A critique of the policy discourse on primary health care under the Aardram mission of Kerala.

In 2017, the State of Kerala in India, launched the 'Aardram' mission for health. One of the aims of the mission was to enhance the primary health care (PHC) provisioning in the state through the family health centre (FHC) initiative. This was envisaged through a comprehensive PHC approach that prioritized preventive, promotive, curative, rehabilitative and palliative services, and social determinants of health. Given this backdrop, the study aimed to examine the renewed policy commitment towards comprehensive PHC and the extent to which it remains true to the globally accepted ideals of PHC. This was undertaken using a critical discourse analysis (CDA) of the policy discourse on PHC. This included examining the policy documents related to FHC and Aardram as well as the narratives of policy-level actors on PHC and innovations for them. Through CDA we examined the discursive representation of PHC and innovations for improving it at the level of local governments in the state. Though the mission envisaged a shift from the influence of market-driven ideas of health, analysis of the current policy discourse on PHC suggested otherwise. The discourse continues to carry a curative care bias within its ideas of PHC. The disproportionate emphasis on strategies for early detection, treatment and infrastructural improvements meant limited space for preventive, protective and promotive dimensions, thus digressing from the gatekeeping role of PHC. The reduced emphasis on preventive and promotive dimensions and depoliticization of social determinants of health within the PHC discourse indicates that, in the long run, the mission puts at risk its stated goals of social justice and health equity envisioned in the FHC initiative.

Harnessing People's Lived Experience to Strengthen Health Systems and Support Equitable Musculoskeletal Health Care.

BACKGROUND: Despite the rising burden of musculoskeletal (MSK) problems (MSK conditions, MSK pain, and MSK injury and trauma) in most countries, actions to improve (strengthen) systems for supporting MSK health are often low on the priority list, relative to other noncommunicable diseases. Delivering effective, person-centered and equitable MSK health care requires strengthening systems for health, for example, through policy, financing, service delivery, and workforce initiatives. A critical, but often overlooked component is genuine integration of lived experience perspectives to cocreate care and systems that are responsive to people's needs and contexts. CLINICAL QUESTION: How can cocreation approaches support effective, person-centered and equitable MSK health care? What principles can stakeholders adopt to build responsive health systems? KEY RESULTS: Lived experience perspectives are not systematically integrated in initiatives to strengthen health systems. However, such integration is critical to creating equitable and person-centered health systems that provide care and support healthy populations. Cocreation principles and frameworks can guide processes to strengthen health systems, which must include historically marginalized groups and consider social and environmental contexts as they relate to health. CLINICAL APPLICATION: Clinicians, educators, and policy-makers play a critical role in creating equitable health systems and environments, and driving system reform with people who have lived experience. Genuine cocreation approaches capture diverse economic development (in particular, low-resource settings where health inequities are more prevalent), span the life course and diagnostic categories, are appropriate and/or adapted for the context and setting, and reflect evolving standards and opportunities for MSK health. J Orthop Sports Phys Ther 2023;53(4):1-10. Epub: 12 December 2022. doi:10.2519/jospt.2022.11427.

Starch-Assisted Synthesis of Bi2S3 Nanoparticles for Enhanced Dielectric and Antibacterial Applications.

Starch [(C6H10O5) n ]-stabilized bismuth sulfide (Bi2S3) nanoparticles (NPs) were synthesized in a single-pot reaction using bismuth nitrate pentahydrate (Bi(NO3)3·5H2O) and sodium sulfide (Na2S) as precursors. Bi2S3 NPs were stable over time and a wide band gap of 2.86 eV was observed. The capping of starch on the Bi2S3 NPs prevents them from agglomeration and provides regular uniform shapes. The synthesized Bi2S3 NPs were quasispherical, and the measured average particle size was ∼11 nm. The NPs are crystalline with an orthorhombic structure as determined by powder X-ray diffraction and transmission electron microscopy. The existence and interaction of starch on the NP's surface were analyzed using circular dichroism. Impedance spectroscopy was used to measure the electronic behavior of Bi2S3 NPs at various temperatures and frequencies. The dielectric measurements on the NPs show high dielectric polarizations. Furthermore, it was observed that the synthesized Bi2S3 NPs inhibited bacterial strains (Bacillus subtilis, Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus) and demonstrated substantial antibacterial activity.

Institutional gender mainstreaming in health in UN Agencies: Promising strategies and ongoing challenges.

While the United Nations has long implemented strategies to tackle deep-rooted gender-based inequalities and discrimination in its programmes and policies, there is limited evidence on successful strategies to foster institutional structures and practices that promote gender equality or institutional gender mainstreaming. This paper explores and analyses the experience of institutional gender mainstreaming within UN Agencies working on global health, highlighting potential areas for learning. Overall, progress on institutional gender mainstreaming has been modest, with slow increases (if any) in investments in financial and human resources. The findings highlight the importance of well-established strategies, such as enforcing accountability, a robust gender architecture, and a cohesive capacity-building policy. Drawing on the experiences of gender experts, the paper shows that equally or more critical to the success of institutional gender mainstreaming were approaches such as leveraging strategic internal and external support and identifying strategic entry points for gender mainstreaming. There is considerable scope for strengthening gender mainstreaming within UN Agencies by reviewing and learning from UN system successes. In addition to learning from practice, the way forward lies in making visible and developing strategies to challenge embedded patriarchal organisational norms and systems.

Trends in Abortion Policies in Low- and Middle-Income Countries.

The decision to terminate a pregnancy is not one that is taken lightly. The need for an abortion reflects limited sexual autonomy, ineffective or lack of access to contraceptive options, or a health indication. Abortion is protected under human rights law. That notwithstanding, access to abortions continues to be contested in many parts of the world, with vested interests from politically and religiously conservative states, patriarchal societies, and cultural mores, not just within local contexts but also within a broader geopolitical context. Criminalization of a women's choice not to carry a pregnancy is a significant driver of unsafe procedures, and even where abortions are provided legally, the policies remain constrained by the practice or by a lack of coherence. This review outlines the trends in abortion policy in low- and middle-income countries and highlights priority areas to ensure that women are safe and able to exercise their reproductive rights.

Factors associated with inequality in composite index of anthropometric failure between the Paniya and kurichiya tribal communities in wayanad district of Kerala.

BACKGROUND: Tribal children in India bear a higher burden of undernutrition when compared to other communities. However, inequality within tribal communities is under-researched. OBJECTIVES: To examine the factors associated with inequality in undernutrition between Paniya and Kurichiya tribal communities in Wayanad district of Kerala. METHODS: A cross-sectional analytical study was conducted during August to October 2018 among 314 children aged 2-5 years belonging to Paniya (151) and Kurichiya (163) communities. Participants were selected using multistage cluster sampling. Data were collected using structured interview schedule based on household food insecurity access scale; relevant individual, parental, and household factors were ascertained; child nutritional status was assessed based on anthropometric measurements. The composite index of anthropometric failure (CIAF) was used as an aggregate indicator of undernutrition. Statistical analysis was done using Chi-square test and univariate and multivariable logistic regression. RESULTS: There were significant differences in the prevalence of stunting, underweight, and wasting between Paniya (52.3%, 58.9%, and 25.2%, respectively) and Kurichiya (28.2%, 31.1%, and 12.3%, respectively) tribal children. Based on the CIAF, 66.9% and 41.1% of Paniya and Kurichiya children, respectively, were undernourished. Intratribal difference was observed to exist in all three forms of anthropometric failures simultaneously. Significant factors associated with CIAF were community identity, household food insecurity, and maternal early marriage. Significant factor associated with all three forms of undernutrition was maternal experience of domestic violence. CONCLUSION: This study demonstrates the child nutritional inequality within the tribal communities and indicates the need for more focused policies and programs among vulnerable tribal groups to ensure food security and empowerment of women.

Sexual and reproductive health services in universal health coverage: a review of recent evidence from low- and middle-income countries.

If universal health coverage (UHC) cannot be achieved without the sexual and reproductive health (SRH) needs of the population being met, what then is the current situation vis-à-vis universal coverage of SRH services, and the extent to which SRH services have been prioritised in national UHC plans and processes? This was the central question that guided this critical review of more than 200 publications between 2010 and 2019. The findings are the following. The Essential Package of Healthcare Services (EPHS) across many countries excludes several critical SRH services (e.g. safe abortion services, reproductive cancers) that are already poorly available. Inadequate international and domestic public funding of SRH services contributes to a sustained burden of out-of-pocket expenditure (OOPE) and inequities in access to SRH services. Policy and legal barriers, restrictive gender norms and gender-based inequalities challenge the delivery and access to quality SRH services. The evidence is mixed as to whether an expanded role and scope of the private sector improves availability and access to services of underserved populations. As momentum gathers towards SRH and UHC, the following actions are necessary and urgent. Advocacy for greater priority for SRH in government EPHS and health budgets aligned with SRH and UHC goals is needed. Implementation of stable and sustained financing mechanisms that would reduce the proportion of SRH-financing from OOPE is a priority. Evidence, moving from descriptive towards explanatory studies which provide insights into the "hows" and "whys" of processes and pathways are essential for guiding policy and programme actions.

Pressure-Induced Amorphization of Diisopropylammonium Perchlorate Studied by Raman Spectroscopy and X-ray Diffraction.

Diisopropylammonium salts have drawn attention in recent years due to their room-temperature ferroelectric properties. Triclinic diisopropylammonium perchlorate (DIPAP) exhibits ferroelectricity at room temperature. We have carried out density functional theory calculations to assign the phonon modes in DIPAP. High-pressure Raman spectra of DIPAP are recorded up to ∼3 GPa. Discontinuity in the NH2 bending and stretching mode frequencies and the appearance of new bands at 0.7 GPa suggest a phase transition by a rearrangement in the hydrogen network. Broadening of lattice modes at 1.3-1.7 GPa indicates a loss of crystalline nature above 1.7 GPa. High-pressure synchrotron X-ray diffraction of DIPAP shows an isostructural phase transition at 0.6 GPa and confirms amorphization at 1.5 GPa that may lead to a loss of ferroelectricity above this pressure. The ambient phase becomes reversible after releasing the pressure. The bulk modulus of DIPAP is determined to be 16.5 GPa.

Availability, Utilization, and Health Providers' Attitudes Towards Safe Abortion Services in Public Health Facilities of a District in West Bengal, India.

Background: The provision of safe abortion services upholds the realization of justice in sexual and reproductive health. Many state-level studies in India have identified poor availability of abortion services in the public sector and negative attitudes toward abortion among health providers, as potential barriers to access. Materials and Methods: A cross-sectional study was done to document the availability and utilization of medical termination of pregnancy (MTP or abortion) services and to assess public sector health providers' attitudes towards safe abortion. It was carried out in a representative district of West Bengal, using a facility checklist and a validated attitude scale. Results: Only 11 of 42 public health facilities had both trained doctors and equipment to provide MTP services. Twelve facilities provided MTP services, of which only three urban-based secondary-level facilities provided second trimester MTPs. There were female providers in just 2 of the 12 MTP-providing facilities. Among the 64 health providers interviewed, 40% were trained to provide MTP. According to the attitude scale, 38% had a negative attitude toward the provision of safe abortion services. There was no statistically significant association between attitudes of health providers and provision of MTP. However, there appeared to be a subtle process of gatekeeping in operation, such as making MTP conditional on acceptance of contraception, requiring the husband's consent, and so on. Conclusions: The study shows the poor availability of abortion services in public sector facilities in a district of West Bengal, although all public health facilities from the primary health center level upwards are authorized to provide abortion services.

Conceptual Framework Explaining "Preparedness for Practice" of Dental Graduates: A Systematic Review.

The lack of a comprehensive conceptual framework explaining the construct of "preparedness for dental practice" necessitates an in-depth exploration and synthesis of the literature. The aim of this systematic review of the literature was to develop a conceptual framework explaining the construct of "preparedness for practice" among dental graduates and to identify the factors influencing the construct through a synthesis of the literature. Articles identified for the review were selected from the databases PubMed, Science Direct, Web of Science, and EBSCO Host. They were analyzed using the framework method of qualitative content analysis to understand the underlying conceptualization of preparedness. Thematic analysis using a grounded theory approach was performed to understand the pathways through which various factors influence preparedness. A conceptual framework explaining preparedness constituted by six domains emerged: academic and technical competence, communication and interpersonal skills, protective mechanisms and adaptive skills, professional attitude and ethical judgment, clinical entrepreneurship and financial solvency skills, and social and community orientation. The factors influencing preparedness were identified under the three themes of training-related factors, gender and experience of graduates, and opportunity of internship along with the nature of post-training work experience. The synthesis provides a conceptual framework explaining preparedness for dental practice and draws attention to the need for further research to understand the construct. The factors influencing preparedness suggest that dental training needs to be reflective of actual workplaces and situations that graduates will encounter as independent practitioners.

Optimization of a spatial light modulator driven by digital video interface graphics to generate holographic optical traps.

We propose a method to optimize spatial light modulators (SLMs) driven by digital video interface graphics in a holographic optical tweezers system. A method analogous to that used to optimize LCD televisions is used to optimize the properties of the graphics card through a diffraction-based experiment and develop a lookup table for the SLM. The optimization allows the SLM to function with its full phase modulation depth with improved diffraction efficiency. Further, we propose a simple and robust method to correct for the spatially varying phase response of the SLM to enhance its diffraction efficiency. The optimization results in an improvement of uniformity in the intensity and quality of the trap spots.

A health equity research agenda for India: results of a consultative exercise.

BACKGROUND: This paper describes the process and outcome of a consultative exercise undertaken to develop a medium-term agenda for the next decade, and to identify a short list of immediate priorities for health equity research in India. This exercise was undertaken over 2014-2017 as part of 'Closing the Gap: Health Equity Research Initiative in India', implemented by the Achutha Menon Centre for Health Science Studies, at the Sree Chitra Tirunal Institute of Medical Sciences and Technology, Trivandrum, in south India. METHODS: We adopted a five-step process for the agenda- and priority-setting exercise. The first step, which lasted for approximately 1 year, consisted of a synthesis of evidence on health inequities in India produced during 2000-2014 and identification of gaps. In the second step, we shared the evidence gaps identified and engaged with diverse stakeholders to develop the research agenda through face-to-face and online consultations. In step three, we consolidated the research agenda and identified continuing gaps. Key informant consultations by phone or email with experts in the areas where gaps were identified constituted the fourth step. In the fifth and final step, we organised an expert group consultation to review the agenda and identify immediate research priorities through a consensus process. Overall, approximately 220 persons participated in the entire process, and consisted of persons from diverse disciplines and sectors. RESULTS: The research agenda and immediate priorities that emerged may be categorised into four themes, namely (1) descriptive research on the extent, nature and time trends in health inequities; (2) explanatory research on the pathways through which health inequities are created, and the political or policy environment that facilitates the process; (3) explanatory research that examines how health systems facilitate or mitigate inequities in healthcare; and (4) intervention research on initiatives that helped to mitigate health inequities, and examines the contributing factors. CONCLUSION: The strength of this research agenda is that it was developed through a broad-based consultation with stakeholders representing diverse disciplines, sectors and constituencies. The use of this agenda will help generate evidence that will facilitate India moving closer to the Sustainable Development Goal of leaving no one behind.

Silent voices: institutional disrespect and abuse during delivery among women of Varanasi district, northern India.

BACKGROUND: A considerable amount of qualitative evidence reporting abusive treatment of women during delivery by health providers is available. However, there is a dearth of information regarding the actual prevalence and nature of such abuse, which this study aimed to explore. METHODS: We conducted a community based cross-sectional study using a contextually adapted version of the Staha (meaning 'respect' in Swahili) project questionnaire among 410 rural women who delivered between June, 2014 to August 2015 at any health facility of Varanasi district, northern India. We selected the women through multi-stage cluster random sampling from two rural blocks of Varanasi, which recorded the highest number of institutional deliveries in 2014-15. RESULTS: The frequency of any abusive behavior (excluding inappropriate demands of money due to its high prevalence-90.5%) was 28.8%. The reported abuses were non-dignified care including verbal abuse and derogatory insults related to the woman's sexual behavior (19.3%); physical abuse (13.4%); neglect or abandonment (8.5%); non-confidential care (5.6%); and feeling humiliation due to lack of cleanliness bordering on filth (4.9%). Women were abused during labor or delivery irrespective of their socio-demographic background. Bivariate analysis using Chi-square tests showed statistically significant associations between abuse and provider type, facility type, and presence of complications during delivery. Binary logistic regression indicated that the odds of being abused was four times higher in those women who experienced complications during delivery. Though statistically insignificant, and contrary to expectations, women also seemed to be abused in private institutions; but with a lower frequency and of lesser severity. CONCLUSIONS: The prevalence of disrespect and abuse during labor or delivery was high among women irrespective of their socio-demographic background or delivery conditions in government as well as private health facilities. If the problem of disrespect and abuse is not addressed, it can be assumed that such harsh practices might promote home deliveries, which despite being more unsafe provide an empathetic environment in lieu of safe facility-based birthing options.

Changing household dietary behaviours through community-based networks: A pragmatic cluster randomized controlled trial in rural Kerala, India.

TRIAL DESIGN: With the rise in prevalence of non-communicable diseases in India and Kerala in particular, efforts to develop lifestyle interventions have increased. However, contextualised interventions are limited. We developed and implemented contextualised behavioural intervention strategies focusing on household dietary behaviours in selected rural areas in Kerala and conducted a community-based pragmatic cluster randomized controlled trial to assess its effectiveness to increase the intake of fruits and vegetables at individual level, and the procurement of fruits and vegetables at the household level and reduce the consumption of salt, sugar and oil at the household level. METHODS: Six out of 22 administrative units in the northern part of Thiruvananthapuram district of Kerala state were selected as geographic boundaries and randomized to either intervention or control arms. Stratified sampling was carried out and 30 clusters comprising 6-11 households were selected in each arm. A cluster was defined as a neighbourhood group functioning in rural areas under a state-sponsored community-based network (Kudumbasree). We screened 1237 households and recruited 479 (intervention: 240; control: 239) households and individuals (male or female aged 25-45 years) across the 60 clusters. 471 households and individuals completed the intervention and end-line survey and one was excluded due to pregnancy. Interventions were delivered for a period of one-year at household level at 0, 6, and 12 months, including counselling sessions, telephonic reminders, home visits and general awareness sessions through the respective neighbourhood groups in the intervention arm. Households in the control arm received general dietary information leaflets. Data from 478 households (239 in each arm) were included in the intention-to-treat analysis, with the household as the unit of analysis. RESULTS: There was significant, modest increase in fruit intake from baseline in the intervention arm (12.5%); but no significant impact of the intervention on vegetable intake over the control arm. There was a significant increase in vegetable procurement in the intervention arm compared to the control arm with the actual effect size showing an overall increase by19%; 34% of all households in the intervention arm had increased their procurement by at least 20%, compared to 17% in the control arm. Monthly household consumption of salt, sugar and oil was greatly reduced in the intervention arm compared to the control arm with the actual effect sizes showing an overall reduction by 45%, 40% and 48% respectively. CONCLUSIONS: The intervention enabled significant reduction in salt, sugar and oil consumption and improvement in fruit and vegetable procurement at the household level in the intervention arm. However, there was a disconnect between the demonstrated increase in FV procurement and the lack of increase in FV intake. We need to explore fruit and vegetable intake behaviour further to identify strategies or components that would have made a difference. We can take forward the lessons learned from this study to improve our understanding of human dietary behaviour and how that can be changed to improve health within this context.

Perceptible isotopic effect in 3D-framework of α-glycine at low temperatures.

Glycine, the most fundamental amino acid, albeit studied for many decades, has kept researchers captivated with interesting structural variations relevant to important biological, astrophysical and technological applications. We report here a noticeable effect of deuteration on the three dimensional hydrogen bonding network of α-glycine using low temperature infrared absorption studies in a wide spectral range, corroborated with Raman scattering studies. These systematic studies in the range 300-4.2 K have demonstrated a relatively compact assembly of glycine molecules in the three dimensional bilayered structure of hydrogenated glycine (gly-h) at low temperatures. This is inferred from a remarkable temperature effect in the weak intra-bilayer hydrogen bond ~ along the b-axis, which strengthens upon cooling. A pronounced increase in the intensity of NH3 torsional and NH stretching modes has been observed. This is accompanied with a large rate of stiffening and softening respectively of these modes upon cooling and a change in slope across 210 K and 80 K. In contrast, the D---O hydrogen bond lengths in fully deuterated isotope (gly-d), as estimated using empirical correlation, show that the weak intra-bilayer hydrogen bond is not strengthened upon cooling down to 180 K, whereas the stronger intra-layer hydrogen bonds in the ac-plane become further strong. The ND3 torsional vibrations show no temperature effect. This implies a relatively stable two dimensional layered structure formed by strongly hydrogen bonded glycine sheets in the ac-plane. Below 180 K, similar qualitative trends have been obtained for the hydrogen bond lengths in the two isotopes. In addition, temperature induced variation of the characteristic "indicator" band of zwitterionic gly-h and gly-d has also been reported.

New High Pressure Phases of Energetic Material TEX: Evidence from Raman Spectroscopy, X-ray Diffraction, and First-Principles Calculations.

Samples of energetic material TEX (C6H6N4O8) are studied using Raman spectroscopy and X-ray diffraction (XRD) up to 27 GPa pressure. There are clear changes in the Raman spectra and XRD patterns around 2 GPa related to a conformational change in the TEX molecule, and a phase transformation above 11 GPa. The molecular structures and vibrational frequencies of TEX are calculated by density functional theory based Gaussian 09W and CASTEP programs. The computed frequencies compare well with Raman spectroscopic results. Mode assignments are carried out using the vibrational energy distribution analysis program and are also visualized in the Materials Studio package. Raman spectra of the high pressure phases indicate that the sensitivity of these phases is more than that of the ambient phase.

Minding the gaps: health financing, universal health coverage and gender.

In a webinar in 2015 on health financing and gender, the question was raised why we need to focus on gender, given that a well-functioning system moving towards Universal Health Coverage (UHC) will automatically be equitable and gender balanced. This article provides a reflection on this question from a panel of health financing and gender experts.We trace the evidence of how health-financing reforms have impacted gender and health access through a general literature review and a more detailed case-study of India. We find that unless explicit attention is paid to gender and its intersectionality with other social stratifications, through explicit protection and careful linking of benefits to needs of target populations (e.g. poor women, unemployed men, female-headed households), movement towards UHC can fail to achieve gender balance or improve equity, and may even exacerbate gender inequity. Political trade-offs are made on the road to UHC and the needs of less powerful groups, which can include women and children, are not necessarily given priority.We identify the need for closer collaboration between health economists and gender experts, and highlight a number of research gaps in this field which should be addressed. While some aspects of cost sharing and some analysis of expenditure on maternal and child health have been analysed from a gender perspective, there is a much richer set of research questions to be explored to guide policy making. Given the political nature of UHC decisions, political economy as well as technical research should be prioritized.We conclude that countries should adopt an equitable approach towards achieving UHC and, therefore, prioritize high-need groups and those requiring additional financial protection, in particular women and children. This constitutes the 'progressive universalism' advocated for by the 2013 Lancet Commission on Investing in Health.