Chander Shekhar

Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study.

BACKGROUND International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries. METHODS Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated. FINDINGS Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations. INTERPRETATION We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems. FUNDING The Lowitja Institute.

Level, Trend and Correlates of Mistimed and Unwanted Pregnancies among Currently Pregnant Ever Married Women in India.

Unintended pregnancy accounts for more than 40% of the total pregnancies worldwide. An Unintended pregnancy can have serious implications on women and their families. With more than one-fourth of the children in India born out of unintended pregnancies such pregnancies are considered to be one of the major public health concerns today. The present study is aimed at determining major predictors of unintended pregnancy among currently pregnant ever-married women in India. The present study has used National Family Health Survey (NFHS) data, conducted by the International Institute for Population Sciences (IIPS), Mumbai, to show the trend, pattern and determinants of mistimed and unwanted pregnancies. Bivariate and multinomial logistic regression model have been used with the help of Stata 13 software. The results show that the likelihood of a mistimed pregnancy is more prevalent among young women whereas the prevalence of unwanted pregnancy is observed more among the women aged 35 years or more. The results also show that the risk of experiencing mistimed pregnancy decreases if the woman belongs to ‘other’ castes and has higher education. The likelihood of unwanted pregnancy decreases among married women aged 18 years and above, those women having higher education, some autonomy and access to any mode of mass communication. Knowledge of these predictors of mistimed and unwanted pregnancy will be helpful in identifying the most vulnerable group and prioritize the intervention strategies of the reproductive health programmes for the population in need.

The incidence of abortion and unintended pregnancy in India, 2015

Summary Background Reliable information on the incidence of induced abortion in India is lacking. Official statistics and national surveys provide incomplete coverage. Since the early 2000s, medication abortion has become increasingly available, improving the way women obtain abortions. The aim of this study was to estimate the national incidence of abortion and unintended pregnancy for 2015. Methods National abortion incidence was estimated through three separate components: abortions (medication and surgical) in facilities (including private sector, public sector, and non-governmental organisations [NGOs]); medication abortions outside facilities; and abortions outside of facilities and with methods other than medication abortion. Facility-based abortions were estimated from the 2015 Health Facilities Survey of 4001 public and private health facilities in six Indian states (Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu, and Uttar Pradesh) and from NGO clinic data. National medication abortion drug sales and distribution data were obtained from IMS Health and six principal NGOs (DKT International, Marie Stopes International, Population Services International, World Health Partners, Parivar Seva Santha, and Janani). We estimated the total number of abortions that are not medication abortions and are not obtained in a health facility setting through an indirect technique based on findings from community-based study findings in two states in 2009, with adjustments to account for the rapid increase in use of medication abortion since 2009. The total number of women of reproductive age and livebirth data were obtained from UN population data, and the proportion of births from unplanned pregnancies and data on contraceptive use and need were obtained from the 2015–16 National Family Health Survey-4. Findings We estimate that 15·6 million abortions (14·1 million–17·3 million) occurred in India in 2015. The abortion rate was 47·0 abortions (42·2–52·1) per 1000 women aged 15–49 years. 3·4 million abortions (22%) were obtained in health facilities, 11·5 million (73%) abortions were medication abortions done outside of health facilities, and 0·8 million (5%) abortions were done outside of health facilities using methods other than medication abortion. Overall, 12·7 million (81%) abortions were medication abortions, 2·2 million (14%) abortions were surgical, and 0·8 million (5%) abortions were done through other methods that were probably unsafe. We estimated 48·1 million pregnancies, a rate of 144·7 pregnancies per 1000 women aged 15–49 years, and a rate of 70·1 unintended pregnancies per 1000 women aged 15–49 years. Abortions accounted for one third of all pregnancies, and nearly half of pregnancies were unintended. Interpretation Health facilities can have a greater role in abortion service provision and provide quality care, including post-abortion contraception. Interventions are needed to expand access to abortion services through better equipping existing facilities, ensuring adequate and continuous supplies of medication abortion drugs, and by increasing the number of trained providers. In view of how many women rely on self-administration of medication abortion drugs, interventions are needed to provide women with accurate information on these drugs and follow-up care when needed. Research is needed to test interventions that improve knowledge and practice in providing medication abortion, and the Indian Government at the national and state level needs to prioritise improving policies and practice to increase access to comprehensive abortion care and quality contraceptive services that prevent unintended pregnancy. Funding Government of UK Department for International Development (until 2015), the David and Lucile Packard Foundation, the John D. and Catherine T. MacArthur Foundation, and the Ford Foundation.

The increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990–2016

Summary Background The burden of diabetes is increasing rapidly in India but a systematic understanding of its distribution and time trends is not available for every state of India. We present a comprehensive analysis of the time trends and heterogeneity in the distribution of diabetes burden across all states of India between 1990 and 2016. Methods We analysed the prevalence and disability-adjusted life-years (DALYs) of diabetes in the states of India from 1990 to 2016 using all available data sources that could be accessed as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, and assessed heterogeneity across the states. The states were placed in four groups based on epidemiological transition level (ETL), defined on the basis of the ratio of DALYs from communicable diseases to those from non-communicable diseases and injuries combined, with a low ratio denoting high ETL and vice versa. We assessed the contribution of risk factors to diabetes DALYs and the relation of overweight (body-mass index 25 kg/m2 or more) with diabetes prevalence. We calculated 95% uncertainty intervals (UIs) for the point estimates. Findings The number of people with diabetes in India increased from 26·0 million (95% UI 23·4–28·6) in 1990 to 65·0 million (58·7–71·1) in 2016. The prevalence of diabetes in adults aged 20 years or older in India increased from 5·5% (4·9–6·1) in 1990 to 7·7% (6·9–8·4) in 2016. The prevalence in 2016 was highest in Tamil Nadu and Kerala (high ETL) and Delhi (higher-middle ETL), followed by Punjab and Goa (high ETL) and Karnataka (higher-middle ETL). The age-standardised DALY rate for diabetes increased in India by 39·6% (32·1–46·7) from 1990 to 2016, which was the highest increase among major non-communicable diseases. The age-standardised diabetes prevalence and DALYs increased in every state, with the percentage increase among the highest in several states in the low and lower-middle ETL state groups. The most important risk factor for diabetes in India was overweight to which 36·0% (22·6–49·2) of the diabetes DALYs in 2016 could be attributed. The prevalence of overweight in adults in India increased from 9·0% (8·7–9·3) in 1990 to 20·4% (19·9–20·8) in 2016; this prevalence increased in every state of the country. For every 100 overweight adults aged 20 years or older in India, there were 38 adults (34–42) with diabetes, compared with the global average of 19 adults (17–21) in 2016. Interpretation The increase in health loss from diabetes since 1990 in India is the highest among major non-communicable diseases. With this increase observed in every state of the country, and the relative rate of increase highest in several less developed low ETL states, policy action that takes these state-level differences into account is needed urgently to control this potentially explosive public health situation. Funding Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Role of induced abortion in attaining reproductive goals in Kyrgyzstan: a study based on KRDHS-1997.

Estimates indicate that about 42 million pregnancies are voluntarily terminated every year at the global level, of which more than 80% occur in developing countries. Abortion has been one of the major reproductive health concerns in post-Soviet nations, especially when it is commonly used as a means of fertility regulation. On average, every woman has had around 1.6 abortions in Kyrgyzstan. This paper attempts to measure the role of abortion in fertility regulation using data from the Kyrgyz Republic Demographic and Health Survey (KRDHS), 1997. The analysis reveals that Kyrgyzstan can attain replacement level fertility in the absence of induced abortion by raising the contraceptive prevalence to 70% at the current level of effectiveness. The study also shows that womens attitude towards becoming pregnant and their partners perception about abortion are significantly associated with the propensity to opt for an induced abortion. Reproductive health programmes need to address these issues, including the enhancement of male involvement in family planning.

Smokeless tobacco use among adult males in India and selected states: Assessment of education and occupation linkages

Abstract This article is an effort to analyze the influence of education and occupation as critical determinants of smokeless tobacco use among adult males in India and its selected states. Global Adult Tobacco Survey (GATS) India 2009–10 data are used to analyze the prevalence of smokeless tobacco use among adult males aged 15 years and above (N = 33,767) by their different education and occupational status. Bivariate and multivariate (Cox proportional survival model) analyses are carried out to assess the linkages of education and occupation with use of smokeless tobacco among adult males. The study suggests that the majority of Indian men are using khaini (18%) and gutkha (13%) (the local terms used for smokeless tobacco). Further, it is observed that education and occupation remain the two important critical predictors of smokeless tobacco use among men. A greater percentage of young men with no education from rural areas use smokeless tobacco (44.3%) than their counterpart group from urban areas. The socioeconomically disadvantaged states, noticeably the east and central (4.992 and 3.218; p < .001) states, record higher prevalence of smokeless tobacco use than other states. Considering the high prevalence of smokeless tobacco use among illiterate and socioeconomically deprived youths, there is an urgent need to sensitize the issue. More concrete efforts to generate awareness on the ill effects of tobacco use among the illiterate and those who are employed in low-profile occupations are needed.

India's Universal Immunisation Programme to prevent children from preventable disease: retention and dropout approach

Abstract Background The Universal Immunisation Programme was integrated with the Reproductive and Child Health Programme to improve childhood immunisation in India. However, there is a lack of empirical research on understanding about childhood immunisation by the standard schedule of WHO. This study aimed to estimate the level of retention and dropouts from one vaccination to the next among Indian children aged 12–23 months. Methods We use data from the nationwide District Level Household and Facility Survey (DLHS-3), which was carried out in all 596 districts and covered 64 702 children aged 12–23 months in India during 2007–08. We used the Kaplan–Meier method to assess the retention rate of childhood immunisation. Findings Only 52·5% (33 959 of 64 702) of children aged 12–23 months have received the full course of vaccination. Children of the poorest and illiterate mothers have the lowest rate of full immunisation. 86·1% (55 688 of 64 702) of children would have been fully vaccinated if each child had been administered all three doses of diphtheria, pertussis, and tetanus (DPT) and polio vaccines and measles vaccine. The retention rate of childhood immunisation was in maximum decline between the second round of DPT and polio (70%, 95% CI 69–71) and the third round (56%, 55–57). On the other hand, if all children are brought under the health-system network by way of registering all births for BCG, the existing dropout rate at different stages of vaccination will yield 60·8% (33 869 of 55 688) of children being fully immunised. Interpretation The findings of this assessment reveal that immunisation coverage varies from one vaccine to another and declines over the schedule prescribed by the WHO. BCG, third-round DPT, and third-round polio vaccination coverage may play a critical role in full immunisation, as the dropout rates were higher for these vaccinations. Specially designed interventions are needed to meet Millennium Development Goals regarding the under-5 mortality rate, infant mortality rate, and proportion of 1-year-old children immunised against measles. Funding DY was supported by the Government of India/National Eligibility Test Doctoral Fellowship award from the University Grants Commission and Ministry of Health and Family Welfare, Government of India. The funders had no role in study design, data collection, analysis, or preparation of the abstract.