Framework for implementing collaborative TB-silicosis activities in India: insights from an expert panel.

Tuberculosis (TB) treatment is more challenging for patients with silicosis, as it complicates the diagnosis of both diseases and increases mortality risk. Silicosis, an incurable occupational disease, confounds the diagnosis of TB and vice versa, making it more difficult to accurately identify and treat either condition. Moreover, TB appears to accelerate the progression of silicosis. Exposure to silica dust, a common cause of silicosis, can also trigger latent TB to become active TB. This correspondence outlines a proposed framework for implementing collaborative TB-silicosis activities in India, aimed at improving early diagnosis and management for both diseases. An expert panel of medical professionals developed this framework through online consultations in October and November 2022. The panel's goal was to establish a consensus on integrating TB-silicosis activities, with a focus on early detection and proper management. The framework suggests testing all patients with silicosis for active TB and screening workers exposed to silica dust for latent TB infection. It also recommends that patients with TB who have a history of occupational exposure to silica dust should be tested for silicosis. Reliable diagnostic tools, such as chest X-rays, are emphasized, providing guidance on their use for both diseases. The proposed collaborative TB-silicosis framework offers a structured approach to identifying and managing these two diseases, contributing to the global goal of eliminating silicosis by 2030 and aligning with the World Health Organization's targets for reducing TB incidence and mortality. It recommends specific strategies for implementation, including testing, referral systems, and workplace-based interventions. The framework also underscores the need for coordinated efforts among stakeholders, including the ministries of health, labor, industry, and environment. This correspondence provides valuable insights into how India can successfully implement collaborative TB-silicosis activities, serving as a model for other regions with similar challenges.

Mixed methods study on latent tuberculosis among agate stone workers and advocacy for testing silica dust exposed individuals in India.

The 2021 tuberculosis (TB) preventive treatment guidelines in India included silicosis as a screening group, yet latent TB infection (LTBI) testing for silica-dust-exposed individuals is underemphasized. Focusing on an estimated 52 million silica-dust-exposed workers, particularly agate-stone workers in Khambhat, Gujarat, our study aims to estimate LTBI prevalence, identify predictors, and gather insights from TB and silicosis experts. Employing a sequential explanatory mixed-methods approach, a cross-sectional study involved 463 agate-stone workers aged ≥ 20 years in Khambhat, using IGRA kits for LTBI testing. In-depth interviews with experts complemented quantitative findings. Among agate-stone workers, 58% tested positive for LTBI, with predictors including longer exposure, type of work, and BCG vaccination. Our findings reveal a nearly double burden of LTBI compared to the general population, particularly in occupations with higher silica dust exposure. Experts advocate for including silica-dust-exposed individuals in high-risk groups for LTBI testing, exploring cost-effective alternatives like improved skin sensitivity tests, and shorter TB preventive treatment regimens to enhance compliance. Future research should explore upfront TB preventive treatment for silica-dust-exposed individuals with high LTBI prevalence and optimal exposure duration. This study underscores the urgent need for policy changes and innovative approaches to TB prevention among silica-dust-exposed populations, impacting global occupational health strategies.

A mixed-methods study on impact of active case finding on pulmonary tuberculosis treatment outcomes in India.

BACKGROUND: Tuberculosis (TB) remains a significant public health burden in India, with elimination targets set for 2025. Active case finding (ACF) is crucial for improving TB case detection rates, although conclusive evidence of its association with treatment outcomes is lacking. Our study aims to investigate the impact of ACF on successful TB treatment outcomes among pulmonary TB patients in Gujarat, India, and explore why ACF positively impacts these outcomes. METHODS: We conducted a retrospective cohort analysis in Gujarat, India, including 1,638 pulmonary TB cases identified through ACF and 80,957 cases through passive case finding (PCF) from January 2019 to December 2020. Generalized logistic mixed-model compared treatment outcomes between the ACF and PCF groups. Additionally, in-depth interviews were conducted with 11 TB program functionaries to explore their perceptions of ACF and its impact on TB treatment outcomes. RESULTS: Our analysis revealed that patients diagnosed through ACF exhibited 1.4 times higher odds of successful treatment outcomes compared to those identified through PCF. Program functionaries emphasized that ACF enhances case detection rates and enables early detection and prompt treatment initiation. This early intervention facilitates faster sputum conversion and helps reduce the infectious period, thereby improving treatment outcomes. Functionaries highlighted that ACF identifies TB cases that might otherwise be missed, ensuring timely and appropriate treatment. CONCLUSION: ACF significantly improves TB treatment outcomes in Gujarat, India. The mixed-methods analysis demonstrates a positive association between ACF and successful TB treatment, with early detection and prompt treatment initiation being key factors. Insights from TB program functionaries underscore the importance of ACF in ensuring timely diagnosis and treatment, which are critical for better treatment outcomes. Expanding ACF initiatives, especially among hard-to-reach populations, can further enhance TB control efforts. Future research should focus on optimizing ACF strategies and integrating additional interventions to sustain and improve TB treatment outcomes.

Acceptance and expectations of healthcare workers and community during the COVID-19 vaccine rollout in Bhavnagar city, western India: a qualitative exploration.

BACKGROUND: COVID-19 vaccine was launched in India on January 16, 2021. There is a paucity of robust evidence from qualitative studies on the acceptability and expectations of potential recipients from the COVID-19 vaccine around the time of its rollout in India. We conducted this study to explore the acceptance and expectations of the COVID-19 vaccine among the healthcare workers and community in Bhavnagar, India. METHODS: During January 2021, in-depth interviews were conducted with potential vaccine recipients in Bhavnagar city-health care workers, people over the age of 50, and people of any age with comorbidities. A total of 28 in-depth interviews were performed, including 16 healthcare workers and 12 community beneficiaries. An in-depth interview guide was developed based on the constructs of the health belief model. Following written informed consent from all participants, all interviews were audio-recorded, transcribed in English and codes were generated using thematic analysis. Qualitative qualifiers were used due describe our study findings. RESULTS: Most of healthcare workers and a majority of people from the community have shown willingness to be vaccinated with COVID-19 vaccine as they had trust on the results of the clinical trials and on the government. Some participants showed hesitancy, which was attributed to concerns regarding safety and efficacy, negative news reports in the media and lack of awareness regarding benefits of vaccine. Some healthcare workers were hesitant due to a lack of transparency in sharing the results of clinical trials. Very few showed refusal in getting vaccinated due to their belief that they won't be infected with SARS-CoV-2 virus as they might have developed immunity against it. Most of the participants expected good efficacy, minimal/no side effects, rapid and wide coverage of vaccine and a perception of getting back to pre-COVID life sooner. CONCLUSIONS: Most of the potential recipients were willing to take the COVID-19 vaccine around the time of its initial roll out. Future vaccine rollout campaigns could reduce refusals by timely demand generation activities on vaccine safety/efficacy, involving leaders/influencers, addressing grievances, and minimizing misinformation.

Prevalence and predictors of high-frequency hearing loss among mine workers in Gujarat, western India: a cross-sectional study on the need to implement a comprehensive hearing conservation program.

BACKGROUND: High-frequency hearing loss (HFHL) stands as a prevalent occupational morbidity globally, with numerous associated risk factors, some of which are modifiable. In the context of a comprehensive hearing conservation program, the initial steps involve early screening and identification of workers with these modifiable risk factors, aiming to reduce the prevalence of hearing loss. Our objective was to estimate the prevalence of HFHL and determine its predictors among mine workers. METHODS: We conducted a cross-sectional study among 226 mine workers in ten open-cast mines in Gujarat state, the western part of India, in November 2020. We collected data on socio-demography, addiction, occupation history and comorbidities, along with anthropometric, blood pressure, and blood sugar measurements. Audiometric evaluations using a portable diagnostic audiometer were employed to assess HFHL, defined as a hearing threshold exceeding 25 decibels (dB) at high frequencies (3000, 4000, 6000, and 8000 Hz). A generalized linear model (GLM) with a binomial family was performed to determine the predictors significantly predicting HFHL after adjusting for confounding variables. RESULTS: The prevalence of HFHL was 35% (95% CI: 29-42%) in our study setting. Office workers demonstrated a prevalence of 19%, whereas other job categories displayed a higher prevalence of 42%, resulting in a significant prevalence difference of 23% and a prevalence ratio of 2.2. The GLM analysis revealed that variables, such as noise exposure during work [adjusted prevalence ratio (aPR) 2.3 (95% CI: 1.2-4.7, p = 0.018)] and noise exposure duration [aPR 1.1 (95% CI: 1.0-1.1, p = 0.042)], were significant predictors of HFHL. CONCLUSIONS: In our study setting, mine workers exhibited a high prevalence of HFHL, with exposure to workplace noise and duration being modifiable predictors. Because HFHL advances slowly and is generally undetected by the individual, we recommend periodic testing using audiometry to identify it among mine workers and, if possible, shifting them from mining activities to office. Furthermore, we advocate for the implementation of a comprehensive hearing conservation program to the extent possible.

Predictors of pulmonary dysfunction vis-à-vis the hypertension status of mine workers in Gujarat, western India: A cross-sectional study on the need to further investigate the role of anti-hypertensive drugs.

BACKGROUND: Mine workers face various health risks from occupational hazards, notably dust-related pulmonary dysfunction. This dysfunction is also attributed to diverse risk factors and health conditions. Despite the variety of underlying mechanisms, conflicting evidence persists regarding hypertension as a potential risk factor for such dysfunction. OBJECTIVE: To determine the predictors of pulmonary dysfunction vis-à-vis the hypertension status of mine workers. METHODS: We conducted a cross-sectional study among 444 mine workers from ten open-cast mines in Gujarat state (western part of India) from November 2020 to February 2022. We collected data on demographics, occupation, addiction, and comorbidities, including measurements like anthropometry, blood pressure, blood sugar, haemoglobin, and lipid levels. Hypertension was confirmed based on self-reported history and/or onsite blood pressure measurement, while pulmonary functions were assessed using a spirometer (expressed as forced expiratory volume in the first second FEV1 and forced vital capacity FVC). Multiple linear regression analysis was performed to determine the significant predictor of FEV1 or FVC vis-à-vis the hypertension status after adjusting for confounding variables. In addition, we assessed the effect of anti-hypertensive medications on pulmonary dysfunction. RESULTS: A total of 41% (95% CI: 36-45%) of mine workers were suffering from hypertension. On multiple linear regression, only being a male and work experience duration were the significant predictors of FEV1 [0.900 (0.475-1.092), p=<0.001; -0.029 (-0.034 - -0.021, p=<0.001] and FVC [1.088 (0.771-1.404), p=<0.001; -0.031 (-0.038 - -0.024, p = 0.001] respectively. While unadjusted analysis indicated hypertension led to FEV1 and FVC reduction, this effect lost significance after adjusting for confounders. Nevertheless, subgroup analysis revealed those on antihypertensive medications had reductions in FEV1 and FVC by -0.263 (95% CI: -0.449 - -0.078, p = 0.006) L and -0.271 (95% CI: -0.476 - -0.067, p = 0.009) L respectively. CONCLUSION: In our study among mine workers, alterations in lung function (FEV1 and FVC) on spirometry were predicted by gender and duration of work experience, while hypertension did not serve as a predictor. It is noteworthy that antihypertensive drugs were found to reduce lung functions on spirometry, highlighting the need for further research.

Need for workplace smoking cessation program among public transit drivers: Evidence from a cross-sectional study in a metropolitan city of Western India.

Background: Air pollution is a significant contributor to respiratory illness globally, and in India, evidence is scarce on whether smoking exacerbates this problem. Objective and Methods: We aimed at assessing if being a smoker among public transit drivers increased risk for respiratory illnesses and affected performance of pulmonary function tests in a cross-sectional study in a metropolitan city of Gujarat, western state of India. We conducted a cross-sectional study among public transit drivers (those who were smoking and not smoking). Administration staff who were not smoking were considered as control group. We collected socio-demographic and medical history including occupational history (N = 296). We collected details of respiratory symptoms with standard tools and assessed pulmonary function tests (PFT) using spirometry. Group differences and regression analyses were conducted in R software. Results: We found that respiratory symptoms among public transit drivers who smoked were higher than those who did not smoke and healthy controls. In PFT diagnosis, drivers who smoke displayed two times higher prevalence of obstructive pattern compared to drivers who did not smoke. There was a significant reduction in the larger as well as the smaller airway functions, reflected in reduction of FEV1/FVC ratio (p < 0.001) and FEF25-75% (p < 0.001), respectively, among drivers who smoked compared to controls. Our results indicate that being a driver with a smoking history leads to a 3.1% greater decrease in the FEV1/FVC ratio and about half a litre reduction in FEF25-75% compared to the drivers who did not smoke. Conclusion: We suggest there is a high need for smoking cessation programmes for public transit drivers as they are at higher risk for respiratory illnesses and reduced pulmonary functions when smoking is added to the existing vehicular exposure.

Silicosis as a predictor of tuberculosis mortality and treatment failure and need for incorporation in differentiated TB care models in India.

BACKGROUND: Differentiated tuberculosis (TB) care is an approach to improve treatment outcomes by tailoring TB management to the particular needs of patient groups based on their risk profile and comorbidities. In silicosis-prone areas, the coexistence of TB and silicosis may exacerbate treatment outcomes. The objective of the study was to determine predictors of TB-related mortality, treatment failure, and loss to follow-up in a silicosis-prone region of western India. METHODS: A retrospective cohort was conducted among 2748 people with TB registered between January 2006 and February 2022 in Khambhat, a silicosis-prone block in western India. Death, treatment failure, and loss to follow up were the outcome variables. The significant predictors of each outcome variable were determined using multivariable logistic regression and reported as adjusted odds ratios (aOR) with 95% confidence intervals (CIs). RESULTS: In the cohort of 2,748 people with TB, 5% presented with silicosis, 11% succumbed to the disease, 5% were lost to follow-up during treatment, and 2% encountered treatment failure upon completion of therapy. On multivariable logistic regression, concomitant silicosis [aOR 2.3 (95% CI 1.5-3.5)], advancing age [aOR 1.03 (95% CI 1.02-1.04)], male gender [aOR 1.4 (95% 1.1-1.9)], human immunodeficiency virus (HIV) positive [aOR 2.2 (95% 1.02-4.6)], and previous TB treatment [aOR 1.5 (95% CI 1.1-1.9)] significantly predicted mortality among people with TB. Concomitant silicosis [aOR 3 (95% CI 1.4-6.5)], previous TB treatment [aOR 3 (95% CI 2-6)], and multi-drug resistant TB [aOR 18 (95% CI 8-41)] were the significant predictors of treatment failure on adjusted analysis. Advancing age [aOR 1.012 (1.001-1.023)], diabetes [aOR 0.6 (0.4-0.8)], and multi-drug resistance [aOR 6 (95% CI 3-12)] significantly predicted loss to follow-up after adjusting for confounders. CONCLUSIONS: Controlling silicosis might decrease TB mortality and treatment failure in silicosis-prone regions. The coexistence of HIV and silicosis may point to an increase in TB deaths in silicosis-prone areas. Silicosis should now be acknowledged as a major comorbidity of TB and should be included as one of the key risk factors in the differentiated TB care approach. Primary care physicians should have a high clinical suspicion for silicosis among individuals diagnosed with TB in silicosis-prone blocks.

Challenges and opportunities for silicosis prevention and control: need for a national health program on silicosis in India.

BACKGROUND: Silicosis has been one of the most serious occupational public health problems worldwide for many decades. The global burden of silicosis is largely unknown, although it is thought to be more prevalent in low and medium-income countries. Individual studies among workers exposed to silica dust in various industries, however, reveal a high prevalence of silicosis in India. This paper is an updated review of the novel challenges and opportunities for silicosis prevention and control in India. MAIN BODY: The unregulated informal sector employs workers on contractual appointment thereby insulating the employers from legislative provisions. Due to a lack of awareness of the serious health risks and low-income levels, symptomatic workers tend to disregard the symptoms and continue working in dusty environments. To prevent any future dust exposure, the workers must be moved to an alternative job in the same factory where they will not be exposed to silica dust. Government regulatory bodies, on the other hand, must guarantee that factory owners relocate workers to another vocation as soon as they exhibit signs of silicosis. Technological advances such as artificial intelligence and machine learning might assist industries in implementing effective and cost-saving dust control measures. A surveillance system needs to be established for the early detection and tracking of all patients with silicosis. A pneumoconiosis elimination program encompassing health promotion, personal protection, diagnostic criteria, preventive measures, symptomatic management, prevention of silica dust exposure, treatment, and rehabilitation is felt important for wider adoption. CONCLUSION: Silica dust exposure and its consequences are fully preventable, with the benefits of prevention considerably outweighing the benefits of treating patients with silicosis. A comprehensive national health program on silicosis within the public health system would strengthen surveillance, notification, and management of workers exposed to silica dust in India.

Plight of migrant construction-site workers during the COVID-19 lockdown in 2020: A qualitative exploration in Bhavnagar, Western India.

BACKGROUND: During the unexpected lockdown implemented in early 2020 in reaction to the coronavirus 2019 (COVID-19) pandemic, a considerable section of India's population of migrant construction-site workers were stuck. OBJECTIVE: Our objective was to explore the lived experiences and consequent perceptions of migrant workers related to the COVID-19 lockdown and the consequences on their lives. METHODS: We conducted structured in-depth interviews (IDIs) with twelve migrant construction-site workers in Bhavnagar, Western India, from November to December 2020, using qualitative research methods. All IDIs were conducted with participant's consent, audio-recorded, transcribed in English, inductively coded, and thematically analyzed. RESULTS: The primary financial challenges mentioned by the migrant workers in the interviews were unemployment, monetary issues, and a difficult sustenance. The social concerns were described as anxious migrant exodus, discrimination, mistreatment, lack of social assistance, inability to fulfil their family's expectations, lack of safe transportation arrangements by the authorities during the exodus, inadequacies in the public distribution system, law and order, and apathy of their employers. The psychological repercussions were described using terms like "fear," "worry," "loneliness," "boredom," "helplessness," and "trapped." Monetary compensation, job opportunities at the native place, and a well-managed migrant exodus were reportedly their key expectations from the government. Healthcare issues mentioned during the lockdown included a lack of facilities to treat common ailments, substandard care, and repeated COVID-19 testing prior to departure. CONCLUSION: The study highlights the need to have rehabilitation mechanisms such as targeted cash transfers, ration kits, and safe transportation services for migrant workers through inter-sectoral coordination for mitigating hardship.

A mixed-methods study on impact of silicosis on tuberculosis treatment outcomes and need for TB-silicosis collaborative activities in India.

Globally, silicosis and tuberculosis (TB) have been targeted for elimination by 2030. The study's objectives were to determine the association of silicosis with unfavorable TB treatment outcomes, as well as to explore experts' perspectives on improving treatment outcomes among silico-tuberculosis patients. A retrospective cohort study evaluated TB treatment outcomes in Khambhat block, the western part of India, between 138 patients with silico-tuberculosis and 2610 TB patients without silicosis in February-March 2022. 'Unfavorable TB treatment outcomes' was defined as a patient stopping treatment for at least one month, a positive sputum smear at the end of treatment, or, a patient dying while on treatment. During April-July 2022, fifteen in-depth interviews with experts in the field of silicosis/tuberculosis were audio-recorded, transcribed, and analyzed to generate codes (thematic analysis). On multivariable logistic regression analysis, patients with silico-tuberculosis had a 2.3 (95% CI 1.6-3.4) times higher odds of unfavorable treatment outcomes. The experts recommended collaborative TB-silicosis activities for improving treatment outcomes of patients with silico-tuberculosis. I conclude from the study's findings that silicosis is associated with unfavorable TB treatment outcomes in this study setting. All patients with silicosis should be screened for TB and treated according to national TB program guidelines. All patients with TB who have a history of occupational dust exposure should be evaluated for silicosis and provided appropriate pulmonary/vocational rehabilitation.

A sequential explanatory mixed-methods study on costs incurred by patients with tuberculosis comorbid with diabetes in Bhavnagar, western India.

Diabetes is one of the commonest morbidity among patients with tuberculosis (TB). We conducted this study to estimate the costs incurred by patients with TB comorbid with diabetes and to explore the perspectives of program managers as well as patients on the reasons and solutions for the costs incurred due to TB-diabetes. We conducted a descriptive cross-sectional study to estimate costs among 304 patients with TB-diabetes comorbidity registered in the public health system during 2017-2020 in the Bhavnagar region of western India, which was followed by in-depth interviews among program functionaries and patients to explore solutions for reducing the costs. Costs, when exceeded 20% of annual household income, were defined as catastrophic as this cut-off was most significantly related to adverse TB outcomes. Among the 304 patients with TB-diabetes comorbidity, 72% were male and the median (interquartile IQR) monthly family income was Indian rupees (INR) 9000 (8000-11,000) [~ US$ 132 (118-162)]. The median (IQR) total costs due to combined TB-diabetes were INR 1314 (788-3170) [~ US$ 19 (12-47)], while that due to TB were INR 618 (378-1933) [~ US$ 9 (6-28)]. Catastrophic costs due to TB were 4%, which increased to 5% on adding the costs due to diabetes. Health system strengthening, an increase in cash assistance, and other benefits such as a nutritious food kit were suggested for reducing the costs incurred. We conclude that, in addition to a marginal increase in the percentage of catastrophic costs, co-existent diabetes nearly doubled the median total costs incurred among patients with TB. Strengthening the TB-diabetes bi-directional activities, tailoring the cash transfer scheme for comorbid patients, and making the common two-drug combination diabetes tablets available at government drug stores would help TB-diabetes comorbid patients cope with the costs of care.

Costs incurred by patients with tuberculosis co-infected with human immunodeficiency virus in Bhavnagar, western India: a sequential explanatory mixed-methods research.

BACKGROUND: India reports the highest number of tuberculosis (TB) and second-highest number of the human immunodeficiency virus (HIV) globally. We hypothesize that HIV might increase the existing financial burden of care among patients with TB. We conducted this study to estimate the costs incurred by patients with TB co-infected with HIV and to explore the perspectives of patients as well as program functionaries for reducing the costs. METHODS: We conducted a descriptive cross-sectional study among 234 co-infected TB-HIV patients notified in the Bhavnagar region of western India from 2017 to 2020 to estimate the costs incurred, followed by in-depth interviews among program functionaries and patients to explore the solutions for reducing the costs. Costs were estimated in Indian rupees (INR) and expressed as median (interquartile range IQR). The World Health Organization defines catastrophic costs as when the total costs incurred by patients exceed 20% of annual household income. The in-depth interviews were audio-recorded, transcribed, and analyzed as codes grouped into categories. RESULTS: Among the 234 TB-HIV co-infected patients, 78% were male, 18% were sole earners in the family, and their median (IQR) monthly family income was INR 9000 (7500-11,000) [~US$ 132 (110-162)]. The total median (IQR) costs incurred for TB were INR 4613 (2541-7429) [~US$ 69 (37-109)], which increased to INR 7355 (4337-11,657) [~US$ 108 (64-171)] on adding the costs due to HIV. The catastrophic costs at a 20% cut-off of annual household income for TB were 4% (95% CI 2-8%), which increased to 12% (95% CI 8-16%) on adding the costs due to HIV. Strengthening health systems, cash benefits, reducing costs through timely referral, awareness generation, and improvements in caregiving were some of the solutions provided by program functionaries and the patients. CONCLUSION: We conclude that catastrophic costs due to TB-HIV co-infection were higher than that due to TB alone in our study setting. Bringing care closer to the patients would reduce their costs. Strengthening town-level healthcare facilities for diagnostics as well as treatment might shift the healthcare-seeking of patients from the private sector towards the government and thereby reduce the costs incurred.

"I lost my faith and stopped taking the medicines" - need for an intervention model based on health belief constructs for improving adherence to tuberculosis treatment.

Background: India is reporting the highest number of tuberculosis (TB) cases worldwide. The health belief model has proved beneficial to understand health-related behaviors among patients with TB. We explored the reasons and solutions for non-adherence to the treatment of TB using the constructs of the health belief model. Methods: We conducted in-depth interviews among patients who were reported 'lost to follow up' (LFU) and among the service providers under the national TB program in the Patan district based on the constructs of the health belief model - perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. All the interviews were audio-recorded and transcripts were analyzed using thematic analysis. Results: The analysis resulted in nine major reasons for LFU which were explained under the health belief model constructs. Perceived susceptibility was reflected by lack of support from health workers, losing faith in government, and dependence on alcohol. Negative counseling by quacks explained perceived severity, while improvement in symptoms corroborated with the perceived benefits. Side effects to anti-TB drugs, high pill burden, stigma, and financial constraints were the perceived barriers reported by the patients. Conclusions: The health belief model explains treatment non-adherence behavior among patients with tuberculosis in India. To eliminate TB, program managers in India need to design a comprehensive intervention model to counsel the patients on the benefits of completing treatment, generate awareness to dispel the myths surrounding the disease, and instill confidence through regular visits by health workers. Primary care physicians should try incorporating counselling of patients with TB in their routine care to reduce LFU.

Does Direct Benefit Transfer Improve Outcomes Among People With Tuberculosis? - A Mixed-Methods Study on the Need for a Review of the Cash Transfer Policy in India.

BACKGROUND: A direct benefit transfer (DBT) program was launched to address the dual epidemic of under-nutrition and tuberculosis (TB) in India. We conducted this study to determine whether non-receipt of DBT was associated with unfavorable treatment outcomes among patients with TB and to explore the perspectives of patients and program functionaries regarding the program. METHODS: We conducted a retrospective cohort study among 426 patients with drug-sensitive pulmonary TB on treatment during January-September 2019 to determine the association between non-receipt of DBT and unfavorable treatment outcomes, which was followed by in-depth interviews of 9 patients and 8 program functionaries to explore their perspectives on challenges and suggestions regarding the DBT program. Multivariate logistic regression was applied to determine whether non-receipt of DBT was independently associated with unfavorable treatment outcomes, while the in-depth interviews were transcribed to describe them as codes and categories. RESULTS: Among the 426 patients, 9% of the patients did not receive DBT and 91% completed their treatment. Non-receipt of DBT was associated with a 5 (95% CI: 2-12) times higher odds of unfavorable treatment outcomes on multivariable analysis. Patients not owning a bank account was the primary challenge perceived by the program staff. The patients perceived the assistance under DBT to be insufficient to buy nutritious food throughout the course of treatment. The program functionaries as well as the patients suggested increasing the existing assistance under DBT along with the provision of a monthly nutritious food-kit. CONCLUSION: DBT improved the treatment completion rates among patients with TB in our setting. Provision of a monthly nutritious food-kit with an increase in the existing assistance under DBT might further improve the treatment outcomes. Future research should determine the long-term financial sustainability for 'DBT plus food-kit' vs. universal cash transfers in India.

Costs incurred by patients with oral potentially malignant disorders: is there a public health need for financial protection in India?

OBJECTIVES: Financial protection mechanisms are in place to overcome the costs of a few diseases in India. Our objective was to estimate the costs incurred due to Oral Potentially Malignant Disorders (OPMD) and to determine predictors of such costs. RESULTS: We found that the median (Interquartile range IQR) total costs of OPMD was Indian Rupees (INR) 500 (350-750), direct medical costs was INR 0 (0-50), direct non-medical costs was INR 150 (40-200) and indirect costs was INR 350 (250-500). The travel cost to attend the health facilities [INR 100 (40-150)] and the patient's loss of wages [INR 200 (150-400)] mainly accounted for the direct non-medical and indirect costs respectively. The median expenditure on smokeless and smoking forms of tobacco was INR 6000 (5400-7200) and INR 2400 (1800-3600) respectively. On multiple linear regression analysis, rural residence, belonging to below poverty line family, being a sole earner in the family, number of months since diagnosis and first visit at a private provider were found to be the significant predictors of total costs of OPMD. Financial protection mechanisms are needed for covering the direct non-medical and indirect costs. Early management of OPMD might mitigate the costs of OPMD.

High-risk health behaviors predict depression among school-going adolescents: the need for integration of mental health with school health program in India.

Our objective was to estimate the prevalence of depression and to determine whether high-risk health behaviors were associated with it among school-going adolescents, thereby assessing the need to integrate mental health services with the school health program. We conducted a cross-sectional study among 260 adolescents in schools of Bhavnagar city (western India) during January-October 2017. To assess depression, Beck Depression Inventory-II (BDI-II) was used and high-risk health behaviors were assessed by the Youth Risk Behavior Surveillance System (YRBSS) tool. Multivariable logistic regression analysis was performed to assess whether high-risk health behaviors were independent predictors of depression. The prevalence of depression was found to be 43%. Among high-risk health behaviors, adolescents carrying a sharp weapon to the school was the lowest (4%) and not eating breakfast was the highest (88%). On multiple logistic regression, feeling unsafe at school, self-perception regarding overweight, being a female, not living with both parents in the same house, being unhappy with school performance, having illness/seriously injured, and immediate family member being seriously ill/injured were found to be the significant predictors of depression among the adolescents. There is a need to address mental health issues like depression and high-risk health behaviors under the school health program through screening interventions.

'We are not aware of notification of tuberculosis': A mixed-methods study among private practitioners from western India.

BACKGROUND: Implementing the Standards for tuberculosis care in India (STCI) guidelines in the private sector is vital. This study attempted to estimate the knowledge and practices regarding STCI guidelines among private practitioners and to explore the reasons and solutions for low tuberculosis (TB) notification rates. METHODS: We conducted a cross-sectional study for assessing the knowledge and practices of the STCI guidelines among 100 full-time allopathic private practitioners in Bhavnagar (in western part of India) from September 2018 to January 2019. Knowledge and practice were categorised as good or poor by assigning scores to the responses to a questionnaire based on the STCI guidelines. It was followed by two focus group discussions to explore the reasons and solutions for low notification rates of TB as perceived by private practitioners. RESULTS: Among the 100 private practitioners, 55% had good knowledge, and 41% had good practice regarding the STCI guidelines; 69% knew about the gazette notification of mandatory notification of TB, and 58% were notifying TB cases to the government. Lack of awareness about the process as well as incentives for notification, time constraints and infrequent visits by health workers were the main reasons perceived by private practitioners for not notifying TB cases to the government. The critical solutions suggested by them were creating awareness regarding the notification process as well as incentives, increasing health worker visits and use of social media for notification. CONCLUSION: Only about half of private practitioners follow the STCI guidelines for TB care, and the notification rates are low in our setting. Regular sensitisation programs need to be arranged for private practitioners to create awareness on TB notification.