Navigating intersectoral collaboration in nutrition programming: implementors' perspectives from Assam, India.

BACKGROUND: There is a growing interest in the use of intersectoral collaborative (ISC) approaches to address complex health-related issues. However, relatively little empirical research exists on the challenges of implementing, fostering and sustaining these approaches. Our study explores the perceptions and experiences of programme implementers regarding the implementation of an ISC approach, focusing on a case study of nutrition programming in Assam, India. METHODS: We conducted qualitative semi-structured face-to-face in-depth interviews with eleven programme implementers from two selected districts of Assam, India. These participants were purposefully sampled to provide a comprehensive understanding of the experiences of implementing intersectoral collaboration. Following the interviews, an inductive thematic analysis was performed on the collected data. RESULTS: The study identified three main themes: operationalisation of ISC in daily practice, facilitators of ISC, and barriers to effective ISC. These were further broken down into six subthemes: defined sectoral mandates, leadership dynamics, interpersonal relationships and engagement, collective vision and oversight, resource allocation, and power dynamics. These findings highlight the complexity of ISC, focusing on the important structural and relational aspects at the macro, meso, and micro levels. Interpersonal relationships and power dynamics among stakeholders substantially influenced ISC formation in both the districts. CONCLUSION: Despite challenges, there is ongoing interest in establishing ISC in nutrition programming, supported by political development agendas. Success relies on clarifying sectoral roles, addressing power dynamics, and engaging stakeholders systematically. Actionable plans with measurable targets are crucial for promoting and sustaining ISC, ensuring positive programme outcomes. The insights from our study provide valuable guidance for global health practitioners and policymakers dealing with similar challenges, emphasising the urgent need for comprehensive research given the lack of universally recognised policies in the realm of ISC in global health practice.

Prevalence of dyslipidemia, hypertension and diabetes among tribal and rural population in a south Indian forested region.

While NCDs are in rise globally, tribal and rural populations residing near to reserve forests with limited exposure to modern lifestyles may bear a unique burden. This study investigates the prevalence and risk factors of hypertension, diabetes, and dyslipidemia among these communities. We conducted a cross-sectional study between 2018 and 2020 in the forest-dwelling population of Chamarajanagar, India. Using multistage stratified sampling based on caste and remoteness, we enrolled 608 participants aged over 18 years, including 259 non-tribal and 349 tribal individuals. Data collection includes the administration of STEPS questionnaire and measurement of fasting blood sugar, lipid levels, and blood pressure. The prevalence of diabetes, hypertension, and dyslipidemia were 4.6%, 28.8%, and 85.7%, respectively, among the study population. We also found abnormal levels of low-density lipoprotein (LDL), high-density lipoprotein (HDL), Triglycerides (TGA), Total cholesterol (TC), and very low-density lipoprotein (VLDL)in 4.9%, 82.4%, 22.7%, 5.8%, and 7.4% of participants, respectively. Significant differences were observed in diabetes, LDL abnormality, TGA abnormality, VLDL abnormality, and TC abnormality, but not in hypertension, dyslipidemia, or HDL abnormality, across the Socio Geographic Discrimination Index. We found a significant difference in diabetes and HDL abnormality, but not in hypertension, dyslipidemia, LDL abnormality, TGA abnormality, TC abnormality, or VLDL abnormality, between tribal and non-tribal populations living in the forest-dwelling area. Waist circumference was a significant independent predictor of diabetes among tribal participants, while wealth index, age, and waist circumference were significant predictors of hypertension. There were no significant predictors for dyslipidemia among tribal participants. Our study suggests that tribal population living in a remote area are at a lower risk of developing diabetes compared to non-tribal populations living in the same geographic area. However, the prevalence of hypertension and dyslipidemia among tribal populations remains high and comparable to that of the general population.

Practices and outcomes of responsive caregiving on child neurodevelopment and mental health across diverse global populations: a scoping review protocol.

INTRODUCTION: Responsive caregiving (RC) leads to positive outcomes in children, including secure attachment with caregivers, emotional regulation, positive social interactions and cognitive development. Through our scoping review, we aim to summarise the practices and outcomes of RC in diverse caregiver and child populations from 0 to 8 years. METHODS AND ANALYSIS: We will use the Arksey and O'Malley framework and the Joanna Briggs Institute methodology for scoping reviews. We shall present our findings as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for scoping review. Only peer-reviewed, English-language articles from 1982 to 2022 will be included from PubMed, Web of Science, APA PsychInfo, APA PsycArticles, SocINDEX and Google Scholar databases. Reference lists of included articles will also be screened. The search strategy will be developed for each database, and search results will be imported into Rayyan. Screening will be done in two phases: (1) titles and abstracts will be screened by two authors and conflicts will be resolved by mutual discussion between both or by consulting with a senior author; and (2) full-texts of shortlisted studies from the first phase will then be screened using the same inclusion/exclusion criteria. A data extraction form will be developed to collate relevant information from the final list of included articles. This form will be pilot tested on the first 10 papers and iteratively refined prior to data extraction from the remaining articles. Results will be presented in figures, tables and a narrative summary. ETHICS AND DISSEMINATION: No ethics approval needed as the review shall only use already published data. We shall publish the review in an open-access, peer-reviewed journal and disseminate through newsletters, social media pages, and presentations to relevant audiences.

Ecological countermeasures to prevent pathogen spillover and subsequent pandemics.

Substantial global attention is focused on how to reduce the risk of future pandemics. Reducing this risk requires investment in prevention, preparedness, and response. Although preparedness and response have received significant focus, prevention, especially the prevention of zoonotic spillover, remains largely absent from global conversations. This oversight is due in part to the lack of a clear definition of prevention and lack of guidance on how to achieve it. To address this gap, we elucidate the mechanisms linking environmental change and zoonotic spillover using spillover of viruses from bats as a case study. We identify ecological interventions that can disrupt these spillover mechanisms and propose policy frameworks for their implementation. Recognizing that pandemics originate in ecological systems, we advocate for integrating ecological approaches alongside biomedical approaches in a comprehensive and balanced pandemic prevention strategy.

Validation of ToucHb, a non-invasive haemoglobin estimation: Effective for normal ranges, needs improvement for anaemia detection.

Non-invasive methods for haemoglobin estimation hold enormous potential for early detection and treatment of anaemia, especially in limited resource settings. We sought to validate the diagnostic accuracy of ToucHb, a non-invasive haemoglobin estimation device available in the Indian market. We prospectively evaluated the diagnostic performance of the ToucHb device using the Automated complete blood count (CBC) method as the gold standard. Persons referred for haemoglobin estimation to the central laboratory of the government medical college hospital in Mysore, southern India were included in the study. Out Of 140 people approached, 127 gave consent; 65% (n = 82) were female with median age of 37 (IQR 28-45). ToucHB reported median haemoglobin value of 14 g/dL compared to 13.3 g/dL for CBC. Within 1 g/dL and 2 g/dL of CBC, 55.2% (70/127) and 74% (94/127) of ToucHb haemoglobin observations fell, respectively. The Bland-Altman plot showed a mean difference of 3 g/dL in haemoglobin between ToucHb and CBC among those with anaemia. The ToucHb device showed 22.2% sensitivity and 94.5% specificity for anaemia detection. In rural resource-limited settings, point of care non-invasive devices such as ToucHb can improve access and acceptance for anaemia screening. However, ToucHb has showed low sensitivity for anaemia detection and low accuracy at lower haemoglobin values. The utility of the instrument is especially limited in detecting anaemia, while it can estimate haemoglobin accurately among those with haemoglobin is in the normal range. Based on these findings, ToucHb and devices that work on the core technology deployed in ToucHb may be better suited to monitor known haemoglobin level rather than in anaemia screening or detection in primary/ secondary care and community settings.

Disproportionate infection, hospitalisation and death from COVID-19 in ethnic minority groups and Indigenous Peoples: an application of the Priority Public Health Conditions analytical framework.

The COVID-19 pandemic has resulted in disproportionate consequences for ethnic minority groups and Indigenous Peoples. We present an application of the Priority Public Health Conditions (PPHC) framework from the World Health Organisation (WHO), to explicitly address COVID-19 and other respiratory viruses of pandemic potential. This application is supported by evidence that ethnic minority groups were more likely to be infected, implying differential exposure (PPHC level two), be more vulnerable to severe disease once infected (PPHC level three) and have poorer health outcomes following infection (PPHC level four). These inequities are driven by various interconnected dimensions of racism, that compounds with socioeconomic context and position (PPHC level one). We show that, for respiratory viruses, it is important to stratify levels of the PPHC framework by infection status and by societal, community, and individual factors to develop optimal interventions to reduce inequity from COVID-19 and future infectious diseases outbreaks.

Response to correspondence article on the research protocol titled Towards Health Equity and Transformative Action on tribal health (THETA) studyto describe, explain and act on tribal health inequities in India: A health systems research study protocol.

In this correspondence, we, co-authors and collaborators involved in the Towards Health Equity and Transformative Action on tribal health (THETA) study respond to a recent article published in Wellcome Open Research titled  Correspondence article on the research protocol titled 'Towards Health Equity and Transformative Action on tribal health (THETA) study to describe, explain and act on tribal health inequities in India: A health systems research study protocol' published in Wellcome Open Research in December 2019 In the first part, we provide overall clarifications on the THETA study and in the second part respond to specific comments by the authors of the aforementioned correspondence.

Social Determinants of Child Undernutrition in Adivasi Population in Northern Kerala: A Study Using Syndemic Framework.

OBJECTIVES: To understand the complex interaction of structural inequalities, co-occurring health conditions, and child undernutrition among the Adivasi population in North Kerala, India. METHODS: A mixed-method approach was employed in this study, which combined a cross-sectional survey and a case study design. A multistage cluster sampling method was used to select 167 children aged 24 to 60 mo from the study population. The mothers of these children were interviewed using a structured questionnaire to assess individual, parental, and household-level factors associated with child undernutrition. Two Paniya settlements, one with a high prevalence of child undernutrition (HPS) and the other with a low prevalence (LPS), were chosen as the primary units of the case study. RESULTS: The study found that the absence of a kitchen garden with fruits and vegetables [adjusted odds ratio (AOR) 2.85; 95% confidence interval (CI): 1.04-7.81] and a history of cough and fever (AOR 2.93; 95% CI: 1.24-6.93) were both associated with a higher risk of undernutrition in children. The case studies revealed that Adivasi children are undernourished due to a complex set of factors that persist throughout their lives, including unequal access to social capital, healthcare, and food security, as well as differences in hygiene practices due to the lack of access to clean water and sanitation. CONCLUSIONS: The findings underscore the need for social interventions to complement the current focus almost entirely on food supplementation programmes. Equitable action on Adivasi child malnutrition requires urgent policy and programmatic attention to social inequalities and access to basic amenities in Adivasi areas.

The role of social vulnerability in improving interventions for neglected zoonotic diseases: The example of Kyasanur Forest Disease in India.

Forest-based communities manage many risks to health and socio-economic welfare including the increasing threat of emerging zoonoses that are expected to disproportionately affect poor and marginalised groups, and further impair their precarious livelihoods, particularly in Low-and-Middle Income (LMIC) settings. Yet, there is a relative dearth of empirical research on the vulnerability and adaptation pathways of poor and marginalised groups facing emerging zoonoses. Drawing on a survey of 229 households and a series of key-informant interviews in the Western Ghats, we examine the factors affecting vulnerability of smallholder and tribal households to Kyasanur Forest Disease (KFD), an often-fatal tick-borne viral haemorrhagic fever endemic in south India. Specifically, we investigate how different socio-demographic and institutional factors interact to shape KFD vulnerability and the strategies employed by households to adapt to disease consequences. Although surveyed households generally perceived KFD as an important health issue in the study region, there was variability in concern about contracting the disease. Overall results showed that poor access to land (AOR = 0.373, 95% CI: 0.152-0.916), being at or below the poverty line (AOR = 0.253, 95% CI: 0.094-0.685) and being headed by an older person (AOR = 1.038, 95% CI: 1.006-1.071) were all significant determinants of perceived KFD vulnerability. Furthermore, KFD vulnerability is also modulated by important extra-household factors including proximity to private hospitals (AOR = 3.281, 95% CI: 1.220-8.820), main roads (AOR = 2.144, 95% CI: 1.215-3.783) and study location (AOR = 0.226, 95% CI: 0.690-0.743). Our findings highlight how homogenous characterisation of smallholder and tribal communities and the 'techno-oriented' approach of existing interventions may further marginalise the most vulnerable and exacerbate existing inequalities. These findings are important for designing context-specific and appropriate health interventions (including the prioritisation of awareness raising, knowledge networks, livelihood diversification) that enhances the resilience of at-risk social groups within the KFD context. More broadly, our findings highlight how a focus on social vulnerability can help national and international health planners improve health interventions and prioritise among diseases with respect to neglected endemic zoonoses.

Factors influencing the emergence of self-reliance in primary health care using traditional medicine: A scoping review.

Self-reliance is the responsible behavior and the ability of an individual to take care of one's own health using local resources. A substantial proportion of the population use traditional medicine (TM) for primary health care (PHC) in low- and middle-income countries (LMIC). The underlying philosophy of the TM approach is self-reliance due to its emphasis on culture, traditions, customs, and local resources. Given the complexity and ambiguity of how self-reliance emerges, there is a need to have clarity in its understanding and the practice in relation to TM. Hence, we conducted this review to synthesize the factors determining the emergence of self-reliance in PHC using TM in resource-poor settings with a specific focus on LMICs. We searched PubMed, Google scholar, and the Social Science Research Network databases, and conducted reference tracking of selected articles. We included articles published between 2000 and 2020 May. Thematic analysis was done using QDA-miner Lite software version 2.1. We retained 29 papers for review and analysis. A conceptual framework was developed that located factors influencing the emergence of self-reliance. Self-reliance manifests through a socially constructed interaction between factors from the macro (policy and environment) to the micro context (community and household). Due to the lack of explanatory models, there is a substantial gap between understanding self-reliance and its application in health policy and practice. Achieving comprehensive PHC and universal health coverage requires policy provisions to create an enabling environment in health-care facilities, communities, and households that allows the emergence of self-reliance.

Crying baby gets the milk? The governmentality of grievance redressal for patient rights violations in Karnataka, India.

BACKGROUND: Patient rights aim to protect the dignity of healthcare-seeking individuals. Realisation of these rights is predicated on effective grievance redressal for the victims of patient rights violations. METHODS: We used a critical case (that yields the most information) of patient rights violations reported in Karnataka state (South India) to explore the power dynamics involved in resolving grievances raised by healthcare-seeking individuals. Using interviews, media reports and other documents pertaining to the case, we explored the 'governmentality' of grievance redressal for patient rights violations, that is, the interaction of micropractices and techniques of power employed by actors to govern the processes and outcomes. We also examined whether existing governmentality ensured procedural and substantive justice to care-seeking individuals. RESULTS: Collective action was necessary by the aggrieved women in terms of protests, media engagement, petitions and follow-up to ensure that the State accepted a complaint against a medical professional. Each institution, and especially the medical professional council, exercised its power by problematising the grievance in its own way which was distinct from the problematisation of the grievance by the collective. The State bureaucracy enacted its power by creating a maze of organisational units and by fragmenting the grievance redressal across various bureaucratic units. CONCLUSION: There is a need for measures guaranteeing accountability, transparency, promptness, fairness, credibility and trustworthiness in the patient grievance redressal system. Governmentality as a framework enabled to study how subjects (care-seeking individuals) are rendered governable and resist dominant forces in the grievance redressal system for patient rights violations.

Overcoming structural barriers to sharing power with communities in global health research priority-setting: Lessons from the Participation for Local Action project in Karnataka, India.

Community engagement is gaining prominence in global health research. But communities rarely have a say in the agendas or conduct of the very health research projects that aim to help them. This paper provides new evidence on how to share power in priority-setting in ways that seek to overcome structural constraints created by the funding environment. The five strategies were identified through case study research on the Participation for Local Action project in Karnataka, India. That project was carried out by researchers in partnership with the Zilla Budakattu Girijana Abhivrudhhi Sangha, an indigenous community development organisation representing the Solega people. The paper describes each identified strategy for sharing power in priority-setting, followed by a report of the pitfalls and challenges that arose when implementing it. Thus, the study also demonstrates that even where actions and strategies are used to address power imbalances, pitfalls will arise that need to be navigated. Given those challenges, considerations to reflect upon before employing the identified strategies are suggested. Ultimately, the paper aims to communicate strategies for sharing power during and after priority-setting and lessons on how to implement them effectively that can be used by global health researchers in the current funding environment.

How is inclusiveness in health systems research priority-setting affected when community organizations lead the process?

Community engagement is gaining prominence in health research. But communities rarely have a say in the agendas or conduct of the very health research projects that aim to help them. One way thought to achieve greater inclusion for communities throughout health research projects, including during priority-setting, is for researchers to partner with community organizations (COs). This paper provides initial empirical evidence as to the complexities such partnerships bring to priority-setting practice. Case study research was undertaken on a three-stage CO-led priority-setting process for health systems research. The CO was the Zilla Budakattu Girijana Abhivrudhhi Sangha, a district-level community development organization representing the Soliga people in Karnataka, India. Data on the priority-setting process were collected in 2018 and 2019 through in-depth interviews with researchers, Sangha leaders and field investigators from the Soliga community who collected data as part of the priority-setting process. Direct observation and document collection were also performed, and data from all three sources were thematically analysed. The case study demonstrates that, when COs lead health research priority-setting, their strengths and weaknesses in terms of representation and voice will affect inclusion at each stage of the priority-setting process. CO strengths can deepen inclusion by the CO and its wider community. CO weaknesses can create limitations for inclusion if not mitigated, exacerbating or reinforcing the very hierarchies that impede the achievement of improved health outcomes, e.g. exclusion of women in decision-making processes related to their health. Based on these findings, recommendations are made to support the achievement of inclusive CO-led health research priority-setting processes.

COVID-19 and Multiple Inequalities The Case of a Coastal Community in Kerala.

Despite the overall achievements, Kerala's handling of its first case of community transmission in the coastal village of Poonthura came under severe criticism. In this article, the potential pathways to the resistance raised by the fisherfolk in Poonthura are explored, thereby placing their responses as historically and politically embedded ones.

Co-production of knowledge as part of a OneHealth approach to better control zoonotic diseases.

There is increased global and national attention on the need for effective strategies to control zoonotic diseases. Quick, effective action is, however, hampered by poor evidence-bases and limited coordination between stakeholders from relevant sectors such as public and animal health, wildlife and forestry sectors at different scales, who may not usually work together. The OneHealth approach recognises the value of cross-sectoral evaluation of human, animal and environmental health questions in an integrated, holistic and transdisciplinary manner to reduce disease impacts and/or mitigate risks. Co-production of knowledge is also widely advocated to improve the quality and acceptability of decision-making across sectors and may be particularly important when it comes to zoonoses. This paper brings together OneHealth and knowledge co-production and reflects on lessons learned for future OneHealth co-production processes by describing a process implemented to understand spill-over and identify disease control and mitigation strategies for a zoonotic disease in Southern India (Kyasanur Forest Disease). The co-production process aimed to develop a joint decision-support tool with stakeholders, and we complemented our approach with a simple retrospective theory of change on researcher expectations of the system-level outcomes of the co-production process. Our results highlight that while co-production in OneHealth is a difficult and resource intensive process, requiring regular iterative adjustments and flexibility, the beneficial outcomes justify its adoption. A key future aim should be to improve and evaluate the degree of inter-sectoral collaboration required to achieve the aims of OneHealth. We conclude by providing guidelines based on our experience to help funders and decision-makers support future co-production processes.

Coproducing tobacco control knowledge: Using virtual platforms to strengthen implementation in India.

Tobacco control is complex and multidimensional. In India, 266.8 million adults use tobacco in some form, with local contextual factors shaping its consumption, production, and trade. Actors have a stake in tobacco represent different sectors; with varying priorities, responding to different ideas, and exerting varying levels of influence often make it difficult to work collaboratively on tobacco control-related issues. Through online networking platforms such as webinars, we emphasize how coproduction of tobacco control knowledge enables participation, prioritizes multisectoral strategies, and enhances tobacco control leadership among policymakers and implementers in their settings. Coproduction of knowledge between and across stakeholders with a focus on "how to" implement tobacco control policies can leverage in negotiating and supplementing the policy implementation process.

The Health of Indigenous Populations in South Asia: A Critical Review in a Critical Time.

Despite South Asia's promising social inclusion processes, staggering social and health inequalities leave indigenous populations largely excluded. Marginalization in the South Asian polity, unequal power relations, and poor policy responses deter Adivasi populations' rights and opportunities for health gains and dignity. The ongoing COVID-19 pandemic is likely to result in a disproportionate share of infections and deaths among the Adivasis, given poor social conditions and exclusions. Poor health of indigenous people, inequalities between indigenous and non-indigenous groups, and failures in enforcing constitutional and legal provisions to reclaim indigenous land and cultural identity herald deeper structural and political fractures. This article unravels health inequalities between the Adivasis and non-Adivasi populations in their social context based on a critical review of secondary sources. We call for intersectoral policies and integrated health care services to address systemic inequalities, discrimination, power asymmetries, and consequent poor health outcomes. The current COVID-19 pandemic should be viewed as a window to pursue real change.

Increasing risks for emerging infectious diseases within a rapidly changing High Asia.

The cold and arid mountains and plateaus of High Asia, inhabited by a relatively sparse human population, a high density of livestock, and wildlife such as the iconic snow leopard Panthera uncia, are usually considered low risk for disease outbreaks. However, based on current knowledge about drivers of disease emergence, we show that High Asia is rapidly developing conditions that favor increased emergence of infectious diseases and zoonoses. This is because of the existing prevalence of potentially serious pathogens in the system; intensifying environmental degradation; rapid changes in local ecological, socio-ecological, and socio-economic factors; and global risk intensifiers such as climate change and globalization. To better understand and manage the risks posed by diseases to humans, livestock, and wildlife, there is an urgent need for establishing a disease surveillance system and improving human and animal health care. Public health must be integrated with conservation programs, more ecologically sustainable development efforts and long-term disease surveillance.

COVID-19 vaccine equity: a health systems and policy perspective.

INTRODUCTION: The global COVID-19 vaccine rollout has highlighted inequities in the accessibility of countries to COVID-19 vaccines. Populations in low- and middle-income countries have found it difficult to have access to COVID-19 vaccines. AREAS COVERED: This perspective provides analyses on historical and contemporary policy trends of vaccine development and immunization programs, including the current COVID-19 vaccination drive, and governance challenges. Moreover, we also provide a comparative health system analysis of the COVID-19 vaccine deployment in some countries from different continents. It recommends that the international Access to COVID-19 Tools Accelerator (ACT-A) partnership requires a strong governance mechanism and urgent financial investment. EXPERT OPINION: All WHO member states should agree on technology transfer and voluntary license-sharing via a commonly governed technology access pool and supported by a just Intellectual Property regime. Contextualized, dynamic understandings and country-specific versions of health systems strengthening are needed to improve vaccine equity in a sustainable matter.

Beyond behaviour as individual choice: A call to expand understandings around social science in health research.

The focus of behavioural sciences in shaping behaviour of individuals and populations is well documented. Research and practice insights from behavioural sciences improve our understanding of how people make choices that in turn determine their health, and in turn the health of the population. However, we argue that an isolated focus on behaviour - which is one link in a chain from macro to the micro interventions - is not in sync with the public health approach which per force includes a multi-level interest. The exclusive focus on behaviour manipulation then becomes a temporary solution at best and facilitator of reproduction of harmful structures at worst. Several researchers and policymakers have begun integrating insights from behavioural economics and related disciplines that explain individual choice, for example, by the establishment of Behavioural Insight Teams, or nudge units to inform the design and implementation of public health programs. In order to comprehensively improve public health, we discuss the limitations of an exclusive focus on behaviour change for public health advancement and call for an explicit integration of broader structural and population-level contexts, processes and factors that shape the lives of individuals and groups, health systems and differential health outcomes.