Mental health disorders affect around one in seven adolescents globally. In India, home to one-fifth of the world's adolescent population, attention to adolescent mental health is increasing, but access to care remains limited, particularly for Adivasi (Indigenous) adolescents. Understanding how Adivasi adolescents conceptualise psychosocial distress and the kinds of support they value is essential to design supportive interventions. We conducted a qualitative study in rural West Singhbhum, Jharkhand. Using purposive sampling, we recruited 88 participants: 53 adolescents aged 10-19 years, 13 teachers, 11 parents, three community health workers, and eight mental health programme staff aged 18-25 years. Trained peer interviewers conducted semi-structured interviews and group discussions with adolescents in the Ho Adivasi language. A team including experienced Ho researchers and peer interviewers analysed data using the Framework approach. Adolescents, parents, and teachers used variations of the Ho root word "udu" to describe distress. "Udu" denoted thoughts or worries, depending on context. Sources of "udu" included family responsibilities and societal expectations that grew with age: girls were expected to do household work and received less support for school, while boys described income-earning pressures and a lack of emotional outlets. Other "udu" causes included violence at home, school, and public spaces, as well as family separation through migration, remarriage, or parental loss. Impacts of severe "udu" ranged from social withdrawal and strained relationships to early marriage, migration for work, and suicide attempts. Adolescents experiencing "udu" preferred informal support from friends, siblings, or teachers, while those with experience of help from respectful community health workers or trusted, trained older peers valued these. Group-based support was widely acceptable. Strengthening access to early care, alongside measures supporting family livelihoods and social protection, could improve Ho and broader Adivasi adolescent mental health.
IntroductionPrimary Health Care (PHC) rooted in community empowerment, integrated service delivery, and multisectoral action is central to efforts toward Universal Health Coverage (UHC), yet little is known about how PHC reforms influence UHC outcomes across contexts. This review examines how PHC approaches affect population coverage, service coverage, and financial protection by identifying what works, for whom, under what circumstances, and why.MethodsA realist review was conducted using studies from countries with the greatest gains in the UHC Service Coverage Index between 2000 and 2021. Forty-two studies met quality criteria following blinded screening, appraisal, and data extraction. Data were synthesized through iterative development of explanatory configurations linking PHC mechanisms, contexts, and UHC outcomes. The evidence base was limited, concentrated mainly in India and China, and largely published after 2020.ResultsTwo key configurations emerged: one on reproductive, maternal, newborn, and child health and nutrition, and another on overall PHC design and delivery. The predominance of RMNCH-focused reforms reflects long-standing reform sequencing in many health systems and highlights how RMNCH platforms often function as foundational entry points for PHC strengthening. Across both configurations, reforms frequently emphasized service expansion, benefit package design, and insurance or financing initiatives, with greater attention to contact than effective coverage. Frontline workers, community organizations, and multisectoral actors played critical roles, while persistent geographic, transport, and equity barriers hindered progress. PHC reforms contributed to improvements in coverage and financial protection but fell short in reaching marginalized groups, reducing financial barriers, and enhancing service quality.DiscussionStrengthening community engagement, regulating private sector roles, and advancing multisectoral collaboration remain essential, and further research is needed to understand how PHC strategies function across diverse contexts to better support UHC.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/view/CRD42024523631.
BACKGROUND:Improving nutrition for all requires understanding how interventions influence nutrition inequalities within society. Intersectionality, which considers how multiple disadvantages intersect, may offer more precise insight into the equity of these interventions. OBJECTIVES:Using an intersectionality-informed approach and mediation with exposure-mediator interaction, we investigated how participation in nutrition-sensitive agriculture interventions tested in the UPAVAN trial affected inequalities in women's diets in Odisha, India. METHODS:We analyzed cross-sectional endline data from 3294 mothers of children aged 0-23 months in 111 UPAVAN intervention villages. We estimated dietary inequalities as excess relative risk of minimum dietary diversity (MDD-W) according to scheduled tribe (ST) identity (ST or non-ST), education (≥5, <5 y), or wealth (higher, lower) and comparing intersectional groups that combine ST/non-ST with education or wealth group. We used a 4-way decomposition to estimate whether these MDD-W inequalities were affected by social group differences in intervention participation rates (mediation only), participation benefits (interaction only), or both combined (mediated interaction). RESULTS:Intervention participation and MDD-W were greater among the more advantaged groups of non-ST, higher education, or higher wealth. Often, the more disadvantaged groups had greater participation benefits (interaction only), which narrowed MDD-W inequalities. However, intersectional groups with 2 disadvantaged characteristics (e.g., poorer ST) had smaller participation benefits than those with 1 disadvantaged characteristic (e.g., wealthier ST), which widened MDD-W inequalities. Differences in participation rates had negligible effects on MDD-W inequalities. Often, any marginal widening of MDD-W inequalities due to disadvantaged groups participating less (mediation only) was suppressed by their greater participation benefits (mediated interaction). CONCLUSIONS:To our knowledge, this is the first intersectionality-informed analysis of nutrition interventions. UPAVAN interventions mostly had equitable impacts, reducing several inequalities in maternal diet quality. We demonstrate how intersectionality-informed analyses can help identify inequities in nutrition interventions and inform the design of inclusive interventions that reach and benefit the most marginalized groups.
Background In the pursuit of Universal Health Coverage (UHC), Community Action for Health (CAH) is considered a crucial strategy. CAH is when communities define healthcare priorities and monitor the effectiveness of health reforms. Globally, CAH has shown improved health literacy, population outcomes, strengthened health systems. In India, CAH has a long history, is integrated into the National Rural Health Mission and National Health Policy and yet, remains under-resourced and under-researched, posing challenges to both sustainability and scale-up. Promoting Community Action for Health- A Co-Produced, Technology-Enabled Platform to Achieve National Goals, or PATANG is a partnership between academic and civil society entities who have experience and interest in CAH. Methods We will employ a mixed-methods, realist-informed, co-production approach across multiple Indian states to 1) synthesise evidence on various CAH approaches, 2) coproduce a learning platform for knowledge sharing and network building, and 3) assess the platform’s impact from the perspectives of civil society, community, and state actors. Under aim 1, we will conduct realist synthesis and critical discourse analysis to explore the contexts, mechanisms, costs and outcomes of CAH initiatives, supplemented by witness seminars and key informant interviews with state and civil society actors. Under aim 2, these insights will inform the co-production of the PATANG platform, comprising multilingual resources, tools, and exchanges that foster collaboration and knowledge-sharing between civil society, community and government actors across the country. Under aim 3, the platform will be evaluated using a mixed-methods, interrupted time series quasi-experimental design outcomes related to health literacy, service utilisation, empowerment, and community engagement. Conclusions PATANG aims to generate actionable insights on scalable CAH tools and practices, provide replicable frameworks, and strengthen collaboration between civil society and government actors. By bridging evidence gaps, PATANG will contribute to reinvigorating CAH as a critical lever for UHC and health equity in India.
Background Interventions with women's groups have been widely implemented to improve health outcomes in low- and middle-income settings, particularly India. While there is a large evidence base on the effectiveness of single interventions, it is challenging to predict whether a women's group intervention delivered in one setting can be expected to work in another. Methods We applied realist principles to develop and refine a mid-range theory on the effectiveness of women's groups interventions, summarised key lessons for implementation, and reflected on the process. We synthesised primary data from several interventions in India, a systematic review, and an analysis of behaviour change techniques. We developed mid-range theories across three areas: maternal and newborn health, nutrition, and violence against women, as well as an overarching mid-range theory on how women's groups can improve health. Results Our overarching mid-range theory suggested that effective interventions should: build group or community capabilities; focus on health outcomes relevant to group members; and approach health issues modifiable through women's individual or collective actions. We identified four key lessons for future interventions with women's groups, including the importance of skilled and remunerated facilitation, sufficient intensity, supply-side strengthening, and the need to adapt delivery during scale up while maintaining fidelity to intervention theory. Conclusions Our experience demonstrated the feasibility of developing mid-range theory from a combination of evidence and insights from practice. It also underscored the importance of community engagement and ongoing research to 'thicken' midrange theories to design effective and scalable women's groups interventions in India and similar settings.
