Addressing family planning needs among low-literate population in peri-urban areas of Delhi, India: a qualitative inquiry

Background: Since several decades, population control has remained one of the major challenges for India. Understanding family planning (FP) related knowledge and practices, especially among low-literate population groups is important for increasing the reach of FP services nearer to them, which is an essential step for population control as well as to prevent unwanted pregnancies.Methods: We conducted a cross-sectional, qualitative research study among low literate population in peri-urban areas of New Delhi, bordered with Uttar Pradesh (U.P.) state. We selected and interviewed 27 participants including married men and women in the age range 18-34 years using semi-structured interview schedules. The focus of inquiry was on fertility awareness; beliefs and practices related to menstruation, pregnancy and FP methods etc. and decision making about FP. The data were processed for thematic analysis.Results: The study revealed lack of basic scientific knowledge about fertility in this community which often resulted into unwanted pregnancies. This finding has major implications especially when the Government’s FP program is geared mainly towards sterilization and conventional spacing methods. The study further confirmed that traditional beliefs and practices like separating women during menstruation still prevail in many joint families, but less likely in the nuclear ones. There were mixed opinions about spacing methods. Husband was reported to be main decision maker in FP process in this male dominated society. Regarding sources of information on FP, women reported elder women, lady clinicians and peers whereas men reported only peers.Conclusions: This study points out various barriers for FP around which basic FP education for both men and women in this community need to be provided. The study will have implications for other parts of India which share the same socio-cultural milieu as this community

Health systems’ responses to the roll-out of antiretroviral therapy (ART) in India: a comparison of two HIV high-prevalence settings

The government of India launched the free anti-retroviral therapy (ART) initiative in 2004 and the programme has since scaled up expansion in a phased manner. Programme authorities acknowledge problems in scale-up, yet discussions have been restricted to operational constraints, with little consideration for how local health system responses to HIV/AIDS influence the delivery of ART. This paper draws on the perspectives of key informants and people living with HIV (PLHIV) to compare delivery of ART in two ART centres in the States of Maharashtra and Andhra Pradesh at two distinct points of time. In 2005, data were collected through key informant interviews (KIIs) using interview guides and a survey of PLHIV using a semi-structured interview schedule. Differences were observed in the functioning and resources of the two centres, indicating different levels of preparedness which in turn influenced PLHIV's pathways in accessing ART. We examine these differences in the light of programme leadership, ownership and the roles of public, private and non-governmental organisation actors in HIV care. KIIs conducted during a follow-up visit in 2009 focused on changes in ART delivery. Many operational problems had been resolved; however, new challenges were emerging as a result of the increased patient load. An understanding of how ART programmes evolve within local health systems has bearing on future developments of the ART programme and must include a consideration of the wider socio-political environment within which HIV programmes are embedded

Public Health Policy and Experience of the 2009 H1N1 Influenza Pandemic in Pune, India.

BACKGROUND: Prior experience and the persisting threat of influenza pandemic indicate the need for global and local preparedness and public health response capacity. The pandemic of 2009 highlighted the importance of such planning and the value of prior efforts at all levels. Our review of the public health response to this pandemic in Pune, India, considers the challenges of integrating global and national strategies in local programmes and lessons learned for influenza pandemic preparedness. METHODS: Global, national and local pandemic preparedness and response plans have been reviewed. In-depth interviews were undertaken with district health policy-makers and administrators who coordinated the pandemic response in Pune. RESULTS: In the absence of a comprehensive district-level pandemic preparedness plan, the response had to be improvised. Media reporting of the influenza pandemic and inaccurate information that was reported at times contributed to anxiety in the general public and to widespread fear and panic. Additional challenges included inadequate public health services and reluctance of private healthcare providers to treat people with flu-like symptoms. Policy-makers developed a response strategy that they referred to as the Pune plan, which relied on powers sanctioned by the Epidemic Act of 1897 and resources made available by the union health ministry, state health department and a government diagnostic laboratory in Pune. CONCLUSION: The World Health Organization's (WHO's) global strategy for pandemic control focuses on national planning, but state-level and local experience in a large nation like India shows how national planning may be adapted and implemented. The priority of local experience and requirements does not negate the need for higher level planning. It does, however, indicate the importance of local adaptability as an essential feature of the planning process. Experience and the implicit Pune plan that emerged are relevant for pandemic preparedness and other public health emergencies

Public Health Policy and Experience of the 2009 H1N1 Influenza Pandemic in Pune, India

Abstract Background: Prior experience and the persisting threat of influenza pandemic indicate the need for global and local preparedness and public health response capacity. The pandemic of 2009 highlighted the importance of such planning and the value of prior efforts at all levels. Our review of the public health response to this pandemic in Pune, India, considers the challenges of integrating global and national strategies in local programmes and lessons learned for influenza pandemic preparedness. Methods: Global, national and local pandemic preparedness and response plans have been reviewed. In-depth interviews were undertaken with district health policy-makers and administrators who coordinated the pandemic response in Pune. Results: In the absence of a comprehensive district-level pandemic preparedness plan, the response had to be improvised. Media reporting of the influenza pandemic and inaccurate information that was reported at times contributed to anxiety in the general public and to widespread fear and panic. Additional challenges included inadequate public health services and reluctance of private healthcare providers to treat people with flu-like symptoms. Policy-makers developed a response strategy that they referred to as the Pune plan, which relied on powers sanctioned by the Epidemic Act of 1897 and resources made available by the union health ministry, state health department and a government diagnostic laboratory in Pune. Conclusion: The World Health Organization’s (WHO’s) global strategy for pandemic control focuses on national planning, but state-level and local experience in a large nation like India shows how national planning may be adapted and implemented. The priority of local experience and requirements does not negate the need for higher level planning. It does, however, indicate the importance of local adaptability as an essential feature of the planning process. Experience and the implicit Pune plan that emerged are relevant for pandemic preparedness and other public health emergencies

Community awareness, use and preference for pandemic influenza vaccines in Pune, India

Vaccination is a cornerstone of influenza prevention, but limited vaccine uptake was a problem worldwide during the 2009–2010 pandemic. Community acceptance of a vaccine is a critical determinant of its effectiveness, but studies have been confined to high-income countries. We conducted a cross-sectional, mixed-method study in urban and rural Pune, India in 2012–2013. Semi-structured explanatory model interviews were administered to community residents (n=436) to study awareness, experience and preference between available vaccines for pandemic influenza. Focus group discussions and in-depth interviews complemented the survey. Awareness of pandemic influenza vaccines was low (25%). Some respondents did not consider vaccines relevant for adults, but nearly all (94.7%), when asked, believed that a vaccine would prevent swine flu. Reported vaccine uptake however was 8.3%. Main themes identified as reasons for uptake were having heard of a death from swine flu, health care provider recommendation or affiliation with the health system, influence of peers and information from media. Reasons for non-use were low perceived personal risk, problems with access and cost, inadequate information and a perceived lack of a government mandate endorsing influenza vaccines. A majority indicated a preference for injectable over nasal vaccines, especially in remote rural areas. Hesitancy from a lack of confidence in pandemic influenza vaccines appears to have been less of an issue than access, complacency and other sociocultural considerations. Recent influenza outbreaks in 2015 highlight a need to reconsider policy for routine influenza vaccination while paying attention to sociocultural factors and community preferences for effective vaccine action

Generating evidence on antibiotic use across human and animal health sectors using the World Health Organization’s Access, Watch, Reserve (AWaRe) classification: Exploratory pilot study in rural Pune, India

Background and Aim: Human antibiotic formulations in animal feed for therapeutic and non-therapeutic purposes have contributed to antimicrobial resistance worldwide; however, little evidence is available in low- and middle-income countries. We aimed to generate evidence of antibiotic use across the human and animal health sectors by investigating the overlap in antibiotic use in community settings in rural blocks of Pune District, India, following the World Health Organization’s (WHO) Access, Watch, Reserve (AWaRe) classification. Materials and Methods: An exploratory pilot study using a cross-sectional design in two randomly selected rural blocks of the Pune district included 138 interviews with general physicians (GPs, n = 62), pharmacists (n = 60), and veterinary practitioners (n = 16) using semi-structured interview schedules and the WHO AWaRe classification. IBM-Statistical Package for the Social Sciences, Version 21.0 software was used for descriptive statistics and to calculate the proportions of the different antibiotic groups. The WHO AWaRe classification was used to describe antibiotic use by the study participants and to assess the overlap in antibiotic use. Results: Our study provides evidence of an overlap in human and animal antibiotic use in rural community settings across the human and animal health sectors. Amoxicillin (access group), penicillin (access group), and ofloxacin (watch group) were used in both human and animal health. Amoxicillin and penicillin were used to treat common bacterial infections, ofloxacin was used to treat skin infections in humans and animals, and ofloxacin was used to treat pneumonia in animals and urinary bladder infections in humans. In contrast, azithromycin (watch group), cefixime (watch group), and amoxicillin (Access Group), with or without other antibiotics, were the most commonly used antibiotics by GPs in humans. Conclusion: We confirmed the overlap in antibiotic use across the human and animal health sectors in rural community settings, suggesting the need for interventions following the One Health approach. Further, research is required to assess the patterns of this overlap, as well as behavior, knowledge, and potential solutions to help avoid this overlap and prevent the rampant use of antibiotics in the animal and human health sectors in rural community settings

Distribution and social determinants of overweight and obesity: a cross-sectional study of non-pregnant adult women from the Malawi Demographic and Health Survey (2015-2016).

OBJECTIVES:Hitherto regarded as a public health issue of well-heeled nations, overweight and obesity have emerged as a problem of concern in developing nations. Although social and demographic factors are equally important as proximal lifestyle factors affecting health, their role is neither well researched nor well understood. We conducted a novel study to determine the distribution, prevalence, and social and demographic determinants of overweight/obesity in Malawi. METHODS:A population-based, quantitative cross-sectional study using data from the Malawi Demographic and Health Survey (2015-2016) was conducted among non-pregnant women aged 18-49 years. A total of 6,443 women were included in the analysis. Overweight/obesity, defined as a body mass index (BMI) ≥25.0 kg/m2 , was the main outcome variable. The analysis was done in SPSS version 20.0; after calculating descriptive statistics, bivariate and multivariate logistic regression was conducted to evaluate associations and determine odds. RESULTS:In total, 16.8% and 6.3% of women were overweight and obese, respectively (p<0.001). Overweight and obesity were more prevalent in urban than in rural areas. The BMI distribution among women varied across different background characteristics. Women from the Ngoni ethnicity were more likely to be overweight/obese than others (adjusted odds ratio [aOR], 1.54; 95% confidence interval [CI], 1.14 to 2.08). Socioeconomic status (SES) and the age of the respondent were highly significant determinants that were strongly associated with being overweight/obese. The richest women were 3 times more likely to be overweight/obese than the poorest (aOR, 3.30; 95% CI, 2.46 to 4.43). CONCLUSIONS:Overweight and obesity were highly prevalent and significantly associated with increasing SES, age, and being from the Ngoni ethnicity. Holistic interventions should also focus on improving social determinants in order to entirely curb the epidemic

Examining sex differentials in the uptake and process of HIV testing in three high prevalence districts of India.

Sex differentials in the uptake of HIV testing have been reported in a range of settings, however, men's and women's testing patterns are not consistent across these settings, suggesting the need to set sex differentials against gender norms in patient testing behaviour and provider practices. A community-based, cross-sectional survey among 347 people living with HIV in three HIV high prevalence districts of India examined reasons for undergoing an HIV test, location of testing and conditions under which individuals were tested. HIV testing was almost always provider-initiated for men. Men were more likely to be advised to test by a private practitioner and to test in the private sector. Women were more likely to be advised to test by a family member, and to test in the public sector. Men were more likely to receive pre-test information than women, when tested in the private sector. Men were also more likely to receive direct disclosure of their HIV positive status by a health provider, regardless of the sector in which they tested. More women than men were repeatedly tested for HIV, regardless of sector. These sex differentials in the uptake and process of HIV testing are partially explained through differences in public and private sector testing practices. However, they also reflect women's lack of awareness and agency in HIV care seeking and differential treatment by providers. Examining gender dynamics that underpin sex differentials in HIV testing patterns and practices is essential for a realistic assessment of the challenges and implications of scaling-up HIV testing and mainstreaming gender in HIV/AIDS programmes

Developing and validating a tablet version of an illness explanatory model interview for a public health survey in pune, India

Mobile electronic devices are replacing paper-based instruments and questionnaires for epidemiological and public health research. The elimination of a data-entry step after an interview is a notable advantage over paper, saving investigator time, decreasing the time lags in managing and analyzing data, and potentially improving the data quality by removing the error-prone data-entry step. Research has not yet provided adequate evidence, however, to substantiate the claim of fewer errors for computerized interviews.; We developed an Android-based illness explanatory interview for influenza vaccine acceptance and tested the instrument in a field study in Pune, India, for feasibility and acceptability. Error rates for tablet and paper were compared with reference to the voice recording of the interview as gold standard to assess discrepancies. We also examined the preference of interviewers for the classical paper-based or the electronic version of the interview and compared the costs of research with both data collection devices.; In 95 interviews with household respondents, total error rates with paper and tablet devices were nearly the same (2.01% and 1.99% respectively). Most interviewers indicated no preference for a particular device; but those with a preference opted for tablets. The initial investment in tablet-based interviews was higher compared to paper, while the recurring costs per interview were lower with the use of tablets.; An Android-based tablet version of a complex interview was developed and successfully validated. Advantages were not compromised by increased errors, and field research assistants with a preference preferred the Android device. Use of tablets may be more costly than paper for small samples and less costly for large studies

Cultural epidemiology of pandemic influenza in urban and rural Pune, India : a cross-sectional, mixed-methods study

To identify and compare sociocultural features of pandemic influenza with reference to illness-related experience, meaning and behaviour in urban and rural areas of India.; Cross-sectional, mixed-methods, cultural epidemiological survey with vignette-based interviews. Semistructured explanatory model interviews were used to study community ideas of the 2009 influenza pandemic. In-depth interviews elaborated respondents' experience during the pandemic.; Urban and rural communities, Pune district, western India.; Survey of urban (n=215) and rural (n=221) residents aged between 18 and 65 years. In-depth interviews of respondents with a history of 2009 pandemic influenza (n=6).; More urban (36.7%) than rural respondents (16.3%, p>0.001) identified the illness in the vignette as 'swine flu'. Over half (56.7%) believed the illness would be fatal without treatment, but with treatment 96% predicted full recovery. Worry ('tension') about the illness was reported as more troubling than somatic symptoms. The most common perceived causes-'exposure to a dirty environment' and 'cough or sneeze of an infected person'-were more prominent in the urban group. Among rural respondents, climatic conditions, drinking contaminated water, tension and cultural ideas on humoral imbalance from heat-producing or cold-producing foods were more prominent. The most widely reported home treatment was herbal remedies; more rural respondents suggested reliance on prayer, and symptom relief was more of a priority for urban respondents. Government health services were preferred in the urban communities, and rural residents relied more than urban residents on private facilities. The important preventive measures emphasised were cleanliness, wholesome lifestyle and vaccines, and more urban respondents reported the use of masks. In-depth interviews indicated treatment delays during the 2009 pandemic, especially among rural patients.; Although the term was well known, better recognition of pandemic influenza cases is needed, especially in rural areas. Improved awareness, access to treatment and timely referrals by private practitioners are also required to reduce treatment delays