
==== Front
J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-201
10.4103/jehp.jehp_66_24
Original Article
Identifying gaps in maternal knowledge and care-seeking for neonatal health: A mixed methods study in rural pregnant women
Yogesh M
Bhavana B M 1
Padhiyar Nanveet
Gandhi Rohankumar
Misra Swati 2
Department of Community Medicine, Shri M P Shah Government Medical College, Jamnagar, Gujarat, India
1 Department of Community Medicine Jamnagar, Gujarat, India
2 Department of Community Medicine, Shri M Pshah Government Medical College Jamnagar, Gujarat, India
Address for correspondence: Dr. Swati Misra, Floor-4, Shri MP Shah Medical College Campus, GG Hospital, Patel Colony Post, Jamnagar - 361 008, Gujarat, India. E-mail: drrohangandhi92@gmail.com
2024
05 7 2024
13 20111 1 2024
04 3 2024
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
BACKGROUND:

Knowledge of neonatal danger signs is crucial for timely care-seeking and improved newborn survival. This study assessed this knowledge among pregnant women in rural western Gujarat.

MATERIALS AND METHODS:

A mixed methods study was conducted among 390 pregnant women selected through a two-stage sampling procedure. Quantitative data were collected using a structured questionnaire. Qualitative data were gathered via in-depth interviews with 20 purposively sampled women. Logistic regression identified determinants of knowledge. Thematic analysis was done for qualitative data.

RESULTS:

The majority of women were young (220, 56.5% ≤25 years), literate (333, 85%), and from rural backgrounds (320, 82%). Overall, 232 (59.5%) knew about cord care, and 301 (77.2%) correctly identified breastfeeding initiation time. Recognition of key danger signs such as fever (311, 79.7%), vomiting (292, 74.8%), and jaundice (275, 70.5%) was high, but only 70 (18%) identified chest in-drawing. Multiparity (adjusted odds ratio (AOR): 1.4, 95% confidence interval (95% CI): 1.2–3.9), lower age (AOR: 3.8, 95% CI: 2.4–5.8), education (AOR: 3.1, 95% CI: 1.5–6.4), inadequate counseling (AOR: 2.2, 95% CI: 1.82–5.190), and normative delivery (AOR: 2.4, 95% CI: 1.16–5.006) were associated with poor knowledge. Qualitative findings revealed reliance on informal sources, family elders, and financial constraints as key barriers along with limited comprehension of some danger signs.

CONCLUSION:

Focused interventions via health workers, family members, and community platforms are needed to increase neonatal danger signs awareness among vulnerable women in the region to enable timely care-seeking.

Danger signs
knowledge
mixed methods
neonatal health
pregnant women
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pmcIntroduction

India continues to report unacceptably high neonatal mortality, accounting for 23% of global newborn deaths in 2019.[1] Despite recent declines, the neonatal mortality rate remains at 28 per 1000 live births.[2] A major contributor is a lack of awareness of danger signs leading to delays in care-seeking.[3] Studies across India have revealed knowledge gaps among mothers regarding lethargy, seizures, hypothermia, and feeding issues.[4,5,6,7,8]

However, research also suggests urban-rural and socioeconomic divides. A study in rural Uttar Pradesh found that only 18% of mothers could recognize >3 danger signs versus 63% in urban Lucknow.[7] Similarly, a Delhi study showed poor recognition of breathing difficulty and lethargy among slum dwellers compared to middle-income urban residents.[8] This highlights the need for contextual insights.

Sociodemographic factors such as lower education, income, and rural residence are associated with poor knowledge.[9,10,11] Inadequate counseling, home delivery, and limited healthcare access exacerbate barriers.[9,11] Dependence on family elders further delays appropriate care-seeking.[12] Qualitative evidence also reveals reliance on informal medication before accessing medical facilities.[13]

The present study aimed to fill key knowledge gaps by undertaking a mixed-methods investigation among rural mothers in western Gujarat. The quantitative component assessed knowledge levels and determinants. The qualitative findings elaborated on the sociocultural influences shaping care-seeking behaviors. This nuanced understanding can inform the design of targeted educational strategies to improve newborn health literacy and survival in this underserved population.

Materials and Methods

Study design and settling

This was a community-based mixed methods study with both a cross-sectional quantitative component and a qualitative component using in-depth interviews conducted in rural villages of western Gujarat from April to December 2023 (duration of data collection for both study components: the quantitative survey was conducted over 6 months, while qualitative interviews were conducted over 2 months).

Study participants and sampling

The sample size was calculated by taking prevalence (42%)[14] L = allowable error, which was taken 5% as absolute. Hence, the minimum required sample size was calculated as (1.96)2 × 42 × (58)/5 × 5 = 390.

A two-stage sampling technique was used. In the first stage, 30 villages were randomly selected using probability proportional to size sampling. In the second stage, 13 pregnant women were randomly selected from each village by using simple random sampling.

For the qualitative component, purposive sampling was used to select 20 women from the quantitative sample for in-depth interviews. Women who exhibited gaps in knowledge during the quantitative survey were preferably selected. Eligibility criteria: pregnant women in the third trimester residing in the study area for at least 1 year were eligible if they provided consent. Women with hearing/speech impairment, cognitive issues, or major pregnancy complications were excluded.

Data collection tools and techniques

Quantitative data were collected for 6 months using a pretested, structured questionnaire. It captured sociodemographic information, obstetric history, and knowledge about neonatal danger signs. Knowledge was assessed via multiple-choice questions.

Qualitative data were collected through in-depth interviews over 2 months by using an open-ended guide. Questions explored knowledge sources, care practices, barriers, and suggestions. Interviews were audio-recorded with consent.

Data collection procedure

The structured questionnaire for collecting quantitative data was first developed in English based on a review of similar studies and the research objectives. It was then translated to Gujarati by a language expert and translated back to English independently to check for consistency. This verified Gujarati version was pilot-tested among 20 pregnant women with characteristics similar to the study population. Inputs regarding comprehensibility, flow of questions, ease of answering, and time taken were obtained. Minor modifications were made accordingly before finalization. Written informed consent was taken from eligible pregnant women agreeing to participate voluntarily. The final questionnaire contained 45 questions spread across four segments: sociodemographics, knowledge assessment, obstetric history, and sources of health information. Trained female investigators who are fluent in Gujarati administered the questionnaires through face-to-face interviews at the participants’ homes. Each interview lasted 30–40 minutes. Investigators read out the questions clearly and recorded responses appropriately after verifying with participants. Doubts were clarified and privacy was maintained during interviews. Quantitative data collection was done over 6 months.

For qualitative data, in-depth interviews were conducted over 2 months by the principal investigator who is well-versed in qualitative methods. An open-ended guide was used to facilitate discussions for around 45 minutes to an hour at the participants’ convenience. With consent, responses were audio recorded, supplemented by written field notes about insights and observations. High standards of ethics were adhered to throughout.

We have described the rigorous translation procedure for ensuring the content validity of the questionnaire. The pretesting and modifications based on feedback establish face validity and quality.

Operational Definition

Knowledge of neonatal danger signs: Participants’ awareness regarding the critical signs in newborns that signify severe illness and require urgent medical care. Assessed via a structured questionnaire with multiple-choice questions about key danger signs.

Good knowledge: Participants correctly identify ≥50% of assessed neonatal danger signs.

Poor knowledge: Participants correctly identify <50% of assessed neonatal danger signs.

Timely care seeking: Taking the newborn to an appropriate healthcare facility within 24 hours of noticing a danger sign.

Delayed care seeking: Not taking the newborn to an appropriate healthcare facility within 24 hours of noticing a danger sign.

Healthcare facility: Hospitals, primary health centers, community health centers, clinics, and trained health workers that can provide appropriate medical care for newborns.

Statistical analysis

Quantitative data were analyzed using statistical software. Frequencies and percentages were calculated for sociodemographic variables and knowledge. Cross-tabulations were done to assess knowledge differences by sociodemographic and obstetric factors. Crude and adjusted odds ratios were obtained using logistic regression. P < 0.05 was considered statistically significant.

Qualitative data were analyzed thematically. Audio recordings were transcribed verbatim and coded to identify key themes and subthemes. Quotes were extracted to support the analysis.

Ethical consideration

Written informed consent was taken from all participants before they participated in the study. Institutional ethical committee approval was taken before the start of the project (Ref. No.: 91/02/2023). Confidentiality was maintained using unique identifiers. Participation was voluntary with the right to withdraw.

Results

Sociodemographic profile of the participants

This cross-sectional study comprised 390 pregnant women from rural western Gujarat. The majority were young, with 56.5% (n = 220) aged ≤25 years. Most participants were literate (85%, n = 333), predominantly Hindu (72.1%, n = 281), and from middle socioeconomic background (38%, n = 148) [Table 1].

Table 1 Sociodemographic characteristics of study participants (n=390)

Variables	Category	Frequency	Percentage	
1. Age	• ≤25	220	56.5	
	• >25	170	43.5	
2. Education (pregnant women)	• Illiterate	57	15	
	• Primary School	19	5	
	• SSC	101	15	
	• HSC	152	39	
	• Graduate and above	101	26	
3. Educations (Spouse)	• Illiterate	42	10.8	
	• Primary School	90	23.1	
	• SSC	141	36.2	
	• HSC	72	18.5	
	• Graduate and above	45	11.8	
4. Religion	• Hindu	281	72.1	
	• Muslim	109	27.9	
	• Others	-	-	
5. Occupation of Pregnant Women	Homemaker	330	84.6	
	Working	60	15.4	
6. Occupation of Spouse	Farmer	220	56.4	
	Government Employed	100	25.6	
	Private employed	70	18	
7. Residence	Rural	320	82	
	Urban	70	18	
Socioeconomic class (Modified BG Prasad Classification)	Class 1	65	16.7	
	Class 2	148	38	
	Class 3	109	27.9	
	Class 4	617	15.6	
	Class 5	7	1.8	

Past obstetric history of the participants

Among parous women (n = 252), 83.7% (n = 211) had 1–3 previous pregnancies and 88% (n = 222) had >1-year interval between consecutive pregnancies. Regarding antenatal care and delivery, 52% (n = 131) had 4–10 ANC visits, and 89.7% (n = 226) delivered previously at government hospitals [Table 2].

Table 2 Past obstetric history of the study participants

Variables	Category	Frequency	Percentage	
1. Ever been pregnant	  Yes	252	64.6	
	  No	138	35.4	
2. Frequency of pregnancy (n=252)	  1–3 times	211	83.7	
	  Above 3 times	41	16.3	
3. Minimum interval between two consecutive pregnancies (n=252)	  ≤1 year	32	12.6	
	  >1 year	222	88	
4. Age at first pregnancy (n=252)	  ≤20	60	24	
	  21–30	188	75.5	
	  ≤30	4	1.5	
5. Number of ANC visits (n=252)	  ≤4	46	18.2	
	  4–10	131	52	
	   ≥10	75	29.8	
6. Site of previous delivery (n=252)	  Government	226	89.7	
	   Private	22	8.7	
	  Home	4	1.6	
7. Total number of births (n=252)	  1-2	211	83.7	
	  >2	41	16.3	
8. History of IUD	  Yes	49	19.5	
	  No	203	80.5	
9. Time taken to reach the health facility	  <30 minutes	110	44	
	  ≤30 minutes	142	66	
10. Mode of delivery	  C-section	87	34.5	
	   Normal Vaginal delivery	165	65.5	
11. Counseled during ANC	  Yes	230	91	
	   No	22	9	
12. Counseled about (n=230) (Multiple options selected)	  Breastfeeding	71	31	
	  Immunization	56	24	
	  Menstrual hygiene	16	7	
	  Family planning	156	67.8	
	  Maternal nutrition	69	30	
13. Counseled during PNC	  Yes	195	77.4	
	  No	57	22.6	
14. Information about neonatal danger signs	  Yes	124	48	
	  No	128	52	
15. Source of Information (n=124)	  Health workers and/or Health professionals	121	96	
	  Others	5	4	

Knowledge of danger signs

The recognition of breastfeeding initiation time was 77.2% (n = 301). However, only 18% (n = 70) could identify the critical sign of chest in-drawing correctly [Table 3].

Table 3 Knowledge of antenatal mothers in neonatal danger signs, n=390

Variables	Category	Frequency, n (%)	
Cord care	Yes	232 (59.5)	
	No	158 (40.5)	
Material to tie cord	Yes	160 (41)	
	No	230 (59)	
Breastfeeding initiation time	Yes	301 (77.2)	
	No	89 (22.8)	
Exclusive breastfeeding	Yes	305 (78)	
	No	85 (22)	
Bathing time	Yes	243 (62.3)	
	No	147 (37.7)	
When bathed the previous child (n=252)	>24 hours	225 (89.28)	
	<24 hours	27 (10.72)	
Immediate immunization	Yes	316 (81)	
	No	74 (19)	
Fever	Yes	311 (79.7)	
	No	79 (20.3)	
Vomiting	Yes	292 (74.8)	
	No	98 (25.2)	
Lethargy	Yes	203 (52)	
	No	187 (48)	
Unable/poor feeding	Yes	246 (63)	
	No	144 (37)	
Cold to touch	Yes	161 (41)	
	No	229 (59)	
Difficulty in breathing	Yes	210 (53.8)	
	No	180 (46.2)	
Umbilical cord redness	Yes	155 (39.7)	
	No	235 (60.3)	
Convulsion	Yes	164 (42)	
	No	226 (58)	
Jaundice	Yes	275 (70.5)	
	No	115 (29.5)	
Chest-retraction/indrawing	Yes	70 (18)	
	No	320 (82)	

Factors associated with knowledge

Younger (≤25 years) women had 3.8 times higher adjusted odds (adjusted odds ratio (AOR): 3.8, 95% confidence interval (95% CI): 2.4–5.8) of better knowledge compared to older women. Literate and working women had around three times and two times higher odds compared to illiterate and unemployed women, respectively (P < 0.05). Women with previous cesarean deliveries had 2.4 times higher adjusted odds (AOR: 2.4, 95% CI: 1.16–5.006) than those with normal vaginal delivery (P = 0.019) [Tables 4 and 5].

Table 4 Association of neonatal danger signs with sociodemographic characteristics, n=390

Variables	Category	COR (CI)	AOR (CI)	
1. Age	≤25	[1]	[1]	
	>25	3.311 (2.1–5.05)	3.768 (2.4–5.8)	
2. Literacy (Antenatal women)	Illiterate	[1]	[1]	
	Literate	1.78 (1.05–3.0)	3.108 (1.5–6.4)	
3. Literacy (Spouse)	Illiterate	1.72 (0.884–3.34)		
	Literate			
4. Religion	Hindu	1.21 (0.775–1.89)		
	Muslim			
5. Occupation (Antenatal mother)	House-wife	[1]	[1]	
	Working	1.8 (1.074–3.23)	2.07 (1.2–3.5)	
6. Socioeconomic Status	Upper	[1]		
	Lower	0.904 (0.606–1.35)		
7. Occupation of a spouse	Farmer	[1]	[1]	
	Government	1.994 (1.23–3.23)	1.8 (1.12–3.177)	
	Private	2.068 (1.190–3.60)	2.063 (1.14–3.73)	
P<0.05: significant, P<0.001: highly significant, COR- Crude Odds Ratio, AOR- Adjusted Odds Ratio, CI- Confidence Interval

Table 5 Association of neonatal danger signs and previous obstetric history of the study participants, n=252

Variables	Category	COR (CI)	AOR (CI)	
1. Age at marriage	<22	[1]	[1]	
	23–29	1.86 (1.067–3.23)	1.120 (1.08–2.37)	
	>30	2.10 (1.14–20)	1.406 (1.21–21)	
2. Number of ANC visits	<4	[1]	[1]	
	5–10	2.211 (1.14–4.279)	0.885 (0.3–2.2)	
	>10	2.396 (1.2–4.631)	0.597 (0.2–1.4)	
3. Total number of births	1	[1]		
	2	0.5 (0.3–1.09)		
	>2	1.06 (0.49–2.048)		
4. History of IUD	Yes	0.845 (0.436–1.63)	
	No	[1]		
5. Mode of delivery	C-section	1.82 (1.062–3.10)	2.4 (1.16–5.006)	
	NVD	[1]	[1]	
6. Counseled during ANC	Yes	0.526 (0.210–1.32)		
	No			
7. Counseled during PNC	Yes	5.5 (2.9–10.38)	2.18 (1.82–5.190)	
	No			
8. Site of delivery	Government	0.169 (0.017–1.69)		
	Home	[1]		
	Private	0.33 (0.029–0.372)		
9. Counseled about neonatal danger signs	Yes	3.676(2.07–6.5)	1.4(1.2–3.9)	
	No			
P<0.05: significant, P<0.001: highly significant, NVD: Normal Vaginal Delivery

Qualitative insights

Themes highlighted dependence on family elders, financial limitations, and health system barriers exacerbating knowledge inadequacies [Table 6].

Table 6 Qualitative data from in-depth interviews on knowledge of neonatal danger signs

Theme	Subthemes	Participants phrases	
Knowledge sources	- Elders in the family	“I learned about newborn care from my mother and grandmother”	
	- ASHA/health workers	“The ASHA worker taught me how to take care of the baby”	
	- Pregnancy education materials	“I read about danger signs in the pregnancy booklet given at the hospital”	
Recognition of danger signs	- Awareness of some common signs such as fever, breathing issues, jaundice	“I know to look out for fever, breathing issues, and poor feeding” “Jaundice is common in newborns here”	
	- Lack of awareness of all danger signs	“I won’t be able to identify all danger signs”	
Care-seeking behaviors	- Preference for home remedies first	“I will take the baby to the doctor if I notice any serious signs”	
	- Reliance on family elders for care-seeking advice	“We prefer home remedies before going to the hospital”	
	- Financial and access barriers	“I will ask the elders in my family if I should take the baby to the doctor”	
Barriers	- Geographical access to health facilities	“The hospital is very far from our village”	
	- Need for family permission	“My husband has to permit me to take the baby to the doctor”	
	- Financial constraints	“I don’t have money for transportation and hospital fees”	
Suggestions for Improvement	- Strengthen counseling by health workers	“Counseling by health workers should be strengthened”	
	- Community awareness programs	“More awareness programs should be organized in villages”	
	- Use of audio-visual aids	“Danger signs should be taught using videos/leaflets”	
	- Involve husbands in newborn health education	“Husbands should also be counseled on newborn care”	

In summary, the results indicate that focused counseling and education of vulnerable women can help improve their neonatal health literacy and care-seeking practices. Younger, illiterate, and multiparous women should be especially targeted. Husband engagement also needs to be strengthened.

Discussion

The present study found that the prevalence of good knowledge of neonatal danger signs was 47%. This finding can be compared with previous studies. A systematic review and meta-analysis conducted in Ethiopia found that women’s knowledge of neonatal danger signs ranged between 9.4% and 88.9% depending on the study population.[15] A study in Ethiopia found that most mothers had a low level of knowledge about neonatal danger signs.[16]

The knowledge of antenatal mothers about neonatal danger signs is that the highest corrected response is for fever (311/390), followed by vomiting (292/390). This finding can be compared with a study in Ethiopia that found that the most frequently mentioned neonatal danger signs were fever, vomiting, and lethargy.[17]

The present study also found that age at marriage, mode of delivery, counseling during PNC, and counseling about neonatal danger signs in a previous pregnancy were associated with good knowledge levels of neonatal danger signs in multivariate analysis. This can be compared with a study in the United States that found that a wife’s age at marriage was one of the factors that explained most of the fertility difference between college-educated and high school-educated wives.[18] A study in Haiti, Malawi, and Senegal found that counseling on danger signs of pregnancy complications during ANC visits can raise expecting women’s awareness so that if danger signs occur, they can seek assistance in time.[19]

The study found that the age of the antenatal mother, education status, occupation of AN mother, and spouse were statistically significant, which can be compared with a study in Ethiopia, which found that mothers within the age range of 20–24 at first childbirth were more likely to attend PNC compared to mothers within the age range of 15–19 at their first childbirth.[20] A study in China found that educational level was a significant predictor of a mother’s knowledge of neonatal danger signs.[21] A study in Ethiopia found that maternal educational level, parity, postnatal care follow-up, and health education were associated with maternal knowledge of neonatal danger signs.[22]

The qualitative findings provided insights into the knowledge and care-seeking practices of women regarding neonatal danger signs. Elders and health workers were identified as key knowledge sources, consistent with studies,[23,24] which also reported reliance on family members and health workers for newborn health information.

While women could recognize some common danger signs such as fever, breathing issues, and jaundice, comprehensive knowledge of all signs was lacking. Similar knowledge gaps have been reported in previous studies,[24,25] which found limited maternal awareness of critical signs such as lethargy, convulsions, and chest in-drawing. Home remedies were preferred as the first response before seeking care from health facilities. Other studies have also highlighted preferences for home treatment before accessing formal care as a key barrier.[24,25] Dependence on elders for care-seeking advice was another emerging theme, consistent with the findings from a previous study.[24] Financial constraints and geographical access barriers also deterred timely care-seeking, as demonstrated in earlier studies.[24,25] Suggested solutions such as improved counseling, community awareness programs, audio-visual aids, and husband engagement aligned with recommendations made by previous studies.[24,25,26]

Limitation and Recommendations

The present study has certain limitations that should be acknowledged. First, the cross-sectional nature of the quantitative component allowed us to assess associations but not determine causality between knowledge levels and influencing factors. Employing a longitudinal cohort design in the future may better establish predictive relationships over time. Second, as participants were sampled from select rural areas for feasibility, findings may not be entirely generalizable to the overall population of Gujarat. Third, self-reported data in surveys can be vulnerable to recall errors or socially desirable reporting tendencies, which might introduce misclassification biases during knowledge evaluation. In addition, though suitable for exploratory qualitative research, our small in-depth interview sample is unlikely to have captured perspectives to saturation across rural sociocultural contexts. Lastly, we did not quantitatively investigate if greater awareness translated into appropriate care-seeking behaviors, which is an important knowledge-practice gap for future studies to address.

Considering the insights gained, we put forth certain recommendations for enhancing newborn health literacy and survival in rural communities. First, female education and women empowerment programs warrant strengthening to curb maternal illiteracy, which emerged as a key barrier. Second, frontline health workers should focus counseling during routine antenatal and postnatal home visits on vulnerable women who typically have lower knowledge levels. Third, innovative mass media solutions such as short videos and mobile apps could raise community awareness regarding neonatal danger signs, especially targeting families. Fourth, initiatives to actively engage husbands and elders through family-centered education models can facilitate retention and shared decision-making. Finally, investigating care-seeking pathways via longitudinal or ethnographic approaches is required to gain a nuanced, context-specific understanding and bridge the knowledge-action disconnect.

Conclusion

This mixed-methods study provided comprehensive insights into the knowledge gaps, sociodemographic determinants, obstetric influences, cultural practices, and barriers related to newborn danger signs among women in rural western Gujarat. The quantitative results demonstrated knowledge disparities among younger, less educated multiparous women from low socioeconomic backgrounds. The qualitative findings elaborated on the drivers of these knowledge differences, highlighting reliance on informal sources, family norms, and health system challenges.

Focused educational interventions via health workers, family members, mass media, and the use of visual tools could help improve awareness among vulnerable women. Husband and community engagement must also be strengthened to enable informed decision-making and timely care-seeking for newborns. The mixed methods approach yielded a nuanced understanding to inform context-specific neonatal health promotion strategies in the study setting.

Author contribution

YM contributed to the conceptualization, data curation, formal analysis, investigation, methodology, resources, supervision, validation, writing (original draft), and writing (review and editing). YM, BM, NP, and RG contributed to the conceptualization, data curation, formal analysis, investigation, writing (original draft), and writing (review and editing). YM, BM, NP, and RG contributed to the methodology, resources, supervision, validation, and writing (review and editing). YM, BM, NP, and RG contributed to the formal analysis, investigation, writing (original draft), and writing (review and editing). All the authors read and approved the final manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

We acknowledge and are grateful to all the patients who contributed to the collection of data for this study. We are also thankful to Dr. Nandini Desai (Dean and Chairperson of MDRU), and Dr. Dipesh Parmar (Professor and Head, of the Department of Community Medicine), Shri M P Shah Government Medical College, Jamnagar, India.
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