An explanatory mixed-method study to unearth the cascade of events of implementation and coverage challenges of Tuberculosis Preventive Treatment in two Tribal-Dominant Districts of Central India

A BSTRACT Context: Tuberculosis preventive treatment (TPT) has the potential to achieve the greatest reduction in new TB cases as a single intervention in the high-burden countries like India. Aims: This study assessed the coverage and adherence of TPT among household child contacts (HHCC) aged <5 years in two resource-constrained districts and explored related health system and beneficiary-level barriers. Design: An explanatory mixed-method design was adopted. Methods and Material: The quantitative phase estimated TPT coverage and adherence through initiation and completion rates, followed by a qualitative phase to explore implementation challenges. Data were collected from 320 HHCC and eight programme stakeholders between November 2022 and March 2023. Results: Of 594 notified TB patients, 320 HHCC were identified and all were eligible for TPT. The initiation rate was 17.5% and completion rate 9.7%. Among non-initiators, 91% were uninformed and 8% considered TPT unnecessary. Around 7% discontinued treatment due to interrupted drug supply. Poor initiation was associated with specific TB Units, limited staff experience, and absence of home visits. Qualitative findings revealed key health system barriers such as ineffective training on TPT rationale, communication, lack of home visits, and Nikshay portal issues. Beneficiary related barriers included hesitancy, migration, misconceptions about TPT, and supply disruptions. Conclusions: TPT coverage and adherence among HHCC were suboptimal, with health system challenges outweighing beneficiary barriers. Strengthening staff training on TPT rationale effective communication, supervision along with ensuring consistent drug supply may prove essential to improve TPT implementation in resource-limited settings.