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Abstract Background The rise in epidemic-prone diseases daily poses a serious concern globally. Evidence suggests that many of these diseases are of animal origin and contribute to economic loss. Considering the limited time and other resources available for the animal and human health sectors, selecting the most urgent and significant risk factors and diseases is vital, even though all epidemic-prone diseases and associated risk factors should be addressed. The main aim of developing this tool is to provide a readily accessible instrument for prioritising risk factors and diseases that could lead to disease emergence, outbreak or epidemic. Methods This tool uses a quantitative and semi-quantitative multi-criteria decision analysis (MCDA) method that involves five steps: Identifying risk factors and diseases, Weighting the criteria, Risk and disease scoring, Calculating risk impact and disease burden score, and Ranking risks and diseases. It is intended to be implemented through a co-creation workshop and involves individual and group activities. The last two steps are automated in the MS Excel score sheet. Results This One Health Risk and Disease (OHRAD) prioritisation tool starts with an individual activity of identifying the risks and diseases from the more extensive list. This, then, leads to a group activity of weighing the criteria and providing scores for each risk and disease. Finally, the individual risk and disease scores with the rankings are generated in this tool. Conclusions The outcome of this OHRAD prioritisation tool is that the top risks and diseases are prioritised for the particular context from One Health perspective. This prioritised list will help experts and officials decide which epidemic-prone diseases to focus on and for which to develop and design prevention and control measures.

Background and Aim: The threat of emerging and epidemic-prone diseases is a significant public health concern and there is an urgent need to work on the prevention and control of these diseases. In view of the limited time and other resources available to the animal and human health sector, it is crucial to prioritize the most essential and critical risk factors and diseases. This scoping review aims to document the available disease and risk prioritization tools by evaluating their characteristics and suitability from the One Health perspective. Materials and Methods: Databases such as PubMed, Scopus, and Google Scholar were used to extract available tools for prioritization. We compared and synthesized the objective of the tool, methodology and prioritization process of the available tools. Results: A total of six tools, including One Health Zoonotic Disease Prioritization, European Centre for Disease Prevention and Control, Strategic Toolkit for Assessing Risks, One Health Systems Mapping and Analysis Resource Toolkit, Health Hazard Assessment and Prioritization tool, Risk Ranger, are included in this scoping review. Various prioritization methods are available; however, multi-criteria decision analysis is the most commonly used. Conclusion: A thorough analysis showed that different tools employ different prioritizing approaches, including mixed-method, quantitative, and qualitative approaches. The summary of the findings suggests the development of a new robust tool with a One Health approach, which will focus on risk prioritization and disease prioritization.

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

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

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

Inadequate water, sanitation, and hygiene (WASH) standards in healthcare facilities (HCFs) pose a severe risk to those who seek treatment. In India, more than one in every four HCFs lack basic water services and only 55% of facilities have access to improved sanitation. The study aims to estimate the cost to meet the standards for making WASH compliant HCFs. This cross-sectional study was centered on assessing 60 selected HCFs of Assam. The assessment comprises four steps: in the first step, domains and sub-domains were identified; in the second step, gaps were analyzed for the selected domains; in the third step, the cost was estimated for the domains and sub-domains, and in the final step, costs were estimated to meet the standards. The findings show that the cost required for the improvement varied for different types of facilities. The total annual cost to make all the selected facilities WASH compliant was found to be USD 13,73,741. The majority (93.3%) of the cost is required for human resources. District hospitals would require significant investment, followed by the sub-divisional hospitals and first referral units. The least cost is required to improve the state dispensary. HIGHLIGHTS This study focuses on estimating the cost to meet the standards of WASH compliant in HCFs in one of the states in India.; There are many studies and tools focusing on the assessment; however, in the case of India, infrastructure development is needed to make the healthcare facilities WASH compliant.; In India, even with funding, the health facility managers are not aware of where and how to utilize it for optimizing WASH.; This study provides evidence on how to find the gaps and improve the health facilities for WASH compliance.;

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

Understanding factors leading to death following the onset of symptoms of tuberculosis (TB) is important to predict prognosis among patients with TB. With aiming the End TB strategy, mortality is declining not as expected globally and in India. Although India is one of the highest incidence countries globally, India lacks evidence of understanding of the factors for TB death. Thus, this study aims to document the characteristics of deaths due to TB in the Western state of India, Gujarat.About 74 deaths were randomly documented from 7 different geographic regions of Gujarat through a community-based death review from Oct 2021 to February 2022. The trained researchers administered a semi-structured questionnaire to capture the demographic, socioeconomic, history of comorbidity and addiction, medical history, case records, and chronology of events preceding death.Most deaths happened within 24 weeks from the onset of symptoms, which reduced to half (12 weeks) in the other cascades, i.e., diagnosis and treatment initiation to the death. Out of 74 reviewed deaths, 47 (64%) deaths had the cause of death as TB, with an average duration of 87 days from onset of symptoms to death. The study observed the time, place, and person distribution on different epidemiological parameters. While analyzing narratives from the relative, the gaps between the system (service provider) and demand (patient perspective) sides were synthesized.It is recommended to conduct such kind of community-based death reviews in the routine practices of the National TB Elimination Program to ensure the appropriate review of the underlying causes of deaths due to TB. The matrix developed in this study is easy to replicate in any other death reviews to understand the intercept of the supply-demand side determinants for the deaths.

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

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

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

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