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.

We assessed uptake of isoniazid preventive therapy (IPT) among child contacts of smear-positive tuberculosis (TB) patients and its implementation challenges from healthcare providers’ and parents’ perspectives in Bhopal, India. A mixed-method study design: quantitative phase (review of programme records and house-to-house survey of smear-positive TB patients) followed by qualitative phase (interviews of healthcare providers and parents). Of 59 child contacts (<6 years) of 129 index patients, 51 were contacted. Among them, 19 of 51 (37%) were screened for TB and one had TB. Only 11 of 50 (22%) children were started and 10 of 50 (20%) completed IPT. Content analysis of interviews revealed lack of awareness, risk perception among parents, cumbersome screening process, isoniazid stock-outs, inadequate knowledge among healthcare providers and poor programmatic monitoring as main barriers to IPT implementation. National TB programme should counsel parents, train healthcare providers, simplify screening procedures, ensure regular drug supply and introduce an indicator to strengthen monitoring and uptake of IPT.

Background: About 14% of the global mental health burden is contributed by India. However, there exists a disparity in mental health patterns, utilization, and prioritization among various Indian states. The state of Madhya Pradesh is a low performer among Indian states, ranking lower than the national average on the Human Development Index, Hunger Index, and Gross Domestic Product (GDP). The state also performes poorly on other health-related indicators. Objectives of Study: To estimate the prevalence and patterns of mental illnesses in the state of Madhya Pradesh, India. Material and Methods: This study used the multistage, stratified, random cluster sampling technique, with selection probability proportionate to size at each stage. A total of 3240 individuals 18 years and older were interviewed. The mixed-method study that was employed had both quantitative and qualitative components. The Mini International Neuropsychiatric Interview along with 10 other instruments were used. Results: The overall weighted prevalence for any mental illness was 13.9%, with 16.7% over the lifetime. The treatment gap for all of the mental health problems is very high (91%), along with high suicidal risk and substance use in the state. Conclusions: This study provides evidence of the huge burden of mental, behavioral, and substance use disorders as well as the treatment gap in Madhya Pradesh. This information is crucial for developing an effective prevention and control strategy. The high treatment gap in the state calls for coordinated efforts from all stakeholders, including policy makers, political leaders, health care professionals, and the society at large to give mental health care its due priority. These findings also highlight the need for multi-pronged interventions rooted in health policy directed at reducing the treatment gap in the short term and disease burden in the long run.

Background and Objectives: Depression, especially in concurrence with chronic medical disorders, is highly prevalent worldwide. An average between 9.3% and 23% of patients with one or more chronic disease have co-morbid depression. This comorbid depression has the worst health scores of all the disease states. Despite this, patients with chronic medical disorders are not commonly screened for depression. Lack of objective screening by health-care providers as well as lack of infrastructure (time/space/personnel) probably contributes to gross underdiagnosis of depression. This issue can be addressed using short objective depression screening score (Patient Health Questionnaire-9 [PHQ-9]) (validated in native languages, e.g., Hindi) and paperless self-administered interface on handheld computer (tablet), which is the objective of the study. Subjects and Methods: One hundred consecutive patients with chronic medical disorders visiting our medicine outpatient department were screened for depression using tablets with PHQ-9 Hindi on a self-administered interface. Results: The overall prevalence of depression was found to be 25% (95% confidence interval 16.6–34.8). Nearly half of the patients with depression had moderate depression (PHQ-9 score 10–14) while rest had moderately severe or very severe depression (PHQ-9 score >14). Association of depression was not found to be statistically significant with age, duration of disease, gender, the type of disease, or the number of disease. Majority of patients rated ease of the use of tablet interface (on a visual analog scale) as very easy (approx 95%). All the patients were able to complete the tablet screener without assistance, answering all of the questions. The median time of completion with interquartile range was 4 (3–5) min. Majority of the patients (63%) completed the questionnaire within 5 min while rest completed it in 5–10 min. Conclusions: It is feasible to use tablets with PHQ-9 questionnaire in native language for screening depression in chronic medical disorders. With high prevalence of comorbid depression, any comprehensive care of patients with chronic medical disorders will not be possible, unless such patients are screened and treated for depression. A self-administered screening questionnaire for depression on handheld tablets can prove to be a handy tool to achieve above aim.

Pre-diagnosis attrition needs to be addressed urgently if we are to make progress in improving MDR-TB case detection and achieve universal access to MDR-TB care. We report the pre-diagnosis attrition, along with factors associated, and turnaround times related to the diagnostic pathway among patient with presumptive MDR-TB in Bhopal district, central India (2014). Study was conducted under the Revised National Tuberculosis Control Programme setting. It was a retrospective cohort study involving record review of all registered TB cases in Bhopal district that met the presumptive MDR-TB criteria (eligible for DST) in 2014. In quarter 1, Line Probe Assay (LPA) was used if sample was smear/culture positive. Quarter 2 onwards, LPA and Cartridge-based Nucleic Acid Amplification Test (CbNAAT) was used for smear positive and smear negative samples respectively. Pre-diagnosis attrition was defined as failure to undergo DST among patients with presumptive MDR-TB (as defined by the programme). Of 770 patients eligible for DST, 311 underwent DST and 20 patients were diagnosed as having MDR-TB. Pre-diagnosis attrition was 60% (459/770). Among those with pre-diagnosis attrition, 91% (417/459) were not identified as ‘presumptive MDR-TB’ by the programme. TAT [median (IQR)] to undergo DST after eligibility was 4 (0, 10) days. Attrition was more than 40% across all subgroups. Age more than 64 years; those from a medical college; those eligible in quarter 1; patients with presumptive criteria ‘previously treated – recurrent TB’, ‘treatment after loss-to-follow-up’ and ‘previously treated-others’; and patients with extra-pulmonary TB were independent risk factors for not undergoing DST. High pre-diagnosis attrition was contributed by failure to identify and refer patients. Attrition reduced modestly with time and one factor that might have contributed to this was introduction of CbNAAT in quarter 2 of 2014. General health system strengthening which includes improvement in identification/referral and patient tracking with focus on those with higher risk for not undergoing DST is urgently required.

Community-based direct observed treatment (DOT) providers are an important bridge for the national tuberculosis programme in India to reach the unreached. The present study has explored the knowledge, attitude, practice and barriers perceived by the community-based DOT providers. Mixed-methods study design was used among 41 community-based DOT providers (Accredited Social Health Activist (ASHAs)) working in 67 villages from a primary health center in Raisen district of Madhya Pradesh, India. The cross-sectional quantitative component assessed the knowledge and practices and three focus-group discussions explored the attitude and perceived barriers related to DOT provision. 'Adequate knowledge' and 'satisfactory practice' related to DOT provision was seen in 14 (34%) and 13 (32%) ASHAs respectively. Only two (5%) received any amount of honorarium for completion of DOT in last 3years. The focus-group discussions revealed unfavourable attitude; inadequate training and supervision, non-payment of honorarium, issues related to assured services after referral and patient related factors as the barriers to satisfactory practice of DOT. Study revealed inadequate knowledge and unsatisfactory practice related to DOT provision among ASHAs. Innovations addressing the perceived barriers to improve practice of DOT provision by ASHAs are urgently required.