Prevalence and Predictors of Internet Addiction Among Adolescents Before the First Wave of COVID-19 Lockdown in India.

Background Internet dependency behavior was found to be prevalent among adolescents even before the first wave of COVID-19 lockdowns across the world including India. Adolescent users develop Internet addiction due to various risk factors. Aim The aim is to measure the prevalence and psychosocial predictors of internet addiction among adolescents before the first wave of the COVID-19 lockdown in India. Methods A cross-sectional, descriptive study before the first wave of the COVID-19 lockdown, included 1199 adolescents of both genders, aged 11 to 19 years, at selected educational settings from a city in south India, by using Young's Internet addiction test (IAT)-20 and structured questioner. Results The study found almost all the participants (100%) were using the internet in a day and the highest number of subjects started using the internet during their 6th standard of education (13%). Before the first wave of COVID-19 lockdown, the prevalence of a total of mild, moderate, and severe forms of internet addiction among adolescents was 65%. Individual, family, and community-related risk factors were found significant association with Internet addiction. The age of 14-16 years (OR 2.050, p= 0.000), duration of internet use in a day (OR 0.740, p= 0.064), financial matters (OR 0.981, p=0.016), total internet addiction score (OR 1.03, p=0.035) and timings of internet use (OR 1.161, p=0.004), were significant predictors of Internet addiction. Conclusion Internet addiction was prevalent and a notable behavior addiction among adolescents during the margin time of pre-pandemic and the first wave of the COVID-19 lockdown in India. The study highlighted many significant psychosocial risk factors and predictors of Internet Addiction in adolescents, thus the need for a panoramic approach to identify internet addiction in adolescents, to bring the modest behavior of healthy use of the internet in adolescents.

A Systematic Review of School-Based Nutrition Interventions for Promoting Healthy Dietary Practices and Lifestyle Among School Children and Adolescents.

Childhood malnutrition is one of the foremost community health problems in the world, particularly in developing countries like India. This current review was conducted to evaluate the effectiveness of various school-centered nutrition interventions/intervention programs developed in recent years, and their impact on the nutritional status, dietary habits, food preferences, lifestyle, and dietary behaviors in relation to diet, as well as physical activities for school children, especially adolescents. This review included studies found in the PubMed/Medline, SCOPUS, and Web of Science (WOS) databases, published from July 2017 to 2023. They were analyzed for eligibility criteria defined for this study, including school children and adolescents, school-based nutrition interventions/strategies/policies/initiatives, nutritional status, physical activity, dietary habits, and lifestyle. The Risk of Bias assessment was conducted using Review Manager version 5.4. Among 1776 potentially related studies, 108 met the eligibility criteria. Following this review, 62 studies were identified as eligible for this study, in which 38 intervention programs were discussed. A total of 13 studies were considered comprehensive and multi-component, 15 were nutrition education interventions, six were identified as physical activity interventions, and four focused on lifestyle and dietary behavior-related interventions. Another 24 of the 62 studies reviewed (approximately 39%) were either original articles, review articles, or articles pertaining to nutritional program guidelines, protocols, and/or reports. These studies uncovered a possible relationship between a decrease in BMI and school children's engagement in diet and/or physical activity. Results also suggest that these programs can be effective, although evidence for the long-term sustainability of changes in BMI was less evident and not fully substantiated/supported. Most of these findings are based on self-reported program data and may consist of biases linked to recall, selection of participants, and the desire to report favorable final measures (physical activity, lifestyle, and dietary habits). This study has the potential for use in public health programs devoted to healthy nutrition behavior and lifestyle practices. This research was primarily conducted by clinical researchers and did not receive any standardized institutional or organization-derived grant funding and support.

Healthy eating - a modifiable contributor to optimize healthy living in the COVID-19 pandemic: a review.

The outbreak of the novel severe acute respiratory syndrome coronavirus 2 infection in 2019 has posed major risks to global health and the economy. This coronavirus disease (COVID-19) pandemic has changed many of our everyday habits, including how we function and socialize, how we eat, and food preferences and selection. The average intake and status of certain vitamins and minerals can result in reduced immunity, which makes people more susceptible to illnesses and exacerbates malnutrition. The most critical factors in this scenario are individual risk evaluation and management techniques. Until general therapies are administered, the nutritional status of each infected patient should be assessed. The differing clinical severity of COVID-19 - from asymptomatic, to mild, to severe, to death - depends on the different metabolic status of the hosts who have contracted the virus, which is determined by their diet, age, gender, health, lifestyle, and environmental factors. A broad systematic exploration on studies of this disease was steered by means of electronic databases and was limited to articles published in English (or with an English abstract) in publications using words like 'health', 'diet', 'food', 'nutritional status', 'COVID-19', 'pandemic', 'modifiable contributor', 'immune system', 'micronutrients', 'vitamin', and so on. Careful individual consideration of the potential dietary, nutritional, medical, lifestyle, and environmental hazards, along with any supplementation with micronutrients wherever required to help to boost the body's natural defence system, with the intention to improve all levels of immunity and the use of effective risk management techniques are appropriate ways to handle the COVID-19 pandemic. © 2021 Society of Chemical Industry.

Continuum of Surgical Skill Acquisition for the Postgraduate Residents During COVID Pandemic: Role of Advanced Simulators in a Multipronged Modular Approach.

Skill acquisition with required competencies as defined by the National Medical Commission for the postgraduate surgical residents can happen in a step-wise manner from novice or advanced beginner to competent levels. This requires well-defined program-specific objectives, teaching-learning and assessment methods as per the competency-based medical education curriculum. Various modalities of teaching for the residents are adapted during the COVID pandemic to maintain the continuum of learning. In this study, we have attempted to develop, implement, and evaluate the effectiveness of acquiring laparoscopic surgical skills using advanced simulators and with large live animal in a real-life situation by a modular training approach. This skill-based program was developed and implemented for final year General Surgery postgraduate residents of Yenepoya Medical College for training laparoscopic surgical competencies. The training was conducted at Advanced Simulation Centres of Yenepoya (Deemed to be University), Mangalore, Karnataka, India. Three training modules were prepared based on the competency-based medical education curriculum for incremental training with advanced simulators and large live animals in a real-life situation which included the sessions on briefing, scenarios, simulations, hands-on activities, debriefing, feedback, and assessment methods. Assessment after the modular training showed statistically significant improvement in their scores, and they scaled up their skill acquisition ladder after each module. The residents and faculty felt that integration from different specialties has increased their confidence levels and communication skills, exploring team dynamics with 1:1 mentorship to make them competent emphasizing the effectiveness of simulation-based training even during the pandemic.

Development of a brief psychological intervention for perinatal depression (BIND-P).

BACKGROUND: Lack of recognition in national programs, poor referral system, and non-availability of trained human resources are the important barriers for the delivery of perinatal depression (PND) services in low- and middle-income countries (LAMICs). To address this there is an urgent need to develop an integrative and non-specialist-based stepped care model. As part of its research thrust on target areas of India's National Mental Health Programme (NMHP), the Indian Council of Medical Research funded a research project on the outcome of PND at four sites. In this article, we describe the development of the primary health care worker-based stepped care model and brief psychological intervention for PND. METHODS: A literature review focused on various aspects of PND was conducted to develop a model of care and intervention under NMHP. A panel of national and international experts and stakeholders reviewed the literature, opinions, perspectives, and proposal for different models and interventions, using a consensus method and WHO implementation toolkit. RESULTS: A consensus was reached to develop an ANM (Auxillary nurse midwife)-based stepped-care model consisting of the components of care, training, and referral services for PND. Furthermore, a brief psychological intervention (BIND-P) was developed, which includes the components of the low-intensity intervention (eg, exercise, sleep hygiene). CONCLUSION: The BIND-P model and intervention provide a practical approach that may facilitate effective identification, treatment, and support women with PND. We are currently evaluating this model across four study sites in India, which may help in the early detection and provision of appropriate and integrative care for PND.

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.

Epidemiological profile and mapping geographical distribution of road traffic accidents reported to a tertiary care hospital, Mangaluru using quantum geographic information system (QGIS).

BACKGROUND: The worldwide annual average of road traffic accident (RTA) is approximately 7,00,000 and out of that 10% occur in India. It is estimated that in India, by 2020 RTA would have its fatal effect on about 5,50,000 people annually. This study was conducted to describe the epidemiological profile and spatial distribution of RTAs using quantum geographic information system (QGIS) software reported to a tertiary care hospital in Mangaluru. METHODS: It was a record based descriptive study conducted in a tertiary care hospital of Mangaluru. The complete enumeration of all RTAs reported to Yenepoya Medical College Hospital (YMCH) during January 2018 to June 2018 was followed. QGIS software was used to depict spatial distribution of the road traffic accident on open street map. RESULTS: A total of 180 cases of RTA was reported to the hospital during the study period, of which 86.1% were males. The mean age of the study participants was 33.99 years. The lower limb was the most common site of injury (48.3%) and fractures were the most common type of injury (55.6%). As per the type of RTA majority (55.6%) was motorbike accidents and drivers (47.8%) were the most common RTA victims. Predominantly RTAs occurred during evening hours of the day (40%). QGIS plotting revealed clustering of RTAs in Dakshina Kannada district, North Karnataka and neighboring districts of Kerala. CONCLUSION: QGIS can be used at the health care system level as an important tool to plan preventive measures and early intervention measures at the site of RTA.

Does provision of cash incentive to HIV-infected tuberculosis patients improve the treatment success in programme settings? A cohort study from South India.

BACKGROUND: In April 2018, the Government of India launched 'Nikshay Poshan Yojana' (NPY), a cash assistance scheme (500 Indian rupees [~8 USD] per month) intended to provide nutritional support and improve treatment outcomes among tuberculosis (TB) patients. OBJECTIVE: To compare the treatment outcomes of HIV-infected TB patients initiated on first-line anti-TB treatment in five selected districts of Karnataka, India before (April-September 2017) and after (April-September 2018) implementation of NPY. METHODS: This was a cohort study using secondary data routinely collected by the national TB and HIV programmes. RESULTS: A total of 630 patients were initiated on ATT before NPY and 591 patients after NPY implementation. Of the latter, 464 (78.5%, 95% CI: 75.0%-81.8%) received at least one installment of cash incentive. Among those received, the median (inter-quartile range) duration between treatment initiation and receipt of first installment was 74 days (41-165) and only 16% received within the first month of treatment. In 117 (25.2%) patients, the first installment was received after declaration of their treatment outcome. Treatment success (cured and treatment completed) in 'before NPY' cohort was 69.2% (95% CI: 65.6%-72.8%), while it was 65.0% (95% CI: 61.2%-68.8%) in 'after NPY' cohort. On adjusted analysis using modified Poisson regression we did not find a statistically significant association between NPY and unsuccessful treatment outcomes (adjusted relative risk-1.1, 95% CI: 0.9-1.3). CONCLUSION: Contrary to our hypothesis and previous evidence from systematic reviews, we did not find an association between NPY and improved treatment outcomes.

Factors associated with awareness and practice about foot care among patients admitted with diabetes mellitus: A cross sectional research from a medical college hospital of southern India.

BACKGROUND: Diabetes Mellitus (DM) causes micro and macro vascular complications. One of the complications of DM is diabetic foot that results in amputations and decreased quality of life. The aim of this study was to assess the awareness and practice about foot care and associated factors among admitted patients in a teaching hospital of coastal Karnataka, India. MATERIAL AND METHODS: A cross-sectional study was conducted in a medical college hospital after obtaining institutional ethics approval from 24th December 2016 to 21st January 2017. Adults with diabetes (N=317) admitted in the hospital were interviewed with a validated structured questionnaire for awareness and practice regarding foot care. The scores obtained were further graded into good and poor. Data was analyzed with SPSS version 22 for descriptive statistics. Bivariate logistic and linear regressions were used to determine the association between variables and awareness/practice scores. RESULTS: Mean age of the participants was 56.98 (±10.54) years with males constituting the majority (63.4%). Good awareness and practice scores were observed among 69.1% and 41.6% participants, respectively. Good awareness scores were associated with male patients (p=0.027), currently not married (p=0.044), below poverty line socioeconomic status (p=0.014) and presence of foot ulcer (p=0.021). Good practice scores was associated with secondary schooling (p=0.003) and receiving insulin (p=0.045). Moderate correlation with coefficient 0.493 (p<0.001) was observed between awareness and practice scores. CONCLUSION: Seven and four out of 10 study participants had good awareness and practice scores about foot care, respectively. A tailor-made health education module addressing the lacunae identified in the awareness and practice domains needs to be provided to the patients with diabetes mellitus.

Quit attempts among tobacco users identified in the Tamil Nadu Tobacco Survey of 2015/2016: a 3 year follow-up mixed methods study.

OBJECTIVES: To determine current tobacco use in 2018/2019, quit attempts made and to explore the enablers and barriers in quitting tobacco among tobacco users identified in the Tamil Nadu Tobacco Survey (TNTS) in 2015/2016. SETTING: TNTS was conducted in 2015/2016 throughout the state of Tamil Nadu (TN) in India covering 111 363 individuals. Tobacco prevalence was found to be 5.2% (n=5208). PARTICIPANTS: All tobacco users in 11 districts of TN identified by TNTS (n=2909) were tracked after 3 years by telephone. In-depth interviews (n=26) were conducted in a subsample to understand the enablers and barriers in quitting. PRIMARY AND SECONDARY OUTCOMES: Current tobacco use status, any quit attempt and successful quit rate were the primary outcomes, while barriers and enablers in quitting were considered as secondary outcomes. RESULTS: Among the 2909 tobacco users identified in TNTS 2015/2016, only 724 (24.9%) could be contacted by telephone, of which 555 (76.7%) consented. Of those who consented, 210 (37.8%) were currently not using tobacco (ie, successfully quit) and 337 (60.7%) continued to use any form of tobacco. Of current tobacco users, 115 (34.1%) have never made any attempt to quit and 193 (57.3.8%) have made an attempt to quit. Those using smoking form of tobacco products (adjusted relative risk (aRR)=1.2, 95% CI: 1.1 to 1.4) and exposure to smoke at home (aRR=1.2, 95% CI: 1.1 to 1.3) were found to be positively associated with continued tobacco use (failed or no quit attempt). Support from family and perceived health benefits are key enablers, while peer influence, high dependence and lack of professional help are some of the barriers to quitting. CONCLUSION: Two-thirds of the tobacco users continue to use tobacco in the last 3 years. While tobacco users are well aware of the ill-effects of tobacco, various intrinsic and extrinsic factors play a major role as a facilitator and lack of the same act as a barrier to quit.

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.

Does mobile phone instructional video demonstrating sputum expectoration improve the sputum sample quality and quantity in presumptive pulmonary TB cases? Protocol for a prospective pragmatic non-randomised controlled trial in Karnataka state, India.

INTRODUCTION: Sputum smear microscopy is the cornerstone of tuberculosis (TB) diagnosis under the Revised National Tuberculosis Control Programme (RNTCP) in India. Instructions on how to produce a good sputum sample are a part of RNTCP training manuals, but its assessment is not emphasised. Healthcare provider's instruction to expectorate a good sputum sample has limitations. Presumptive TB patients often submit inadequate (in quantity and/or quality) sputum samples, which may result in false-negative results. Objectives of the study are, among the selected RNTCP designated microscopy centres in Dakshina Kannada district, Karnataka, India, (a) to assess the effectiveness of mobile phone instructional video demonstrating sputum expectoration on sputum quality and quantity and (b) to explore the mobile phone video implementation challenges as perceived by the healthcare providers. METHODS AND ANALYSIS: This is a pragmatic, prospective, non-randomised controlled trial in two pairs of RNTCP Designated Microscopy Centres (located at secondary and primary healthcare facilities) of Dakshina Kannada district, India. Presumptive pulmonary TB patients aged ≥18 years will be included. We will exclude who are severely ill, blind, hearing impaired, patients who have already brought their sputum for examination, and transported sputum. In the intervention group, participants will watch a mobile phone instructional video demonstrating submission of an adequate sputum sample. The control group will follow the usual ongoing procedure for sputum submission. This study would require 406 participants for each group to achieve a power of 90% for detecting a difference of 15% between the two groups. The participant enrolment started in December 2019. ETHICS AND DISSEMINATION: Yenepoya University Ethics Committee, Mangaluru, India, has approved the study protocol (YEC-1/158/2019). It complies with the Declaration of Helsinki, local laws, and the International Council for Harmonization-good clinical practices. Investigators will present the results in scientific forums, publish in a scientific journal, and share with RNTCP officers. TRIAL REGISTRATION NUMBER: Clinical Trial Registry of India (CTRI/2019/06/019887).

Enablers and Challenges in the Implementation of Active Case Findings in a Selected District of Karnataka, South India: A Qualitative Study.

BACKGROUND: Active case finding (ACF) for tuberculosis (TB) is a promising tool to enhance early case detection among marginalized populations. As opposed to passive case finding, it involves systematically searching for TB in individuals who would not spontaneously present for care. The National TB Program (NTP) of India has initiated ACF for TB through the existing general health system since the end of 2017. However, prior to scale-up, there is need for exploring the implementation challenges and solutions to improve the efficiency of this program. OBJECTIVES: (1) To explore the enablers and challenges in the implementation of ACF for TB by NTP in the Bengaluru rural district of Karnataka, South India, and (2) to explore the perceived solutions to improve the efficiency of ACF activity. METHODS: A qualitative descriptive study was conducted in the Bengaluru rural district during July 2018. In-depth interviews using purposively selected health care providers involved in active case finding (n = 9) and presumptive TB patients (n = 9) and presumptive TB patients (. RESULTS: The challenges in conduct of ACF were as follows: inadequate training of health care workers, shortage of staff, indifferent attitude of community due to stigma, lack of awareness about TB, illiteracy, inability to convince patients for sputum test, and delay in getting CBNAAT results. The field staff recommended the installation of mobile CBNAAT machine, involvement of general health staff in activity, training of health workers on counseling of patients, and issue of identity cards for community health workers/volunteers so that people recognize them. CONCLUSION: The health system challenges in conduct of ACF need to be addressed by training the health staff involved in activity and also improving the access to TB diagnostics.

To start or to complete? - Challenges in implementing tuberculosis preventive therapy among people living with HIV: a mixed-methods study from Karnataka, India.

Background: Isoniazid preventive therapy (IPT) has been shown to reduce the risk of tuberculosis (TB) among people living with HIV (PLHIV). In 2017, India began a nationwide roll-out of IPT, but there is a lack of evidence on the implementation and the challenges.Objectives: Among PLHIV newly initiated on antiretroviral therapy (ART) from January 2017 to June 2018, to: (i) assess the proportion who started and completed IPT and (ii) explore reasons for non-initiation and non-completion from health-care providers' and patients' perspectives.Methods: An explanatory mixed-methods study was conducted in two selected districts of Karnataka, South India. A quantitative phase (cohort analysis of routinely collected program data) was followed by a qualitative phase involving thematic analysis of in-depth interviews with providers (n = 22) and patients (n = 8).Results: Of the 4020 included PLHIV, 3780 (94%) were eligible for IPT, of whom, 1496 (40%, 95% CI: 38%-41%) were initiated on IPT. Among those initiated, 423 (28.3%) were still on IPT at the time of analysis. Among 1073 patients with declared IPT outcomes 870 (81%, 95% CI: 79%-83%) had completed the six-month course of IPT. The main reason for IPT non-initiation and non-completion was frequent drug stock-outs. This required health-care providers to restrict IPT initiation in selected patient subgroups and earmark six-monthly courses for each patient to ensure that, once started, treatment was not interrupted. The other reasons for non-completion were adverse drug effects and loss to follow-up.Conclusion: The combined picture of 'low IPT initiation and high completion' seen in our study mirrors findings from other countries. Drug stock-out was the key challenge, which obliged health-care providers to prioritize 'IPT completion' over 'IPT initiation'. There is an urgent need to improve the procurement and supply chain management of isoniazid.

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.

Are the medical interns ready to deal with the treatment, prevention and control of Nipah virus infection at the tertiary care hospital?

CONTEXT: Nipah virus infection is an emerging life threatening zoonotic disease. Health care workers are at the highest risk of getting the infection. OBJECTIVES: To assess the level of knowledge and attitude regarding Nipah virus infection among medical interns of a tertiary care hospital, Mangaluru and also to assess the readiness of medical interns dealing with cases of Nipah virus infection. SETTING AND DESIGN: A cross-sectional study was conducted among 94 medical interns of a teaching hospital in Mangaluru. METHODS AND MATERIAL: Questionnaire comprising of 33 questions was used to assess the knowledge, attitude and practice behaviors of the medical interns. STATISTICAL ANALYSIS USED: Descriptive statistics as mean and standard deviation and Pearson correlation coefficient. RESULTS: The mean knowledge, attitude and practice scores were 10.28 (± 2.31), 8 (± 2.9) and 15.85 (± 3.7). Three (3.2%) of the medical interns correctly knew the best modality of diagnosis of Nipah. All the interns correctly answered the samples to be collected for diagnosis and 72 (76.6%) correctly answered the lab where samples have to be sent. Majority i.e. 64 (68.1%) of the medical interns correctly enumerated the preventive measures to be employed. Eighty four (89.4%) of them were aware about the availability of vaccine. The correlation between the adequate facilities available with practice domain and training provided with practice domain were found to be statistically significant. CONCLUSION: In this study, the knowledge, attitude and practice regarding Nipah virus infection were found to be inadequate. There is an urgent need to address these gaps.

'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.

Are they there yet? Linkage of patients with tuberculosis to services for tobacco cessation and alcohol abuse - a mixed methods study from Karnataka, India.

BACKGROUND: Tobacco use and alcohol abuse are associated with higher risk of tuberculosis (TB) infection, progression to active TB and adverse treatment outcomes among patients with TB. Revised National Tuberculosis Control Programme (RNTCP) treatment guidelines (2016) require the documentation of tobacco and alcohol use among patients with TB and their linkage to tobacco and alcohol abuse treatment services. This study aimed to assess the extent of documentation of tobacco and alcohol usage data in the TB treatment card and to explore in-depth, the operational issues involved in linkage. METHODS: A convergent parallel mixed methods study was conducted. All new TB treatment cards of adult patients registered under RNTCP between January and June 2017 in Dakshina Kannada district were reviewed to assess documentation. Document review was done to understand the process of linkage (directing patients to tobacco and alcohol abuse treatment services). In-depth interview of health care providers (n = 7) and patients with TB (n = 5) explored into their perspectives on linkage. RESULTS: Among 413 treatment cards reviewed, tobacco use was documented in 322 (78%), of whom 86 (21%) were documented as current tobacco users. Sixteen (19%) out of these 86 patients were linked to tobacco cessation services. Alcohol usage status was documented in 319 (77%) cards of whom 71(17%) were documented as alcohol users. Eleven (16%) out of these 71 patients were linked to alcohol abuse treatment services. The questions in the treatment card lacked clarity. Guidelines on eliciting history of substance abuse and criteria for linkage were not detailed. Perceived enablers for linkage included family support, will power of the patients and fear of complications. Challenges included patient's lack of motivation, financial and time constraints, inadequate guidelines and lack of co-ordination mechanisms between TB programme and tobacco/alcohol abuse treatment services. CONCLUSION: Documentation was good but not universally done. Clear operational guidelines on linkage and treatment guidelines for health care providers to appropriately manage the patients with comorbidities are lacking. Lack of coordination between the TB treatment programme and tobacco cessation as well as alcohol treatment services was considered a major challenge in effective implementation of the linkage services.

Outcomes and implementation challenges of using daily treatment regimens with an innovative adherence support tool among HIV-infected tuberculosis patients in Karnataka, India: a mixed-methods study.

BACKGROUND: In India, a new care package consisting of (i) daily regimen with fixed-dose combination drugs, collected once-a-month and self-administered by the patient, (ii) 'one stop service' at antiretroviral treatment (ART) centre for both HIV and tuberculosis (TB) treatment and (iii) technology-enabled adherence support (99DOTS, which required patients to give a missed phone call after consuming drugs) was piloted for treatment of TB among HIV-infected TB patients. Conventional care included intermittent regimen (drugs consumed thrice-weekly) delivered under direct observation of treatment supporter and the patients needing to visit TB and HIV care facilities, separately for treatment. OBJECTIVE: To assess the effect of new care package on TB treatment outcomes among HIV-TB patients registered during January-December 2016, as compared to conventional care and explore the implementation challenges. METHODS: A mixed-methods study was conducted in four districts of Karnataka, India where new care package was piloted in few ART centres while the rest provided conventional care. Quantitative component involved a secondary cohort analysis of routine programme data. Adjusted relative risk(aRR) was calculated using Poisson regression to measure association between new care package and unsuccessful treatment outcome. We conducted in-depth interviews with healthcare providers and patients to understand the challenges. RESULTS: Unsuccessful TB treatment outcomes (death, loss to follow-up and failure) were higher in new care package (n = 871) compared to conventional care (n = 961) (30.5% vs 23.4%; P value<0.001) and aRR was 1.3(95% CI: 1.1-1.7). Key challenges included patients' inability to give missed call, increased work load for ART staff, reduced patient-provider interaction, deficiencies in training and lack of role clarity among providers and reduced involvement of TB program staff. CONCLUSION: With new care package, TB treatment outcomes did not improve as expected and conversely declined compared to conventional care. TB and HIV programs need to address the operational challenges to improve the outcomes.

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.