Exploring private sector perspectives on barriers and facilitators in availing tuberculosis care cascade services: a qualitative study from the Indian state.

INTRODUCTION: The private sector plays an important role in tuberculosis (TB) elimination by providing access to quality TB care services like diagnosis and treatment, advocacy for preventive measures, innovation to address challenges in TB elimination, vaccines etc. The study aims to understand the perspectives of private practitioners on patients' TB care cascade to reinforce existing interventions by assuring the quality of care to TB patients. METHODS: The study utilized a qualitative design through in-depth interviews of private practitioners and was conducted in Ranchi and Purbi Singhbhum District of Jharkhand State from March-August 2021. The pilot-tested, semi-structured, open-ended interview guide questionnaire collected information from private practitioners on various aspects of the TB care cascade. The data from the provider interviews were transcribed into multiple codes and themes on the TB program. An inductive analysis was carried out with a focus on content credibility to eliminate bias. Ethical approval was received from the Institutional Ethics Committee of the Indian Institute of Public Health Gandhinagar (IIPHG), India. Written consent was taken from the private practitioners involved in the study. RESULT: In-depth interviews of 17 private practitioners reveal various factors contributing to delays in TB care cascades, especially delay in access to TB diagnosis and TB Care, delay in providing treatment once after diagnosis and poor adherence to the TB treatment. According to the perception of private practitioners, there was an array of client, provider and system side factors affecting the TB care cascade gaps positively and negatively. Positive aspects mainly emerged from interviews: strong governance, consistent supply chain management, innovative PPP models and financial schemes reducing out-of-pocket expenditure (OOPE). Various factors affecting the TB care cascade negatively include awareness among the patient, socio-economic status, approach and decision-making power of providers, adverse effects of drugs, staff capacity building, etc. CONCLUSIONS: Engaging private practitioner in TB elimination efforts is critical to achieving global targets and reducing the burden of TB. The study helps to determine geography-specific barriers and facilitators of the TB care cascade to achieve the aim of providing universal access to TB healthcare with the inclusion of private practitioners.

Deaths among tuberculosis patients of the western state of India: A secondary record based analytical study on its determinants.

INTRODUCTION: India has a significant TB burden, and ongoing attempts are being made to eradicate the disease. Globally, the number of TB deaths is declining, but not quickly enough to meet the End TB Goals. The National Strategic Plan (NSP) 2017-2025 in India set in motion an ambitious effort to expand the scope and efficacy of the National Tuberculosis Elimination Program (NTEP). METHODS: A descriptive retrospective study based on secondary data was conducted on information obtained from the electronic TB notification register for 2019, abstracted from Ni-kshay. Further, descriptive analysis was undertaken to identify the factors associated with deaths and successful treatment outcomes. The binomial logistic regression model estimates the crude relative risk and a 95% confidence interval to describe the association between predictor variables and TB treatment outcomes. RESULTS: After applying the eligibility criteria for the study population, a total of 1,44,643 (88%) TB patients were included in the study. 1,35,934 (94%) TB patients had completed the treatment and survived, while 8709 (6%) TB patients died. A significant association of treatment outcomes was observed in age, gender, key population, site of diseases, type of case, type of health facilities, HIV and Diabetes. When a logistic regression was applied, the model showed the association of the independent variables with the risk of death in TB patients. CONCLUSION: The epidemiological factors associated with treatment outcomes among TB patients should be audited systematically. A structure of TB death surveillance and response system should be established with a mortality audit, including a community-based death review (CBDR) and a facility-based medical audit (FBMA) in case the patient is hospitalized or discharged from a hospital.

Dissecting WASH Assessment Tools and Recommending a Comprehensive Tool for Indian Healthcare Facilities.

Providing adequate Water Sanitation and Hygiene (WASH) in Health Care Facilities (HCFs) has many benefits, including achieving Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC). However, there is a significant shortage of statistics on the status of WASH in Healthcare Facilities (WinHCF), resulting in roadblocks in developing improvement strategies. Further, there is a lack of detailed comparison of WASH components covered in available tools against the standards. The present study aims to dissect the national and international tools for WASH assessment in HCFs to suggest comprehensive WASH indicators. The databases like PubMed, Scopus, ScopeMed, Cochrane and Google Scholar were used to extract the available tools. The assessment process, methodology, and components of national and various international tools were compared and synthesized. A total of seven tools, namely WASH FIT 2, Facet, SARA, SPA, TOOL BOX-II, CDC and Kayakalp, were compared on eight components: water, sanitation, hand hygiene, healthcare waste, environmental cleaning and hygiene, infrastructure, workforce management, policy and protocols. Although most tools have covered the same indicators, the methodology and definitions differ. Few of the tools fail to capture the basic indicators defined by Joint Monitoring Programme (JMP). The critical indicators of policy and protocols are only covered in WASH FIT 2, Kayakalp, and TOOL BOX-II. Likewise, most tools fail to capture the indicator of cleaning, IPC practices and climate resilience. The present review also highlighted the limitations of selected tools regarding definitions, methodology and implementation. Hence, based on the review findings, a comprehensive short tool has been developed to monitor WASH in HCF of India. It comprises all the essential fundamental indicators identified from various tools, and recommended by the JMP service ladder with proper definitions. This tool can be helpful for hospital staff and managers for the routine monitoring of WASH in HCFs and improve the quality of care and IPC practices in HCFs.

Capacity Building, Knowledge Enhancement, and Consultative Processes for Development of a Digital Tool (Ni-kshay SETU) to Support the Management of Patients with Tuberculosis: Exploratory Qualitative Study.

BACKGROUND: Achieving the target for eliminating tuberculosis (TB) in India by 2025, 5 years ahead of the global target, critically depends on strengthening the capacity of human resources as one of the key components of the health system. Due to the rapid updates of standards and protocols, the human resources for TB health care suffer from a lack of understanding of recent updates and acquiring necessary knowledge. OBJECTIVE: Despite an increasing focus on the digital revolution in health care, there is no such platform available to deliver the key updates in national TB control programs with easy access. Thus, the aim of this study was to explore the development and evolution of a mobile health tool for capacity building of the Indian health system's workforce to better manage patients with TB. METHODS: This study involved two phases. The first phase was based on a qualitative investigation, including personal interviews to understand the basic requirements of staff working in the management of patients with TB, followed by participatory consultative meetings with stakeholders to validate and develop the content for the mobile health app. Qualitative information was collected from the Purbi Singhbhum and Ranchi districts of Jharkhand and Gandhinagar, and from the Surat districts of Gujarat State. In the second phase, a participatory design process was undertaken as part of the content creation and validation exercises. RESULTS: The first phase collected information from 126 health care staff, with a mean age of 38.4 (SD 8.9) years and average work experience of 8.9 years. The assessment revealed that more than two-thirds of participants needed further training and lacked knowledge of the most current updates to TB program guidelines. The consultative process determined the need for a digital solution in easily accessible formats and ready reckoner content to deliver practical solutions to address operational issues for implementation of the program. Ultimately, the digital platform named Ni-kshay SETU (Support to End Tuberculosis) was developed to support the knowledge enhancement of health care workers. CONCLUSIONS: The development of staff capacity is vital to the success or failure of any program or intervention. Having up-to-date information provides confidence to health care staff when interacting with patients in the community and aids in making quick judgments when handling case scenarios. Ni-kshay SETU represents a novel digital capacity-building platform for enhancing human resource skills in achieving the goal of TB elimination.

Why and where?-Delay in Tuberculosis care cascade: A cross-sectional assessment in two Indian states, Jharkhand, Gujarat.

Tuberculosis (TB) is the second leading cause of death due to infectious diseases globally, and delay in the TB care cascade is reported as one of the major challenges in achieving the goals of the TB control programs. The main aim of this study was to investigate the delay and responsible factors for the delay in the various phases of care cascade among TB patients in two Indian states, Jharkhand and Gujarat. This cross-sectional study was conducted among 990 TB patients from the selected tuberculosis units (TUs) of two states. This study adopted a mixed-method approach for the data collection. The study targeted a diverse profile of TB patients, such as drug-sensitive TB (DSTB), drug resistance TB (DRTB), pediatric TB, and extra-pulmonary TB. It included both public and private sector patients. The study findings suggested that about 41% of pulmonary and 51% of extra-pulmonary patients reported total delay. Delay in initial formal consultation is most common, followed by a delay in diagnosis and treatment initiation in pulmonary patients. While in extra-pulmonary patients, delay in treatment initiation is most common, followed by the diagnosis and first formal consultation. DR-TB patients are more prone to total delay and delay in the treatment initiation among pulmonary patients. Addiction, co-morbidity and awareness regarding monetary benefits available for TB patients contribute significantly to the total delay among pulmonary TB patients. There were system-side factors like inadequacy in active case findings, poor infrastructure, improper adverse drug reaction management and follow-up, resulting in delays in the TB care cascade in different phases. Thus, the multi-disciplinary strategies covering the gambit of both system and demand side attributes are recommended to minimize the delays in the TB care cascade.

Challenges and Motivators to Organ Donation: A Qualitative Exploratory Study in Gujarat, India.

Purpose: Despite the global efforts to improve organ donation, there is a demand-supply gap for organs in India. The only solution to meet this disparity is to improve deceased donor transplants in the country through victims of road accidents. The government has instituted several initiatives to achieve this goal. However, challenges and barriers continue to affect the organ donation process. The present study aims to document the motivating factors and obstacles in the decision of families to donate organs in Ahmedabad, Gujarat and their suggestions to improve the processes involved in organ donation. Patients and Methods: A qualitative exploratory study (in-depth interview) of ten relatives of deceased organ donors was conducted from Oct 2021 to Feb 2022. Interviews were audio recorded, and detailed notes were taken during the interview. Thematic analysis was done using ATLAS.ti version 8 software. Results: The significant motivators identified were family members' belief or conviction that it would help save the lives of others; a sense of moral obligation to do so as bodies of brain-dead persons can contribute to this noble goal, no use of the body after death, an extension of life, and being a role model for others. The challenges were mistrusting the organ donation process, fear of being responsible for any mishappening, and feeling of shock. The suggestions to improve organ donation included awareness creation, simplifying the legal process for accidental deaths, providing benefits to the donor family, and a system for identifying potential donors and their counselling. Conclusion: The present study reflects the need for a more comprehensive awareness campaign to generate awareness and remove the misconception about organ donation in India. The findings of the study can be helpful for policymakers to amend the current organ donation process in India and improve the disequilibrium of demand and supply of deceased donations in India.

Complexity of Decision-Making!: Case Studies of Cadaveric Organ Donations in Ahmedabad, India.

Background: The disequilibrium in the demand-supply nexus of organ donation prevails an urgent need for understanding the process and cascade of the donation. There is a lack of evidence in organ donation literature within India that focuses on factors influencing familial consent, the decision-making process, and psychosocial factors that can predict successful organ donation. Such evidence can assist in designing interventions and policy dialogue focusing on the discussion on enhancing donation decisions with relatives. Thus, the present study is an effort to document the decision-making complexity systematically among successful cadaveric organ donation cases. Methods: A qualitative exploratory, including the network assessment was implemented between October 2021 and February 2022 in one of the western states of India, Gujarat. A semi-structured interview guide that was comprised of thematic, open-ended questions focused on understanding the network for the decision-making process was prepared, and trained interviewers conducted the interview at the suitable place of the donor's relative. Results: The 10 interviews among the closest relatives of the deceased were conducted and the decision-making process indicated the involvement of multiple actors. The social network analysis reveals a minimum node of 2 to 7, with the highest ties of 22. The maximal degree was 3.6, and the density of 1 of these networks. Out of 10, in most cases, the ties were more than 2, with a maximum of 22 ties, which shows that more people communicated to each other before the final decision-making. Conclusion: The analysis indicates that the decision-making for deceased organ donation is a complex process as in most cases, multiple family members were involved and interaction happened before the final decision-making. The study explains the decision-making during the cadaveric organ donation process by exploring families' experiences. Further research is recommended to generate evidence on the factors and the family dynamics, including the complexity of successful organ donation.

Sociocultural Determinants of Nutritional Status Among Children Under Five Years of Age: An Ethnographic Study From Gujarat.

Background The magnitude of child malnutrition, including severe child malnutrition, is high in India, and Gujarat has a higher prevalence of child malnutrition. Prior studies have employed anthropometric measures to identify the prevalence and associated factors of children's undernutrition. The present study explored community-level determinants of malnutrition among malnourished and well-nourished children in Devbhumi Dwarka district of Gujarat State, India. Methods A qualitative research employing focused ethnographic methodologies was used. In-depth observations of 60 families in a home food environment were carried out. Each child was observed at their respective homes for three consecutive days. Data were analyzed using thematic analysis techniques. Results The study revealed that lack of knowledge on malnutrition, inadequate feeding practices, poor socioeconomic status, insufficient hygiene and sanitation practices, lack of food variety, use of health facilities, and birth complications were the major community-based determinants of malnutrition. Conclusion The study identified community-level determinants of malnutrition among children under five years in the Devbhumi Dwarka district. To tackle the immediate and underlying causes of malnutrition, interventions are urgently needed to create community awareness about malnutrition as a disease and optimal infant and young child feeding (IYCF) practices using behavior change communication strategies.

Health-Related Quality of Life (HRQoL) of Patients with Tuberculosis: A Review.

Tuberculosis (TB) is a major killer and cause of human suffering worldwide and imposes a substantial reduction in patients' health-related quality of life (HRQoL). HRQoL indicates the consciousness of patients regarding their physical and mental health. It is, therefore, very relevant in comprehending and measuring the exact impact of the disease state. Therefore, we undertook this review to summarize the available evidence on the impact of TB and its treatment on HRQoL. An in-depth understanding of HRQoL in TB patients can identify the existing management gaps. We undertook a systematic search through PubMed and CENTRAL. Data were extracted and tabulated for study design, targeted population, QoL instrument used, QoL domain assessed, and key findings. We included studies that assessed the effect of TB on the QoL both during and after treatment. There are no specific HRQoL assessment tools for utilization among TB patients. HRQoL is markedly impaired in patients with TB. The factors affecting HRQoL differ with active and latent TB, socio-demographics, socio-economic status, presence of co-infections, etc. This review's findings can help to frame appropriate policies for tackling HRQoL issues in TB patients.

Gaps and Interventions across the Diagnostic Care Cascade of TB Patients at the Level of Patient, Community and Health System: A Qualitative Review of the Literature.

Tuberculosis (TB) continues to be one of the important public health concerns globally, and India is among the seven countries with the largest burden of TB. There has been a consistent increase in the notifications of TB cases across the globe. However, the 2018 estimates envisage a gap of about 30% between the incident and notified cases of TB, indicating a significant number of patients who remain undiagnosed or 'missed'. It is important to understand who is 'missed', find this population, and provide quality care. Given these complexities, we reviewed the diagnostic gaps in the care cascade for TB. We searched Medline via PubMed and CENTRAL databases via the Cochrane Library. The search strategy for PubMed was tailored to individual databases and was as: ((((((tuberculosis[Title/Abstract]) OR (TB[Title/Abstract])) OR (koch *[Title/Abstract])) OR ("tuberculosis"[MeSH Terms]))) AND (((diagnos *) AND ("diagnosis"[MeSH Terms])))). Furthermore, we screened the references list of the potentially relevant studies to seek additional studies. Studies retrieved from these electronic searches and relevant references included in the bibliography of those studies were reviewed. Original studies in English that assessed the causes of diagnostic gaps and interventions used to address them were included. Delays in diagnosis were found to be attributable to both the individuals' and the health system's capacity to diagnose and promptly commence treatment. This review provides insights into the diagnostic gaps in a cascade of care for TB and different interventions adopted in studies to close this gap. The major diagnostic gaps identified in this review are as follows: people may not have access to TB diagnostic tests, individuals are at a higher risk of missed diagnosis, services are available but people may not seek care with a diagnostic facility, and patients are not diagnosed despite reaching health facilities. Therefore, reaching the goal to End TB requires putting in place models and methods to provide prompt and quality assured diagnosis to populations at par.

Evidence of Antimicrobial Resistance from Maternity Units and Labor Rooms: A Water, Sanitation, and Hygiene (WASH) Study from Gujarat, India.

The main objective of this study was to determine the microbial contamination and antimicrobial resistance pattern among isolated bacteria from the environment surfaces of maternity units and labor rooms of healthcare facilities in the Gujarat state of India. The cross-sectional study was conducted in ten healthcare facilities, where the microbiological swab samples were collected from various pre-decided environmental surfaces of the maternity and labor rooms as part of the Water, Sanitation and Hygiene (WASH) assessment. The swabs were analyzed by conventional microbiological culture methods to identify microorganisms, including antimicrobial susceptibility testing. The study provides an insight into the microbial contamination of the visibly clean areas, i.e., the maternity ward, labor room, and general wards of the healthcare facilities. The labor rooms were found to be highly contaminated in comparison to other selected sites. The microbiological findings revealed a predominance of Gram-negative bacteria, specifically Pseudomonas species. The antibiotic susceptibility testing indicates resistance against many commonly used antibiotics. This study produces an identified necessity for enhancing microbiological surveillance in labor rooms and maternity units. This study also highlights the importance of microbiological status along with the WASH status of healthcare facilities.

Challenges in the execution of public health research: Reflections from Public Health Research Initiative (PHRI) grant management in India.

Background: Well-planned health research is fundamental to the success of any public health system in leading to better population health outcomes. Although the Indian public health system is unique, it lacks strong linkages between research and practice. There is a pressing need to address the gap in the research to reduce the disease burden in the country. Although various efforts are made to enhance public health research, such research is rarely documented as a process. The objective of the present paper is to document issues and challenges in managing public health research grants awarded to the PHRI fellows from 2013-to 2021 under the PHRI project. Method: A mixed-method approach, including qualitative (in-depth) interviews and secondary review, was adopted to collect the challenges in executing PHRI grants (during 2013-2021). The in-depth interviews were conducted among the PHRI execution team, whereas the secondary document review was conducted among the PHRI fellows, and the findings are documented under major themes like administrative, technical, and financial issues and/or challenges. Result: A total of 35 candidates 16 intramural (IM) candidates affiliated with PHFI or IIPH institutes and 19 extramural (EM) candidates affiliated to other academic institutes were selected for the fellowship, The common challenges identified amongst intra & extramural fellows were inability to disseminate the study findings, challenges in communication and getting audited statements, changes in study methods without prior permission, mid study attrition of CO-PIs and high budget utilization. The specific difficulties identified from extramural fellows were change in institute affiliation, lack of support to fund utilization from the parent institute and difficulties in field validation. Conclusion: The present perspective emphasizes that the management and implementation of a research grant is the crucial part of achieving a project's desired outcome. The learnings of PHRI grant execution allows the researchers to understand the issues in terms of methodological rigour and financial guidelines, rigorous tracking of the project activities, and complying with the terms of funding agreement are crucial. The challenges explored in this grant execution recommend developing a structured public health grant management leadership program for researchers and executors.

Contributing Factors in the Tuberculosis Care Cascade in India: A Systematic Literature Review.

Tuberculosis (TB) care cascade is a recently evolved care model for patient retention across the sequential stages of care for a successful treatment outcome. The care cascade is multi-folded and complex in setting where the health system is reforming for its resilience. India, one of the countries with the highest burden of tuberculosis mortality and morbidity, is not an exception to this complexity. With the diverse challenges in the Indian health system and societal diversity, it is essential to understand the factors contributing to this TB care cascade. Thus, this study aims to map all the contributing factors to the TB care cascade in India. Further, it also captures the different patterns of factors explored so far in different countries' regions. This systematic literature review was conducted between October 2020 and February 2021 in India using PubMed databases, Web of Science, and Google Scholar. Two reviewers extracted the data from eligible studies to summarize and tabulate important findings. Data were extracted and tabulated for study design, location of the study, type of TB patients, methodological approach, system side challenges, and demand-side challenges in the study's findings. Out of 692 initial hits from the literature search, 28 studies were finally included to synthesize evidence in this review as per the inclusion and exclusion criteria. This review provides an insight into different factors such as the system-side (health workforce, institutional) and the demand-side (individual, societal) contributing towards the care cascade. The prime factors reflected in most of the studies were socio-economic condition, disease awareness, myths/beliefs, addictions among the demand-side factors and accessibility, the attitude of the healthcare staff, delay in referral for diagnosis among the system-side factors. The accountability for addressing these diverse factors is recommended to close the gaps in the TB care cascade.

Cluster-randomised trial to test the effect of a behaviour change intervention on toilet use in rural India: results and methodological considerations.

BACKGROUND: Effective and scalable behaviour change interventions to increase use of existing toilets in low income settings are under debate. We tested the effect of a novel intervention, the '5 Star Toilet' campaign, on toilet use among households owning a toilet in a rural setting in the Indian state of Gujarat. METHODS: The intervention included innovative and digitally enabled campaign components delivered over 2 days, promoting the upgrading of existing toilets to achieve use by all household members. The intervention was tested in a cluster randomised trial in 94 villages (47 intervention and 47 control). The primary outcome was the proportion of households with use of toilets by all household members, measured through self- or proxy-reported toilet use. We applied a separate questionnaire tool that masked open defecation questions as a physical activity study, and excluded households surveyed at baseline from the post-intervention survey. We calculated prevalence differences using linear regression with generalised estimating equations. RESULTS: The primary study outcome was assessed in 2483 households (1275 intervention and 1208 control). Exposure to the intervention was low. Post-intervention, toilet use was 83.8% in the control and 90.0% in the intervention arm (unadjusted difference + 6.3%, 95%CI 1.1, 11.4, adjusted difference + 5.0%, 95%CI -0.1, 10.1. The physical activity questionnaire was done in 4736 individuals (2483 intervention and 2253 control), and found no evidence for an effect (toilet use 80.7% vs 82.2%, difference + 1.7%, 95%CI -3.2, 6.7). In the intervention arm, toilet use measured with the main questionnaire was higher in those exposed to the campaign compared to the unexposed (+ 7.0%, 95%CI 2.2%, 11.7%), while there was no difference when measured with the physical activity questionnaire (+ 0.9%, 95%CI -3.7%, 5.5%). Process evaluation suggested that insufficient campaign intensity may have contributed to the low impact of the intervention. CONCLUSION: The study highlights the challenge in achieving high intervention intensity in settings where the proportion of the total population that are potential beneficiaries is small. Responder bias may be minimised by masking open defecation questions as a physical activity study. Over-reporting of toilet use may be further reduced by avoiding repeated surveys in the same households. TRIAL REGISTRATION: The trial was registered on the RIDIE registry ( RIDIE-STUDY-ID-5b8568ac80c30 , 27-8-2018) and retrospectively on clinicaltrials.gov ( NCT04526171 , 30-8-2020).

Visually clean is not necessarily microbiologically safe: Learnings from WASH assessment of maternity units of Gujarat, India.

BACKGROUND AND AIMS: Water Sanitation and Hygiene (WASH) within the context of Sustainable Development Goal (SDG) is well debated; however, WASH in health care sector is still in nascent phase, especially for maternity units. Although there are studies on WASH in maternity units, least are focused towards the microbiological safety. The objective of present study is to compare the visual assessment with microbiological assessment of selected maternity units of Gujarat (India) and to document microbiological contamination and drug resistance. METHODS: A cross-sectional study was carried out in 10 selected maternity units of Sabarkantha and Gandhinagar district of Gujarat, India, during Feb-March 2018. Two steps of Tool Box Plus were used for documentation: visual and microbiological assessment. Antimicrobial Resistance (AMR) patterns amongst positive microorganisms were also documented. RESULTS: Although the majority of the studied maternity units were visually clean, the microbiological findings contraindicated the same. The overall visual score across all facilities was close to 50% indicating good visual cleanliness. Out of 195 samples collected, 18% (35) samples were positive for pathogenic organisms and the majority were identified from mops and labour table. 1/3rd of organisms were resistant to > 5 antibiotics. Pathogenic organism identified includes Acitenobacter, Klebsilla, MR CONS, E coli, Psudomonas Aeruginosa and Pseudomonas species. CONCLUSIONS: Visual assessment alone which is currently used for assessment of hygiene is not a proxy for safety. It should be validated by the microbiological method. Microbiology surveillance should be explored to get valuable insights on the effectiveness of cleaning practices of the maternity units.