COVID-19 Disrupted Provision and Utilization of Health and Nutrition Services in Uttar Pradesh, India: Insights From Service Providers, Household Phone Surveys, and Administrative Data

BACKGROUND: The coronavirus (COVID-19) pandemic may substantially affect health systems, but little primary evidence is available on disruption of health and nutrition services. OBJECTIVES: This study aimed to 1) determine the extent of disruption in provision and utilization of health and nutrition services induced by the pandemic in Uttar Pradesh, India; and 2) identify how adaptations were made to restore service provision in response to the pandemic. METHODS: We conducted longitudinal surveys with frontline workers (FLWs, n = 313) and mothers of children \u3c 2 y old (n = 659) in December 2019 (in-person) and July 2020 (by phone). We also interviewed block-level managers and obtained administrative data. We examined changes in service provision and utilization using Wilcoxon matched-pairs signed-rank tests. RESULTS: Compared with prepandemic, service provision reduced substantially during lockdown (83-98 percentage points, pp), except for home visits and take-home rations (∼ 30%). Most FLWs (68%-90%) restored service provision in July 2020, except for immunization and hot cooked meals (\u3c 10%). Administrative data showed similar patterns of disruption and restoration. FLW fears, increased workload, inadequate personal protective equipment (PPE), and manpower shortages challenged service provision. Key adaptations made to provide services were delivering services to beneficiary homes (∼ 40%-90%), social distancing (80%), and using PPE (40%-50%) and telephones for communication (∼ 20%). On the demand side, service utilization reduced substantially (40-80 pp) during the lockdown, but about half of mothers received home visits and food supplementation. Utilization for most services did not improve after the lockdown, bearing the challenges of limited travel (30%), nonavailability of services (26%), and fear of catching the virus when leaving the house (22%) or meeting service providers (14%). CONCLUSIONS: COVID-19 disrupted the provision and use of health and nutrition services in Uttar Pradesh, India, despite adaptations to restore services. Strengthening logistical support, capacity enhancement, performance management, and demand creation are needed to improve service provision and utilization during and post-COVID-19

Specificity Matters: Unpacking Impact Pathways of Individual Interventions Within Bundled Packages Helps Interpret the Limited Impacts of a Maternal Nutrition Intervention in India

BACKGROUND: To address gaps in coverage and quality of nutrition services, Alive & Thrive (A&T) strengthened the delivery of maternal nutrition interventions through government antenatal care (ANC) services in Uttar Pradesh, India. The impact evaluation of the A&T interventions compared intensive ANC (I-ANC) with standard ANC (S-ANC) areas and found modest impacts on micronutrient supplementation, dietary diversity, and weight-gain monitoring. OBJECTIVES: This study examined intervention-specific program impact pathways (PIPs) and identified reasons for limited impacts of the A&T maternal nutrition intervention package. METHODS: We used mixed methods: frontline worker (FLW) surveys (n = ∼500), counseling observations (n = 407), and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed 7 PIP domains: training and materials, knowledge, supportive supervision, supply chains, data use, service delivery, and counseling. RESULTS: Exposure to training improved in both I-ANC and S-ANC areas with more job aids used in I-ANC compared with S-ANC (90% compared with 70%), but gaps remained for training content and refresher trainings. FLWs\u27 knowledge improvement was higher in I-ANC than S-ANC (22-36 percentage points), but knowledge of micronutrient supplement benefits and recommended foods was insufficient (90%), but supportive supervision was limited by staff vacancies and competing work priorities. Supplies of iron-folic acid and calcium supplements were low in both areas (30-50% stock-outs). Use of monitoring data during review meetings was higher in I-ANC than S-ANC (52% compared with 36%) but was constrained by time, understanding, and data quality. Service provision improved in both I-ANC and S-ANC areas, but counseling on supplement benefits and weight-gain monitoring was low (30-40%). CONCLUSIONS: Systems-strengthening efforts improved maternal nutrition interventions in ANC, but gaps remained. Taking an intervention-specific perspective to the PIP analysis in this package of services was critical to understand how common and specific barriers influenced overall program impact

Validez de las categorías relacionadas con la identidad de genero en la CIE-11 y el DSM-5 entre personas transgenero que buscan procedimientos medicos que afirmen su genero

BACKGROUND/OBJECTIVE : The most recent versions of the two main mental disorders classifications-the World Health Organization's ICD-11 and the American Psychiatric Association's DSM-5-differ substantially in their diagnostic categories related to transgender identity. ICD-11 gender incongruence (GI), in contrast to DSM-5 gender dysphoria (GD), is explicitly not a mental disorder; neither distress nor dysfunction is a required feature. The objective was compared ICD-11 and DSM-5 diagnostic requirements in terms of their sensitivity, specificity, discriminability and ability to predict the use of gender-affirming medical procedures. METHOD : A total of 649 of transgender adults in six countries completed a retrospective structured interview. RESULTS : Using ROC analysis, sensitivity of the diagnostic requirements was equivalent for both systems, but ICD-11 showed greater specificity than DSM-5. Regression analyses indicated that history of hormones and/or surgery was predicted by variables that are an intrinsic aspect of GI/GD more than by distress and dysfunction. IRT analyses showed that the ICD-11 diagnostic formulation was more parsimonious and contained more information about caseness than the DSM-5 model. CONCLUSIONS : This study supports the ICD-11 position that GI/GD is not a mental disorder; additional diagnostic requirements of distress and/or dysfunction in DSM-5 reduce the predictive power of the diagnostic model.Partially funded by unrestricted grants by the World Health Organization Department of Mental Health and Substance Abuse to participating institutions in Brazil, India, Lebanon, Mexico, and South Africa for the development and implementation of ICD-11 field studies. Financial support for the French study was provided by the Direction Générale de la Santé (DGS), Ministry of Health, France.http://www.elsevier.es/ijchpam2023Psychiatr

Validity of categories related to gender identity in ICD-11 and DSM-5 among transgender individuals who seek gender-affirming medical procedures

Background/Objective: The most recent versions of the two main mental disorders classifications—the World Health Organization's ICD-11 and the American Psychiatric Association's DSM–5—differ substantially in their diagnostic categories related to transgender identity. ICD-11 gender incongruence (GI), in contrast to DSM-5 gender dysphoria (GD), is explicitly not a mental disorder; neither distress nor dysfunction is a required feature. The objective was compared ICD-11 and DSM-5 diagnostic requirements in terms of their sensitivity, specificity, discriminability and ability to predict the use of gender-affirming medical procedures. Method: A total of 649 of transgender adults in six countries completed a retrospective structured interview. Results: Using ROC analysis, sensitivity of the diagnostic requirements was equivalent for both systems, but ICD-11 showed greater specificity than DSM-5. Regression analyses indicated that history of hormones and/or surgery was predicted by variables that are an intrinsic aspect of GI/GD more than by distress and dysfunction. IRT analyses showed that the ICD-11 diagnostic formulation was more parsimonious and contained more information about caseness than the DSM-5 model. Conclusions: This study supports the ICD-11 position that GI/GD is not a mental disorder; additional diagnostic requirements of distress and/or dysfunction in DSM-5 reduce the predictive power of the diagnostic model

A Quasi-Experimental Evaluation of a Nutrition Behavior Change Intervention Delivered Through Women’s Self-Help Groups in Rural India: Impacts on Maternal and Young Child Diets, Anthropometry, and Intermediate Outcomes

Background: Women's self-help groups (SHGs) have become one of the largest institutional platforms serving the poor. Nutrition behavior change communication (BCC) interventions delivered through SHGs may improve maternal and child nutrition outcomes. Objective: To understand the effects of a nutrition BCC intervention delivered through SHGs in rural India on intermediate outcomes and nutrition outcomes. Methods: We compared 16 matched blocks where communities were supported to form SHGs and improve livelihoods; 8 blocks received a 3-year nutrition intensive (NI) intervention with nutrition BCC, agriculture- and rights-based information, facilitated by a trained female volunteer; another 8 blocks received standard activities (STD) to support savings/livelihoods. Repeated cross-sectional surveys of mother-child pairs were conducted in 2017-18 (n = 1609 pairs) and 2019-20 (n = 1841 pairs). We matched treatment groups over time and applied difference-in-difference regression models to estimate impacts on intermediate outcomes (knowledge, income, agriculture/livelihoods, rights, empowerment) and nutrition outcomes (child feeding, woman's diet, woman and child anthropometry). Analyses were repeated on households with at least one SHG member. Results: 40% of women were SHG members and 50% were from households with at least one SHG member. Only 10% of women in NI blocks had heard of intervention content at endline. Knowledge improved in both NI and STD groups. There was a positive NI impact on knowledge of timely introduction of animal sourced foods to children (p<0.05) but not on other intermediate outcomes. No impacts were observed for anthropometry or diet indicators except child animal source food consumption (p<0.01). In households with at least one SHG member, there was a positive NI impact on child unhealthy food consumption (p<0.05). Conclusions: Limited impacts may be due to limited exposure or skills of volunteers, and a concurrent national nutrition campaign. Our findings add to a growing literature on SHG-based BCC interventions and the conditions necessary for their success

Behavior change interventions to address unhealthy food consumption: A scoping review

High intakes of sodium, sugar, saturated fats, and trans-fats contributed to 187.7 million disability adjusted life years from noncommunicable diseases globally. Understanding of the global evidence on interventions to reduce consumption of various types of unhealthy food across diverse contexts is needed. We conducted a scoping review to examine the existing evidence on behavior change interventions (BCIs) to address unhealthy food consumption. Through a systematic search of 3 databases conducted in December 2022, 2730 records were retrieved, and 145 studies met the eligibility criteria for review. Only 19% of the studies (n = 28) were from low- and middle-income countries. The key target group for most BCIs was adults ≥20 y (n = 79). Interventions were conducted across 7 types of settings: schools (n = 52), digital (n = 30), community (n = 28), home (n = 14), health facility (n = 12), worksite (n = 6), and market (n = 3). There were 4 mutually inclusive intervention types-information, education, and communication (n = 141); food/beverage substitution (n = 10); interactive games (n = 7); and labeling/warnings at point-of-purchase (n = 3). The study outcomes included consumption of sugar-sweetened beverages (n = 74), packaged salty snacks/fast food (n = 61), sweets (n = 43), and saturated fat (n = 41). Drivers of food choice behaviors, such as knowledge, attitudes, and beliefs; motivation and expectancies; and self-efficacy were reported in 43% of studies. On the basis of reported impact of BCIs on study outcomes, more interventions targeted at adults had positive impacts compared with those targeted at children; intervention packages, including multiple information, education, and communication components also reported impacts more often than single informational interventions. Interpretation of the findings was complicated by the lack of comparability in interventions, evaluation designs, outcome measures of unhealthy food consumption, duration of interventions, and study contexts. Future studies should invest in critical yet underrepresented regions, examine behavioral determinants of unhealthy food consumption and the sustainability of behavior change, and conduct further analysis of effectiveness from experimental studies

A Comprehensive Review of Microbial Contamination in the Indoor Environment: Sources, Sampling, Health Risks, and Mitigation Strategies

The quality of the indoor environment significantly impacts human health and productivity, especially given the amount of time individuals spend indoors globally. While chemical pollutants have been a focus of indoor air quality research, microbial contaminants also have a significant bearing on indoor air quality. This review provides a comprehensive overview of microbial contamination in built environments, covering sources, sampling strategies, and analysis methods. Microbial contamination has various origins, including human occupants, pets, and the outdoor environment. Sampling strategies for indoor microbial contamination include air, surface, and dust sampling, and various analysis methods are used to assess microbial diversity and complexity in indoor environments. The review also discusses the health risks associated with microbial contaminants, including bacteria, fungi, and viruses, and their products in indoor air, highlighting the need for evidence-based studies that can relate to specific health conditions. The importance of indoor air quality is emphasized from the perspective of the COVID-19 pandemic. A section of the review highlights the knowledge gap related to microbiological burden in indoor environments in developing countries, using India as a representative example. Finally, potential mitigation strategies to improve microbiological indoor air quality are briefly reviewed

Scale and sustainability: The impact of a women’s self-help group program on household economic well-being in India

Microfinance groups are a prominent source of small-scale rural credit in many developing countries. In India, evidence of the impact of the now ubiquitous women-only savings and credit self-help groups (SHGs) on household consumption and asset accumulation is inconclusive and based on small-scale interventions. Further, little is known about the sustainability of impacts at scale. We use panel data on close to 2500 households from five states in India to estimate the impact of SHG membership on household expenditure and asset ownership. Over four years, we find small but significant impacts of SHG membership on household expenditure and livestock ownership. Membership duration has a modest effect, suggesting that initial impacts may taper off as the program scales up, though small sample sizes limit our ability to draw inferences. Accompanying evidence on pathways is compelling; related work shows that SHG participation improves information, empowerment, and access to entitlements. While the direct impacts of SHG membership may not suffice to fill gaps in access to credit faced by the rural poor, impacts along these additional pathways could intensify the benefits of these group

Impact of COVID-19 on household food insecurity and interlinkages with child feeding practices and coping strategies in Uttar Pradesh, India: a longitudinal community-based study

Objectives The COVID-19 pandemic has profound negative impacts on people’s lives, but little is known on its effect on household food insecurity (HFI) in poor setting resources. This study assessed changes in HFI during the pandemic and examined the interlinkages between HFI with child feeding practices and coping strategies.Design A longitudinal survey in December 2019 (in-person) and August 2020 (by phone).Setting Community-based individuals from 26 blocks in 2 districts in Uttar Pradesh, India.Participants Mothers with children &lt;2 years (n=569).Main outcomes and analyses We measured HFI by using the HFI Access Scale and examined the changes in HFI during the pandemic using the Wilcoxon matched-pairs signed-rank tests. We then assessed child feeding practices and coping strategies by HFI status using multivariable regression models.Results HFI increased sharply from 21% in December 2019 to 80% in August 2020, with 62% households changing the status from food secure to insecure over this period. Children in newly or consistently food-insecure households were less likely to consume a diverse diet (adjusted OR, AOR 0.57, 95% CI 0.34 to 0.95 and AOR 0.51, 95% CI 0.23 to 1.12, respectively) compared with those in food-secure households. Households with consistent food insecurity were more likely to engage in coping strategies such as reducing other essential non-food expenditures (AOR 2.2, 95% CI 1.09 to 4.24), borrowing money to buy food (AOR 4.3, 95% CI 2.31 to 7.95) or selling jewellery (AOR 5.0, 95% CI 1.74 to 14.27) to obtain foods. Similar findings were observed for newly food-insecure households.Conclusions The COVID-19 pandemic and its lockdown measures posed a significant risk to HFI which in turn had implications for child feeding practices and coping strategies. Our findings highlight the need for further investment in targeted social protection strategies and safety nets as part of multisectoral solutions to improve HFI during and after COVID-19

Scale and Sustainability: The Impact of a Women’s Self-Help Group Program on Household Economic Well-Being in India

Microfinance groups are a prominent source of small-scale rural credit in many developing countries. In India, evidence of the impact of the now ubiquitous women-only savings and credit self-help groups (SHGs) on household consumption and asset accumulation is inconclusive and based on small-scale interventions. Further, little is known about the sustainability of impacts at scale. We use panel data on close to 2500 households from five states in India to estimate the impact of SHG membership on household expenditure and asset ownership. Over four years, we find small but significant impacts of SHG membership on household expenditure and livestock ownership. Membership duration has a modest effect, suggesting that initial impacts may taper off as the program scales up, though small sample sizes limit our ability to draw inferences. Accompanying evidence on pathways is compelling; related work shows that SHG participation improves information, empowerment, and access to entitlements. While the direct impacts of SHG membership may not suffice to fill gaps in access to credit faced by the rural poor, impacts along these additional pathways could intensify the benefits of these groups.</p