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Concept: States and territories of India

44

Not all eligible women use the available services under India’s Janani Suraksha Yojana (JSY), which provides cash incentives to encourage pregnant women to use institutional care for childbirth; limited evidence exists on demand-side factors associated with low program uptake. This study explores the views of women and ASHAs (community health workers) on the use of the JSY and institutional delivery care facilities. In-depth qualitative interviews, carried out in September-November 2013, were completed in the local language by trained interviewers with 112 participants consisting of JSY users/non-users and ASHAs in Jharkhand, Madhya Pradesh and Uttar Pradesh. The interaction of impeding and enabling factors on the use of institutional care for delivery was explored. We found that ASHAs' support services (e.g., arrangement of transport, escort to and support at healthcare facilities) and awareness generation of the benefits of institutional healthcare emerged as major enabling factors. The JSY cash incentive played a lesser role as an enabling factor because of higher opportunity costs in the use of healthcare facilities versus home for childbirth. Trust in the skills of traditional birth-attendants and the notion of childbirth as a ‘natural event’ that requires no healthcare were the most prevalent impeding factors. The belief that a healthcare facility would be needed only in cases of birth complications was also highly prevalent. This often resulted in waiting until the last moments of childbirth to seek institutional healthcare, leading to delay/non-availability of transportation services and inability to reach a delivery facility in time. ASHAs opined that interpersonal communication for awareness generation has a greater influence on use of institutional healthcare, and complementary cash incentives further encourage use. Improving health workers' support services focused on marginalized populations along with better public healthcare facilities are likely to promote the uptake of institutional delivery care in resource-poor settings.

Concepts: Health care, Pregnancy, Childbirth, Motivation, Incentive, States and territories of India, Uttar Pradesh, Madhya Pradesh

27

Dengue fever is re-emerging as a major scourge in south-east Asian countries affecting about 50-100 million people and causing about 25,000 mortality annually. India as a whole is under the risk of infection of this disease. We genetically characterized viruses causing Dengue infections in Kerala, one of the worst affected states of the Country during the disease outbreaks 2008-2010. All the 4 serotypes of the virus: DENV-1, DENV-2, DENV-3 & DENV-4 were found to be prevalent in the state. The genotypes recognized for these were III, IV, III and I respectively. The phylogenetic analysis evidenced that the re-emergence of serotype DENV-4 reported in Maharashtra and Andhra Pradesh recently, is spreading to different regions of the Country. The circulation of all the 4 Dengue serotypes in Kerala, may lead to increase in the prevalence of more severe complications of this emerging disease, such as Dengue Hemorrhagic fever and Dengue shock syndromes.

Concepts: Disease, Virus, Infection, Ribavirin, Fever, Dengue fever, Dengue, States and territories of India

25

The burden of micronutrient malnutrition is very high in India. Food fortification is one of the most cost-effective and sustainable strategies to deliver micronutrients to large population groups. Global Alliance for Improved Nutrition (GAIN) is supporting large-scale, voluntary, staple food fortification in Rajasthan and Madhya Pradesh because of the high burden of malnutrition, availability of industries capable of and willing to introduce fortified staples, consumption patterns of target foods and a conducive and enabling environment. High extraction wheat flour from roller flour mills, edible soybean oil and milk from dairy cooperatives were chosen as the vehicles for fortification. Micronutrients and levels of fortification were selected based on vehicle characteristics and consumption levels. Industry recruitment was done after a careful assessment of capability and willingness. Production units were equipped with necessary equipment for fortification. Staffs were trained in fortification and quality control. Social marketing and communication activities were carried out as per the strategy developed. A state food fortification alliance was formed in Madhya Pradesh with all relevant stakeholders. Over 260,000 MT of edible oil, 300,000 MT of wheat flour and 500,000 MT of milk are being fortified annually and marketed. Rajasthan is also distributing 840,000 MT of fortified wheat flour annually through its Public Distribution System and 1.1 million fortified Mid-day meals daily through the centralised kitchens. Concurrent monitoring in Rajasthan and Madhya has demonstrated high compliance with all quality standards in fortified foods.

Concepts: Nutrition, Milk, Food, Wheat, Maize, Flour, Micronutrient, States and territories of India

24

Concern around potentially increasing alcohol use among young people has been growing in public discourse in India. However, there are few published studies on this issue. We studied the prevalence, patterns and correlates of alcohol use among adolescents in Ernakulam, Kerala State, India.

Concepts: India, Tamil Nadu, States and territories of India, Kerala, Communist Party of India, States Reorganisation Act, Kochi, India, Ernakulam district

23

Global food prices have risen sharply since 2007. The impact of food price spikes on the risk of malnutrition in children is not well understood.

Concepts: India, Famine, States and territories of India, 2007–2008 world food price crisis, Andhra Pradesh, Telugu language, Krishna River, Godavari River

20

We aimed to define characteristics of TB patients in Puducherry and two districts of Tamil Nadu, India and calculate the population attributable fractions (PAF) of TB from malnutrition and alcohol.

Concepts: Tuberculosis, India, Malnutrition, Tamil Nadu, Tamil language, States and territories of India, Andhra Pradesh, Puducherry

13

Pragmatic and adaptive trial designs are increasingly used in quality improvement (QI) interventions to provide the strongest evidence for effective implementation and impact prior to broader scale-up. We previously showed that an on-site coaching intervention focused on the World Health Organization Safe Childbirth Checklist (SCC) improved performance of essential birth practices (EBPs) in one facility in Karnataka, India. We report on the process and outcomes of adapting the intervention prior to larger-scale implementation in a randomized controlled trial in Uttar Pradesh (UP), India.

Concepts: Randomized controlled trial, Design, World Health Organization, States and territories of India, Urdu, Delhi, Bihar, Bharatiya Janata Party

13

In India, quality surveillance for acute encephalitis syndrome (AES), including laboratory testing, is necessary for understanding the epidemiology and etiology of AES, planning interventions, and developing policy. We reviewed AES surveillance data for January 2011-June 2012 from Kushinagar District, Uttar Pradesh, India. Data were cleaned, incidence was determined, and demographic characteristics of cases and data quality were analyzed. A total of 812 AES case records were identified, of which 23% had illogical entries. AES incidence was highest among boys <6 years of age, and cases peaked during monsoon season. Records for laboratory results (available for Japanese encephalitis but not AES) and vaccination history were largely incomplete, so inferences about the epidemiology and etiology of AES could not be made. The low-quality AES/Japanese encephalitis surveillance data in this area provide little evidence to support development of prevention and control measures, estimate the effect of interventions, and avoid the waste of public health resources.

Concepts: Public health, Epidemiology, Greek loanwords, Encephalitis, States and territories of India, Uttar Pradesh, Gautama Buddha, Kushinagar

10

Adherence to evidence-based essential birth practices is critical for improving health outcomes for mothers and newborns. The WHO Safe Childbirth Checklist (SCC) incorporates these practices, which occur during 4 critical pause points: on admission, before pushing (or cesarean delivery), soon after birth, and before discharge. A peer-coaching strategy to support consistent use of the SCC may be an effective approach to increase birth attendants' adherence to these practices.

Concepts: Childbirth, Obstetrics, Epidural, Caesarean section, Breech birth, States and territories of India, Ventouse, Delhi

9

Substantial investments have been made in clinical social franchising to improve quality of care of private facilities in low- and middle-income countries but concerns have emerged that the benefits fail to reach poorer groups. We assessed the distribution of franchise utilization and content of care by socio-economic status (SES) in three maternal healthcare social franchises in Uganda and India (Uttar Pradesh and Rajasthan). We surveyed 2179 women who had received antenatal care (ANC) and/or delivery services at franchise clinics (in Uttar Pradesh only ANC services were offered). Women were allocated to national (Uganda) or state (India) SES quintiles. Franchise users were concentrated in the higher SES quintiles in all settings. The percent in the top two quintiles was highest in Uganda (over 98% for both ANC and delivery), followed by Rajasthan (62.8% for ANC, 72.1% for delivery) and Uttar Pradesh (48.5% for ANC). The percent of clients in the lowest two quintiles was zero in Uganda, 7.1 and 3.1% for ANC and delivery, respectively, in Rajasthan and 16.3% in Uttar Pradesh. Differences in SES distribution across the programmes may reflect variation in user fees, the average SES of the national/state populations and the range of services covered. We found little variation in content of care by SES. Key factors limiting the ability of such maternal health social franchises to reach poorer groups may include the lack of suitable facilities in the poorest areas, the inability of the poorest women to afford any private sector fees and competition with free or even incentivized public sector services. Moreover, there are tensions between targeting poorer groups, and franchise objectives of improving quality and business performance and enhancing financial sustainability, meaning that middle income and poorer groups are unlikely to be reached in large numbers in the absence of additional subsidies.

Concepts: Obstetrics, States and territories of India, Uttar Pradesh, Madhya Pradesh, Delhi, Haryana, Public sector, Franchising