronym AYUSH), in government health services. A range of operational and ethical challenges has manifested during this process of large health system reform. We explored the practices and perceptions of health system actors, in relation to AYUSH providers' roles in government health services in three Indian states - Kerala, Meghalaya, and Delhi. Research methods included 196 in-depth interviews with a range of health policy and system actors and beneficiaries, between February and October 2012, and review of national, state, and district-level policy documents relating to AYUSH integration. The thematic 'framework' approach was applied to analyze data from the interviews, and systematic content analysis performed on policy documents. We found that the roles of AYUSH providers are frequently ambiguously stated and variably interpreted, in relation to various aspects of their practice, such as outpatient care, prescribing rights, emergency duties, obstetric services, night duties, and referrals across systems of medicine. Work sharing is variously interpreted by different health system actors as complementing allopathic practice with AYUSH practice, or allopathic practice, by AYUSH providers to supplement the work of allopathic practitioners. Interactions among AYUSH practitioners and their health system colleagues frequently take place in a context of partial information, preconceived notions, power imbalances, and mistrust. In some notable instances, collegial relationships and apt divisions of responsibilities are observed. Widespread normative ambivalence around the roles of AYUSH providers, complicated by the logistical constraints prevalent in poorly resourced systems, has the potential to undermine the therapeutic practices and motivation of AYUSH providers, as well as the overall efficiency and performance of integrated health services

Effects of social determinants on children’s health in informal settlements in Bangladesh and Kenya through an intersectionality lens: a study protocol

Introduction Several studies have shown that residents of urban informal settlements/slums are usually excluded and marginalised from formal social systems and structures of power leading to disproportionally worse health outcomes compared to other urban dwellers. To promote health equity for slum dwellers, requires an understanding of how their lived realities shape inequities especially for young children 0–4 years old (ie, underfives) who tend to have a higher mortality compared with non-slum children. In these proposed studies, we aim to examine how key Social Determinants of Health (SDoH) factors at child and household levels combine to affect under-five health conditions, who live in slums in Bangladesh and Kenya through an intersectionality lens. Methods and analysis The protocol describes how we will analyse data from the Nairobi Cross-sectional Slum Survey (NCSS 2012) for Kenya and the Urban Health Survey (UHS 2013) for Bangladesh to explore how SDoH influence under-five health outcomes in slums within an intersectionality framework. The NCSS 2012 and UHS 2013 samples will consist of 2199 and 3173 under-fives, respectively. We will apply Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy approach. Some of SDoH characteristics to be considered will include those of children, head of household, mothers and social structure characteristics of household. The primary outcomes will be whether a child had diarrhoea, cough, fever and acute respiratory infection (ARI) 2 weeks preceding surveys. Ethics and dissemination The results will be disseminated in international peer-reviewed journals and presented in events organised by the Accountability and Responsiveness in Informal Settlements for Equity consortium and international conferences. Ethical approval was not required for these studies. Access to the NCSS 2012 has been given by Africa Population and Health Center and UHS 2013 is freely availabl

Improving accountability for equitable health and well-being in urban informal spaces: Moving from dominant to transformative approaches

This article critically reviews the literature on urban informality, inequity, health, well-being and accountability to identify key conceptual, methodological and empirical gaps in academic and policy discourses. We argue that critical attention to power dynamics is often a key missing element in these discourses and make the case for explicit attention to the operation of power throughout conceptualization, design and conduct of research in this space. We argue that: (a) urban informality reflects the exercise of power to confer and withhold advantage; (b) the dominant biomedical model of health poorly links embodied experiences and structural contexts; (c) existing models of accountability are inadequate in unequal, pluralistic governance and provision environments. We trace four conceptual and empirical directions for transformative approaches to power relations in urban health equity research

Examination of physical activity for health promotion, and attitudes towards aging, among adults - cross-cultural comparisons; healthcare provider recommendations; toolkit evaluation.

Despite the well-known health benefits of physical activity, the majority of adults do not obtain the recommended daily amount. Three studies, using three different research designs, were conducted to examine physical activity, for health promotion and disease prevention, among relatively healthy adults. The Cross-cultural Intergenerational Comparisons of Attitudes towards Aging and Physical Activity study, a cross-sectional survey, examined 475 participants belonging to one of three groups (Indians in India, Indians in the United States, and Americans in the United States) on physical activity level, barriers to physical activity participation, and attitudes towards personal aging. Differences were observed among the groups on self-rated general health, occurrence of preventive examinations, and barriers to physical activity. Physical activity level was positively correlated with optimistic attitudes towards personal aging. The Healthcare Provider Physical Activity Prescription Intervention, a randomized comparison trial, examined the impact, at one month and three months, of written prescriptions of physical activity, with or without additional resources, made by healthcare providers (physicians and diabetes counselors) to patients on preventive care office visits. Self-reported physical activity increased (p=0.04) in the overall sample of 24 patients who completed questionnaires at baseline as well as three months, as well as in the intervention group receiving a physical activity toolkit in addition to the written prescription (p=0.01). The Adoption and Utilization of the “First Step to Active Health” Toolkit in a Healthy Adult Population study, an observational project, examined the adoption and utilization of a physical activity toolkit, comprising a resistance band and instructional materials on its use, in a healthy adult population already enrolled in a 12-week walking program. Physical activity level dropped (p=0.003) from baseline to follow-up, at six to eight weeks, in the nineteen participants who completed the study. The toolkit was well-received by the participants, with most of them finding it useful and versatile. These studies highlight the imperative to address environmental barriers to physical activity, particularly in India, and bolster the social environment, supporting the provision of physical activity recommendations, as well as additional resources, to encourage participation in physical activity

Cross Cultural Comparison of Attitides towards Aging and Physical Activity

An online cross-sectional survey was used to examine 475 adults (239 men and 236 women) on physical activity level, barriers to physical activity participation, and attitudes towards personal aging. Participants were grouped, by citizenship and residence, as Indians in India, Indians in the United States, or Americans in the United States. Cross-cultural differences were observed on self-rated general health, occurrence of preventive examinations, and several barriers to physical activity. Physical activity level was positively correlated with self-rated general health, and with optimism regarding aging, suggesting that enhanced physical activity may hold the key to a higher evaluation of personal health, and more positive expectations of aging

Establishing Prospective Road Traffic Injury Surveillance in India: Challenges and Solutions

There are many challenges in establishing surveillance systems for road injuries in India, predominantly rapid staff turnover, heavy workload and the absence of already existing data recording and management in hospitals. Pending administrative solutions such as improved staffing and posting, the chief measures to address these challenges were sustained dialogue and rapport-building with hospital administrators, training of data collectors, and enlisting the aid of bridge personnel, such as interns. Reiterating the value of surveillance data to negotiate for hospital resources commensurate with the high burden of road injuries may help convince hospital administrators to sustain such surveillance initiatives

Establishing Prospective Road Traffic Injury Surveillance in India: Challenges and Solutions

To describe the challenges and lessons learned in establishing road traffic injury surveillance in two large government teaching hospitals in two States of South India, with solutions that eventually helped streamline the process

Cultural consonance, constructions of science and co-existence: a review of the integration of traditional, complementary and alternative medicine in low- and middle-income countries.

This review examined the determinants, patterns and imports of official recognition, and incorporation of different traditional, complementary and alternative systems of medicine (TCAM) in the public health establishment of low- and middle-income countries, with a particular focus on India. Public health systems in most countries have tended to establish health facilities centred on allopathy, and then to recognize or derecognize different TCAM based on evidence or judgement, to arrive at health-care configurations that include several systems of medicine with disparate levels of authority, jurisdiction and government support. The rationale for the inclusion of TCAM providers in the public health workforce ranges from the need for personnel to address the disease burden borne by the public health system, to the desirability of providing patients with a choice of therapeutic modalities, and the nurturing of local culture. Integration, mostly described as a juxtaposition of different systems of medical practice, is often implemented as a system of establishing personnel with certification in different medical systems, in predominantly allopathic health-care facilities, to practise allopathic medicine. A hierarchy of systems of medicine, often unacknowledged, is exercised in most societies, with allopathy at the top, certain TCAM systems next and local healing traditions last. The tools employed by TCAM practitioners in diagnosis, research, pharmacy, marketing and education and training, which are seen to increasingly emulate those of allopathy, are sometimes inappropriate for use in therapeutic systems with widely divergent epistemologies, which call for distinct research paradigms. The coexistence of numerous systems of medicine, while offering the population greater choice, and presumably enhancing geographical access to health care as well, is often fraught with tensions related to the coexistence of philosophically disparate, even opposed, disciplines, with distinct and unaligned notions of evidence and efficacy, and ethical and operational challenges of the administration of a plural workforce