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   Table of Contents - Current issue
Coverpage
April-June 2017
Volume 61 | Issue 2
Page Nos. 65-150

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EDITORIAL  

Community medicine: Beyond boundaries Highly accessed article p. 65
Arun Kumar Sharma
DOI:10.4103/ijph.IJPH_93_17  PMID:28721953
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ORIGINAL ARTICLES Top

Out-of-Pocket health expenditure and sources of financing for delivery, postpartum, and neonatal health in urban slums of Bhubaneswar, Odisha, India Highly accessed article p. 67
Kirti Sundar Sahu, Bhavna Bharati
DOI:10.4103/ijph.IJPH_168_15  PMID:28721954
Background: Out-of-pocket expenditure (OOPE) is an obstacle in the path of getting universal health coverage in India. Objective: This study aimed to explore the OOPE, sources of funding, and experience of catastrophic expenditure (CE) for healthcare related to delivery, postpartum, and neonatal morbidity. Methods: A community-based, cross-sectional survey was conducted among a sample of 240 recently delivered women from the slums of Bhubaneswar, Odisha. Information on background, details of delivery, expenditure on delivery and on morbidities, and sources of funding was collected using a structured interview schedule. Results: Only 29.6% of the households incurred OOPE, and the others incurred either nil OOPE or had a net income because of benefits received from Janani Shishu Suraksha Karyakram (JSSK), Janani Suraksha Yojana (JSY), and “Mamata” schemes of the government. The median total OOPE was found to be 2100 INR (100–38,620). Multivariate analysis found parity, place of delivery, type of delivery, and presence of morbidity to be significantly associated with incurring any OOPE. Nearly 15% of the households incurred OOPE exceeding 40% of the reported monthly household income including 9%, whose OOPE was 100% or more of the reported household monthly income. Conclusion: While mechanisms such as JSSK, JSY, and Mamata had benefitted the vast majority, around half of those who did incur OOPE experienced CE. Additional insurance facility for cesarean section delivery might reduce the excessive financial burden on households.
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Spatiotemporal clustering of dengue cases in Thiruvananthapuram district, Kerala p. 74
Joanna Sara Valson, Biju Soman
DOI:10.4103/ijph.IJPH_26_16  PMID:28721955
Background: Dengue cases are increasing in Kerala since 2010. Information on clustering of cases across locations and time periods is vital for disease surveillance and timely control. Objectives: The objective is to study spatiotemporal clustering of dengue cases and their climatic and physioenvironmental correlates in Thiruvananthapuram district during 2010–2014. Methods: Health department data on reported cases of dengue were obtained from January 2011 to June 2014. Cases were individually geocoded, using Google Earth. Moran's I index was estimated to analyze spatial autocorrelation using GeoDa software. Space–time clustering across 178 geo-divisions within the district was analyzed using SaTScan software. Correlation analysis was done for space–time clustering with climatic variables. Results: Definite spatial and temporal trends were found on analysis of a total of 8279 dengue cases. Significant spatial autocorrelation (Moran's I = 0.32, P< 0.01) and space–time clusters with very high log-likelihood ratios (P < 0.01) were found across geo-divisions. Pallichal panchayat was the most likely cluster in every year. The monthly incidence of dengue cases showed a significant positive association (P < 0.05) with a 2-month lag of mean minimum temperature (ρ = 0.39), 1-month lag of rainfall (ρ = 0.33), and 1-month lag of humidity (ρ = 0.38). Dengue occurrences showed an inverse association (P < 0.01) with mean maximum temperatures of the respective months (ρ= -0.48). Conclusion: Spatial analysis using epidemiological tools reveals spatial and temporal clustering of dengue cases within the district and their association with climatic parameters. This information can be used in controlling outbreaks in the future. This work upholds scope and feasibility of geospatial research in public health in India.
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Direction of uneven health-care expenditure: Evidence from Northeast India p. 81
Tiken Das, Pradyut Guha
DOI:10.4103/ijph.IJPH_315_15  PMID:28721956
Background: Although the need for ensuring universal coverage in health has received the attention of policymakers under the Millennium Development Goals program, the skewed pattern of health-care expenditure has been increased globally. Objective: To find out the pattern of public health-care expenditure in northeastern states of India and also to identify the nature of inter-state variation in health-care expenditure among the states. Methods: The study was based on the secondary data collected from the State Finance Figures of Budgetary Statistics of Reserve Bank of India. The period of study was 13 years (2002–2003 to 2014–2015). The study used descriptive statistics and composite supply-side index separately for revenue and capital expenditure by randomizing through the population census figures of 2001 and 2011 for examining the pattern of interstate variation in health-care expenditure. Results: It has been observed that the states having higher mean expenditure registered low compound annual growth rate in health expenditure and thereby causing low per capita value and lower value of the composite index. Conclusion: Thus, the largely populated state needs the due attention of policymaker in reducing the skewed pattern of health-care expenditure.
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Nutritional status of Mid-Day Meal programme beneficiaries: A cross-sectional study among primary schoolchildren in Kottayam district, Kerala, India p. 86
Rajeev Jayalakshmi, Vinoda Thulaseedharan Jissa
DOI:10.4103/ijph.IJPH_320_15  PMID:28721957
Background: The efficiency of Mid-Day Meal (MDM) Programme in India to ensure the optimum nutritional status of its beneficiaries is rarely studied. Objective: This study assessed the nutritional status of 6–10-year-old schoolchildren who were the beneficiaries of MDM and the child-related factors affecting their nutritional status. Methods: A cross-sectional study was performed among 322 children from 12 randomly selected primary schools in one block panchayat of Kerala state. The background information was collected from children and their parents, and anthropometric measurements of the children were observed. The prevalence of undernutrition was estimated using conventional indices (stunting, underweight, and wasting) and composite index of anthropometric failure (CIAF). Logistic regression analysis was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Results: The prevalence of CIAF was 45.7% (95% CI: 40.3%–51.1%) and that of stunting, underweight, and wasting were 13.4% (9.7%–17.1%), 38.8% (33.5%–44.1%), and 30.7% (25.7%–35.7%), respectively. The prevalence of wasting (42.6% vs. 28.4%, P = 0.039) and severe underweight (20.4% vs. 7.1%, P = 0.002) was statistically significantly high among occasional/never users compared to regular users of MDM Programme. Children born with <2.5 kg showed an OR of 1.76 (95% CI: 0.99–3.11) for being undernourished compared to children born with normal weight (≥2.5 kg) when adjusted for age, sex, birth order, and illness in the past 2 weeks. Conclusion: This study showed a higher prevalence of undernutrition among school-age children who were the beneficiaries of MDM Programme, and this indicates the need for continuous nutritional interventions and surveillance among these children.
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Cost analysis of a simulation-based training for health workforce in India p. 92
Gursimer Jeet, Shankar Prinja, Arun Kumar Aggarwal
DOI:10.4103/ijph.IJPH_189_15  PMID:28721958
Background: Training of health-care workforce including doctors, staff nurses, and Auxiliary Nurse Midwives using simulation techniques for skill enhancement have been used in a variety of clinical settings to improve the quality of training. India adopted the skills laboratories model for capacity building of health workers in maternal and child health in Bihar state. Objective: Current economic evaluation was performed with the objective of assessing the financial and economic cost of implementing skills laboratories. Methods: Data on all resources spent for the development of skill laboratory and implementing training during financial year 2011 were collected from Patna district in Bihar state. We used standard methods to estimate the full financial and economic costs of implementing the skills laboratories from a health system perspective. Results: Overall cost of implementing 20 permanent and 10 mobile skills laboratory training in Bihar was Indian Rupee (INR) 8849895 from a financial perspective. The cost was nearly two times higher when using an economic perspective to account for opportunity cost of all resources used. The unit cost of training a participant using permanent and mobile laboratory was INR 6856 and INR 7474, respectively assuming an annual volume of 90 training. The optimum number of training which should be operated annually in a skills laboratory to make it most efficient is about 70–80 training per annum. Conclusions: Economic implications of skills laboratory organization should be borne while planning scale up in Bihar and other states. Further research on the effectiveness of two models of skill laboratory, that is, permanent and mobile and their cost is recommended.
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A study of falls among elderly persons in a rural area of Haryana p. 99
Aniket Sirohi, Ravneet Kaur, Anil Kumar Goswami, Kalaivani Mani, Baridalyne Nongkynrih, Sanjeev Kumar Gupta
DOI:10.4103/ijph.IJPH_102_16  PMID:28721959
Background: Falls are a common, disabling, and frequently fatal health concern among elderly persons. Assessment of the prevalence of falls and associated factors can lead to the identification of corrective measures, which can help in preventing falls and their consequent effects on health and well-being of the elderly. Objectives: The objective is to determine the prevalence of falls among elderly persons in a rural area and to study the association of falls with sociodemographic variables and selected health conditions. Methods: In a community-based, cross-sectional study conducted among 456 elderly persons in a rural area, information regarding sociodemographic details, selected health conditions, and history of falls in the past 12 months was recorded. Univariate analysis followed by stepwise multivariate logistic regression analysis was carried out. The effect of sociodemographic and various health conditions on falls was analyzed using logistic regression analysis. Results: Among the 456 study participants, the prevalence of falls in the past 12 months was 36.6% (95% confidence interval [CI] =32.1–40.0). The prevalence among women was 40.6% (95% CI = 34.5–46.7) and among men was 31.5% (95% CI = 25.0–37.9). Low socioeconomic status, urgency of micturition, knee pain, visual impairment, hearing impairment, functional disability, and depression were significantly associated with falls. Conclusions: Falls are common among elderly persons. Health programs for the elderly must include prevention of falls and rehabilitation of fall-related injuries.
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Alcohol consumption, hazardous drinking, and alcohol dependency among the population of Andaman and Nicobar Islands, India p. 105
Sathya Prakash Manimunda, Attayuru Purushottaman Sugunan, Kandavelu Thennarasu, Dhanasekara Pandian, Kasturi S Pesala, Vivek Benegal
DOI:10.4103/ijph.IJPH_230_15  PMID:28721960
Background: Harmful use of alcohol is one of the globally recognized causes of health hazards. There are no data on alcohol consumption from Andaman and Nicobar Islands. Objective: The objective of the study was to assess the prevalence and pattern of alcohol use among the population of Andaman and Nicobar Islands, India. Methods: A representative sample of 18,018 individuals aged ≥14 years were chosen by multistage random sampling and administered a structured instrument, a modified version of the Gender, Alcohol, and Culture: An International Study (GENACIS) which included sociodemographic details and Alcohol Use Disorders Identification Test (AUDIT). Results: The overall prevalence of alcohol consumption was 35% among males and over 6.0% in females, aged 14 and above. Two out of every five alcohol users fit into a category of hazardous drinkers. One-fourth of the total users (23%) are alcohol dependents. Both the hazardous drinking and dependent use are high among males compared to females. Almost 18.0% of male drinkers and 12.0% of female drinkers reported heavy drinking on typical drinking occasions. The predominant beverages consumed were in the category of homebrews such as toddy and handia. Conclusion: The present study highlights the magnitude of hazardous drinking and alcohol dependence in Andaman and Nicobar Islands, India and the complex sociocultural differences in the pattern of alcohol use. Based on the AUDIT data, among the population of Andaman and Nicobar Islands (aged 14 and above), one out of ten requires active interventions to manage the harmful impact of alcohol misuse.
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Determinants of child sex ratio in West and South Districts of Tripura, India p. 112
Himadri Bhattacharjya, Subrata Baidya
DOI:10.4103/ijph.IJPH_224_15  PMID:28721961
Background: Indian census 2011 has detected declined child sex ratio in the West and South districts of Tripura State. Objectives: To find out the sex ratio at birth and to identify the factors affecting child sex ratio in west and south districts of Tripura. Methods: This community-based cross-sectional study combined with a qualitative component was conducted among 3438 couples chosen by multistage sampling. Quantitative data were collected by a structured interview schedule. Data were analyzed by computer using SPSS version 15.0. Chi-square test was applied for testing the significance of study findings and P < 0.05 was considered statistically significant. Qualitative data were collected by Focus Group Discussions and analyzed by qualitative free listing and pile sorting considering Smith's S value. Results: Sex ratio at birth in West and South Tripura districts during 2013 was found to be 972 and 829 respectively. Son preference was higher among couples irrespective of their literacy, residence, occupation, family type and religion except Christianity. Expenditure at marriage, lesser contribution to parent's family and fears of adverse situations at in law's house after marriage etc. were causes for lesser daughter preference. Very few pregnant women underwent ultrasonography for sex determination of fetus. Girls had differential or delayed medical care and higher death rate. The desire for children was found to be limited after male births. Conclusions: Low daughter preference was mostly due to economic reasons and prolonged contraception following male birth. Literacy, occupation and residence of study subjects did not modify prevalent higher male preference.
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Urinary tract infection among pregnant women at a secondary level hospital in Northern India p. 118
Shashi Kant, Ayush Lohiya, Arti Kapil, Sanjeev Kumar Gupta
DOI:10.4103/ijph.IJPH_293_15  PMID:28721962
Background: Urinary tract infection (UTI) during pregnancy is frequently associated with complications. Currently, in India, there is no regular screening for UTI, and facility for diagnosis of UTI is not available at peripheral government health centers. Objective: To estimate the proportion of pregnant women with UTI among antenatal clinic attendees in rural Haryana. Methods: Eligible participants were pregnant women attending antenatal clinic of secondary care center of rural Haryana from March to May 2015. Consecutive sampling was done to select pregnant women. Interview schedule was administered to the selected women, and midstream urine sample was collected. Urine sample was plated on MacConkey agar, and colony count was done using standard methods. Results: A total of 1253 pregnant women were included in the study. The proportion of women with symptoms of UTI on the basis of history was 33.3% (95% confidence interval [CI] - 30.7, 35.9), and UTI by colony count was 3.3% (95% CI - 2.4, 4.5). The presence of UTI was found to be significantly associated with the presence of any symptom of UTI on multivariate analysis (odds ratio [95% CI] - 7.35 [1.95, 27.77]). Conclusions: The burden of UTI among pregnant women attending antenatal clinic of a sub-district hospital was considerable, more so among the women that presented with symptoms suggestive of UTI. The study suggested that considering the burden of UTI and its complications, diagnosis of UTI at a resource-constrained setting like a secondary care hospital can be done after screening women for symptoms suggestive of UTI.
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REVIEW ARTICLE Top

Pediatric HIV in India: Current scenario and the way forward p. 124
Anita Nath
DOI:10.4103/ijph.IJPH_314_15  PMID:28721963
In India, the prevention of parent-to-child transmission and antiretroviral therapy services for HIV-infected mothers and children have been rapidly scaled up over the recent years. Despite these advances, a large number of HIV-infected children are born in every year. A thorough literature review has been done by retrieving related studies (published from the year 2000 onward); using a Medline search and by extracting recent findings from the official websites of the National AIDS Control Organization, UNAIDS, UNICEF, and World Health Organization. The efforts that are made to control pediatric HIV are challenged by a large range of factors such as low health service utilization, poor drug adherence, delayed infant diagnosis, discriminatory attitude of health providers, loss to follow-up, and poor coordination in managing continuum of care. These challenges may be addressed by adopting innovative and effective strategies and strengthening the existing health system. This would bring about a significant reduction in pediatric HIV incidence and improve the outcomes in children who are HIV infected.
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COMMENTARIES Top

Economic implications of tobacco industry in India: An overview p. 131
Khushbu Sharma, Mohammed Junaid, Madan Kumar Parangimalar Diwakar
DOI:10.4103/ijph.IJPH_245_15  PMID:28721964
Tobacco usage has become engraved in the cultural practices of our country since time immemorial. With increased demand comes increased production, employment, and growth of the tobacco industry but for a deadly cost of human lives which fall prey to its use in either forms. In this article, we describe the economic burden faced by the country due to the emerging tobacco epidemic. The need of the hour is to understand the impact faced due to the tobacco industry in the country and to bring in appropriate efforts to reduce loss of economy and human lives.
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The rise of global health diplomacy: An interdisciplinary concept linking health and international relations p. 134
Vijay Kumar Chattu
DOI:10.4103/ijph.IJPH_67_16  PMID:28721965
Global health diplomacy (GHD) is relatively a very new field that has yet to be clearly defined and developed though there are various definitions given by different experts from foreign policy, global health, diplomacy, international relations, governance, and law. With the intensification of globalization and increasing gaps between countries, new and reemerging health threats such as HIV/AIDS, tuberculosis, influenza, severe acute respiratory syndrome, Ebola, and Zika and a gradual rethinking on security concepts framed a new political context. The health problems addressed diplomatically have also become diverse ranging from neglected tropical diseases, infectious diseases, sale of unsafe, counterfeit drugs to brain drain crisis. We see that global health has become more diverse as the actors widened and also the interests appealing not only to the traditional humanitarian ideals associated with health but also to the principles grounded in national and global security. Recently, we are witnessing the increased priority given to the GHD because the issue of health is discussed by various actors outside the WHO to shape the global policy for health determinants. In fact, the area of health has become the part of UN Summit Diplomacy involving the G8, G20, BRICS, and the EU. The recent WHO Pandemic Influenza Framework, UN High Level Framework on Prevention and Control of Noncommunicable Diseases, and the WHO Framework Convention on Tobacco Control are some of the examples of long-term negotiation processes for agreements that took place.
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BRIEF RESEARCH ARTICLES Top

Use of skin-lightening products among outpatient attendees in a North Indian Hospital p. 137
Celestine Wong, Samuel Wong, Howard Tang, Rashi Minocha, Rajesh Singh, Nathan Grills
DOI:10.4103/ijph.IJPH_318_15  PMID:28721966
In India, fair skin is a highly valued physical attribute. Skin lightener products comprise 60% of the dermatological market. This cross-sectional study was conducted in the general medical outpatient clinics of Champa Christian Hospital to elucidate the perceptions of fair skin and determinants/pattern of skin lighter use. Demographics, pattern of skin lightener use and incidence of side effects, perceptions of lighter skin tones were the main outcomes and measures studied. The use of skin lighteners was highly prevalent in our study population. Believing that lighter skin is beneficial for self-esteem is a predictor for skin lightener use. Higher education was associated with lower perceived benefits of fairer skin and therefore reduced skin lightener use. Further education and increased community awareness are important to address the issues surrounding potential over-use of skin-lightening products.
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Sexual behavior of transgenders and their vulnerability to HIV/AIDS in an Urban Area of Eastern India p. 141
Abhik Sinha, Dipendra Narayan Goswami, Dibakar Haldar, Sarmila Mallik, Sukamal Bisoi, Prasanta Ray Karmakar
DOI:10.4103/ijph.IJPH_248_14  PMID:28721967
Transgender (TG) people experience a gender identity that is different from their anatomical sex. For their high-risk sex behavior, they are important group for targeted intervention of HIV/AIDS. The objective of the study was to find the sexual behavior of TG people and to assess few aspects of their vulnerability to HIV/AIDS. This cross-sectional survey was done from June to August 2012, in field practice area of “Kosish,” a nongovernmental organization run by TGs in Alipore of Kolkata metropolitan city, India. Information was collected by interviewing 90 TG of 11 selected hotspots using a predesigned questionnaire. Results revealed that 4.5% were illiterate. Drug abuse was reported by 22.2% participants. Inconsistent condom use was found. Venereal disease research laboratory reactivity was found in 11.11%. Nearly 16.7% had experienced sexual violence in the past 3 months. Thus, interventions for overall empowerment of the TGs are recommended.
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LETTERS TO EDITOR Top

A comment on assessment and comparison of pregnancy outcome among anaemic and nonanaemic primigravida mothers p. 144
Renu Chauhan
DOI:10.4103/ijph.IJPH_321_16  PMID:28721968
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AUTHORS REPLY Top

Assessment and comparison of pregnancy outcome among anemic and nonanemic primigravida mothers p. 144
Rohini Sehgal
DOI:10.4103/ijph.IJPH_433_16  PMID:28721969
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LETTERS TO EDITOR Top

Adverse events following immunization: A challenge in India p. 146
Anju R Marak, Dhriti Kumar Brahma, Joonmoni Lahon
DOI:10.4103/ijph.IJPH_222_16  PMID:28721970
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Implementation of epidemic disease act: An experience from a North Indian jurisdiction p. 148
Swati Negi, Avinash Shroff, Anil Garg, Gaurav Aggarwal, Jitendra Kumar Meena, Sonu Goel
DOI:10.4103/ijph.IJPH_158_16  PMID:28721971
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BOOK REVIEW Top

Textbook of chronic noncommunicable diseases: The health challenge of the 21st century p. 150
Sanjay Zodpey
DOI:10.4103/ijph.IJPH_114_17  
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