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AbstractThe positive effect of women's empowerment on the use of contraceptives is well established. However, the reverse effect, i.e. the potential effect of use of contraceptives on women's empowerment, is relatively unexplored. This study examined the direct impact of contraceptive use on women's empowerment in currently married women aged 15–49 years in India using data from the National Family Health Survey-4 conducted in 2015–16. A two-stage least squares (2SLS) regression model was used to account for the issue of endogeneity that appears in a general logit model. The use of contraceptives by the sample women was found to be associated with greater women's empowerment in terms of both their mobility and decision-making power. The pathways to greater women's empowerment are often presumed to be factors such as changing perception of their domestic role and sense of control over their own body. While these are integral, this paper highlights how the possible control over family size and birth interval through use of contraception may also be critical pathways to increasing women's empowerment.

This study examined the trend in extreme weather event related mortality reported in India during 2001–14 and explored the regional, age and sex differentials in such fatalities. We used age and sex-segregated data on the number of accidental deaths by natural causes released by Government of India under the National Data Sharing and Accessibility Policy. Various extreme weather events were grouped into five broad categories: cold wave, extreme precipitation, heat wave, lightning, and tropical cyclone. During 2001–14, 25% of all accidental deaths due to natural causes happened as a result of extreme weather events. Deaths due to extreme precipitation and tropical cyclones declined over time, whereas increasing trend was observed for lightning, and extreme temperature conditions. Most of the extreme weather event induced deaths were due to lightning, followed by extreme precipitation and temperature extremes. The burden of death was highest in the central part of India. States of Andhra Pradesh, Bihar, Uttar Pradesh, Maharashtra and West Bengal were affected the most by extreme weather events. More males and older population died than their counterparts. Findings suggest that people are adaptive to some extreme weather events such as cold wave and cyclones; whereas adaptation and coping with the heat wave and extreme precipitation seems to be less. Building awareness on the adaptive mechanisms to different extremes and a community-centered alert system can help in reducing fatalities due to extreme weather events.

Mobility among Female Sex Workers (FSWs) interrupts their demand for, and utilization of, health services under any intervention. Various strategic interventions are meant to provide access to care and reduce the incidence of HIV and other STIs among FSWs. This paper applies a bivariate probit regression analysis to explain the probability of mobile FSWs being reached by the system and being exposed to interventions jointly with a wide variety of characteristics of mobile FSWs in India. The data used are based on a cross-section survey among 5,498 mobile FSWs in 22 districts of four high HIV prevalence states in southern India. A majority of mobile FSWs (59%) were street-based and about 70 percent of them were members of SW organization and nearly half (46%) were highly mobile. The majority of them (90%) had been contacted by outreach workers from any system in the last two years in their current location and 94 percent were exposed to interventions in terms of getting free or subsidized condoms. Bivariate probit analysis revealed that comprehensive interventions are able to reach more vulnerable mobile FSWs effectively, e.g. new entrants, highly mobile, reported STIs, tested for HIV ever and serving a high volume of clients. The results complement the efforts of government and other agencies in response to HIV. However, the results highlight that specific issues related to various subgroups of this highly vulnerable population remain unaddressed calling for tailoring the response to the specific needs of the sub-groups.

Mobility among Female Sex Workers (FSWs) interrupts their demand for, and utilization of, health services under any intervention. Various strategic interventions are meant to provide access to care and reduce the incidence of HIV and other STIs among FSWs. This paper applies a bivariate probit regression analysis to explain the probability of mobile FSWs being reached by the system and being exposed to interventions jointly with a wide variety of characteristics of mobile FSWs in India. The data used are based on a cross-section survey among 5,498 mobile FSWs in 22 districts of four high HIV prevalence states in southern India. A majority of mobile FSWs (59%) were street-based and about 70 percent of them were members of SW organization and nearly half (46%) were highly mobile. The majority of them (90%) had been contacted by outreach workers from any system in the last two years in their current location and 94 percent were exposed to interventions in terms of getting free or subsidized condoms. Bivariate probit analysis revealed that comprehensive interventions are able to reach more vulnerable mobile FSWs effectively, e.g. new entrants, highly mobile, reported STIs, tested for HIV ever and serving a high volume of clients. The results complement the efforts of government and other agencies in response to HIV. However, the results highlight that specific issues related to various subgroups of this highly vulnerable population remain unaddressed calling for tailoring the response to the specific needs of the sub-groups.

Background: Financial inclusions of marginalized key populations (e.g. female sex workers and men who have sex with men) have not been given appropriate attention in the government's programs in India. This study explores the financial inclusions status and main hindrances for accessing the financial services among key populations in undivided Andhra Pradesh. Data and Methods: Data from a cross-sectional survey—the Behavioural Tracking Survey (BTS) -2014—conducted with key populations (e.g. FSWs (N = 2400) and MSM (N = 1200)), in undivided Andhra Pradesh state in India was used here. Frequency and bivariate statistical techniques were used here for the analysis. Results: In Andhra Pradesh, just over one-thirds of FSWs and more than half the MSM do not have a bank account.The main reason for not having a bank account is lack of money or having too little money among key populations. A very few had managed to invest in microfinance institutions, global benefits groups/groups saving schemes and health/life insurance policies. Informal institutions are the preferred source for loans among key populations. Conclusion: This study advocates for more support from government, NGOs, international agencies and financial institutions to enhance key populations' financial sustainability and a comprehensive financial inclusion among key populations.

SummaryFemale sex workers (FSWs) are vulnerable to HIV infection. Their socioeconomic and behavioural vulnerabilities are crucial push factors for movement for sex work. This paper assesses the factors associated with the likelihood of movement of sex workers from their current place of work. Data were derived from a cross-sectional survey conducted among 5498 mobile FSWs in 22 districts of high in-migration across four states in southern India. A multinomial logit model was constructed to predict the likelihood of FSWs moving from their current place of work. Ten per cent of the sampled mobile FSWs were planning to move from their current place of sex work. Educational attainment, marital status, income at current place of work, debt, sexual coercion, experience of violence and having tested for HIV and collected the results were found to be significant predictors of the likelihood of movement from the current place of work. Consistent condom use with different clients was significantly low among those planning to move. Likewise, the likelihood of movement was significantly higher among those who had any STI symptom in the last six months and those who had a high self-perceived risk of HIV. The findings highlight the need to address factors associated with movement among mobile FSWs as part of HIV prevention and access to care interventions.

Background: To assess the association between female sex workers' (FSWs) degree of community collectivisation and self-efficacy, utilisation of sexually transmitted infection (STI) services from government-run health centres in Andhra Pradesh, India. Methods: Cross-sectional analyses of 1,986 FSWs recruited using a probability-based sampling from five districts of Andhra Pradesh during 2010–2011. Multiple logistic regression models were constructed to assess associations. The independent variables included—collective efficacy, collective agency and collective action—measured using a series of items that assessed the grouping of the community on issues that concern most sex workers. An additional independent variable included FSWs belonging to an area where there was a project partnership with government health centres to provide STI treatment services to FSWs. The outcome indicators included self-efficacy for service utilisation from government health facilities and the treatment for STIs from government health facilities at least once in the past year experience of STI symptoms. Results: Of the 1,986 FSWs, nearly two-fifths (39.5%) reported a high level of overall collectivisation (collective efficacy: 89%, collective agency: 50.7%; collective action: 12.7%). Sex workers with a high degree compared with low degree of overall collectivisation were significantly more likely to report high self-efficacy to use government health facilities (75.0% vs 57.3%, adjusted OR 2.5, 95% CI 2.0 to 3.1) and to use government health centres for STI treatment in past 1 year (78.1% vs 63.2%, adjusted OR 2.1, 95% CI 1.6 to 2.8), irrespective of project partnership with government centres. Conclusion: The current research findings reinforce the need for stronger community mobilisation for better utilisation of government health facilities for STI and HIV prevention interventions.

AbstractThis paper assesses the reasons for non-use of contraceptive methods, and the possible complexity of reported data on women in India. The study used recent data from two successive rounds of the National Family Health Survey (NFHS) (2005–06: N=37,296; 2015–16: N=247,024), which surveyed currently married women aged 15–49 years. The reporting on non-use of contraceptives and the changing pattern of the reasons for non-use were analysed, classified into fertility and other cited reasons. The self-reported reasons for non-use of contraception were verified with other related information captured in the survey. Bivariate and logistic regression analyses were conducted. Sexual abstinence (not having sex: 10%; infrequent sex: 3%) and infecundity (menopausal/hysterectomy: 12%; subfecund/infecund: 10%) were the most commonly reported reasons for non-use of contraceptive methods in 2015–16, followed by refusal to use (10%). The proportion of non-users who wanted to have a child soon (25% to 21%), were pregnant (16% to 13%), in postpartum amenorrhoea (68% to 40%) and who had method-related reasons (10% to 6%) declined over time (from 2005–06 to 2015–16, respectively). A higher proportion of less-educated women reported abstinence (6%) and menopause/hysterectomy (19%) than educated women. Abstinence was more commonly reported in states with low prevalence of modern contraceptive use. The findings suggest that the increasing trend of abstinence and infecundity among non-users of contraception may be a concern for future research and reproductive health programmes, as it questions both the quality of data and sexual health of married couples.

Globally, natural disasters have caused a large scale of damage and destruction every year, affecting millions of people, the economy, and development – and developing countries are the most severely affected. Odisha is one of India's most disaster-prone states. This study explores the effects of, and resilience to, cyclones, floods, droughts, and heatwaves in Odisha, and identifies government strategies that help mitigate these natural disasters. We mainly used primary data collected through a qualitative study undertaken from April 2017 to June 2017 in three districts of Odisha. We conducted in-depth interviews and focus group discussions with community members and key stakeholders at different levels. In addition, our study analyzed secondary data on natural disasters using DesInventar, a disaster information management system data source. The findings show that floods, cyclones, and drought in recent years, along with heatwaves and lightning, have severely affected the people of Odisha. The impacts of these natural disasters are calamitous – particularly on livelihoods, food security, health, water, and sanitation. These natural disasters, which have affected agriculture, fisheries, prawn cultivation, roadside vendors, and daily wage laborers, have both short- and long-term effects on the livelihoods of people in Odisha, leaving them with scarce employment opportunities. The vulnerable and marginalized sections of the population have been the most severely affected, and common coping mechanisms have included selling off livestock, borrowing food, taking loans and mortgages, and migration. The government's measures/programs, such as an Early Warning System, Public Distribution System, Multipurpose Cyclone Rehabilitation Centers, Seasonal Residential Care Centers, and Indira Awas Yojana, play a major role in mitigating the effect of disasters among rural communities. Our study indicates that natural disasters have impacted the population of the state socioeconomically, physically, and psychologically. The ...

Globally, natural disasters have caused a large scale of damage and destruction every year, affecting millions of people, the economy, and development – and developing countries are the most severely affected. Odisha is one of India's most disaster-prone states. This study explores the effects of, and resilience to, cyclones, floods, droughts, and heatwaves in Odisha, and identifies government strategies that help mitigate these natural disasters. We mainly used primary data collected through a qualitative study undertaken from April 2017 to June 2017 in three districts of Odisha. We conducted in-depth interviews and focus group discussions with community members and key stakeholders at different levels. In addition, our study analyzed secondary data on natural disasters using DesInventar, a disaster information management system data source. The findings show that floods, cyclones, and drought in recent years, along with heatwaves and lightning, have severely affected the people of Odisha. The impacts of these natural disasters are calamitous – particularly on livelihoods, food security, health, water, and sanitation. These natural disasters, which have affected agriculture, fisheries, prawn cultivation, roadside vendors, and daily wage laborers, have both short- and long-term effects on the livelihoods of people in Odisha, leaving them with scarce employment opportunities. The vulnerable and marginalized sections of the population have been the most severely affected, and common coping mechanisms have included selling off livestock, borrowing food, taking loans and mortgages, and migration. The government's measures/programs, such as an Early Warning System, Public Distribution System, Multipurpose Cyclone Rehabilitation Centers, Seasonal Residential Care Centers, and Indira Awas Yojana, play a major role in mitigating the effect of disasters among rural communities. Our study indicates that natural disasters have impacted the population of the state socioeconomically, physically, and psychologically. The effect on livelihoods, directly and indirectly, exacerbates income, food security, and health. There is an urgent need to focus on reducing people's underlying vulnerabilities by taking proactive measures, engaging the community in decision-making, and generating alternative and sustainable livelihoods.

Background & Objectives: Providing sexually transmitted infection (STI) services to female sex workers (FSWs) in rural and resource constrained settings is a challenge. This paper describes an approach to address this challenge through a partnership with government health facilities, and examines the effect of this partnership on the utilization of STI services by FSWs in Andhra Pradesh, India. Methods: Partnerships were formed with 46 government clinics located in rural areas for providing STI treatment to FSWs in 2007. Government health facilities were supported by local and State level non-government organizations (NGOs) through provision of medicines, training of medical staff, outreach in the communities, and other coordination activities. Data from programme monitoring and behaviour tracking survey were used to examine the accessibility and acceptability in utilization of STI services from partnership clinics. Results: The number of FSWs accessing services at the partnership clinics increased from 1627 in 2007 to over 15,000 in 2010. The average number of annual visits by FSWs to these clinics in 2010 was 3.4. In opinion surveys, the majority of FSWs accessing services at the partnership clinics expressed confidence that they would continue to receive effective services from the government facilities even if the programme terminates. The overall attitude of FSWs to visit government clinics was more positive among FSWs from partnership clinic areas compared to those from non-partnership clinic areas. Interpretation & Conclusions: The partnership mechanism between the NGO-supported HIV prevention programme and government clinic facilities appeared to be a promising opportunity to provide timely and accessible STI services for FSWs living in rural and remote areas.

The benefits of employing a rights-based approach in family planning (FP) programmes have made the client's rights to informed choices and quality care an essential part of any such programme. client-provider interaction is one of the critical components of the quality of care (QoC) framework of FP. While several studies have assessed QoC in FP services in India, very few have focused on the in-depth assessment of the interaction between the client and the provider during service delivery. The present study used the mystery client approach to assess the quality of interactions between clients and FP service providers in two of the most populous states of India: Bihar and Uttar Pradesh (UP). Findings highlighted that the providers spent very little time with the clients, gave them information on only one or two FP methods, and rarely talked about possible side-effects of the methods. Furthermore, the providers seemed hesitant to suggest any FP method other than condoms to newly married women. This study concluded that despite being a government priority, the quality of client-provider interaction in these two states was extremely poor.

Background: The Knowledge Network project was launched in 2010 to build evidence on the HIV epidemic by using the data generated by HIV programme implementing organisations in India. This paper describes the implementation of the programme and the strategies adopted to enhance the capacity of individuals to document and publish HIV prevention programme learnings. Further, it discusses the outcomes of the initiative. Methods: A multipronged approach was adopted, where a group of experts were brought together to collaborate with programme implementing organisations, review available data, develop research questions and guide peer-reviewed publications. Further, scientific writing courses were conducted to support individuals from HIV programme implementing organisations as well as educational and government organisations (mentees) to build the documentation capacity of individuals leading programme implementation and current and future researchers. The impact and quality of evidence generated was measured by examining the number of papers published, the number of citations, and the number of papers with at least 10 citations. Additionally, course participants' responses to open-ended questions in the anonymous course evaluation questionnaires are presented as verbatim quotes. Results: Overall, 99 papers on HIV programmatic learnings from India were finalised under the programme, of which 95 have been published. In all, 67 papers were co-authored by mentees. Most papers were published in high-impact factor (1 or more) journals and 72% were cited at least once in the literature. The main themes documented include key populations' HIV risk, HIV risk of general population groups, HIV/STI service delivery models and community mobilisation interventions. Conclusion: The study demonstrates that an integrated approach, involving partnership, capacity-building and mentorship, can maximise the use of available data and build the evidence base on HIV programmatic learnings. The capacity-building model adopted in the ...

Although India has over 600,000 registered AYUSH practitioners who are engaged in homeopathic, Ayurvedic, and Unani systems of medicine, they have not been integrated into the country's national health system. While practitioners of these systems of medicine treat all illnesses, they have a special niche in providing services to address men's sexual health concerns (Gupt Rog). A project on Research and Intervention in Sexual Health: Theory to Action was undertaken by the International Institute for Population Sciences/Mumbai, the Population Council/New Delhi, and partners, in three slum communities in Mumbai, from 2001–07. The objective was to control the spread of sexually transmitted infections including HIV through the involvement of doctors practicing all forms of medicine. A holistic approach was employed to integrate key concepts from AYUSH and allopathic systems of medicine. This manual, which includes exercises and supplementary material to facilitate the understanding, learning, and application of concepts into practice, has great potential to prevent and manage STIs and HIV as the Government of India scales up efforts to develop and promote the AYUSH system of medicine.