Gender disparities in health care expenditures and financing strategies (HCFS) for inpatient care in India

Gender disparity in prevalence of mental health issues in Kerala: a systematic review and meta-analysis

BACKGROUND

Kerala is a state in south India, appreciated for its education, better health indicators and quality of life. However, there is a proportionately high prevalence of mental health illnesses and suicides reported in the state. It is unclear if there is any disparity in the gender categories in this. With this systematic review, we aim to systematically study the gender disparity in the prevalence of mental health (MH) issues among adolescents, younger and older adults in Kerala.

METHODS

A search strategy was built and several databases like Pubmed, Cochrane, Scopus, EMBASE, EBSCOhost, Web of Science, and ProQuest were used alongside grey literature to identify relevant articles. The study was conducted according to the PRISMA guidelines following a prespecified protocol. After relevant data extraction, the estimates were pooled using random effects model due to the high heterogeneity assessed by tau-squared, Cochran Q, and prediction interval. Subgroup analyses, and meta-regression were used to reduce heterogeneity. We also identified the influence and heterogeneity contributed by individual studies using influence plots, Baujat plot, clustering, and performed several sensitivity analyses.

RESULTS

Twenty articles were included in the review and meta-analysis. The pooled odds ratio of mental health illnesses amongst females compared to males in Kerala was 1.31 (95% CI: 1.0 - 1.73) and falls within a prediction interval of 0.38 to 4.53. The individual studies showed high heterogeneity (I2 = 92%, p = p < 0.01) and hence, subgroup analysis was done for several prespecified subgroups based on etiology, geography, demography, study settings, and age groups. Heterogeneity was significantly reduced by subgrouping based on etiology, study setting and age (p, 0.001, p < 0.001, p = 0.001). In etiologic subgrouping the highest pooled odds was in comorbidities associated MH issues (2.54) and least in non-specific (0.97). In age subgrouping, the highest pooled odds was in elderly (2.53) and least in adolescents (0.63). The odds was highest in health care facility (2.21) and least in educational institution (0.78) based studies. Meta-regression based on the size of the study failed to reduce heterogeneity.

INTERPRETATIONS

A gender disparity was evident in the prevalence of mental health issues, with a higher Odds in females especially among the elderly and adults. A Gender transformative approach in legislative, health systems and policy frameworks will be the answer to this.

Self-reported symptom burden among patients attending public health care facilities in India: Looking through ICPC-3 lens

INTRODUCTION

The objectives of this study were: 1) to describe the socio-demographics and classify the chief complaints and reasons to encounter facilities of patients presenting to public healthcare facilities; 2) to explore differences in these complaints and: International Classification of Primary Care-3 (ICPC-3) groups across socio-demographic and health system levels.

METHODS

This is a cross-sectional study conducted in three districts of Odisha, India. Within each district, the district hospital (DH), one Sub-district hospital (SDH) (if available), two Community health centers (CHCs), and two Primary health care centers (PHCs) were selected. Thus, a total of three DHs, three SDHs, six CHCs, and six PHCs were covered. Two tertiary healthcare facilities were also included. Patients aged 18 years and older, attending the Outpatient Departments (OPD) of sampled health facilities were chosen as study participants through systematic random sampling.

RESULTS

A total of 3044 patients were interviewed. In general, 65% of the sample reported symptoms as their chief complaint for reason of encounter, whereas 35% reported disease and diagnosis. The most common reasons to encounter health facilities were fever, hypertension, abdominal pain, chest pain, arthritis, skin disease, cough, diabetes, and injury. Among the symptoms, the highest number of patients reported the general category (29%), followed by the digestive system (16%). In the disease category, the circulatory system has the highest proportion, followed by the musculatory system. In symptom categories, general, digestive, and musculatory systems were the key systems for the reasons of encounter in outpatient departments irrespective of different groups of the population. In terms of different tiers of health systems, the top three reasons to visit OPD were dominated by the circulatory system, respiratory system, and musculatory system.

CONCLUSION

This is the first Indian study using the ICPC-3 classification for all three levels of health care. Irrespective of age, socio-economic variables, and tiers of healthcare, the top three groups to visit public health facilities according to the ICPC-3 classification were consistent i.e., general, digestive, and circulatory. Implementation of standard management and referral guidelines for common diseases under these groups will improve the quality and burden at public health facilities in India.

Burden of undiagnosed depression among older adults in India: a population based study

BACKGROUND

The study explored the levels and associated factors of undiagnosed depression among community-dwelling older Indian adults. It also identified the socio-demographic predictors of undiagnosed depression among the study population at national and state levels.

METHODS

The study employed data from the Longitudinal Ageing Study in India wave-I, 2017-18. Based on the data on depression from interviewee's self-reporting and measurement on Composite International Diagnostic Interview- Short Form (CIDI-SF) and Centre for Epidemiological Studies- Depression scale (CES-D) scales, we estimated undiagnosed depression among older adults (age 60+). We estimated multivariable binary logistic regressions to examine the socio-demographic and health-related predictors of undiagnosed depression among older adults.

FINDINGS

8% (95% CI: 7.8-8.4) of the total older adults had undiagnosed depression on CIDI-SF scale and 5% (95% CI: 4.8-5.3) on the combined CIDI-SF and CES-D. Undiagnosed depression was higher among those who were widowed, worked in the past and currently not working, scheduled castes, higher educated and the richest. Lack of health insurance coverage, presence of any other physical or mental impairment, family history of Alzheimer's/Parkinson's disease/ psychotic disorder, lower self-rated health and poor life satisfaction were significant predictors of undiagnosed depression on both CIDI-SF and combined scales.

CONCLUSION

To improve the health of older adults in India, targeted policy efforts integrating mental health screening, awareness campaigns and decentralization of mental healthcare to primary level is needed. Further research could explore the causal factors behind different levels of undiagnosed depression.

Examining the factors contributing to a reduction in hardship financing among inpatient households in India

In India, the rising double burden of diseases and the low fiscal capacity of the government forces people to resort to hardship financing. This study aimed to examine the factors contributing to the reduction in hardship financing among inpatient households in India. The study relies on two rounds of National Sample Surveys with a sample of 34,478 households from the 71st round (2014) and 56,681 households from the 75th round (2018). We employed multivariable logistic regression and multivariate decomposition analyses to explore the factors associated with hardship financing in Indian households with hospitalized member(s) and assess the contributing factors to the reduction in hardship financing between 2014 and 2018. Notably, though hardship financing for inpatient households has decreased between 2014 and 2018, households with catastrophic health expenditure (CHE) had higher odds of hardship financing than those without CHE. While factors such as CHE, prolonged hospitalization, and private hospitals had impoverishing effects on hardship financing in 2014 and 2018, the decomposition model showed the potential of CHE (32%), length of hospitalization (32%), and private hospitals (24%) to slow down this negative impact over time. The findings showed the potential for further improvements in financial health protection for inpatient care over time, and underscore the need for continuing efforts to strengthen the implementation of public programs and schemes in India such as Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY).

Addressing disparities in rural and remote access for rheumatology practice through a transformative tele-healthcare delivery system: Experience of a large cohort of patients in eastern India

Background We present the experience of telerheumatology consultation services carried out in an eastern state of India. Methods We did this prospective, observational study of patients with rheumatological disorders and followed through telemedicine between December 2015 and May 2019. Results During the study period, we provided teleconsultation to 3583 patients with the help of 11 201 telemedicine visits. Patients resided at a median distance of 248 (13 to 510) km from the telemedicine hub. The cumulative savings of the patients as a result of this service were ₹2.4 crore (24 million). The median travel time saved was 7 hours (30 minutes to 12 hours) per patient per visit and a median of ₹6700 was saved per visit per patient. Conclusion Sustained efforts over a long period can lead to the delivery of essential rheumatology services via telemedicine to an under-priviledged population, reduce the financial burden of the poor, and help women to access healthcare services in remote parts of low- and middle-income countries (LMICs).

A step closer towards achieving universal health coverage: the role of gender in enrolment in health insurance in India

BACKGROUND

There is limited understanding of how universal health coverage (UHC) schemes such as publicly-funded health insurance (PFHI) benefit women as compared to men. Many of these schemes are gender-neutral in design but given the existing gender inequalities in many societies, their benefits may not be similar for women and men. We contribute to the evidence by conducting a gender analysis of the enrolment of individuals and households in India's national PFHI scheme, Rashtriya Swasthya Bima Yojana (RSBY).

METHODS

We used data from a cross-sectional household survey on RSBY eligible families across eight Indian states and studied different outcome variables at both the individual and household levels to compare enrolment among women and men. We applied multivariate logistic regressions and controlled for several demographic and socio-economic characteristics.

RESULTS

At the individual level, the analysis revealed no substantial differences in enrolment between men and women. Only in one state were women more likely to be enrolled in RSBY than men (AOR: 2.66, 95% CI: 1.32-5.38), and this pattern was linked to their status in the household. At the household level, analyses revealed that female-headed households had a higher likelihood to be enrolled (AOR: 1.36, 95% CI: 1.14-1.62), but not necessarily to have all household members enrolled.

CONCLUSION

Findings are surprising in light of India's well-documented gender bias, permeating different aspects of society, and are most likely an indication of success in designing a policy that did not favour participation by men above women, by mandating spouse enrolment and securing enrolment of up to five family members. Higher enrolment rates among female-headed households are also an indication of women's preferences for investments in health, in the context of a conducive policy environment. Further analyses are needed to examine if once enrolled, women also make use of the scheme benefits to the same extent as men do. India is called upon to capitalise on the achievements of RSBY and apply them to newer schemes such as PM-JAY.

Child marriage as a risk factor for non-communicable diseases among women in India

BACKGROUND

Child marriage, defined as marriage under the age of 18 years, remains pervasive in India. Global evidence documents a negative association between child marriage and women's reproductive and sexual health outcomes; however, its relationship with non-communicable diseases (NCDs) remains underexplored.

METHODS

We utilize biomarkers and self-reported data from the nationally representative National Family and Health Survey 4 (2015-2016) to examine the associations between child marriage and hypertension, diabetes, heart disease, asthma and thyroid disorder among currently married women (N = 421 107). We use regression models adjusted for a range of demographic and socio-economic controls to assess the association between child marriage and NCDs among women in India. We further assess whether and to what extent these relationships are mediated by early motherhood using the Karlson, Holm and Breen method of decomposition.

RESULTS

Child marriage was associated with hypertension [adjusted odds ratio 1.20 (95% CI: 1.17-1.24)], diabetes [1.29 (1.22-1.37)], heart disease [1.27 (1.18-1.36)], asthma [1.19 (1.11-1.28)] and thyroid disorder [1.10 (1.02-1.18)]. Early motherhood also increased the risk of NCDs among women. Furthermore, it emerged as a pathway linking child marriage with hypertension, diabetes and heart disease; however, it provided a partial explanation for the disadvantage associated with child marriages.

CONCLUSIONS

Child marriage emerges as a risk factor for NCDs among women in India. Health systems need to recognize the enduring influence of child marriages on women's health and ensure early detection and effective treatment of NCDs for this vulnerable group.

Gender differences in vision health-seeking behavior and vision health outcomes among rural Chinese schoolchildren by birth order and family size

BACKGROUND

The gender gap remains a major impediment in the path toward equality, and it is especially wide in low-income countries. Gender differences in health-seeking behaviors may be a factor. Family size and childbirth order are two critical factors affecting family resource allocation. This study examines gender differences in healthcare-seeking behaviors among children with visual impairment in rural China across different family structures (birth order and family size).

METHODS

We draw on a dataset containing 19,934 observations constructed by combining data from 252 different school-level surveys spanning two provinces. The surveys were all conducted in 2012 using uniform survey instruments and data collection protocols in randomly selected schools across western provinces in rural China. The sample children range in grades from 4 to 5. Our analysis compares rural girls with rural boys regarding vision health outcome and behavior (vision examination and correction).

RESULTS

The findings revealed that girls have worse vision than boys. Regarding vision health behaviors, girls have a lower overall vision examination rate than boys. There is no gender difference when the sample student is the only child or the youngest child in the family, but there is still a gender difference when the sample student is the oldest child in the family or the middle child in the birth order. When it comes to vision correction behavior, boys are more likely to own eyeglasses than girls are for groups of students with mild visual impairment, even when the sample student is the only child in the family. However, when the sample student has another brother or sister (the sample student is the youngest, the oldest child in the family, or the middle child in the birth order), the gender difference disappears.

CONCLUSIONS

Gender differences in vision health outcomes are correlated with gender differences in vision health-seeking behaviors among rural children. Depending on the birth order and family size, gender disparities in visual health practices vary. In the future, consideration should be given to providing medical subsidies to reduce the cost of vision health behaviors and to provide information interventions to change gender inequality in households and promote equality in children's vision health behaviors.

TRIAL REGISTRATION

The trial was approved by the Stanford University Institutional Review Board (Protocol No. ISRCTN03252665). Permission was received from local Boards of Education in each region and the principals of all schools. The principles of the Declaration of Helsinki were followed throughout. Written informed consent was obtained from at least one parent for all child participants.

Awareness of India's national health insurance scheme (PM-JAY): a cross-sectional study across six states

The literature suggests that a first barrier towards accessing benefits of health insurance in low- and middle-income countries is lack of awareness of one's benefits. Yet, across settings and emerging schemes, limited scientific evidence is available on levels of awareness and their determinants. To fill this gap, we assessed socio-demographic and economic determinants of beneficiaries' awareness of the Pradhan Mantri Jan Arogya Yojana (PM-JAY), the national health insurance scheme launched in India in 2018, and their awareness of own eligibility. We relied on cross-sectional household (HH) survey data collected in six Indian states between 2019 and 2020. Representative data of HHs eligible for PM-JAY from 11 618 respondents (an adult representative from each surveyed HH) were used. We used descriptive statistics and multivariable logistic regression models to explore the association between awareness of PM-JAY and of one's own eligibility and socio-economic and demographic characteristics. About 62% of respondents were aware of PM-JAY, and among the aware, 78% knew that they were eligible for the scheme. Regression analysis confirmed that older respondents with a higher educational level and salaried jobs were more likely to know about PM-JAY. Awareness was lower among respondents from Meghalaya and Tamil Nadu. Respondents from Other Backward Classes, of wealthier socio-economic status or from Meghalaya or Gujarat were more likely to be aware of their eligibility status. Respondents from Chhattisgarh were less likely to know about their eligibility. Our study confirms that while more than half of the eligible population was aware of PM-JAY, considerable efforts are needed to achieve universal awareness. Socio-economic gradients confirm that the more marginalized are still less aware. We recommend implementing tailored, state-specific information dissemination approaches focusing on knowledge of specific scheme features to empower beneficiaries to demand their entitled services.

Illnesses and hardship financing in India: an evaluation of inpatient and outpatient cases, 2014-18

BACKGROUND

Progress towards universal health coverage requires strengthening the country's health system. In developing countries, the increasing disease burden puts a lot of stress on scarce household finances. However, this burden is not the same for everyone. The economic burden varies across the disease groups and care levels. Government intervention is vital in formulating policies in addressing financial distress at the household level. In India, even when outpatient care forms a significant proportion of out-of-pocket expenditure, government schemes focus on reducing household expenditure on inpatient care alone. Thus, people resort to hardship financing practices like informal borrowing or selling of assets in the event of health shocks. In this context, the present study aims to identify the disease(s) that correlates with maximum hardship financing for outpatients and inpatients and to understand the change in hardship financing over time.

METHODS

We used two waves of National Sample Survey Organisation's data on social consumption on health- the 71^st and the 75^th rounds. Descriptive statistics are reported, and logistic regression is carried out to explain the adjusted impact of illness on hardship financing. Pooled logistic regression of the two rounds is estimated for inpatients and outpatients. Marginal effects are reported to study the changes in hardship financing over time.

RESULTS

The results suggest that cancer had the maximum likelihood of causing hardship financing in India for both inpatients (Odds ratio 2.41; 95% Confidence Interval (CI): 2.03 - 2.86 (71^st round), 2.54; 95% CI: 2.21 - 2.93 (75^th round)) and outpatients (Odds ratio 6.11; 95% CI: 2.95 - 12.64 (71^st round), 3.07; 95% CI: 2.14 - 4.40 (75^th round)). In 2018, for outpatients, the hardship financing for health care needs was higher at public health facilities, compared to private health facilities (Odds ratio 0.72; 95% CI: 0.62 - 0.83 (75^th round). The marginal effects model of pooled cross-section analysis reveals that from 2014 to 2018, the hardship financing had decreased for inpatients (Odds ratio 0.747; 95% CI:0.80 - -0.70), whereas it had increased for outpatients (Odds ratio 0.0126; 95% CI: 0.01 - 0.02). Our results also show that the likelihood of resorting to hardship financing for illness among women was lesser than that of men.

CONCLUSION

Government intervention is quintessential to decrease the hardship financing caused by cancer. The intra-household inequalities play an important role in explaining their hardship financing strategies. We suggest the need for more financial risk protection for outpatient care to address hardship financing.

Catastrophic expenditure and treatment attrition in patients seeking comprehensive colorectal cancer treatment in India: A prospective multicentre study

BACKGROUND

Although colorectal cancer is increasing in India, the cost of comprehensive treatment and its consequences for patients and households are unknown. This study aimed to describe catastrophic expenditure and treatment attrition in patients with a treatment plan for colorectal cancer.

METHODS

A prospective, multicentre, cohort study was conducted in five tertiary hospitals in India from December 2020 to March 2022. Consecutive patients with a new treatment plan for colorectal cancer were followed-up for six months. The total cost of treatment was reported, including out-of-pocket payments (OOPP, paid by patients at the time-of-service use) and covered by third parties (insurance, public funds). The primary outcome was catastrophic expenditure, defined as OOPPs greater than 25% of patient's annual household income and the secondary outcome was treatment attrition, defined as unplanned interruption of the treatment course not recommended by the clinical team.

FINDINGS

Of 226 patients included, 20 died within six months of being offered a treatment plan and four were lost to follow-up. The median total cost of colorectal cancer treatment was 407,508 Indian Rupees (INR/5340 USD), to which the biggest contributor was the patient's OOPP (median 330,277 INR/4328 USD). Surgery and anaesthesia costs (median 85,944 INR/1126 USD) were higher than radiotherapy (median 55,525 INR/728 USD) and chemotherapy (median 14,780 INR/194 USD). The overall catastrophic expenditure rate was 90.1% (182/202) and the treatment attrition rate was 9.4% (19/202). Patients with treatment attrition made lower OOPPs than those who completed treatment (median 205,926 vs 349,398 INR, p < 0.01) but had a similar risk of catastrophic expenditure (OR 0.23, 95%CI 0.03-2.28, p = 0.186).

INTERPRETATION

Most treatment costs for colorectal cancer were paid out-of-pocket by patients and catastrophic expenditure was common. Treatment attrition rates at tertiary centres were low, suggesting greater attrition at previous stages of care. Better financial protection may allow more patients to receive comprehensive cancer treatment while avoiding household financial catastrophe.

FUNDING

This research was funded by the National Institute for Health Research (NIHR) (NIHR 16.136.79) using UK aid from the UK Government to support global health research, by the India Institute of the University of Birmingham and by the Global Challenges program of the University of Birmingham. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government.

Blocked by Gender: Disparities in COVID19 infection detection in Tamil Nadu, India

Globally, a gender gap in COVID-19 has been noted with men reporting higher share of both morbidity and deaths compared to women. While the gender gap in fatalities has been similar across the globe, there have been interesting disparities in the detection of COVID-19 cases in men and women. While wealthier, more developed nations have generally seen similar case detection in men and women, LMICs especially in Asia have seen far greater proportion of COVID-19 cases among men than women. We utilize age and sex-disaggregated data from the southern Indian state of Tamil Nadu across two waves of the pandemic (May 2020 - Nov 2020, and March 2021, to June 2021) and find that there were only ~70% as many detected COVID-19 cases among women as there were among men. Our initial reading suggested that this might be a protective effect of lower labor force participation rates among women across much of South Asia. However, subsequent sero-prevalence results from Tamil Nadu conducted on October-November 2020, and June-July, 2021 suggest that infection incidence has been similar among men and women; as is the case in countries with better health infrastructure. This empirical puzzle suggests that reduced case detection among women cannot be immediately associated with limited public exposure, but rather evidence of a chronic neglect of women in healthcare access. Overall, we contend that an attention to the gender context holds promise to effective interventions in detection and prevention that goes beyond the traditional epidemiological logic of diseases.

Ecosystems Determinants of Nutritional Adequacy Among the Indian Preschool Children

Given the specified importance of dietary diversity in reducing the burden of malnutrition, our study explores the reasons for the high rate of malnutrition in India through assessment of a comprehensive range of ecosystem factors leading to poor nutrients intake. The study uses the Dietary Diversity Score (DDS) to investigate preschoolers, through differences in wealth, gender, and health. Demographic and Health Survey (2015-16) data of 1,40,470 preschool children between the ages of 2-5 years, is investigated using the Bronfenbrenner's Ecological Systems Theory. Multiple linear regression models developed to investigate the association between variables, depict the importance of vaccination (p-value < 0.01, 95% CI 0.02-0.06) as positively impacting the outcome measures. Interestingly, overall wealth index does not impact the dietary diversity of the child. The lower wealth index, however, significantly impacts the DDS of the female child as compared to the male child (p-value < 0.1, 95% CI - 0.03 to 0.02), indicating that the lower wealth index plays a role in developing the non-egalitarian gender attitudes for female children. Policy implications involve adapting biofortified foods with higher density of nutrients with major focus on female children to minimize the gender gap and leveraging the digital technology such as telemedicine, and advanced techniques such as artificial intelligence, machine learning, and big data to offer real-time surveillance to address the healthcare needs in the ongoing immunization programs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41745-022-00339-4.

A community-based, cross-sectional study of gender egalitarianism: A promising scenario from an urban field practice area attached to a teaching institute from Central India

Context

Gender-based discrimination is more predominant in India. In spite of various laws, gender inequality is an evil that plagues society even today. This is an important challenge for meeting our Sustainable Development Goals.

Methods

This cross-sectional study was carried out in an urban field practice area. Study subjects were married women and their husbands in the age-group of 15-49 years along with their under-five children. Gender egalitarianism was assessed for factors like education, employment and media exposure. Factors which were studied for revealing gender egalitarianism among children included sex ratio, immunization status, nutritional status and health care expenditure. Completed family size and preference for the sex of the child were enquired about to assess the inclination towards male gender of the baby. Anthro software was used for statistical analysis.

Results

Gender egalitarianism was found with regards to education. However, significant difference was noted in the employment status of men and women. Overall, sex ratio was in favor of girls. Though gender inequality was evident from the results, it was more in favor of girls. There was no evidence of gender bias for immunization of children. It was observed that more boys were stunted than girls and almost equal proportion of boys and girls were wasted.

Conclusions

Factors like high literacy, control over income, access to financial resources made women more empowered and such empowered women were less likely to show son preference. Hence, there was no gender inequality among children in the present study.

Examining the rural-urban divide in predisposing, enabling, and need factors of unsafe abortion in India using Andersen's behavioral model

BACKGROUND

The prevalence of unsafe abortions significantly varies with geography; therefore, more research is needed to understand the rural-urban differences in unsafe abortion practices in India. The present study aims to explore the rural-urban differences in predisposing, enabling, and need factors of unsafe abortion in India.

METHODS

The present study used the fourth round of the National Family Health Survey (2015-16) and included the women aged 15-49 who terminated pregnancies by induced abortion during the 5 years prior to the survey (N = 9113) as the study sample. Descriptive statistics, bivariate chi-square significance test and multivariate logistic regression model were used to accomplish the study objectives.

RESULTS

The findings revealed that almost one-third of pregnancies were terminated through unsafe measures with sharp rural-urban contrast. The likelihood of unsafe abortions increases with decreasing women's age and spousal level of education. Younger women in urban settings were more vulnerable to unsafe abortion practices. In rural settings, women with an uneducated spouse are more likely to have unsafe abortions (OR: 1.92). Poor households were more likely to undergo unsafe abortions, which were more common in rural settings (OR: 1.26). The unmet need for family planning was revealed to be a significant need factor for unsafe abortion, particularly in rural settings.

CONCLUSION

Although abortion is legal, India's high estimated frequency of unsafe abortions reveals a serious public health issue. Due to socio-economic vulnerability, unmet family planning needs, and a lack of awareness, significant numbers of women still practice unsafe abortions in India.

Trust Deficit in Surgical Systems in an Urban Slum in India Under Universal Health Coverage: A Mixed Method Study

Objectives: We carried out a mixed method study to understand why patients did not avail of surgical care in an urban slum in India.

Methods: In our earlier study, we found that out of 10,330 people, 3.46% needed surgery; 42% did not avail of surgery (unmet needs). We conducted a follow-up study to understand reasons for not availing surgery, 141 in met needs, 91 in unmet needs. We administered 2 instruments, 16 in-depth interviews and 1 focused group discussion.

Results: Responses from the 2 groups for “the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting” scale did not have significant difference except for, prescription of medicines, patients with unmet needs were less likely to agree (p = 0.076). Results between 2 groups regarding “Patient perceptions of quality” did not show significant difference except for doctors answering questions where a higher proportion of unmet need group agreed (p = 0.064). Similar observations were made in the in depth interviews and focus group.

Conclusion: There is a need for understanding trust issues with health service delivery related to surgical care for marginalized populations.

Epidemiology of sepsis and risk factors for mortality in intensive care unit: a hospital based prospective study in South India

OBJECTIVE

The present study was aimed at elucidating the epidemiology of sepsis, with a special emphasis on identifying the common bacterial aetiology, proportion of infections caused by multi-drug resistant (MDR) bacteria, and risk factors associated with 28-day mortality at a university hospital in South India.

METHODS

A prospective study was undertaken from January 2017 to March 2018. Adult patients with the diagnosis of sepsis requiring intensive care unit (ICU) care were recruited. Baseline clinical, epidemiological, and laboratory data were recorded, and their association with 28-day mortality was assessed using logistic regression models.

RESULTS

400 subjects with a qSOFA score ≥2 at the time of ICU admission were included in the study. The mean age was 55.7 ± 16.6 years, and 69% were males. The mean SOFA score at the time of admission was 9.9 ± 2.7. Bacterial aetiology of sepsis was established in 53.5% of cases and 24% were caused by MDR pathogens. Carbapenem resistance was observed in 37% of the Gram-negative isolates. Escherichia coli (34.1%) was the leading pathogen. Overall, the 28-day mortality in ICU was 40%. 38% died within 48 h of ICU admission. Hypertension and SOFA > 9, male gender, and baseline-creatinine values >2.4 mg/dl were risk factors for mortality.

CONCLUSIONS

Male gender, hypertension, SOFA > 9, and increased creatinine were identified as the predictors for mortality. Infectious aetiology remained undetected in nearly half of the cases using routine microbiology culture methods. Mortality within the first 48 h of admission to ICU is high and prompts the need for increasing awareness about early sepsis diagnosis in community health care settings.

Why is women's utilization of a publicly funded health insurance low?: a qualitative study in Tamil Nadu, India

BACKGROUND

The continuing impetus for universal health coverage has given rise to publicly funded health insurance schemes in lower-middle income countries. However, there is insufficient understanding of how universal health coverage schemes impact gender equality and equity. This paper attempts to understand why utilization of a publicly funded health insurance scheme has been found to be lower among women compared to men in a southern Indian state. It aims to identify the gender barriers across various social institutions that thwart the policy objectives of providing financial protection and improved access to inpatient care for women.

METHODS

A qualitative study on the Chief Minister's Comprehensive Health Insurance Scheme was carried out in urban and rural impoverished localities in Tamil Nadu, a southern state in India. Thirty-three women and 16 men who had a recent history of hospitalization and 14 stakeholders were purposefully interviewed. Transcribed interviews were content analyzed based on Naila Kabeer's Social Relations Framework using gender as an analytical category.

RESULTS

While unpacking the navigation pathways of women to utilize publicly funded health insurance to access inpatient care, gender barriers are found operating at the household, community, and programmatic levels. Unpaid care work, financial dependence, mobility constraints, and gender norms emerged as the major gender-specific barriers arising from the household. Exclusions from insurance enrollment activities at the community level were mediated by a variety of social inequities. Market ideologies in insurance and health, combined with poor governance by State, resulted in out-of-pocket health expenditures, acute information asymmetry, selective availability of care, and poor acceptability. These gender barriers were found to be mediated by all four institutions-household, community, market, and State-resulting in lower utilization of the scheme by women.

CONCLUSIONS

Health policies which aim to provide financial protection and improve access to healthcare services need to address gender as a crucial social determinant. A gender-blind health insurance can not only leave many pre-existing gender barriers unaddressed but also accentuate others. This paper stresses that universal health coverage policy and programs need to have an explicit focus on gender and other social determinants to promote access and equity.

Assessing cardiovascular disease risk factor screening inequalities in India using Lot Quality Assurance Sampling

Background

Cardiovascular diseases (CVDs) are the leading cause of mortality in India. India has rolled out Comprehensive Primary Health Care (CPHC) reforms including population based screening for hypertension and diabetes, facilitated by frontline health workers. Our study assessed blood pressure and blood sugar coverage achieved by frontline workers using Lot Quality Assurance Sampling (LQAS).

Methods

LQAS Supervision Areas were defined as catchments covered by frontline workers in primary health centres in two districts each of Uttar Pradesh and Delhi. In each Area, 19 households for each of four sampling universes (males, females, Above Poverty Line (APL) and Below Poverty Line (BPL)) were visited using probability proportional to size sampling. Following written informed consent procedures, a short questionnaire was administered to individuals aged 30 or older using tablets related to screening for diabetes and hypertension. Using the LQAS hand tally method, coverage across Supervision Areas was determined.

Results

A sample of 2052 individuals was surveyed, median ages ranging from 42 to 45 years. Caste affiliation, education levels, and occupation varied by location; the sample was largely married and Hindu. Awareness of and interaction with frontline health workers was reported in Uttar Pradesh and mixed in Delhi. Greater coverage of CVD risk factor screening (especially blood pressure) was seen among females, as compared to males. No clear pattern of inequality was seen by poverty status; some SAs did not have adequate BPL samples. Overall, blood pressure and blood sugar screening coverage by frontline health workers fell short of targeted coverage levels at the aggregate level, but in all sites, at least one area was crossing this threshold level.

Conclusion

CVD screening coverage levels at this early stage are low. More emphasis may be needed on reaching males. Sex and poverty related inequalities must be addressed by more closely studying the local context and models of service delivery where the threshold of screening is being met. LQAS is a pragmatic method for measuring program inequalities, in resource-constrained settings, although possibly not for spatially segregated population sub-groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05914-y.

Evaluation of a community-based intervention for health and economic empowerment of marginalized women in India

BACKGROUND

Empowered women have improved decision-making capacity and can demand equal access to health services. Community-based interventions based on building women's groups for awareness generation on maternal and child health (MCH) are the best and cost-effective approaches in improving their access to health services. The present study evaluated a community-based intervention aimed at improving marginalized women's awareness and utilization of MCH services, and access to livelihood and savings using the peer-led approach from two districts of India.

METHODS

We used peer educators as mediators of knowledge transfer among women and for creating a supportive environment at the household and community levels. The intervention was implemented in two marginalized districts of Uttar Pradesh, namely Banda and Kaushambi. Two development blocks in each of the two districts were selected randomly, and 24 villages in each of the four blocks were selected based on the high percentage of a marginalized population. The evaluation of the intervention involved a non-experimental, 'post-test analysis of the project group' research design, in a mixed-method approach. Data were collected at two points in time, including qualitative interviews at the end line and tracking data of the intervention population (n = 37,324) through an online management information system.

RESULTS

Most of the women in Banda (90%) and Kaushambi (85%) attended at least 60% of the education sessions. Around 39% of women in Banda and 35% of women in Kaushambi registered for the livelihood scheme, and 94 and 80% of them had worked under the scheme in these two places, respectively. Women's awareness about MCH seemed to have increased post-intervention. The money earned after getting work under the livelihood scheme or from daily savings was deposited in the bank account by the women. These savings helped the women investing money at times of need, such as starting their work, in emergencies for the medical treatment of their family members, education of their children, etc. CONCLUSION: Peer-led model of intervention can be explored to improve the combined health and economic outcomes of marginalized women.

Gender bias in hospitalization financing from borrowings, selling of assets, contribution from relatives or friends in India

Background

Studies from India have documented gender differentials in hospitalization financing. Much of this work focused either on children or adults, but not across age-groups. No research to date has focused on gender differentials in case of catastrophic hospitalization expenditures. This study assesses gender differentials in distressed financing (borrowing, selling of assets, contributions from relatives or friends) for hospitalization in cases of catastrophic expenditures for hospitalization in India, for young, adult and older adult patients.

Methods

We conducted a cross-sectional analysis of India’s 2017-18 National Sample Survey, which collected data on hospitalization and expenditures. We used multivariable probit regression and adjusted marginal effects to assess the associations between gender and the use of distressed financing for catastrophic hospitalization expenditures. Models were stratified by age, and run both with and without sample selection. Secondary analyses assessed gender differentials in the use of distressed financing for hospitalization in case of health insurance cover or not.

Results

Multivariable sample selection-adjusted probit regression shows that in households which incurred severe catastrophic hospitalization expenditures, the probability of using distressed financing for hospitalization of young or older females was 10% points lower than their male counterparts. In households which did not incur severe catastrophic hospitalization expenditures, there was no significant gender differential in use of distressed financing for hospitalization for any age group. In households which incurred severe catastrophic hospitalization expenditures, the probability of using distressed financing for hospitalization was lower for older females than for older males irrespective of health insurance cover.

Conclusion

There appears to be a clear gender discrimination in distressed financing of hospitalization costs among younger and older individuals in households that incurred severe catastrophic hospitalization expenditures in India. Health systems should consider how to otherwise support necessary hospitalization financing for girls and older women.

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Young and older females experience bias in hospitalization financing.

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Biases were concentrated in severe catastrophic hospitalization expenditures.

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Health insurance did not protect older females against this gender bias.

Effect of weight loss on the retinochoroidal structural alterations among patients with exogenous obesity

PURPOSE

To evaluate the changes in the retinochoroidal vasculature in patients with exogenous obesity using swept-source optical coherence tomography (SS-OCT) and OCT angiography (OCTA).

METHODS

In this prospective study, 60 patients diagnosed with obesity (47 males) (mean age: 46.47±10.9 years) were included, of which 30 patients underwent bariatric surgery (Group A), and 30 patients underwent conservative management (exercise/diet) (Group B). Parameters including choroidal thickness (CT), choroidal vascularity index (CVI) and retinal capillary density index (CDI) and arteriovenous ratio (AVR) were measured at the baseline and three months follow up. 30 eyes (30 age and gender-matched) of normal participants were included for comparison.

RESULTS

Baseline CT was lower in 60 participants with obesity compared to controls. Compared with normal subjects, subjects with obesity had higher mean CVI (0.66±0.02 versus 0.63±0.04; p<0.01), smaller FAZ area (0.26±0.07 versus 0.45±0.32; p<0.01), higher CDI (superficial plexus: 0.7±0.04 versus 0.68±0.06; p = 0.04, deep plexus: 0.38±0.02 versus 0.35±0.06; p = 0.01), and lower AVR (0.68±0.05 versus 0.70±0.03 versus; p<0.01). At 3-month after intervention, CT showed a significant increase in participants from Group A (329.27±79μm; p<0.01) but not in Group B from baseline. No significant change was noted in CVI or CDI at 3-month in either group compared to baseline. AVR significantly increased in Group B (p = 0.03).

CONCLUSION

Subclinical changes in retinochoroidal vasculature occurs in participants with exogenous obesity compared to healthy subjects. Surgical intervention (bariatric surgery) may have a favorable outcome on the choroidal thickness in these patients.