Humming (Simple Bhramari Pranayama) as a Stress Buster: A Holter-Based Study to Analyze Heart Rate Variability (HRV) Parameters During Bhramari, Physical Activity, Emotional Stress, and Sleep.

Objective In this study, our goal was to understand the comparative impact of humming, physical activity, emotional stress, and sleep on several heart rate variability (HRV) parameters, including the stress index (SI), and to assess the effectiveness of humming (simple Bhramari) as a stress buster based on the HRV parameters. Methods This pilot study assessed the long-term HRV parameters of 23 participants in terms of four activities: humming (simple Bhramari), physical activity, emotional stress, and sleep. The single-channel Holter device measured the readings, and data was analyzed using Kubios HRV Premium software for time and frequency-domain HRV parameters, including the stress index. Regarding statistical analysis, single-factor ANOVA followed by paired t-test was used to compare the results of HRV parameters "during" the four activities to understand if humming generates the outcome to enhance the autonomic nervous system. Results Our findings revealed that humming generates the lowest stress index compared to all three other activities (physical activity, emotional stress, and sleep). Several additional HRV parameters also supported the positive impact on the autonomic nervous, equivalent to stress reduction. Conclusions Humming (simple Bhramari) can be an effective stress-buster based on the assessment of several HRV parameters during its practice and in comparison with other activities. A regular daily humming routine can help enhance the parasympathetic nervous system and slow down sympathetic activation.

Treatment outcomes and associated factors among patients with drug-sensitive tuberculosis on daily fixed-dose combination drugs: A cohort study from Ahmedabad, India.

Background and Aim: The National Tuberculosis Elimination Program (NTEP) has been progressive in addressing the issues related to tuberculosis (TB) control in the country, with constant programmatic changes based on evidence available from operational research. Our objectives were 1. to assess the sociodemographic and clinical characteristics, and the treatment outcomes of patients on fixed-dose combination (FDC) daily regimen and 2. to assess the factors associated with unsuccessful treatment outcomes among patients with DS-TB. Materials and Methods: A retrospective cohort study was conducted based on record review. The study population included all patients with drug-sensitive TB, registered and initiated on treatment under NTEP "new category" from January to June 2018 and under "previously treated category" from January to March 2018. Quantitative data downloaded from Nikshay in Excel format was imported. Results: A total of 8301 patients with DS-TB registered under NTEP. Mean (standard deviation [SD]) age of DS-TB patients was 35.3 + 16.9 years, and 63.2% were in the age group of 15-44 years. Also, 60.1% were male, 2.5% were human immunodeficiency virus (HIV) positive, 65.3% were pulmonary TB cases, and 70.4% obtained treatment from public providers. Proportion of "successful" and "unsuccessful" outcomes was 87.9% and 12.1%, respectively, in the new treatment category and 78.3% and 21.7%, respectively, in the previously treated category. Among the patients classified under new category, the unsuccessful treatment outcome remained significantly high after adjustments with known confounders among patients aged 45-54 years (adjusted relative risks [aRR] 1.59, 95% confidence interval [CI] 1.31-1.93) and 55-64 years (aRR 1.67, 95% CI 1.36-2.05) compared to patients aged <15 years. Conclusion: Unsuccessful treatment outcome was significantly high among patients aged 45-54 years. Various adherence mechanisms implemented can be evaluated for further upscaling and improving the program effectiveness.

Effectiveness of mHealth-based educational interventions to improve self-care during pregnancy: A pragmatic randomized controlled trial from northern India.

OBJECTIVES: To assess and compare the effectiveness of mHealth-based educational interventions on improving pregnancy self-care knowledge, attitude, and practice (KAP) and the satisfaction in using the interventions. METHODS: We conducted a three-group, pragmatic, randomized controlled trial (July 2019-June 2020) among pregnant women (aged 20-45 years, gestation <20 weeks, and no pre-existing diseases) attending the prenatal clinic of a tertiary care hospital in northern India. Participants were randomly assigned to three arms (Group 1, specially developed mobile application; Group 2, Whatsapp, and Group 3, Control-Standard of care) using block randomization. Blinding was not performed. The educational intervention (for Groups 1 and 2) included general details about pregnancy, self-care preventive practices, and self-management of minor illnesses during pregnancy. The control group received routine instructions delivered by the doctors as part of the standard of care. After 3 months, the post-intervention KAP assessment and satisfaction with interventions/care received were carried out. RESULTS: Of the 150 pregnant women who participated (50 per group), 70 (46.6%) were graduates and 66 (44.0%) were primigravidas. Mean age was 28 years. Pregnant women in Groups 1 and 2 showed a statistically significant (P < 0.001) improvement in KAP on pregnancy self-care compared with the control group post-intervention. However, the same was insignificant (P > 0.05) between Groups 1 and 2. Participant satisfaction with the intervention was significantly high among Group 2 compared with the control group (P < 0.001). CONCLUSION: mHealth-based delivery of self-care education effectively improved KAP among pregnant women. The effectiveness of mHealth-based intervention must be assessed in primary healthcare settings before scaling up. DETAILS OF TRIAL REGISTRATION: Registered with Clinical Trial Registry India-CTRI/2019/10/021794 registered on October 29, 2019 (http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=37444&EncHid=&userName=CTRI/2019/10/021794).

Digital screening and brief intervention for alcohol misuse in college students: A pilot, mixed-methods, cluster randomized controlled trial from a low-resourced setting.

INTRODUCTION: We examined the feasibility and acceptability of digital screening and brief intervention (d-SBI) for alcohol misuse in college students; the effectiveness of d-SBI was our secondary outcome. We also explored the barriers and facilitators of d-SBI. METHODS: The study design is a mixed-methods, pilot, and cluster randomized trial. Five colleges from a northern city in India were randomly allocated to d-SBI and control groups. One hundred and ninety-one students were screened, and 25 (male = 23 and female = 2) participants (age 19.62 ± 2.58 years) fulfilled eligibility. All participants completed follow-up assessments at 3 months. In-depth interviews were done with 11 participants. Alcohol Use Disorder Identification Test (AUDIT) based screening brief intervention was provided on a web portal- or mobile application in the d-SBI group. The control group received digital screening and brief education. Direct questions and usage statistics assessed the measurement acceptability of the intervention. We compared the change in AUDIT scores in the intervention groups over 3 months post-intervention. Thematic analyses of transcripts of interviews were done by inductive coding. RESULTS: Most participants reported that d-SBI was user-friendly (80%), advice was appropriate (80%), and perceived it to be useful (72%). Ninety-six percent of users, who logged in, completed screening. There was a significant decrease in AUDIT scores both in d-SBI (p < .001) and control groups (p < .001). Time and group significantly affected the mean AUDIT score, but time × group interaction was non-significant. Thematic analysis revealed six overarching themes. CONCLUSIONS: Digital SBI for alcohol misuse is acceptable, feasible, and possibly effective among college students from low-resource settings.

Digital screening and brief intervention for illicit drug misuse in college students: A mixed methods, pilot, cluster, randomized trial from India.

BACKGROUND: Adolescence and early adulthood are vulnerable periods for substance use-related disorders later in life. The use of internet-enabled interventions can be useful, especially in low-resource settings. AIMS: To examine the feasibility, acceptability, and preliminary effectiveness of single-session digital screening and brief intervention (d-SBI) for illicit drug misuse in college students and explore barriers and facilitators of d-SBI. METHODS: Design: Mixed-methods, pilot cluster randomized trial. SETTING: Four conveniently selected colleges were randomized into intervention and control groups. PARTICIPANTS: 219 students were screened, and 37 fulfilled eligibility. Twenty-four completed follow-ups. In-depth interviews were done with ten students. Intervention and Comparator: Following a digital screening, Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) based brief intervention was provided in the d-SBI group. The control group received brief education. MEASUREMENTS: Acceptability was assessed by direct questions and usage statistics. ASSIST scores of groups were assessed at baseline and 3 months. Inductive coding of the interview transcript was done. RESULTS: More than 50 % of participants found d-SBI user-friendly, appropriate, and useful. Eighty percent of users, who logged in, completed screening. Per-protocol analysis showed a reduction in cannabis-ASSIST score over 3 months. The mean ASSIST score for other drugs combined did not differ significantly between groups. The difference in risk transition (moderate to low) was not significant. Qualitative analysis revealed three overarching themes- recruitment, engagement, and behavior change. CONCLUSIONS: Digital SBI for drug misuse is feasible among college students. d-SBI might be effective in reducing cannabis use.

Serum Calcitonin Gene-Related Peptide Is Elevated in Patients With Migraine and Ophthalmoplegia.

BACKGROUND: There is ongoing debate about whether the oculomotor (III), trochlear (IV), or abducens (VI) nerve paresis in patients with migraine is directly attributable to migraine (ophthalmoplegic migraine [OM]) or is due to an inflammatory neuropathy (recurrent painful ophthalmoplegic neuropathy [RPON]). As migraine is associated with elevated serum calcitonin gene-related peptide (CGRP) levels, we studied serum CGRP levels among patients with OM/RPON to determine whether they are elevated during and between attacks. This is the first study assessing CGRP levels in the serum of patients with OM/RPON. METHODS: The aim of this case-control study was to assess serum CGRP levels in patients with ophthalmoplegia and a headache consistent with migraine according to ICHD-3 criteria. Serum CGRP levels were measured during the ictal and interictal phases in 15 patients with OM/RPON and compared with age-matched and sex-matched controls without migraine (12 patients). RESULTS: The median serum CGRP levels were significantly elevated ( P = 0.021) during the ictal phase (37.2 [36.4, 43.6] ng/L) compared with controls (32.5 [30.1, 37.3] ng/L). Serum CGRP levels during the attack correlated with the total duration of ophthalmoplegia. A CGRP level of 35.5 ng/L in the ictal phase of the attack had a sensitivity of 86.7% and specificity of 75.0% in diagnosing a patient with OM/RPON. CONCLUSIONS: Elevated serum CGRP levels during the ictal phase of OM/RPON favor migraine as the underlying cause of episodic headache with ophthalmoplegia.

Effect of Various Lengths of Respiration on Heart Rate Variability during Simple Bhramari (Humming).

Background: Heart rate varies during breathing and the heart rate variability (HRV) facilitates the autonomic homeostatic capacity. The maximum HRV was observed at around 10 s of prolonged respiration as per HRV biofeedback literature. However, there is a gap in understanding the variations in HRV by different respiration lengths during simple Bhramari practice. Objective: To assess the effect of various respiration lengths (8, 10, 12, and 14 s) on HRV during the simple Bhramari (humming) practice. Methodology: A total of 118 individuals (67 males, 51 females) signed up for the study based on convenience sampling at a wellness center. A randomized (simple permutation) within-subject crossover design with repeated measures was used to measure their HRV during the simple Bhramari practice. The results were analyzed with one-way ANOVA and paired samples t-test. Results: The results indicate that, unlike the 10 s of respiration during HRV biofeedback breathing, maximum HRV during humming happens between 12 and 14 s of long breathing. Conclusions: The unique findings of the study demonstrate the maximization of HRV between the respiration lengths of 12 and 14 s. Future work should explore expanding the research to a broader group of participants, including individuals with chronic conditions and other demographic variables and mantra chanting.

COVID-19 vaccination uptake and adverse events following COVID-19 immunization in pregnant women in Northern India: a prospective, comparative, cohort study.

Objectives: The most commonly used vaccine in India, Covishield, is a recombinant adenovirus vector vaccine for which safety data in pregnant women are not available. The present study was conducted to assess the uptake of COVID-19 vaccines and monitor adverse events following COVID-19 immunization among pregnant women in northern India. Patients and Methods: A prospective cohort study was conducted among pregnant women registered with the antenatal clinics in Chandigarh Union Territory (U.T.) in northern India. The study included 247 pregnant women and a comparative group of age-matched, non-pregnant women (247) who received the first dose of the COVID-19 vaccine and were followed up by telephone interviews for adverse events following immunization at three time points until 28 days after vaccination. Multivariate regression (logistic and linear) was used for the adjusted analysis, with adverse events following immunization and the duration of adverse events following immunization as the outcomes. Results: The COVID-19 vaccination uptake rate was 66.8% among the pregnant women. The 28-day incidence rate of adverse events following immunization among the pregnant women was 76.5%. The overall 28-day incidence of adverse events following immunization in pregnant women did not differ significantly from that of non-pregnant women (P=0.153). Conclusion: The Covishield vaccine is safe for pregnant women in India. Further follow-up of the cohort for feto-maternal outcomes needs to be conducted with an adequate sample size to confirm the overall safety profile of the vaccine.

Rural community health workers' readiness for mobile-phone based telemedicine uptake in India.

Objective: Healthcare services using mobile-phone based telemedicine provide simple technology that does not require sophisticated equipment. This study assessed community health workers' knowledge, attitude, and practice (i.e., their readiness) at the village level for uptake of mobile-phone based telemedicine. Materials and Methods: This cross-sectional study was conducted among 80 community health workers, including Auxiliary Nurse Midwives, Multipurpose Health Workers and Accredited Social Health Activists working in a rural health block of India. A pre-tested, semi-structured, interviewer-assisted, self-administered questionnaire was used to assess their mobile-phone based telemedicine readiness. Results: Sixty (75.0%) health workers owned mobile phones. The median readiness score for mobile-phone based telemedicine was 109.0. The Accredited Social Health Activists showed a better attitude toward mobile-phone based telemedicine than others. There was a significant moderate positive correlation (r=0.67) between knowledge and practice domains. Community health workers who had smartphones showed a significantly better attitude than those who did not. Conclusion: Training programs on telemedicine service delivery, focused on Auxiliary Nurse Midwives/ Multipurpose Health Workers, can improve their attitudes towards telemedicine. A better attitude of the Accredited Social Health Activists must be leveraged to initiate mobile-phone based telemedicine services on a pilot basis initially and later scaled up in other settings.

Incidence, prevalence, and national burden of interstitial lung diseases in India: Estimates from two studies of 3089 subjects.

BACKGROUND AND OBJECTIVE: The epidemiology of interstitial lung diseases (ILDs) in developing countries remains unknown. The objective of this study was to estimate the incidence, prevalence, and national burden of ILDs in India. METHODS: Data of consecutive subjects (aged >12 years) with ILDs included in a registry between March 2015 and February 2020 were analyzed retrospectively. The proportion of each ILD subtype was determined. The crude annual incidence and prevalence of ILDs for our region were estimated. Subsequently, the primary estimates of the national annual incident and prevalent burden of ILD and its subtypes were calculated. Alternative estimates for each ILD subtype were calculated using the current and a large, previous Indian study (n = 1,084). Data were analyzed using SPSS version 22 and are presented descriptively. RESULTS: A total of 2,005 subjects (mean age, 50.7 years; 47% men) were enrolled. Sarcoidosis (37.3%) was the most common ILD subtype followed by connective tissue disease (CTD)-related ILDs (19.3%), idiopathic pulmonary fibrosis (IPF, 17.0%), and hypersensitivity pneumonitis (HP, 14.4%). The crude annual incidence and prevalence of ILDs were 10.1-20.2 and 49.0-98.1, respectively per 100,000 population. The best primary estimates for the crude national burden of all ILDs, sarcoidosis, CTD-ILD, IPF, HP, and other ILDs (in thousands) were 433-867, 213-427, 75-150, 51-102, 54-109, and 39-78. The respective alternative estimates (in thousands) were sarcoidosis, 127-254; CTD-ILD, 81-162; IPF, 46-91; HP, 130-261; other ILDs, 49-98. CONCLUSION: In contrast to developed countries, sarcoidosis and HP are the ILDs with the highest burden in India.

Could cattle dung burning have contributed to the epidemic of COVID-19-associated mucormycosis in India? Results of an experimental aero-mycological study.

BACKGROUND: Several hypotheses have been proposed for explaining the outbreak of coronavirus disease 2019 (COVID-19)-associated mucormycosis in India, including the burning of cattle dung cakes, though no study has yet been conducted to support this claim. METHODS: We conducted an aero-mycological study to evaluate whether Mucorales in the air increased during or after burning cattle dung cakes. We further compared the growth of Mucorales in the indoor air samples from houses with and without cattle. We also cultured fresh and dried cattle dung and soil samples for Mucorales. RESULTS: We noted no significant difference in the proportion of air samples growing Mucorales during (4/22 [18.2%]) and after (3/2 [13.6%]) cattle dung burning than that collected immediately before (4/22 [18.2%]). Mucorales were isolated in 15.4% of the indoor air samples obtained from different houses (both rural and urban); the proportion of samples growing Mucorales was not significantly different in households with and without cattle. We also observed growth of Mucorales in 6 of the 8 [75%] fresh and 3 of the 6 [50%] dried dung samples. The most common Mucorales isolated from soil and dung samples was Lichtheimia corymbifera, while Rhizopus arrhizus was the most common species isolated from indoor air samples. CONCLUSIONS: We found no significant increase in the proportion of air samples growing Mucorales during or after burning cattle dung cake than that before. It seems unlikely that cattle dung burning contributes to the occurrence of mucormycosis.

Effect of COVID-19 lockdown on the pathway of care and treatment outcome among patients with tuberculosis in a rural part of northern India: a community-based study.

Objectives: The coronavirus disease 2019 (COVID-19) pandemic affected routine healthcare services across all spectra, and tuberculosis (TB) care under the National Tuberculosis Elimination Program have been affected the most. However, evidence available at the community level is minimal. The clinical features, care cascade pathway, and treatment outcomes of TB patients pre- and during/post-COVID-19 pandemic lockdown in a rural community health block in northern India were assessed and compared. Materials and Methods: This was a retrospective cohort study that included all patients diagnosed with TB and initiated treatment under programmatic settings between January 1 and June 30, 2020, in a rural TB unit in northern India. The periods from January 1 to March 23 and March 24 to June 30 were marked as pre-lockdown and during/post-lockdown, respectively. Results: A total of 103 patients were diagnosed and treated for TB during the study period. A significantly higher proportion of pulmonary TB cases were reported during/post-lockdown (43, 82.7%) compared to that pre-lockdown (32, 62.7%), and a higher diagnostic delay was noted during/post-lockdown (35, 81.4%). Through adjusted analysis, patients diagnosed during/post-lockdown period (adjusted risk ratio [aRR], 0.85; 95% confidence interval [CI], 0.73-0.98) and previously treated (aRR, 0.77; 95% CI, 0.60-0.995) had significantly lower favorable treatment outcomes. Conclusions: The symptom and disease (pulmonary/extrapulmonary) pattern have changed during/post-lockdown. The care cascade delays are still high among TB patients, irrespective of the lockdown status. Lockdown had a significant adverse impact on the outcomes of TB treatment.

Definition, diagnosis, and management of COVID-19-associated pulmonary mucormycosis: Delphi consensus statement from the Fungal Infection Study Forum and Academy of Pulmonary Sciences, India.

COVID-19-associated pulmonary mucormycosis (CAPM) remains an underdiagnosed entity. Using a modified Delphi method, we have formulated a consensus statement for the diagnosis and management of CAPM. We selected 26 experts from various disciplines who are involved in managing CAPM. Three rounds of the Delphi process were held to reach consensus (≥70% agreement or disagreement) or dissensus. A consensus was achieved for 84 of the 89 statements. Pulmonary mucormycosis occurring within 3 months of COVID-19 diagnosis was labelled CAPM and classified further as proven, probable, and possible. We recommend flexible bronchoscopy to enable early diagnosis. The experts proposed definitions to categorise dual infections with aspergillosis and mucormycosis in patients with COVID-19. We recommend liposomal amphotericin B (5 mg/kg per day) and early surgery as central to the management of mucormycosis in patients with COVID-19. We recommend response assessment at 4-6 weeks using clinical and imaging parameters. Posaconazole or isavuconazole was recommended as maintenance therapy following initial response, but no consensus was reached for the duration of treatment. In patients with stable or progressive disease, the experts recommended salvage therapy with posaconazole or isavuconazole. CAPM is a rare but under-reported complication of COVID-19. Although we have proposed recommendations for defining, diagnosing, and managing CAPM, more extensive research is required.

Prevalence, Pattern, and Factors Associated With Self-reported Disability Among the Bhutanese Population: A Secondary Data Analysis of Population and Housing Census.

We analyzed the Population and Health Census of Bhutan (PHCB) 2017 to assess the prevalence and pattern of self-reported disability among people aged ≥15 years and the associated factors. The PHCB 2017 used the Washington Group Short Set on Functioning questionnaire to assess the disability ("lot of difficulty" or "cannot do at all") in seeing, hearing, mobility, cognition, self-care, and communication. Of the 536 443 persons included in the analysis, 384 101(71.6%) were aged <45 years, 283 453(52.8%) were men, and 206 103(38.4%) were from the rural area. The prevalence of any self-reported disability was 2.8%, among whom 34.2% reported multiple disabilities. The disability prevalence (any) was significantly higher among people aged ≥65 years, illiterate, economically inactive, permanent residents, residing in a rural area, and from central and eastern regions of the country compared with their respective counterparts. Further research on access to rehabilitation and linking with social protection schemes for the disabled is required in this country.

Pattern of non-communicable diseases during pregnancy and their effect on feto-maternal outcome: A prospective observational study.

OBJECTIVE: To assess patterns of non-communicable diseases (NCDs) and pregnancy outcomes of women in a tertiary care hospital. METHODS: This was a prospective observational study, conducted over 1 year. All NCDs in women who delivered or aborted were studied. Maternal and neonatal outcomes were noted. RESULTS: In all, 1003 NCDs occurred in 894 women. Chronic hypertension was the commonest, involving 309 (30.8%) women. Others included cardiovascular (159, 15.9%), neurological (142, 14.2%), endocrine (115, 11.5%), autoimmune (76, 7.6%), chronic kidney (48, 4.8%), and chronic respiratory (43, 4.3%) diseases, psychiatric disorders (38, 3.8%), cancers (20, 2.0%), and chronic liver disease (18, 1.8%). Most (599, 67.0%) were diagnosed before pregnancy and 145 (16.2%), 81 (9.1%), and 69 (7.7%) were diagnosed in the first, second, and third trimesters, respectively. Maternal deaths occurred in 6 (0.7%) women and near miss in 19 (2.1%) women. Only 9 (1.5%) women with NCD diagnosed before pregnancy had maternal near miss or death, compared with 16 (5.4%) diagnosed during pregnancy (P < 0.001). Of live births, 281 (35.3%) were low birth weight, 49 (6.1%) were very low birth weight, and 24 (3.0%) were extremely low birth weight. CONCLUSION: Chronic hypertension was the commonest NCD, which along with cardiovascular and neurological disorders constituted around 60% of all NCDs. One-third of NCDs were initially diagnosed during pregnancy. Maternal morbidity was lower if NCDs were diagnosed before pregnancy.

Demographic and clinical factors associated with early hospital Coronovirus disease 2019 deaths in a low middle income setting: A record-based analysis of 20,641 deaths from India.

Understanding the demographic and clinical characteristics cases and deaths is essential for better clinical and public health management of coronavirus disease-2019 (COVID-19) in resource-limited settings. We analyzed the COVID-19 deaths reported from India, to describe the demographic and clinical characteristics and identify the factors associated with early hospital deaths (within one day of hospitalization) and survival duration. We conducted a record review of the publicly available data on COVID-19 deaths reported between January 30th and November 30th, 2020. After imputation for missing data, we calculated unadjusted and adjusted prevalence ratio, and regression coefficient for factors associated with early hospital death and survival duration. Of the 20,641 COVID-19 deaths analyzed: a) 14,684 (71.1%) were males; b) 10,134 (50.9%) were aged <65 years; c) 9,722 (47.1%) treated at public hospitals and d) 5405 (27.1%) were early hospital deaths. Breathlessness was the most common presenting complaint. Diabetes (11,075,53.7%), hypertension (95,77,46.5%) and coronary artery disease (2,821,13.7%) were the common comorbidities. After adjustment, early hospital death was significantly higher among patients aged <65 years, without severe acute respiratory illness (SARI) at admission, non-diabetics, and cared at public hospitals compared to their counterparts. Similarly, the survival duration was at least one day higher among patients presented with SARI, chronic liver disease and cared at a private hospital. The analysis covered >10% of India's COVID-19 deaths, providing essential information regarding the COVID-19 epidemiology. The characteristics associated with early hospital death and survival duration among the COVID-19 fatalities may be deliberated as markers for prognosis and compared with survivors.

Community Preparedness and Practices for Prevention and Control of COVID-19 (COP-COVID): An Assessment from Rural Northern India.

OBJECTIVES: The study assessed the community preparedness to manage the coronavirus disease 2019 (COVID-19) and access to health-care services during the lockdown of 2020 in a rural health block of northern India. METHODS: A cross-sectional study was conducted during June-July, 2020, in 25 villages and 5 wards of a rural administrative block of Haryana. A pretested, semi-structured investigator-administered checklist was used to assess the community preparedness and practices for COVID-19 prevention/control and health-care access through direct observations and interviewing community health workers and beneficiaries. RESULTS: Active surveillance for influenza-like illness was carried out in 86.7% of the study units, although the frequency was once a month. There was poor adherence (adherence: 0-3%) to COVID-19 infection prevention and control (IPC) measures such as physical distancing and use of face masks. Rural beneficiaries reported difficulty in accessing essential health-care services than their urban counterparts. CONCLUSIONS: A qualitative study to understand the facilitators and barriers for the non-adherence to IPC measures by the study population and formulating behavior change communication strategies for improving the IPC measures is needed. Repeat, cross-sectional surveys at regular intervals may be planned to gauge the change and effect of the interventions on the community preparedness and practices.

Dietary behavior of school-going adolescents in Bhutan: Findings from the global school-based student health survey in 2016.

OBJECTIVES: Bhutan is experiencing a dual burden of undernutrition and overnutrition among adolescents. Understanding dietary behavior is vital to designing evidence-based interventions to improve adolescent nutrition and prevent non-communicable diseases in adults. The aim of this study was to assess the pattern of dietary behavior and associated sociodemographic, behavioral, and metabolic risk factors among school-going adolescents in Bhutan. METHODS: The Bhutan Global School-based Student Health Survey 2016 studied students in grades 7 to 11 (N = 7576), sampled from 50 schools, randomly selected based on probability proportional to enrollment size, using a standardized self-administered questionnaire. Consumption of adequate fruits and vegetables (each at least twice daily, or a combination of at least five times daily), high-protein food at least twice weekly) in the past 30 d, no fast food in the past week, and no carbonated/sweetened drinks in the past 30 d were studied. Weighted prevalence of dietary behaviors and adjusted prevalence ratio (95% confidence interval) for factors associated with them were calculated. RESULTS: Of 5809 students from 13 to 17 y of age comprising 3255 (56%) girls and 3184 (54.8%) day students, 1166 (20.1%) were underweight, 1655 (28.5%) were tobacco users, and 1349 (23.2%) were alcohol users. Adequate fruit and vegetable intake, high protein consumption, not consuming fast foods and carbonated beverages were reported by 29.6%, 31.8%, 9.6%, and 14.9%, respectively. Being a day student, sex, and not reporting health risk behaviors were significantly associated with any healthy dietary behavior. CONCLUSION: Healthy eating behavior was low among Bhutanese adolescents. Policies influencing availability, affordability, and acceptability of healthy diets through peer-led, school- and community-based interventions are required to promote adolescent health and prevent non-communicable diseases.