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Effects of improved drinking water quality on early childhood growth in rural Uttar Pradesh, India: A propensity-score analysis.

ABSTRACT: CONTEXT:Recent randomised controlled trials in Bangladesh and Kenya concluded that household water treatment, alone or in combination with upgraded sanitation and handwashing, did not reduce linear growth faltering or improve other child growth outcomes. Whether these results are applicable in areas with distinct constellations of water, sanitation and hygiene (WaSH) risks is unknown. Analysis of observational data offers an efficient means to assess the external validity of trial findings. We studied whether a water quality intervention could improve child growth in a rural Indian setting with higher levels of circulating pathogens than the original trial sites. METHODS:We analysed a cross-sectional dataset including a microbiological measure of household water quality. All households accessed water from an improved source. We applied propensity score methods to emulate a randomised trial investigating the hypothesis that receipt of drinking water meeting Sustainable Development Goal (SDG) 6.1 quality standards for absence of faecal contamination leads to improved growth. Growth outcomes (stunting, underweight, wasting, and their corresponding Z-scores) were assessed in children 12-23 months of age. For each outcome, we estimated the mean and 95% confidence interval of the absolute risk difference between treatment groups. FINDINGS:Of 1088 households, 442 (40.62%) received drinking water meeting SDG 6.1 standards. The adjusted risk of child underweight was 7.4% (1.3% to 13.4%) lower among those drinking water satisfying SDG 6.1 norms than among controls. Evidence concerning the relationship of drinking water meeting SDG 6.1 norms to length-for-age and weight-for-age was inconclusive, and there was no apparent relationship with stunting or wasting. CONCLUSIONS:In contexts characterised by high pathogen transmission, water quality improvements have the potential to reduce the proportion of underweight children, but are unlikely to impact stunting or wasting. Further research is required to assess how these modelled benefits can best be achieved in real world settings.

SUBMITTER: Johri M

PROVIDER: S-EPMC6324831 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Project description:The National Health Policy (2017) of India advocates Universal Health Coverage through inclusive growth, decentralization, and rebuilding a cohesive community through a participatory process. To achieve this goal, understanding social organization, and community relationships - defined as social capital - is critical. This study aimed to explore the influence of individual and community-level social capital on a critical health system performance indicator, three-doses of diphtheria-pertussis-tetanus (DPT3) immunization among 12-59 month children, in rural Uttar Pradesh (UP), India. The analysis is based on a cross-sectional survey from two districts of UP, which included 2239 children 12-59 months of age (level 1) from 1749 households (level 2) nested within 346 communities (level 3). We used multilevel confirmatory factor analysis to generate standardized factor scores of social capital constructs (Organizational Participation, Social Support, Trust and Social Cohesion) of the household heads and mothers both at individual and community level, which were then used in the multilevel logistic regressions to explore the independent and contextual effect of social capital on a child's DPT3 immunization status. The result showed only community-level Social Cohesion of the mothers was associated with a child's DPT3 immunization status (Adjusted odds ratio = 1.25, 95% confidence interval = 1.12-1.54; p = 0.04). Beyond its independent effect on utilization of immunization service, the collective Social Cohesion of the mothers significantly modified the relationship of child age, mother's knowledge of immunization, community wealth, and communities' contact with frontline workers with immunization status of the child. With a strong theoretical underpinning, the result substantially contributes to understanding the individual and contextual predictors of immunization service utilization and further advancing the literature of social capital in India. This study can serve as a starting point to catalyze social capital within the health interventions for achieving wellbeing and the collective development of society.

Project description:BackgroundUttar Pradesh (UP), India continues to have a high burden of mortality among young children despite recent improvement. Therefore, it is vital to understand the risk factors associated with under-five (U5) deaths and episodes of severe illness in order to deliver programs targeted at decreasing mortality among U5 children in UP. However, in rural UP, almost every child has one or more commonly described risk factors, such as low socioeconomic status or undernutrition. Determining how risk factors for childhood illness and death are understood by community members, community health workers and facility staff in rural UP is important so that programs can identify the most vulnerable children.MethodsThis qualitative study was completed in three districts of UP that were part of a larger child health program. Twelve semi-structured interviews and 21 focus group discussions with 182 participants were conducted with community members (mothers and heads of households with U5 children), community health workers (CHWs; Accredited Social Health Activists and Auxiliary Nurse Midwives) and facility staff (medical officers and staff nurses). All interactions were recorded, transcribed and translated into English, coded and clustered by theme for analysis. The data presented are thematic areas that emerged around perceived risk factors for childhood illness and death.ResultsThere were key differences among the three groups regarding the explanatory perspectives for identified risk factors. Some perspectives were completely divergent, such as why the location of the housing was a risk factor, whereas others were convergent, including the impact of seasonality and certain occupational factors. The classic explanatory risk factors for childhood illness and death identified in household surveys were often perceived as key risk factors by facility staff but not community members. However, overlapping views were frequently expressed by two of the groups with the CHWs bridging the perspectives of the community members and facility staff.ConclusionThe bridging views of the CHWs can be leveraged to identify and focus their activities on the most vulnerable children in the communities they serve, link them to facilities when they become ill and drive innovations in program delivery throughout the community-facility continuum.

Project description:In the absence of adequate social security, out-of-pocket health expenditure compels households to adopt coping strategies, such as utilizing savings, selling assets, or acquiring external financial support (EFS) by borrowing with interest. Households' probability of acquiring EFS and its amount (intensity) depends on its social capital - the nature of social relationships and resources embedded within social networks. This study examines the effect of social capital on the probability and intensity of EFS during health events in Uttar Pradesh (UP), India. The analysis used data from a cross-sectional survey of 6218 households, reporting 3066 healthcare events, from two districts of UP. Household heads (HH) reported demographic, socioeconomic, and health-related information, including EFS, for each household member. Self-reported data from Shortened and Adapted Social Capital Assessment Tool in India (SASCAT-I) was used to generate four unique social capital measures (organizational participation, social support, trust, and social cohesion) at HH and community-level, using multilevel confirmatory factor analysis. After descriptive analysis, two-part mixed-effect models were implemented to estimate the probability and intensity of EFS as a function of social capital measures, where multilevel mixed-effects probit regression was used as the first-part and multilevel mixed-effects linear model with log link and gamma distribution as the second-part. Controlling for all covariates, the probability of acquiring EFS significantly increased (p = 0.04) with higher social support of the HH and significantly decreased (p = 0.02) with higher community social cohesion. Conditional to receiving any EFS, higher social trust of the HH resulted in higher intensity of EFS (p = 0.09). Social support and trust may enable households to cope up with financial stress. However, controlling for the other dimensions of social capital, high cohesiveness with the community might restrict a household's access to external resources demonstrating the unintended effect of social capital exerted by formal or informal social control.

Project description:BackgroundIn 2018, 875 000 under-five children died in India with children from poor families and rural communities disproportionately affected. Community health centres are positioned to improve access to quality child health services but capacity is often low and the systems for improvements are weak.MethodsSecondary analysis of child health program data from the Uttar Pradesh Technical Support Unit was used to delineate how program activities were temporally related to public facility readiness to provide child health services including inpatient admissions. Fifteen community health centres were mapped regarding capacity to provide child health services in July 2015. Mapped domains included human resources and training, infrastructure, equipment, drugs/supplies and child health services. Results were disseminated to district health managers. Six months following dissemination, Clinical Support Officers began regular supportive supervision and gaps were discussed monthly with health managers. Senior pediatric residents mentored medical officers over a three-month period. Improvements were assessed using a composite score of facility readiness for child health services in July 2016. Usage of outpatient and inpatient services by under-five children was also assessed.ResultsThe median essential composition score increased from 0.59 to 0.78 between July 2015 and July 2016 (maximum score of 1) and the median desirable composite increased from 0.44 to 0.58. The components contributing most to the change were equipment, drugs and supplies and service provision. Scores for trained human resources and infrastructure did not change between assessments. The number of facilities providing some admission services for sick children increased from 1 in July 2015 to 9 in October 2016.ConclusionsFacility readiness for the provision of child health services in Uttar Pradesh was improved with relatively low inputs and targeted assessment. However, these improvements were only translated into admissions for sick children when clinical mentoring was included in the support provided to facilities.

Project description:BackgroundIn India, the distribution and retention of biomedical doctors in public sector facilities in rural areas is an obstacle to improving access to health services. The Government of Uttar Pradesh is developing a comprehensive, ten-year Human Resources for Health (HRH) strategy, which includes policies to address rural distribution and retention of government doctors in Uttar Pradesh (UP). We undertook a stakeholder analysis to understand stakeholder positions on particular policies within the strategy, and to examine how stakeholder power and interests would shape the development and implementation of these proposed policies. This paper focuses on the results of the stakeholder analysis pertaining to rural distribution and retention of doctors in the government sector in UP. Our objectives are to 1) analyze stakeholder power in influencing the adoption of policies; 2) compare and analyze stakeholder positions on specific policies, including their perspectives on the conditions for successful policy adoption and implementation; and 3) explore the challenges with developing and implementing a coordinated, 'bundled' approach to strengthening rural distribution and retention of doctors.MethodsWe utilized three forms of data collection for this study - document review, in-depth interviews and focus group discussions. We conducted 17 interviews and three focus group discussions with key stakeholders between September and November 2019.ResultsWe found that the adoption of a coordinated policy approach for rural retention and distribution of doctors is negatively impacted by governance challenges and fragmentation within and beyond the health sector. Respondents also noted that the opposition to certain policies by health worker associations created challenges for comprehensive policy development. Finally, respondents believed that even in the event of policy adoption, implementation remained severely hampered by several factors, including weak mechanisms of accountability and perceived corruption at local, district and state level.ConclusionBuilding on the findings of this analysis, we propose several strategies for addressing the challenges in improving access to government doctors in rural areas of UP, including additional policies that address key concerns raised by stakeholders, and improved mechanisms for coordination, accountability and transparency.

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Effects of improved drinking water quality on early childhood growth in rural Uttar Pradesh, India: A propensity-score analysis.

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