The Plasma Glucose Threshold Values Associated with Adverse Pregnancy Outcomes Among Asian Indian Pregnant Women: MAASTHI Birth Cohort Analysis.

Background: To assess the association of adverse pregnancy and infant outcomes with different cut-off levels of glucose intolerance during pregnancy in the MAASTHI cohort. Design: Pregnant women (n = 1470) underwent Oral glucose tolerance test between 24 and 36 weeks using a 75-g oral glucose load, with plasma glucose estimations measured at fasting and two hours later. Follow-up was done within 72 hours of delivery for recording type of delivery, infant weight, mid-upper arm circumference, and skinfold thickness. Results: The odds of having higher skinfold thickness (>90th percentile) were 43% higher (AOR = 1.43; 95% CI: 1.18, 1.74) and the odds of being overweight at birth was 34% higher (AOR = 1.34; 95% CI: 1.09, 1.62) for every 1 standard deviation (9.9 mg/dL) increase in fasting plasma glucose (FPG) in male infants. The odds of delivering via caesarean section were 45% higher in women with female foetus (1.45,95% CI 1.15,1.82) for every one SD (23.4 mg/dl) increase in 2-h post-load Glucose. Conclusion: The impact of maternal glucose levels on infant and maternal outcomes differed notably between sex of the child. Compared to female infants, male infants exhibited a stronger association with elevated risks for adverse outcomes, including higher infant weight and increased skinfold thickness.

Glucose intolerance, in simple terms, refers to a condition where the body has difficulty processing sugar (glucose) properly. Normally, when we eat, our body breaks down carbohydrates into glucose, which is then used by cells for energy. However, in glucose intolerance, this process does not work as efficiently. This can lead to higher-than-normal blood sugar levels, which, if persistent, can increase the risk of developing type 2 diabetes over time. In this study, the researchers investigated how glucose intolerance during pregnancy results in negative health outcomes in mothers and infants in a South Indian City. This is significant as the adverse impact of glucose intolerance in Indian women is not widely studied. The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study was considered by WHO for defining GDM diagnosis primarily focused on Caucasian populations. Given the known ethnic differences in glucose metabolism and the high prevalence of gestational diabetes in India, understanding glucose intolerance, specifically in Indian women, is essential. In this research, all pregnant mothers underwent an oral glucose tolerance test between the 24th and 36th weeks of pregnancy. They fasted for 12 hours before their blood samples were taken to measure their fasting glucose levels. Then, they drank a glucose solution containing 75 g of glucose. After waiting for 2 hours, their glucose levels were measured again. Those with fasting glucose levels equal to or greater than 92 mg/dl and 2-hour post-load plasma glucose levels equal to or greater than 153 mg/dl were diagnosed with gestational diabetes mellitus (GDM). After delivery, the weight and fat deposition under the skin; known as skinfold thickness (adiposity) were measured using a skinfold caliper. The risks of higher weight and skinfold were seen in male infants compared to female infants. The overall risk of adiposity and C-section were higher than those reported in the HAPO study, highlighting the need for large-scale studies among the Indian population to better understand and address these associations.

A realist evaluation of the implementation of a national tobacco control program and policy in India.

There is a growing interest in studying and unpacking implementation of policies and programmes as it provides an opportunity to reduce the policy translation time lag taken for research findings to translate to policies and get implemented and understand why policies may fail. Realist evaluation is a theory-driven approach that embraces complexity and helps to identify the mechanisms generating the observed policy outcomes in given context. We aimed to study facilitators and barriers while implementing the Cigarettes and Other Tobacco Products Act, 2003 (COTPA) a comprehensive national tobacco control policy, and the National Tobacco Control Programme (NTCP), 2008 using realist evaluation. We developed an initial program theory (IPT) based on a realist literature review of tobacco control policies in Low- and Middle-Income Countries (LMICs). Three diverse states -Kerala, West Bengal, and Arunachal Pradesh- with varying degree of implementation of tobacco control law and program were chosen as case studies. Within the three selected states, we conducted in-depth interviews with 48 state and district-level stakeholders and undertook non-participant observations to refine the IPT. Following this, we organized two regional consultations covering stakeholders from 20 Indian states for a second iteration to further refine the program theory. A total of 300 Intervention-Context-Actor-Mechanism-Outcome (ICAMO) configurations were developed from the interview data, which were later synthesized into state-specific narrative program theories for Kerala, West Bengal and Arunachal Pradesh. We identified five mechanisms: collective action, felt accountability, individual motivation, fear, and prioritization that were (or were not) triggered leading to diverse implementation outcomes. We identified facilitators and barriers to implementing the COTPA and the NTCP, which have important research and practical implications for furthering the implementation of these policies as well as implementation research in India. In the future, researchers could build on the refined program theory proposed in this study to develop a middle-range theory to explain tobacco control policy implementation in India and other LMICs.

Training of Community Health Workers in Diabetes Lead to Improved Outcomes for Diabetes Screening and Management in Low- and Middle-Income Countries: Protocol for a Systematic Review.

BACKGROUND: Diabetes is a growing concern worldwide, particularly in low- and middle-income countries (LMICs). Type 2 diabetes mellitus constitutes a significant proportion of cases and is associated with debilitating microvascular complications. Type 2 diabetes mellitus is steadily increasing among the LMICs where many barriers to health care exist. Thus, task shifting to community health workers (CHWs) has been proposed as a solution to improve diabetes management in these settings. However, CHWs often lack the necessary training to manage diabetes effectively. Thus, a systematic review is required to present evidence of the highest degree for this intervention. OBJECTIVE: This study aims to establish the protocols for a systemic review. METHODS: Using the Participants Intervention Comparator Outcome Time Study Design (PICOTS) framework, this study outlines a systematic review aiming to evaluate the impact of training programs for CHWs in diabetes management in LMICs. Quantitative studies focusing on CHWs, diabetes training, focusing on diabetes management outcomes like hemoglobin A1c levels and fasting blood glucose levels, between January 2000 and December 2023 and found on databases such as PubMed, Ovid MEDLINE, Evidence Based Medicine Reviews, BASE, Google Scholar, and Web of Science will be included. We will include randomized controlled trials but will also include observational studies if we find less than 5 randomized controlled trials. An author committee consisting of 3 reviewers will be formed, where 2 reviewers will conduct the review independently while the third will resolve all disputes. The Cochrane Methods Risk of Bias Tool 2 will be used for assessing the risk of bias and the Grading of Recommendations, Assessment, Development and Evaluation approach for the meta-analysis and narrative synthesis analysis will be used. The results will be presented in a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram. RESULTS: The review will begin in May 2024 and conclude in 3 months. CONCLUSIONS: The review will synthesize existing evidence and provide insights into the effectiveness of such programs, informing future research and practice in diabetes care in LMICs. TRIAL REGISTRATION: PROSPERO CRD42022341717; https://tinyurl.com/jva2hpdr. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/57313.

Low levels of Vitamin D during pregnancy associated with gestational diabetes mellitus and low birth weight: results from the MAASTHI birth cohort.

Introduction: India has a high prevalence of Vitamin D insufficiency among women of childbearing age. In this study, we aimed to evaluate the potential relationship between Vitamin D deficiency and gestational diabetes mellitus (GDM) and low birth weight (LBW) of newborns in the "Maternal antecedents of adiposity and studying the transgenerational role of hyperglycaemia and insulin" (MAASTHI) birth cohort. Methods: A prospective cohort study involving 230 participants was conducted in public hospitals located in urban Bengaluru, India. Healthy pregnant women who visited these hospitals for antenatal care (ANC) and who were between 14 and 36 weeks of gestational age were recruited after obtaining their informed consent. An oral glucose tolerance test (OGTT) was administered between 24 and 36 weeks of pregnancy and blood samples were preserved at -80°C for Vitamin D analysis. Follow-up at birth included recording the child's birth weight. Results: We found that 178 (77.4%) of the study participants were vitamin D deficient, 44 (19.1%) were diagnosed with GDM, and 64 (27.8%) gave birth to LBW babies. Women in the lowest quartile of serum Vitamin D levels had three times higher odds of developing GDM than women in the higher quartiles [OR = 3.22 (95% CI: 1.03, 10.07), p = 0.04] after adjusting for age, parity, socioeconomic status, season, and adiposity. For every one-unit increase in Vitamin D levels, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) decreased by nearly 18%. Furthermore, causal mediation analysis showed that a decrease in one unit of Vitamin D is associated with a decrease of 0.015 units of fasting blood sugar (FBS) and 0.019 units of postprandial blood sugar (PPBS) as it flows through the mediator variable insulin resistance. Vitamin D-deficient women were twice at risk of giving birth to LBW babies (OR 2.04, 95% CI 0.99, 4.19, p = 0.05). Discussions: Low levels of Vitamin D during pregnancy are associated with a greater risk of pregnant women developing GDM and giving birth to LBW babies in urban Bengaluru.

Correction: The importance of investing in data, models, experiments, team science, and public trust to help policymakers prepare for the next pandemic.

[This corrects the article DOI: 10.1371/journal.pgph.0002601.].

Corrigendum: What Is the Modern Human Eating? Dietary Transition of the Age-Old to the Modern Man of India.

[This corrects the article DOI: 10.3389/phrs.2022.1604058.].

Undesirable Levels of Practice Behaviours and Associated Knowledge amongst Community Health Workers in Rural South India Responsible for Type 2 Diabetes Screening and Management.

BACKGROUND: Type 2 diabetes (T2DM) poses an enormous global health care challenge, especially among rural communities. Healthcare in these areas can be inadequate and inaccessible due to socio-demographic barriers. To overcome this situation, many low- and middle-income countries are resorting to task shifting, using community health workers (CHWs) for diabetes management. However, its successful implementation depends on the practice behaviours and knowledge of these workers. OBJECTIVE: This cross-sectional study aimed to evaluate the proficiency of CHWs involved in diabetes screening and management in rural South India by identifying the existing practice behaviours and knowledge gaps. METHODS: Employing a customised questionnaire, developed through inputs from experts and government officials, we assessed practice behaviours and the corresponding knowledge base of 275 CHWs. Analytical methodologies consisted of descriptive statistics, logistic regression, and mosaic plots for comprehensive data interpretation. RESULTS: The study showcased significant deficiencies in both practice behaviours (97%) and knowledge (95%) with current mean levels ranging from 48 to 50%, respectively, among the participants. The identified areas of insufficiency were broadly representative of the core competencies required for effective diabetes management, encompassing diabetes diagnosis and referral, HbA1c testing, diabetes diet, diabetes type and self-management, microvascular complications and their screening, peripheral neuropathy management, and diabetes risk assessment. In several areas, correct practice behaviour was reported by a relatively large number of CHWs despite incorrect answers to the related knowledge questions such as referral to the health centres, self-management, and calculation of diabetes risk assessment. CONCLUSION: This study highlights widespread deficiencies (97% CHWs) in diabetes management practices and knowledge (95% CHWs). To overcome these deficiencies, a thorough needs assessments is vital for effective CHW training. Training of CHWs should not only identify prior knowledge and/or behaviour but also their interrelationship to help create a robust and flexible set of practice behaviours.

Assessing the Burden of COVID-19 among Children Aged 6-14 Years in Karnataka, India: A Cross-sectional Survey.

Background: India experienced three coronavirus disease (COVID-19) waves, with the third attributed to the highly contagious Omicron variant. Before the national vaccination rollout for children above 6, understanding severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin G (IgG) positivity in the pediatric population was essential. This study aims to assess the burden of Covid-19 infection and to estimate the seroprevalence in children aged 6 to 14 years in the state of Karnataka. Material and Methods: We surveyed 5,358 children aged 6-14 across Karnataka using 232 health facilities, from June 6 to 14, 2022. We determined the sample size using the PPS (Population Proportional to Size) technique and employed cluster sampling. We tested all participants for SARS-CoV-2 IgG with an enzyme-linked immunosorbent assay (ELISA) kit and SARS-CoV-2 RNA with reverse transcription-polymerase chain reaction (RT-PCR). We sequenced samples with a cycle threshold (CT) value below 25 using whole genomic sequencing (WGS). Result: We found an adjusted seroprevalence of IgG at 75.38% statewide, and we found 0.04% of children RT-PCR positive for COVID-19. We determined a case-to-infection ratio of 1:37 and identified the SARS-CoV-2 strains as Omicron, BA.5, and BA.2.10. Conclusion: The study showed a high seroprevalence of IgG among children with low active infection. Omicron, BA. 5, and BA. 2.10 variants were detected through WGS.

Are advertising policies affirmative in restricting the marketing of foods high in fat, salt and sugar (HFSS) in India?: evidence from SWOT Analysis.

The regulatory Indian environment for advertising high fat, salt, and sugar (HFSS) foods and non-alcoholic beverages, on various media was reviewed. Identified national-level policies were categorised as mandatory or self-regulatory based on legal content. For each mandatory regulation, Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was undertaken to determine how existing policies could be strengthened to safeguard children from unhealthy food advertisements. Thirteen policies (nine mandatory; four self-regulatory) relevant to advertising in India were identified. Of the nine mandatory policies, Guidelines for Prevention of Misleading Advertisements and Endorsements for Misleading Advertisements, 2022, is the only policy that restricts HFSS food advertisements to children across all media. There are key shortfalls, including limited scope of 'child-targeted' advertisements and lack of criteria to define HFSS foods. A robust regulatory framework is needed to protect children from HFSS food marketing, not just what is 'directed' at them, with clear evidence-based food classification criteria.

Correction: Contact tracing of COVID-19 in Karnataka, India: Superspreading and determinants of infectiousness and symptomatic infection.

[This corrects the article DOI: 10.1371/journal.pone.0270789.].

The importance of investing in data, models, experiments, team science, and public trust to help policymakers prepare for the next pandemic.

The COVID-19 pandemic has brought about valuable insights regarding models, data, and experiments. In this narrative review, we summarised the existing literature on these three themes, exploring the challenges of providing forecasts, the requirement for real-time linkage of health-related datasets, and the role of 'experimentation' in evaluating interventions. This literature review encourages us to broaden our perspective for the future, acknowledging the significance of investing in models, data, and experimentation, but also to invest in areas that are conceptually more abstract: the value of 'team science', the need for public trust in science, and in establishing processes for using science in policy. Policy-makers rely on model forecasts early in a pandemic when there is little data, and it is vital to communicate the assumptions, limitations, and uncertainties (theme 1). Linked routine data can provide critical information, for example, in establishing risk factors for adverse outcomes but are often not available quickly enough to make a real-time impact. The interoperability of data resources internationally is required to facilitate sharing across jurisdictions (theme 2). Randomised controlled trials (RCTs) provided timely evidence on the efficacy and safety of vaccinations and pharmaceuticals but were largely conducted in higher income countries, restricting generalisability to low- and middle-income countries (LMIC). Trials for non-pharmaceutical interventions (NPIs) were almost non-existent which was a missed opportunity (theme 3). Building on these themes from the narrative review, we underscore the importance of three other areas that need investment for effective evidence-driven policy-making. The COVID-19 response relied on strong multidisciplinary research infrastructures, but funders and academic institutions need to do more to incentivise team science (4). To enhance public trust in the use of scientific evidence for policy, researchers and policy-makers must work together to clearly communicate uncertainties in current evidence and any need to change policy as evidence evolves (5). Timely policy decisions require an established two-way process between scientists and policy makers to make the best use of evidence (6). For effective preparedness against future pandemics, it is essential to establish models, data, and experiments as fundamental pillars, complemented by efforts in planning and investment towards team science, public trust, and evidence-based policy-making across international communities. The paper concludes with a 'call to actions' for both policy-makers and researchers.

Psychosocial and sociodemographic factors associated with gestational blood glucose levels in women attending public hospitals: Results from baseline of MAASTHI cohort.

BACKGROUND: Understanding psychosocial environment is important for improving maternal and fetal health outcomes during pregnancy. We aimed to identify the association between gestational blood glucose levels and psychosocial and demographic factors in pregnant women. METHODS: In the MAASTHI pregnancy cohort in Bengaluru, we assessed depressive symptoms, and social support using validated scales at baseline in first trimester. A 2-hour 75 g oral glucose tolerance test (OGTT) was administered between 24-36 weeks of gestation. We examined the relation between psychosocial factors assessed at baseline and gestational blood glucose levels in second/third trimester using multivariate linear regression and explored association between serum cortisol and gestational blood glucose levels in subgroup samples. RESULTS: We found that 9% of pregnant women had depressive symptoms and 14.3% had Gestational Diabetes Mellitus (GDM). Psychosocial factors, including depressive symptoms, have a significant correlation with gestational fasting(ß = 0.12, p-value<0.05) and postprandial blood sugar level(ß = 0.23, p-value<0.05) and poor social support were found to have a significant association with gestational fasting blood glucose levels(ß = 1.45, p-value <0.05) and postprandial blood sugar levels(ß = 2.60, p-value <0.05). The sociodemographic factors such as respondent education, occupation, social and economic status were associated with gestational blood sugar after adjusting for potential confounder variables. CONCLUSION: Depressive symptoms and poor social support earlier in pregnancy were significantly associated with increased gestational blood glucose levels. Early detection and recognition of modifiable psychosocial risk factors can reduce glucose intolerance during pregnancy. Evaluating the benefits of screening for psychosocial factors and timely management of gestational diabetes mellitus can be helpful in India.

Statistical analysis plan and protocol updates for Gestational diabetes in Uganda and India: Design and Evaluation of Educational Films for Improving Screening and Self-management (GUIDES) trial.

BACKGROUND: Timely detection and management of gestational diabetes mellitus (GDM) have been identified as a high priority for policymakers in low- and middle-income countries (LMICs). The GUIDES trial will evaluate a package of three interconnected film-based interventions aimed at improving the timely detection and management of GDM. The protocol for this trial has previously been published; this publication outlines the statistical analysis plan for the trial. METHODS AND DESIGN: The GUIDES study is a multi-country cluster-randomised controlled trial consisting of one trial conducted in Uganda and one in India (30 clusters in each country). Mixed effects models will be used to compare the primary study outcomes of the proportion of women who are tested for GDM between 24 and 32 weeks of pregnancy and the mean fasting blood sugar of women with GDM at 34-week follow-up while accounting for clustering. Secondary analyses will compare the proportion of women with self-reported GDM diagnosis at 32 weeks of pregnancy and the proportion of women with adverse perinatal outcomes related to GDM up to 4 weeks after birth in each trial arm. TRIAL STATUS AND DISCUSSION: Follow-up is expected to end in March 2023 in Uganda and in May 2023 in India. Analyses will be carried out following this statistical analysis plan in the month following trial completion. TRIAL REGISTRATION: ClinicalTrials.gov NCT03937050. Registered on 3 May 2019. Clinical Trials Registry India CTRI/2020/02/023605. Registered on 26 February 2020.

Association of high cortisol levels in pregnancy and altered fetal growth. Results from the MAASTHI, a prospective cohort study, Bengaluru.

Background: The role of maternal stress levels on mothers' mental health and fetal growth has been previously studied. However, the evidence linking cortisol exposure during pregnancy to growth outcomes in infants is sparsely available from lower and middle-income countries. We aim to investigate the association of serum cortisol levels in pregnancy with infant birth outcomes and postpartum depressive symptoms in a public health facility in India. Methods: The current study is a part of the maternal antecedents of adiposity and studying the transgenerational role of hyperglycemia and insulin (MAASTHI) prospective cohort. We assessed the relationship between maternal exposure to serum cortisol and adverse neonatal outcomes and postpartum depressive symptoms. Serum cortisol levels in stored blood samples were measured in 230 pregnant women as a biomarker for stress during pregnancy. Pregnant women between 18 and 45 years of age were recruited for the study, presenting at ≥14 weeks of gestation and providing voluntary written informed consent. The Edinburgh Postnatal Depression Scale assessed postpartum depressive symptoms, and detailed infant anthropometric measurements were carried out at birth. Findings: We found that higher levels (>17.66 µg/L) are significantly associated with low birth weight (OR = 2.28; 95% CI 1.21-4.32) and lower weight for length (OR = 2.16; 95% CI 1.07-4.35). The odds of developing postpartum depressive symptoms in pregnant women with higher mean cortisol cut-off levels is 2.3-fold [OR: 2.33, 95% CI (1.17, 4.64)] compared than women with lower cortisol levels. No significant association was found between serum cortisol and infants' birth weight for gestational age, head circumference, the sum of skinfold thickness, and crown-rump length. Interpretation: Our results support the hypothesis that higher maternal cortisol levels may adversely impact birth weight, weight for length in newborns, and postpartum depressive symptoms in mothers. Funding: This study was supported by the India Alliance Senior Fellowship [Grant No. IA/CPHS/20/1/505278] awarded to Giridhara R. Babu.

Maternal depressiveness and infant growth outcomes: Findings from the MAASTHI cohort study in India.

OBJECTIVE: The study aims to examine the association between depressiveness in mothers on infant obesity and stunting at one year of age. METHODS: We enrolled 4829 pregnant women, followed them up at public health facilities in Bengaluru for one year after birth. We collected information on women's sociodemographic characteristics, obstetric history, depressive symptoms during pregnancy and delivery within 48 h. We took infant anthropometric measurements at birth and one year. We used chi-square tests, and calculated an unadjusted odds ratio using univariate logistic regression. We used multivariate logistic regression to examine the association between maternal depressiveness, childhood adiposity, and stunting. RESULTS: We found that the prevalence of depressiveness was 31.8% in mothers who delivered in public health facilities in Bengaluru. Infants born to mothers with depressiveness at birth had 3.9 times higher odds of having larger waist circumference than infants born to mothers with no depressiveness (AOR: 3.96, 95% Confidence Interval: 1.24,12.58) and 1.9 times higher odds of having a larger sum of skinfold thickness (AOR: 1.99, 95% CI: 1.18,3.38). Additionally, we found that infants born to mothers with depressiveness at birth had 1.7 times higher odds of stunting than infants born to mothers with no depressiveness (AOR: 1.72; 95%CI: 1.22,2.43) after adjusting for confounders. CONCLUSION: Our study highlights a high prevalence of depressiveness among mothers seeking antenatal care at a public hospital is associated with an increased risk of infant adiposity and stunting at one year. Further research is needed to understand the underlying mechanisms and identify effective interventions.

Vitamin B6 Levels and Impaired Folate Status but Not Vitamin B12 Associated with Low Birth Weight: Results from the MAASTHI Birth Cohort in South India.

Vitamins B12 and B6 and folate are known to have implications for pregnancy outcomes. We aimed to describe B6, B12, and folate status in pregnancy and investigate their associations with low birth weight and preterm delivery in mothers recruited from public hospitals in urban Bengaluru. Pregnant women between 18 and 45 years were included in the MAASTHI prospective cohort study. Each participant's age, socioeconomic status, and anthropometry were recorded during baseline and followed up after delivery. Blood samples were collected between the 24th and 32nd weeks of gestation and stored at -80° for analysis. B6, B12, folate, homocysteine, and methylmalonic acid (MMA) levels were analyzed in the stored samples. We found low plasma vitamin B12, folate, and B6 levels in 48.5%, 42.0%, and 10.4% of the women (n = 230), respectively. Elevated MMA and homocysteine were observed among 73.6% and 6.1% of the women, respectively. We found B6 levels were significantly associated with birth weight (ß(SE) -0.002(0.0), p = 0.001) after adjusting for age, parity, adiposity, gestational diabetes, and socioeconomic status of the mother. Those with impaired folate deficiency were twice at risk (AOR 1.95 (1.29, 3.07), p = 0.002) of low birth weight. Vitamin B6 levels and impaired folate status were associated with low birth weight in the MAASTHI birth cohort.

Population Preferences for Primary Care Models for Hypertension in Karnataka, India.

Importance: Hypertension contributes to more than 1.6 million deaths annually in India, with many individuals being unaware they have the condition or receiving inadequate treatment. Policy initiatives to strengthen disease detection and management through primary care services in India are not currently informed by population preferences. Objective: To quantify population preferences for attributes of public primary care services for hypertension. Design, Setting, and Participants: This cross-sectional study involved administration of a household survey to a population-based sample of adults with hypertension in the Bengaluru Nagara district (Bengaluru City; urban setting) and the Kolar district (rural setting) in the state of Karnataka, India, from June 22 to July 27, 2021. A discrete choice experiment was designed in which participants selected preferred primary care clinic attributes from hypothetical alternatives. Eligible participants were 30 years or older with a previous diagnosis of hypertension or with measured diastolic blood pressure of 90 mm Hg or higher or systolic blood pressure of 140 mm Hg or higher. A total of 1422 of 1927 individuals (73.8%) consented to receive initial screening, and 1150 (80.9%) were eligible for participation, with 1085 (94.3%) of those eligible completing the survey. Main Outcomes and Measures: Relative preference for health care service attributes and preference class derived from respondents selecting a preferred clinic scenario from 8 sets of hypothetical comparisons based on wait time, staff courtesy, clinician type, carefulness of clinical assessment, and availability of free medication. Results: Among 1085 adult respondents with hypertension, the mean (SD) age was 54.4 (11.2) years; 573 participants (52.8%) identified as female, and 918 (84.6%) had a previous diagnosis of hypertension. Overall preferences were for careful clinical assessment and consistent availability of free medication; 3 of 5 latent classes prioritized 1 or both of these attributes, accounting for 85.1% of all respondents. However, the largest class (52.4% of respondents) had weak preferences distributed across all attributes (largest relative utility for careful clinical assessment: ß = 0.13; 95% CI, 0.06-0.20; 36.4% preference share). Two small classes had strong preferences; 1 class (5.4% of respondents) prioritized shorter wait time (85.1% preference share; utility, ß = -3.04; 95% CI, -4.94 to -1.14); the posterior probability of membership in this class was higher among urban vs rural respondents (mean [SD], 0.09 [0.26] vs 0.02 [0.13]). The other class (9.5% of respondents) prioritized seeing a physician (the term doctor was used in the survey) rather than a nurse (66.2% preference share; utility, ß = 4.01; 95% CI, 2.76-5.25); the posterior probability of membership in this class was greater among rural vs urban respondents (mean [SD], 0.17 [0.35] vs 0.02 [0.10]). Conclusions and Relevance: In this study, stated population preferences suggested that consistent medication availability and quality of clinical assessment should be prioritized in primary care services in Karnataka, India. The heterogeneity observed in population preferences supports considering additional models of care, such as fast-track medication dispensing to reduce wait times in urban settings and physician-led services in rural areas.

How do tobacco control policies work in low-income and middle-income countries? A realist synthesis.

BACKGROUND: The burden of tobacco use is disproportionately high in low- and middle-income countries (LMICs). There is scarce theorisation on what works with respect to implementation of tobacco control policies in these settings. Given the complex nature of tobacco control policy implementation, diversity in outcomes of widely implemented policies and the defining role of the context, we conducted a realist synthesis to examine tobacco control policy implementation in LMICs. METHODS: We conducted a systematic realist literature review to test an initial programme theory developed by the research team. We searched EBSCOHost and Web of Science, containing 19 databases. We included studies on implementation of government tobacco control policies in LMICs. RESULTS: We included 47 studies that described several contextual factors, mechanisms and outcomes related to implementing tobacco control policies to varying depth. Our initial programme theory identified three overarching strategies: awareness, enforcement, and review systems involved in implementation. The refined programme theory identifies the plausible mechanisms through which these strategies could work. We found 30 mechanisms that could lead to varying implementation outcomes including normalisation of smoking in public places, stigmatisation of the smoker, citizen participation in the programme, fear of public opposition, feeling of kinship among violators and the rest of the community, empowerment of authorised officials, friction among different agencies, group identity among staff, shared learning, manipulation, intimidation and feeling left out in the policy-making process. CONCLUSIONS: The synthesis provides an overview of the interplay of several contextual factors and mechanisms leading to varied implementation outcomes in LMICs. Decision-makers and other actors may benefit from examining the role of one or more of these mechanisms in their particular contexts to improve programme implementation. Further research into specific tobacco control policies and testing particular mechanisms will help deepen our understanding of tobacco control implementation in LMICs. PROSPERO REGISTRATION NUMBER: CRD42020191541.