Opportunistic screening for diabetes mellitus and hypertension in primary care settings in Karnataka, India: a few steps forward but still some way to go.

Background: Opportunistic screening for individuals aged ≥30 years at all levels of healthcare for early detection of diabetes mellitus (DM) and hypertension (HTN) is an integral strategy under the national program to control non-communicable diseases. There has been no systematic assessment of the screening process in primary care settings since its launch. The objective was to determine the number and proportion eligible for screening, number screened, diagnosed and treated for DM and HTN among persons aged ≥30 years in two selected primary health centres (PHCs) in Dakshina Kannada district, Karnataka, India during March-May 2019 and to explore the enablers and barriers in the implementation of screening from the perspective of the health care providers (HCPs) and beneficiaries . Methods: This was a sequential explanatory mixed-methods study with a quantitative (cohort design) and a descriptive qualitative component (in-depth interviews and focus group discussions) with HCPs and persons seeking care. Those that were not known DM/HTN and not screened for DM/HTN in one year were used to estimate persons eligible for screening. Results: Of 2697 persons, 512 (19%) were eligible for DM screening, 401 (78%) were screened; 88/401 (22%) were diagnosed and 67/88 (76%) were initiated on treatment. Of 2697, 337 (13%) were eligible for HTN screening, 327 (97%) were screened, 55 (17%) were diagnosed with HTN; of those diagnosed, 44/55 (80%) were initiated on treatment.  The documentation changes helped in identifying the eligible population. Patient willingness to undergo screening and recognition of relevance of screening were screening enablers.  Overworked staff, logistical and documentation issues, inadequate training were the barriers. Conclusion: Nearly 19% were eligible for DM screening and 13% were eligible for HTN screening. The yield of screening was high. We noted several enablers and barriers. The barriers require urgent attention to reduce the gaps in delivery and uptake of services.

Magnitude and Reasons for Gaps in Tuberculosis Diagnostic Testing and Treatment Initiation: An Operational Research Study from Dakshina Kannada, South India.

BACKGROUND: In India, ensuring all Persons with Presumptive TB (PPTB) undergo TB diagnostic tests and initiating all diagnosed TB patients on treatment are two major implementation challenges. OBJECTIVES: In a coastal district of Karnataka state, South India, to (1) determine the number and proportion of PPTB who did not undergo any TB diagnostic test, and the number and proportion of TB patients who were not initiated on treatment (2) explore the facilitators and barriers in TB diagnostic testing and treatment initiation from health care providers' perspective. METHODS: For objective-1, we used a cross-sectional design involving review of data of PPTB enrolled for care during January-March 2019 and for objective-2, we used a qualitative design involving key informant interviews of health care providers. RESULTS: Of 8822 PPTB patients enrolled for evaluation of TB, 767 (9%) had not undergone any TB diagnostic test. In those who had undergone any TB diagnostic test, a total of 822 were diagnosed with TB and of them, 26 (3%) were not initiated on treatment. Cartridge-based nucleic acid amplification tests was used as a diagnostic test only among 1188 (13.5%) PPTB patients. The gaps in diagnostic testing were due to: non-availability of doctors/lab-technicians, inadequate knowledge about TB diagnostic tests among health care providers, reluctance of patients to undergo the TB diagnostic tests due to stigma/confidentiality issues and sub-optimal engagement of private health facilities for TB control. CONCLUSION: About 9% of PPTB not undergoing any test for TB and 3% of the TB patients not initiated on treatment are of major concern. Revised National TB Control Programme needs to address the identified barriers to improve the process of TB diagnosis and treatment initiation.

Assessing the implementation of a mobile App-based electronic health record: A mixed-method study from South India.

BACKGROUND: Government of India recognizes the use of "information, communication, and technology" in the provision of comprehensive primary healthcare. In 2014-2015, Karuna Trust, a nongovernmental organization, Bengaluru, India, introduced an electronic health record (EHR) innovation, namely "Comprehensive Public Health Management" application (CPHM App). Data could be entered in an offline mode followed by syncing with cloud. The CPHM App was piloted in primary health center (PHC) Gumballi, in Karnataka, with focus on household survey and maternal and child health (MCH) services. OBJECTIVES: To compare the consistency of selected MCH process indicators for Health Management Information System [HMIS] available from paper-based records and those generated through the CPHM App (2016-2017). We also explored the implementation enablers, barriers, and suggested solutions from the user perspective. METHODS: A sequential mixed-method study design was followed. Quantitative phase involved aggregate data analysis looking into the consistency of selected MCH process indicators available from paper-based records and those generated through the CPHM App (2016-2017) followed by thematic analysis of in-depth interviews of healthcare providers. Consistency was defined as a percentage where the numerator was the HMIS-related process indicator data from CPHM App and denominator was the data from paper-based records. RESULTS: Three out of 12 selected MCH indicators had consistency of >80%. The quarterly consistency reduced over the 2 years. Dual burden of entry and regular monitoring of paper-based records by district health and family welfare department were the reasons why more importance was given to entry in paper-based records. Ability to generate aggregate indicators with CPHM App, easy to use and retrieve data in the field, and reminder facility for planned health activities were some of the factors facilitating CPHM implementation. The key barriers were limited technical expertise and support from the technical team and no internet connectivity in the field and traveling to PHC to sync the data. Provision of real-time technical support and availability of data connectivity in the field were some of the solutions suggested. CONCLUSION: There should be a minimum of 1-2 years of simultaneous use of EHR and paper-based records after which one must shift to EHR.

Schoolchild as a health educator for parents regarding hypertension: A quasi-experimental study among school students of South India.

BACKGROUND: An alarming trend of sustained blood pressure elevation among children and adolescents has been found. Health education to schoolchildren in their formative age is the most effective method to be able to modify their habits, and further, they can be enrolled as an effective health educator for their parents. OBJECTIVE: To study the effectiveness of health education module on study participants about prevention and control of hypertension (HTN) and the effectiveness of child as a health educator on parents' knowledge about prevention and control of HTN. MATERIALS AND METHODS: This quasi-experimental study was conducted with a control group among high school students in two urban secondary schools. There were 110 students and 100 parents each in the intervention and control groups. Modular training with interactive teaching-learning methods was conducted for students in the intervention group. They, in turn, educated their parents. RESULTS: Postintervention, the study results showed a higher median for various domains in the intervention group as compared to the control group among both students and parents. On applying Mann-Whitney test, this difference was statistically significant with P < 0.001. CONCLUSION: The increase in the knowledge of parents belonging to the intervention group suggests the effective transfer of knowledge from the students to their parents.

'Have we missed reporting adverse drug reactions under Revised National TB Control Programme?' - A mixed method study in Bengaluru, India.

OBJECTIVE: Prompt identification, reporting and management of ADRs during anti tuberculosis treatment can ensure better compliance and treatment outcomes. The study was conducted to identify the gaps and associated factors in reporting of ADRs under RNTCP; assess knowledge, attitude and practice of RNTCP staff regarding pharmacovigilance programme and explore the barriers in reporting of ADRs from provider's perspective. METHODS: Mixed method research with sequential explanatory design was carried out in Tuberculosis Units of RNTCP administrative district of Bangalore city during July to December 2017. Quantitative study was carried out among 222 patients on intensive phase of Category I and Category II DOTS to study the incidence, severity and causality of ADRs; and records of these patients were analysed for gaps in reporting. Knowledge, attitude and practice (KAP) regarding recording and reporting aspect of pharmacovigilance programme was assessed among RNTCP staff. As part of the qualitative study, focus group discussion was carried out among RNTCP staff to study barriers for reporting ADRs from the provider's perspective. RESULTS: Record analysis at the time of recruitment showed documentation of ADRs in only five patients. Subsequent analysis of patient records during the middle and end of the intensive phase (IP) did not show documentation of any ADRs. Simultaneously interviews with patients revealed 116 (52.2%), 72 (32.4%) and 53 (23.8%) patients reported one or more symptoms of ADRs. The commonest ADR symptom reported were fatigability and gastrointestinal symptoms followed by musculoskeletal symptoms. KAP among 25 RNTCP staff showed that 96% of them felt reporting of ADRs was necessary and 92% reported the ADRs to their seniors, however 12% were scared to report. The main reason expressed for non-reporting was 'managing ADRs is more important than reporting' (52%). Also, 32% felt the need for retraining of staff on reporting and documentation. Barriers to reporting of ADRs were both health-system related like insufficient training and inadequate guidelines provided to RNTCP staff and patient-related factors like lack of awareness and reluctance to report ADRs. CONCLUSION: Successful implementation of RNTCP and achievement of TB elimination requires provision of adequate information regarding ADRs to patients and intense follow-up and probing at each contact by programme staff to effectively manage ADRs.

Effectiveness of life skills health education program: A quasi-experimental study among school students of South India.

BACKGROUND: Adolescence is a vital stage of growth and development; however, many adolescents do die prematurely due to accidents, suicide, violence, poor mental stability, depression, and other illnesses that are either preventable or treatable. Life skills are important for the promotion of well-being of adolescents and to develop positive attitude and values to lead a healthy life. OBJECTIVES: The study was conducted to assess the change in life skills postintervention and study the association between different variables and the postintervention life skills score. MATERIALS AND METHODS: A quasi-experimental study was conducted among 137 adolescents each in urban and rural schools. Life skills training module based on ten domains of life skills given by the World Health Organization was implemented using interactive teaching-learning methods. After 6 months of implementation of life skills training sessions, a postintervention assessment was done using the life skills assessment scale, and the differences in the scores were measured. RESULTS: Higher life skills score was observed postintervention, and this difference was statistically significant (P < 0.001). Higher postintervention mean score (above 15) was seen in critical thinking (19.58), self-awareness (18.03), creative thinking (15.78), and interpersonal thinking (15.15). CONCLUSION: Increase in the postintervention scores using an educational intervention module and interactive teaching-learning methods suggests effectiveness of the life skills education program. Implementing this health promotion module on life skills in the school curriculum will address the overall development of the personality of the school students.

'I am on treatment since 5 months but I have not received any money': coverage, delays and implementation challenges of 'Direct Benefit Transfer' for tuberculosis patients - a mixed-methods study from South India.

Background: In March 2018, the Government of India launched a direct benefit transfer (DBT) scheme to provide nutritional support for all tuberculosis (TB) patients in line with END TB strategy. Here, the money (@INR 500 [~8 USD] per month) is deposited electronically into the bank accounts of beneficiaries. To avail the benefit, patients are to be notified in NIKSHAY (web-based notification portal of India's national TB programme) and provide bank account details. Once these details are entered into NIKSHAY, checked and approved by the TB programme officials, it is sent to the public financial management system (PFMS) portal for further processing and payment. Objectives: To assess the coverage and implementation barriers of DBT among TB patients notified during April-June 2018 and residing in Dakshina Kannada, a district in South India. Methods: This was a convergent mixed-methods study involving cohort analysis of patient data from NIKSHAY and thematic analysis of in-depth interviews of providers and patients. Results: Of 417 patients, 208 (49.9%) received approvals for payment by PFMS and 119 (28.7%) got paid by 1 December 2018 (censor date). Reasons for not receiving DBT included (i) not having a bank account especially among migrant labourers in urban areas, (ii) refusal to avail DBT by rich patients and those with confidentiality concerns, (iii) lack of knowledge and (iv) perception that money was too little to meet the needs. The median (IQR) delay from diagnosis to payment was 101 (67-173) days. Delays were related to the complexity of processes requiring multiple layers of approval and paper-based documentation which overburdened the staff, bulk processing once-a-month and technological challenges (poor connectivity and issues related to NIKSHAY and PFMS portals). Conclusion: DBT coverage was low and there were substantial delays. Implementation barriers need to be addressed urgently to improve uptake and efficiency. The TB programme has begun to take action.

Use of Verbal Autopsy to Determine Underlying Cause of Death during Treatment of Multidrug-Resistant Tuberculosis, India.

Of patients with multidrug-resistant tuberculosis (MDR TB), <50% complete treatment. Most treatment failures for patients with MDR TB are due to death during TB treatment. We sought to determine the proportion of deaths during MDR TB treatment attributable to TB itself. We used a structured verbal autopsy tool to interview family members of patients who died during MDR TB treatment in India during January-December 2016. A committee triangulated information from verbal autopsy, death certificate, or other medical records available with the family members to ascertain the underlying cause of death. For 66% of patient deaths (47/71), TB was the underlying cause of death. We assigned TB as the underlying cause of death for an additional 6 patients who died of suicide and 2 of pulmonary embolism. Deaths during TB treatment signify program failure; accurately determining the cause of death is the first step to designing appropriate, timely interventions to prevent premature deaths.