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Background One of the most pressing global threats to public health is the use of tobacco, which not only claims lives but also has significant negative social and economic impacts. Over 8 million individuals die globally each year as a result of using tobacco products. Children aged 13–15 years, are currently estimated to consume tobacco with a high rate of 8.4% in India, and 5.4% in the state of Gujarat. Almost half of the adolescents aged 13–15 year who consumed tobacco reported starting tobacco use at around 10 years of age. Preventing tobacco-related mortality is an urgent issue, globally. Objective This study aims to report the prevalence of tobacco consumption (TOCO) among 10–13-year-old school going slum children in the city of Gandhidham, which is the first such study in this population. Methodology Our study had a cross-sectional mixed method design and included 404 slum school going Early Adolescents (EAs) representing 3303 slum EAs. The subjects were recruited from 26 schools using multi-stage stratified random sampling technique with three tiers. A validated Global Youth Tobacco Survey (GYTS) questionnaire was used for students along with qualitative interviews of 17 teachers from the same schools between January and July 2024. Result This study revealed that 19.1% were Ever Tobacco Users (ETUs) while 6.2% were Current Tobacco Users (CTUs). Socio-environmental factors such as TOCO by parents, friends, siblings/cousins, teachers and those who purchased tobacco for family members significantly influence the consumption of tobacco. These findings were corroborated with the results from the qualitative interviews with teachers. Conclusion The high prevalence of tobacco use, coupled with disturbingly early initiation ages, highlights the importance of the future health of this vulnerable population. The fact that nearly one in five early adolescents has experimented with tobacco, and that initiation often occurs even before the age of 10, calls for a radical rethinking of tobacco prevention strategies. Traditional approaches that target older adolescents may be too late for this population, suggesting the need for prevention efforts to begin in early childhood.

Introduction We investigated the burden of surgical conditions, level of unmet needs and reasons for non-utilization of surgical services in a slum of Ahmedabad, India. Methods A community-based cross-sectional study was carried out from August to December 2019. Inclusion criteria was age > 14 years; any type of injury/condition that requires surgery; subject has had surgery in last 1 year, and death information of family members. Data were stored and coded in Microsoft excel and exported to IBM SPSS statistics version 25 software for data analysis. Frequencies and proportions (categorical variable) are used to summarize utilization of surgical services and understanding surgical need. The Surgeons Overseas Assessment of Surgical was used to identify surgical met and unmet needs translated into local language. Open Data Kit software was used to install questionnaire in the “Tablet” to collect information and stress-free workflow in field. Results Out of 10,330 population in 2066 households, 7914 were more than 14 years of age. 3.46% ( n  = 274) people needed surgery; 116 did not avail surgery and were categorized in “unmet need.” Fifty percent of individuals with surgical needs had abdominal- or extremities-related problems followed by eyes surgery need (14%); back, chest and breast surgical need was 13.5%. Seventeen percent of participants with surgical needs had wounds related to injury or accident while 63% had wounds that were not related to injury. Almost all participants had gone to a physician to seek healthcare, however 42% did not avail surgical care needed for a variety of reasons. Forty-six percent of participants needing surgical care underwent major surgical procedure, while 11% had minor procedures. Financial reasons (34.5%) and lack of trust (35.3%) were major reasons for not availing surgical care. Conclusions and Relevance Ahmedabad is a relatively high income metropolitan city, has universally free health care and multiple healthcare facilities. Despite this, we have shown that there is significant unmet need for surgical procedures in the low-income population. A unique finding was that most patients sought a consultation but approximately 50% did not avail of the free surgical procedures under the universally free health care system in this city. We propose creation of community healthcare workers focused on surgical conditions.

Many low-middle income countries have focused on improving access to and quality of obstetric care, as part of promoting a facility based intra-partum care strategy to reduce maternal mortality. The state of Gujarat in India, implements a facility based intra-partum care program through its large for-profit private obstetric sector, under a state-led public-private-partnership, the Chiranjeevi Yojana (CY), under which the state pays accredited private obstetricians to perform deliveries for poor/tribal women. We examine CY performance, its contribution to overall trends in institutional deliveries in Gujarat over the last decade and its effect on private and public sector deliveries there. District level institutional delivery data (public, private, CY), national surveys, poverty estimates, census data were used. Institutional delivery trends in Gujarat 2000-2010 are presented; including contributions of different sectors and CY. Piece-wise regression was used to study the influence of the CY program on public and private sector institutional delivery. Institutional delivery rose from 40.7% (2001) to 89.3% (2010), driven by sharp increases in private sector deliveries. Public sector and CY contributed 25-29% and 13-16% respectively of all deliveries each year. In 2007, 860 of 2000 private obstetricians participated in CY. Since 2007, >600,000 CY deliveries occurred i.e. one-third of births in the target population. Caesareans under CY were 6%, higher than the 2% reported among poor women by the DLHS survey just before CY. CY did not influence the already rising proportion of private sector deliveries in Gujarat. This paper reports a state-led, fully state-funded, large-scale public-private partnership to improve poor women's access to institutional delivery - there have been >600,000 beneficiaries. While caesarean proportions are higher under CY than before, it is uncertain if all beneficiaries who require sections receive these. Other issues to explore include quality of care, provider attrition and the relatively low coverage.

Nipah (Nee-pa) viral disease is a zoonotic infection caused by Nipah virus (NiV), a paramyxovirus belonging to the genus Henipavirus of the family Paramyxoviridae. It is a biosafety level-4 pathogen, which is transmitted by specific types of fruit bats, mainly Pteropus spp. which are natural reservoir host. The disease was reported for the first time from the Kampung Sungai Nipah village of Malaysia in 1998. Human-to-human transmission also occurs. Outbreaks have been reported also from other countries in South and Southeast Asia. Phylogenetic analysis affirmed the circulation of two major clades of NiV as based on currently available complete N and G gene sequences. NiV isolates from Malaysia and Cambodia clustered together in NiV-MY clade, whereas isolates from Bangladesh and India clusterered within NiV-BD clade. NiV isolates from Thailand harboured mixed population of sequences. In humans, the virus is responsible for causing rapidly progressing severe illness which might be characterized by severe respiratory illness and/or deadly encephalitis. In pigs below six months of age, respiratory illness along with nervous symptoms may develop. Different types of enzyme-linked immunosorbent assays along with molecular methods based on polymerase chain reaction have been developed for diagnostic purposes. Due to the expensive nature of the antibody drugs, identification of broad-spectrum antivirals is essential along with focusing on small interfering RNAs (siRNAs). High pathogenicity of NiV in humans, and lack of vaccines or therapeutics to counter this disease have attracted attention of researchers worldwide for developing effective NiV vaccine and treatment regimens.

Background There has been little evaluation of the postpartum quality of life (QOL) of women in India and its association with the mode of birth. This study piloted the use of the generic EQ-5D-5L questionnaire to assess postpartum QOL experienced by rural Indian women. Methods A convenience sample of rural women who gave birth in a health facility in Gujarat or Madhya Pradesh was recruited into this pilot study. QOL was measured during three interviews within 30 days of birth using the EQ-5D-5L questionnaire. Patient-level quality-adjusted life days (QALDs) were estimated. Multivariate regression was used to adjust for selected baseline characteristics. Results Forty-six women with cesarean section and 178 with vaginal birth from 17 public and private health facilities were studied. Postpartum QOL in both groups improved between interviews 1 and 3. Comparing between vaginal and cesarean births indicated that the vaginal birth group had a higher QOL (0–3 days postpartum: 0.28 vs. 0.57, 3–7 days postpartum: 0.59 vs. 0.81; P  < 0.001) and was more likely to report no or slight problems in 4 of 5 health dimensions (mobility, self-care, usual activities, pain or discomfort; P  ≤ 0.04) during interviews 1 and 2. Postpartum QOL converged, but still differed between groups by the time of interview 3 (21–30 days postpartum: 0.85 vs. 0.93; P  < 0.001). While most women reported no problems by the end of the first postpartum month, the difference in the ability to perform usual activities persisted ( P  = 0.001). In result, fewer QALDs were attained by women in the cesarean section group between day 1 and day 21 postpartum (13.1 vs. 16.6 QALDs; P  < 0.001). Subgroup analysis showed that having had an episiotomy during vaginal birth was also associated with reduced QOL postpartum, but to a lesser extent than cesarean section. Similar results were obtained when adjusting for socioeconomic, pregnancy and birth characteristics, but postpartum QOL already ceased to be statistically different between groups before interview 3. Conclusions Vaginal births, even with episiotomy, were associated with a higher postpartum QOL than cesarean births among the Indian women in our pilot study. Finding these expected results suggests that the EQ-5D-5L questionnaire is a suitable instrument to assess postpartum QOL in Indian women.

Introduction Toxoplasma gondii is a protozoan parasite causing toxoplasmosis in humans, with lifelong presence in brain and muscular tissues [1, 2]. [...]temperament characteristics among children born to Toxoplasma-positive mothers are unclear. [...]the objective of this small-scale, exploratory study was to explore the association of maternal Toxoplasma positivity with child's gross-motor development and temperament through structured, well-established, parent-reported questionnaires. Methods Study Area and Subject Recruitment T. gondii prevalence study was previously conducted among pregnant women in Modasa-Bhiloda blocks, Aravalli district, Gujarat, India covering > 100 villages through universal sampling [6, 13]. Mother's Toxoplasma infection status Child's bio-parameters IgG+  PCR+IgG+  PCR−IgG+  PCR−IgG− p-valuea p-valueb Frequency (% within mother's Toxoplasma infection status category) Born as low birth weight infant n = 189 n = 95 n = 94 n = 59 39 (20.6) 18 (18.9) 21 (22.3) 15 (25.4) 0.44 0.63 Median (interquartile range), n p-valuec p-valued Age (months) 16 (6), 189 16 (6), 95 17 (8), 94 16 (6), 59 0.69 0.89 Height (cm) 76 (9), 180 76 (8), 93 76 (9), 87 73 (9), 54 0.19 0.4 Weight (kg) 10 (2), 181 10 (1), 93 10 (2), 88 10 (1), 54 0.65 0.67 Age during which infant learned to lift his/her head independently (months) 5 (1), 189 5 (1), 95 5 (1), 94 5 (1), 59 0.85 0.66 Age during which infant learned to move/turn around independently (months) 6 (0), 189 6 (0), 95 6 (0), 94 6 (0), 59 0.49 0.79 Age during which infant learned to sit independently (months) 9 (1), 188 9 (1), 94 9 (1), 94 9 (1), 59 0.62 0.84 Age during which infant learned to kneel independently (months) 8 (1), 187 8 (1), 94 8 (1), 93 8 (1), 59 0.51 0.49 Age during which infant learned to walk independently (months) 12 (1), 176 12 (1), 94 12.5 (1), 82 12 (1), 57 0.92 0.99 In contrast to another study [12], gross motor skill development did not show significant differences between categories of children born to Toxoplasma-positive and Toxoplasma-negative mothers (Table 1).

Objectives: We carried out a mixed method study to understand why patients did not avail of surgical care in an urban slum in India. Methods: In our earlier study, we found that out of 10,330 people, 3.46% needed surgery; 42% did not avail of surgery (unmet needs). We conducted a follow-up study to understand reasons for not availing surgery, 141 in met needs, 91 in unmet needs. We administered 2 instruments, 16 in-depth interviews and 1 focused group discussion. Results: Responses from the 2 groups for “the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting” scale did not have significant difference except for, prescription of medicines, patients with unmet needs were less likely to agree ( p = 0.076). Results between 2 groups regarding “Patient perceptions of quality” did not show significant difference except for doctors answering questions where a higher proportion of unmet need group agreed ( p = 0.064). Similar observations were made in the in depth interviews and focus group. Conclusion: There is a need for understanding trust issues with health service delivery related to surgical care for marginalized populations.

Background: Government of Gujarat introduced a public-private partnership scheme called the Chiranjeevi Yojana (CY) in 2005, to improve access to delivery care for poor women. Till date, more than 1 million deliveries have been conducted under CY. Although CY has been evaluated, this is the only study using primary data to evaluate the quality of care. Objective: The objective of this study was to (i) determine the quality of free delivery care and (ii) examine the differences in the quality of care between public sector facilities and accredited private sector facilities. Methodology: The community-based survey was conducted in three districts of Indian state of Gujarat. Trained data collectors used pretested questionnaire in vernacular language between 7th and 10th days of delivery. Overall surveyed mothers were 3858 in the prospective study; analytic sample was 1616 mothers. Statistical analysis includes Chi-square test using IBM SPSS version 20. Results: Quality of care was perceived to be good in both public sector and accredited private sector. When free delivery care was compared between two sectors, private sector was perceived to have better quality of care. This difference was statistically significant for indicators, such as infrastructure, allowed to eat/change positions, application of pressure on abdomen, and weighing of baby. Conclusion: The study highlights the need for engaging private sector to improve access to delivery care for poor women. Quality assurance programs in Gujarat need to address respectful care issues in the public sector. Future research should include qualitative study to understand the drivers of quality delivery care.

Hospital cleaning has been shown to impact on rates of healthcare-associated infections (HCAIs) and good environmental hygiene is critical to quality care, yet those tasked with the role of ensuring a safe and clean environment often go unrecognised as members of the healthcare workforce. Sepsis is a leading cause of maternal and newborn death, a significant proportion of these cases are estimated to be due to HCAIs. Deliveries in health institutions have now reached 75% globally, and in low and middle income countries the corresponding increased pressure on facilities  has impacted both quality of care provided and quality of the birth environment in terms of infection prevention and control (IPC) and HCAIs. The paper discusses the neglected role of health facility cleaners, providing evidence from the literature and from needs assessments conducted by The Soapbox Collaborative and partners in Bangladesh, India, The Gambia and Zanzibar. While not the primary focus of the assessments, common themes emerged consistently pointing to institutional neglect of cleaning and cleaners. The paper argues that low status within facilities, wider societal marginalisation, lack of training, and poor pay and working conditions contribute to the lack of prioritisation placed on health facility environmental hygiene. With increased international attention focused towards health facility water, sanitation and hygiene and a growing focus on IPC, now is the time to address the neglect of this frontline healthcare workforce. We propose that provision of and improved training can enable the recognition of the valuable role cleaning staff play, as well as equipping these staff with the tools required to perform their job to the highest standard. In addition to training, wider systems changes are necessary to establish improvements in environmental hygiene and the role of cleaning staff, including addressing resource availability, supportive supervision, and an increased emphasis on preventative healthcare.

Bypassing available facilities for childbirth has important implications for maternal health service delivery and human resources within a health system. The results are the additional expenses imposed on the woman and her family, as well as the inefficient use of health system resources. Bypassing often indicates a lack of confidence in the care provided by the facility nearest to the mother, which implies a level of dysfunctionality that the health system needs to address. Over the past decade, India has experienced a steep rise in the proportion of facility births. The initiation of programs promoting facility births resulted in a rise from 39% in 2005 to 85% in 2014. There have been no reports on bypassing facilities for childbirth from India. In the context of steeply rising facility births, it is important to quantify the occurrence of and study the relative contributions of maternal characteristics and facility functionality to bypassing. 1) To determine the extent of bypassing health facilities for childbirth among rural mothers in three districts of Gujarat, India, 2) to identify associations between the functionality of an obstetric care (OC) facility and it being bypassed, and 3) to assess the relative contribution of maternal and facility characteristics to bypassing. A cross-sectional survey of 166 public and private OC facilities reporting ≥30 births in the 3 months before the survey was conducted in three purposively selected districts (Dahod, Sabarkantha, and Surendranagar) in the state of Gujarat, India. Besides information on each facility, data from 946 women giving birth at these facilities were also gathered. Data were analyzed using a multilevel mixed-effects logistic regression model. Off all mothers, 37.7% bypassed their nearest facility for childbirth. After adjusting for maternal characteristics, for every one-unit increase in the facility's emergency obstetric care (EmOC) signal functions, the odds of bypassing a facility for childbirth decreased by 37% (adjusted odds ratio [AOR] 0.63, 95% confidence interval [CI]: 0.53-0.76). This study shows that independent of maternal characteristics, in our setting, women will bypass obstetric facilities that are not adequately functional, and travel further to others that are more functional. It is important that the health system should focus on facility functionality, especially in the context of sharply rising hospital births.