Rural Central India Research Articles

Stress and Stressor of Women: A Cross-sectional Study from Rural Population in Central India

Abstract Introduction: A meta-analysis of gender differences in depression using nationally representative samples in the USA found that twice as many women as men are depressed. Mental distress is a leading cause of health-related burden for the Indian population, which is aggravated by a high prevalence of socioeconomic adversity such as physical and sexual abuse, poverty, low education, and gender inequality. The index study was conducted to assess the prevalence and determinants of psychological distress among women in central rural India. Methodology: The data presented in the index article are a baseline assessment done as part of the community-based pragmatic cluster trial. The study was conducted in the catchment area of three primary health centers, Bela, Borkhedi, and Panchgaon, in the district of Nagpur, Maharashtra. Furthermore, 1050 women members of self-help groups in the district of Nagpur comprised the study population. Result: The mean age of the women was 38.2 years (standard deviation [SD]: 9.8). Around 987 (94%) women have attained primary education, and 52% of the participants were engaged in some occupation. Around half of the men and 10% of the women had the habit of daily tobacco chewing. Around 58.6% of participants’ husbands had the habit of drinking alcohol. 62.5% of the female participants were experiencing very high psychological distress. Lower socioeconomic status (adjusted odds ratio (AOR) = 2.1 [95% confidence interval (CI): 1.1–4.0]), comorbid condition (AOR = 2.0 [95% CI: 1.2–3.3]), marital status of women (single, widowed, divorced) (AOR = 3.4 [95% CI: 1.2–9.4]), and experiencing domestic violence (AOR = 4.7 [95% CI: 1.9–11.2]) were significantly associated with high psychological distress in multivariable logistic regression analysis. Conclusion: The high prevalence of psychological distress among women and its significant association with comorbidities such as diabetes mellitus, hypertension, and thyroid disorder hints us to incorporate the mechanism to screen for stress routinely at the health and wellness center under Ayushman Bharat, along with other risk factors for non-communicable disease.

Impact of vitamin D in acute ischemic stroke: A randomized clinical trial in rural central India

Introduction: Stroke is associated with several known risk factors, such as diabetes, raised blood pressure, high cholesterol levels, atrial fibrillation, and smoking. However, there are many instances in which these risk factors cannot be identified. In recent times, significant attention has been placed on vitamin D (vit D) deficiency as a particular risk factor. Various investigations have identified a link between low vit D levels and an increased incidence of strokes. This study aims to evaluate the role of vit D in assessing the prognosis of acute ischemic stroke (AIS) patients at a rural tertiary care teaching hospital. Methods: In this randomized control trial, 137 patients with AIS admitted to the medical intensive care unit/medicine wards were enrolled from June 2004 to September 2004. A consecutive sample of vit D levels was collected from patients with confirmed ischemic stroke, as determined by computed tomography scan or magnetic resonance imaging upon admission. Patients were divided into two groups: those with normal serum vit D levels and those with vit D-deficiency. Furthermore, the deficient group was supplemented with vit D. All three groups were compared after 3 months using the modified Rankin score (m-RS). Results: The study population was divided into three groups: group A had AIS patients with vit D deficiency who were supplemented with vit D; group B included AIS patients with vit D deficiency who were given a placebo; and group C comprised AIS patients with normal vit D levels who were given conventional stroke treatment. Groups A and B exhibited higher National Institutes of Health Stroke Scale (NIHSS) score with mean values of 25.5 and 27, respectively, while group C had a lower NIHSS with a mean of 17. On further follow-up at 3 months, the m-RS of groups C and A were 2 and that of group B was 3. Conclusions: Our findings suggest that the severity of stroke is greater in the vit D-deficient group, as evidenced by their higher NIHSS scores. Additionally, our results indicate that vit D supplementation may have a significant impact on recovery outcomes post-stroke. Patients who received vit D supplementation had significantly lower m-RS, suggesting improved functional recovery.

Systems delay in women with breast cancer - A sequential explanatory mixed-methods study from central rural India.

Globally, breast cancer is the most common malignant tumor in both developed and developing nations, with an incidence of 2 million cases every year and around 6 lakh deaths. Even after the availability of healthcare facilities, delays in the management of breast cancer are seen in both developed and developing countries. To assess the patient and system-level delays and to determine the factors that cause the identified delays in women with breast cancer from central rural India. The present Mixed-method study was conducted in a tertiary care hospital in central rural India among 128 female breast cancer patients. Socio-demographic and clinical information of the patients was summarized using frequency and proportions. Delays were reported using a median number of days and interquartile range. To assess the factors associated with the delays, we used Negative log-binomial regression analysis. Qualitative data analysis was done by manual thematic analysis. The mean age of the study participants was 50.54, SD was 10.46, Median was 50, and the Interquartile range (IQR) was 43-58 years. A median patient delay of 45 days, and IQR was 15-120. A median system delay of 19 days and IQR was 7-35 days. We identified seven themes addressing the factors influencing delays at various levels by thematic analysis. Negative log-binomial regression models were built for the association of the socio- demographic and clinical variables with patient and system delays. Our study concludes that there is a substantial delay at patient level reporting to healthcare care providers, which needs an increase in awareness levels in the community through dedicated Behavior Change Communication strategies along with addressing identified socio-cultural and economic determinants influencing delay at various levels.

Intimate Partner Violence and Mental Health Problems in Married Women in Rural Central India: A Community-based Cross-sectional Study.

Intimate partner violence (IPV) is a significant social issue affecting women in rural India, with deleterious consequences for their physical and mental health. The "mental health problems and psychosocial factors associated with IPV" is an under-researched topic in Central India. The cross-sectional observational descriptive study was part of a project aimed at strengthening the health sector response to gender-based violence. Eighty consenting women from 19 villages in a district in Central India, who acknowledged experiencing IPV, participated in the study. A predesigned and pretested sociodemographic questionnaire, the WHO multicountry women's questionnaire, and self-report scales for depression, anxiety, stress, and post-traumatic stress disorder (PTSD) were used to interview the women. The mean age of the respondents was 31.13 ± 6.96 years. The majority of the women (95%) experienced severe physical violence. In addition, a majority of these women simultaneously faced emotional abuse, whereas more than one-third suffered from sexual abuse from their partners. Self-reporting measures showed that nearly two-thirds of the participants had PTSD and moderate-to-severe depression and anxiety. A substantial number of study participants believed that IPV is a private matter for a couple and justified violence if the wife was unfaithful, disobedient, or neglectful of children and household duties. The under-reporting of IPV, presence of misconceptions, and high prevalence of associated mental health problems among IPV-affected women highlight the need for interventions tailored to the needs of battered women.

How are young people spending their leisure time? Findings from a formative research study in rural central India using a daily activity schedule, V-Can Project

Introduction. The younger population is disproportionately affected by NCDs, which are also rapidly affecting the poorer sections of the Indian population. Adolescents' unhealthy food intake and lack of physical activity are major contributors to the emergence of non-communicable diseases (NCDs). Objective. To understand the way leisure time is utilized by the individuals of 10-30 years age from the rural central India, in order to find opportunities for promoting recreational activities. Methods. A qualitative study was conducted using Daily Activity Schedule for formative research for V-CaN (Vitalizing Communities against No communicable diseases) project in 12 villages selected using convenience sampling maintaining variability with individuals of age 10-30 years. The activity was conducted separately with boys and girls, and content analysis was performed to analyze data

Association of Personality Traits of Alcohol-dependent Patients with Their Psychiatric Comorbidities: A Cross-sectional Study from Central Rural India

Introduction: Alcohol dependence syndrome (ADS) is a significant health problem all over the world. Alcohol-dependent individuals have a high prevalence of psychiatric comorbidities and nonadaptive personality traits that may influence the pathogenesis, treatment outcome, clinical course, and relapse of ADS. Aim: The aim of this study was to assess the personality traits and psychiatric comorbidities of alcohol-dependent patients and to determine the association of personality traits with psychiatric comorbidities in ADS. Methodology: An observational study was conducted on 100 patients of ADS from Acharya Vinoba Bhave Rural Hospital, Sawangi Wardha, Maharashtra. They were assessed through semi-structured sociodemographic pro forma, Mini-International Neuropsychiatric Interview PLUS, and 16 Personality Factor Inventory. Results: Most of the patients scored high on personality traits such as dominance (67%), warmth (56%), sensitivity (70%), social boldness (56%), openness to change (65%), vigilance (77%), and perfectionism (52%) while they scored low on factors privateness (50%) and liveliness (35%). The prevalence of psychiatric comorbidity was found to be 49%, with mood disorders (21%) being the most common diagnosis. Personality factors dominance (0.0001) and social boldness (0.042) were significantly associated with psychiatric comorbidities with P < 0.05. Conclusion: The personality traits and psychiatric comorbidity need to be addressed at the time of management to improve outcome.

Community engagement in health promotion campaigns: A qualitative photo content analysis from vitalizing communities against NCD risk factors (V-CaN) field trial in rural central India.

India faces a critical challenge with 5.8 million annual deaths from non-communicable diseases (NCDs). Maharashtra, where NCDs constitute 66% of the disease burden. The youth, lacking awareness, are vulnerable. Vitalizing communities against NCD risk factors (V-CaN) melawa, inspired by the "Pandharpur Wari" pilgrimage, aims to bridge implementation gaps and empower communities. "Arogya chi wari" integrates health practices with cultural events, offering a unique approach. Photo documentation from V-CaN melawa becomes a powerful tool for assessing community engagement qualitatively. The aim of the study was to qualitatively analyze photos from V-CaN melawas, exploring community engagement in health promotion against NCD risk factors. V-CaN melawas were organized in the field practice area of the department of community medicine. These melawas were part of the cluster randomized field trial named V-CaN, which is being implemented in a rural area of the Wardha district of Maharashtra. The V-CaN days, also known as melawas, were organized with the aim of facilitating behavioral change among participants. A qualitative study using photo content analysis was conducted, reviewing 2000 pictures from 59 V-CaN melawas. Thematic content analysis was employed, with researchers selecting 61 photos based on uniqueness. Six major themes emerged: health promotion, health system involvement, intersectoral coordination, inclusiveness, community resource mobilization, and innovation. Examples include nutrition exhibitions, health screenings, and innovative games. The analysis showcases diverse community participation in V-CaN melawas, emphasizing inclusivity, collaboration, and innovation. While qualitative, the study lays the foundation for future quantitative assessments of the intervention's impact on health outcomes and community attitudes.

Prevalence and factors associated with depression among the elderly in rural areas of central India: a mixed method study

Background: The global demographic shift towards an aging population has raised concerns about the mental health of the elderly, particularly in rural areas. This study sought to tackle this issue by quantitatively evaluating the prevalence of geriatric depression in rural areas of central India and qualitatively investigating the factors that contribute to late-life depression. Methods: This mixed-method study conducted in the rural areas of central India aimed to assess the prevalence of depression among the elderly and explore gender-specific factors contributing to late-life depression. Results: Quantitative data were collected from 308 elderly individuals aged 60 years and above, revealing a high prevalence of depressive symptoms (75.6%). Factors significantly associated with depression included female gender, age over 70 years, lower educational attainment, financial dependency, and comorbidities. Qualitative analysis through focus group discussions highlighted gender-specific perceptions of depression risk factors, emphasizing the need for tailored interventions. Conclusions: The findings underscore the urgent need for targeted mental health interventions addressing socio-economic disparities and gender-specific challenges in rural elderly populations. A nuanced, gender-sensitive approach is crucial for promoting well-being and reducing the burden of depression among the elderly in rural central India.

A study on health care utilization out-of-pocket expenditure in rural central India: A cross-sectional study

Background Out-of-pocket health expenditures have significant adverse effects, potentially resulting in impoverishment and impacting the quality of life. Awareness of patterns of healthcare utilization and out-of-pocket expenses is essential for informing healthcare scheme decisions. According to estimates from the World Health Organization in 2005, illness and the financial strain of healthcare costs force 25 million households into poverty each year. The goal of the study is to assess the proportion of households incurring out-of-pocket expenditure (OOPE) and The mean quality expended by households on healthcare. Methods In Wardha district, a cross-sectional study will be conducted. The pre-tested semi-structured survey will be administered to examine a sample of adult age groups, to identify sociodemographic data, utilization of healthcare services, and OOPE. A sample of 246 participants was selected by random sample method. Conclusion This study will help to improve and assess healthcare utilization and reduce out-of-pocket expenditures that lead to catastrophe and impoverishment. Awareness of the participants about health insurance. And they were known about the healthcare services.

Male Partner Involvement in Birth Preparedness, Complication Readiness and Obstetric Emergencies in Central Rural India: A Cross-Sectional Study.

Childbirth is mainly thought to be a woman'sconcern, and mortality can be prevented by making a birth plan constituting birth preparedness and complication readiness with the entire family as one unit. Indian National Plans aim to increase male involvement, but the policies lack directions and monitoring systems; hence, it becomes important to address this issue. A cross-sectional study conducted in a rural hospital and a community-based setup included 350 male participants, consisting of new fathers or expecting fathers, who were interviewed with the help of a questionnaire. Only 28.29% of male participants were well involved in the process of birth preparedness and complication readiness. 83% of the husbands accompanied their respective wives during ANC visits (mean number of visits: 5.76). 33% of males were aware of various danger signs and complications related to pregnancy. The males with better education (p-value < 0.005) and economic status (p-value < 0.0001) had better birth preparedness. Several variables in the study were positively correlated with the amount of money saved. Interpretation and conclusion: Male involvement during pregnancy significantly impacts maternal and child health outcomes. However, this study highlights a lack of awareness and involvement among males. We strongly recommend enhancing existing maternal and child health (MCH) programs to include components focused on male partner engagement in birth preparedness, complication readiness, and obstetric emergencies.

Implementation of a quality improvement initiative for standardising essential newborn care in a teaching public hospital in rural central India

ObjectiveOur aim was to refine the essential newborn care practices by employing the multidisciplinary peer team-led quality improvement (QI) projects.DesignIn 2017, concerning the same, the department focused on early initiation...

A Cross-Sectional Observational Study to Assess the Efficacy of Triglyceride to High-Density Lipoprotein Ratio as a Marker of Insulin Resistance in Subjects of Central Rural India.

The rising prevalence of insulin resistance (IR), obesity, and its complications in India is due to lifestyle changes, eating patterns, stress, and genetic factors. Markers for IR are often expensive, invasive, or impractical for use in economically disadvantaged or remote areas. To address this, we evaluated the efficacy of the triglyceride to high-density lipoprotein (TG/HDL) ratio as a simple, reliable, accessible, and affordable surrogate marker of IR in comparison to the homeostatic model assessment for insulin resistance (HOMA-IR). This cross-sectional observational study was performed at a tertiary care center in central India and included 815 subjects aged 18 to 60 years after excluding those with systemic diseases, drugs affecting weight, or pregnant or lactating women. Descriptive and inferential statistical analysis was done to represent the study findings. Males and obese subjects were more insulin resistant than females and non-obese subjects, respectively. The TG/HDL had a sensitivity of 91.81%, a specificity of 92.88%, a positive predictive value of 94.46%, and a negative predictive value of 89.56%, with a diagnostic accuracy of 92.27% when compared to HOMA-IR. We concluded that TG/HDL serves as a simple, affordable, and accurate marker of IR in a diverse population of central India. There is a definite scope to use the same for large-scale screening, epidemiological research, and routine clinical practice.

A study on health care utilization and out of pocket expenditure in rural central India: A cross-sectional study

Background Out-of-pocket health expenditures have significant adverse effects, potentially resulting in impoverishment and impacting the quality of life. Awareness of patterns of healthcare utilization and out-of-pocket expenses is essential for informing healthcare scheme decisions. According to estimates from the World Health Organization in 2005, illness and the financial strain of healthcare costs force 25 million households into poverty each year. The goal of the study is to assess the proportion of households incurring out-of-pocket expenditure (OOPE) and The mean quality expended by households on healthcare. Methods In Wardha district, a cross-sectional study will be conducted. The pre-tested semi-structured survey will be administered to examine a sample of adult age groups, to identify sociodemographic data, utilization of healthcare services, and OOPE. A sample of 246 participants was selected by random sample method. Conclusion This study will help to improve and assess healthcare utilization and reduce out-of-pocket expenditures that lead to catastrophe and impoverishment. Awareness of the participants about health insurance. And they were known about the healthcare services.

Assessment of Morbidity Profile and Perceptions in regards to Physical Activity amongst Display Screen Equipment Users working in a University Located in Central Rural India: A Mixed method study

Introduction Sedentary nature of desk job workers makes them prone to various diseases, and using display screen equipment increases the risk. This study focused on the intricate associates linked with sedentary behavior, physical activity patterns, and morbidity profiles among display screen equipment users employed at a university in central rural India. Sedentary lifestyles, particularly those prevalent in desk-based occupations, contribute significantly to non-communicable diseases, including hypertension, diabetes, and cardiovascular diseases. Display screen users face additional risks such as vision-related issues, strain on eyesight, and musculoskeletal disorders. Objective The study aimed to comprehensively understand the morbidity profile and perceptions of physical activity among display screen equipment users. Method This shall be a cross-sectional study with a mixed method component conducted at a medical university located in central India from January 24 to June 2024. A sample size of 97 participants was determined based on a previous study, and data collection shall be done utilizing systematic random sampling. Data will be gathered using the International Physical Activity Questionnaire (IPAQ) and Standardized Nordic Scale for musculoskeletal disorders through an online survey. Study implication This study aims to elicit morbidity patterns among Display screen users and their perceptions and practices regarding physical activity. This will also increase awareness regarding physical activity and associated morbidities regarding display screen use.

Epidemiology of heart failure in rural Chhattisgarh, India.

Background Cardiovascular diseases, including heart failure (HF), are leading causes of death and disability in India. However, most studies in India only include urban populations or rural regions with improved access and may not represent the poorest patients or regions. We studied the epidemiology of HF patients admitted to a secondary care hospital in rural Chhattisgarh, India. Methods We did a retrospective chart review of patients hospitalized with HF in 2018 to obtain their demographic data and risk factors for developing HF. We reviewed echocardio-grams to assign patients to their most probable HF category. Results We studied 88 HF patients with a mean age of 42 years including 55 (62.5%) women. The most common categories of HF were cardiomyopathy (36.8%), rheumatic heart disease (RHD; 25.3%) and right heart failure (RHF; 18.4%). Prior tuberculosis was more prevalent in patients with RHF compared with other types of HF (43.8% v. 13.9%). Conclusions HF patients in this study from rural central India were young and predominantly women. Cardiomyopathy, RHD and RHF due to past tuberculosis were common causes of HF in this population. Further studies are needed to expand upon these single centre findings to better understand the risk factors and outcomes of HF among the rural poor.

Unraveling Factors Shaping the Acceptance and Non-acceptance of Non-scalpel Vasectomy in Rural Central India: A Cross-Sectional Study.

Background India, with a population exceeding 1.43 billion, faces significant demographic challenges, necessitating effective family planning measures. Non-scalpel vasectomy (NSV) is a less complex and cost-effective male contraceptive, yet its acceptance remains low, especially compared to female sterilization. Understanding the determinants of NSV acceptance is crucial for informed decisions on family planning methods. Methods This cross-sectional study investigated NSV acceptance among males who underwent non-scalpel vasectomy (acceptors of NSV) and spouses of women who underwent tubectomy (non-acceptors of NSV). The study was conducted among 116 NSV acceptors and 116 non-acceptors from rural Central India. Data were collected over six months, employing a pre-designed questionnaire covering socio-demographic details, reasons for acceptance/non-acceptance, and information sources for the same. Statistical analysis was done utilizing Epi Info 7.2.6 (Centers for Disease Control and Prevention [CDC], Atlanta, GA), employing descriptive statistics and tests of association. Results Significant associations were found between NSV acceptance (p<0.05) and the age and education of study subjects, age of wife, duration since marriage, and total number of children. Incentives also played a significant role (p=0.014). Opposition to NSV, mainly from wives, was a key factor for non-acceptance (38%). Reasons for acceptance included a previous cesarean section (40.52%), the simplicity of the NSV procedure (26.72%), and the wife's illness (23.28%). Non-acceptance reasons comprised family/friend opposition (38%), lack of awareness/ignorance (25.00%), and fear of surgery (23.28%). Study subjects perceived community reluctance to NSV as mainly due to misbeliefs (30.17%), fear of surgery (27.58%), and illiteracy (26.29%). Conclusion The study highlights socio-demographic factors influencing NSV acceptance and identifies key reasons for acceptance/non-acceptance. Community-based interventions, increased advertisement, and health provider counseling were suggested for enhancing acceptance. Despite challenges, participant satisfaction with NSV was high. These findings contribute to understanding the complex dynamics surrounding NSV acceptance in rural Central India, informing future family planning strategies.

A cross sectional comparative study to assess body image dissatisfaction in men and women in rural central India

Background In recent decades, the topic of body image has frequently been discussed. Some people view their bodies favorably, whereas others think negatively of them (1). An unhealthy body image can lead to terrible outcomes and is unpleasant (2). This is a significant public health problem that calls for effective intervention. So far, studies on body image issues in the past have tended to concentrate more on women. Therefore, there is a great demand for research on young people’s body image dissatisfaction as well as for comparative studies. Our objective was to assess the prevalence of body image issues in men and women aged 18 to 35 in rural central India and to determine the gender differences in body dissatisfaction. Methods This is a cross sectional study based on young adults aged 18 to 35 in rural central India. It is a convenience-based sampling and the formula used is Krejcie-Morgan Formula, using this the sample size came out to be 190. The ethics committee’s approval will be secured and the students will be asked for their informed consent before providing socio-demographic information and completing the following questionnaires: 1. Body image dissatisfaction scale. 2. Body image questionnaire. Results Once we get the answers to the aforementioned questionnaires, we will be able to evaluate the prevalence of body image problems among adults in rural central India and also compare the gender disparities in body dissatisfaction.

A prospective observational study of sepsis-associated coagulopathy (SAC) in septic shock in the pediatric intensive care unit of tertiary care hospital in central rural India

Background: Sepsis-associated coagulopathy (SAC) is a frequently encountered clinical scenario in pediatric critical care practice. The disruptions within the normal coagulation cascade in cases of sepsis significantly impact the ultimate patient outcome. Objective: This study aims to evaluate the associations between sepsis-associated coagulopathy (SAC) in pediatric septic shock cases and their corresponding clinical outcomes. Methods: This study will be conducted within a tertiary care Pediatric Intensive Care Unit (PICU), focusing on children aged one month to 18 years who have been admitted to manage sepsis. Cases diagnosed with sepsis will undergo evaluation and treatment according to the established PICU protocol. Coagulation profiles, encompassing International Normalized Ratio (INR), activated Partial Thromboplastin Time (aPTT), Prothrombin Time (PT), and platelet counts, will be subjected to analysis. Any deviations in coagulation parameters will be compared and correlated with morbidity and mortality outcomes. Expected results: This study will establish correlations between the severity of sepsis and its subsequent outcomes, specifically concerning aberrations in coagulation profile levels. A meticulous analysis will focus on critically ill cases necessitating various interventions and exhibiting deviant coagulation patterns. Conclusions: This research aims to unravel potentially pivotal prognostic correlations within sepsis cases. The coagulation profile, a standard investigation, can be a predictive tool for outcomes within the Pediatric Intensive Care Unit (PICU).

Is Serum Magnesium Associated with Prehypertension? Two-Year Cross-sectional Study at Rural Central India

AbstractBackground:Prehypertension (HTN) raises the likelihood of developing HTN. Very few studies have been conducted on the serum magnesium responsible for causing pre-HTN.Materials and Methods:In this cross-sectional study, 300 subjects (150 cases and 150 controls) were enrolled to investigate the association between serum magnesium levels and pre-HTN. One hundred and fifty individuals with pre-HTN were compared with 150 controls without pre-HTN. All subjects had undergone anthropometric measurements such as body mass index (BMI) and waist–hip ratio along with lipid profile.Results:Levels of serum magnesium were low among the study population with pre-HTN when compared to controls without pre-HTN. Prehypertensive individuals show high BMI (24.09 ± 2.10 vs. 21.54 ± 2.02), waist–hip ratio (0.86 ± 0.08 vs. 0.82 ± 0.07), fasting blood sugar levels (103.15 ± 7.47 vs. 94.41 ± 8.21), serum triglyceride (141.12 ± 41.41 vs. 128.37 ± 23.46), and total cholesterol (175.95 ± 28.12 vs. 159.59 ± 19.03) levels when compared to controls. Multivariate logistic regression analysis was conducted which revealed a strong correlation between pre-HTN and hypomagnesemia.Conclusion:This study found a positive correlation between pre-HTN and low blood magnesium levels.

Role of Tumour Budding in Breast Cancer and Its Correlation with Other Prognostic Factors: A Cross Sectional Study in Rural Central India

Role of Tumour Budding in Breast Cancer and Its Correlation with Other Prognostic Factors: A Cross Sectional Study in Rural Central India