Isoniazid Preventive Therapy Care Cascade among Under-Five Child Contacts of Pulmonary Tuberculosis Patients in Urban Kalaburagi District India and Its Associated Determinants

Isoniazid Preventive Therapy Care Cascade among Under-Five Child Contacts of Pulmonary Tuberculosis Patients in Urban Kalaburagi District India and Its Associated Determinants | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Isoniazid Preventive Therapy Care Cascade among Under-Five Child Contacts of Pulmonary Tuberculosis Patients in Urban Kalaburagi District India and Its Associated Determinants Dr Leela Keerthy T, Dr Seema P This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9335672/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 17 You are reading this latest preprint version Abstract Background Isoniazid Preventive Therapy (IPT) substantially reduces the risk of progression from latent tuberculosis infection to active disease in children under five years of age who reside with infectious pulmonary tuberculosis patients. Despite robust programmatic guidelines, India's preventive care cascade continues to face significant implementation challenges, with persistent losses at multiple stages from identification to treatment completion. Objectives This study aimed to (i) characterise the IPT care cascade among under-five household contacts of pulmonary tuberculosis index cases in urban Kalaburagi district, (ii) identify sociodemographic factors associated with IPT completion, and (iii) explore caregiver- and system-level barriers and facilitators influencing IPT initiation and completion. Methods A sequential explanatory mixed-methods study was conducted at two urban tuberculosis units (TUs) in Kalaburagi district, Karnataka, India. The quantitative component comprised a community-based cross-sectional investigation of 179 under-five child contacts identified from 91 pulmonary tuberculosis index cases registered during 2022. The qualitative component involved in-depth interviews with ten purposively selected caregivers. Cascade indicators were described as proportions; associations between sociodemographic variables and IPT completion were examined using chi-square or Fisher's exact tests, with odds ratios (ORs) and 95% confidence intervals (CIs) calculated. Qualitative data were analysed thematically and integrated with quantitative findings at the interpretation stage. Results Of the 179 eligible child contacts, 70.9% underwent tuberculosis screening. Among those screened, only 49.6% initiated IPT, and 49.2% of initiators completed the full six-month course, yielding an overall cascade completion rate of 17.3% (31/179). IPT completion was significantly higher among children from nuclear families (OR 4.62; 95% CI: 1.49–14.35), smaller households (OR 7.54; 95% CI: 2.45–23.25), higher socioeconomic strata (OR 12.35; 95% CI: 2.50–60.97), and households with fewer under-five contacts (OR 5.60; 95% CI: 1.40–22.46). Qualitative analysis identified five themes: limited caregiver knowledge of tuberculosis transmission and prevention; delayed diagnosis with initial reliance on private healthcare; trust in frontline health workers as a facilitating factor; practical challenges and elder-mediated social pressure; and missed opportunities attributable to inadequate counselling. Conclusion Substantial attrition occurs at both the initiation and completion stages of the IPT care cascade, representing a missed opportunity for tuberculosis prevention in this urban setting. Programmatic responses should prioritise structured caregiver counselling at the point of index case registration, sustained community-level follow-up by Anganwadi and ASHA workers, and the development of child-friendly IPT formulations. Routine cascade monitoring should be incorporated into National Tuberculosis Elimination Programme (NTEP) reporting systems. Tuberculosis Isoniazid Preventive Therapy child contacts IPT care cascade mixed methods India NTEP Introduction Tuberculosis (TB) remains the leading cause of mortality from a single infectious pathogen, responsible for an estimated 10 million new infections and 1.25 million deaths worldwide each year.¹ India bears a disproportionate share of this burden, accounting for approximately 26% of global TB cases, and continues to face the challenge of eliminating the disease by 2025 under its National Strategic Plan.² Transmission occurs primarily via airborne droplet nuclei expelled by individuals with active pulmonary TB; a single untreated patient may infect 10–15 contacts annually.³ Children under five years of age are particularly vulnerable owing to their immunological immaturity, which markedly increases their susceptibility to severe and disseminated forms of TB, including miliary disease and tuberculous meningitis, which carry significant morbidity and mortality.⁴ Isoniazid Preventive Therapy (IPT), administered at a daily dose of 10 mg/kg for six months, is a cornerstone of tuberculosis prevention and has been demonstrated to reduce the risk of progression from latent TB infection to active disease by approximately 60%.⁵ In accordance with the Programmatic Management of Tuberculosis Preventive Treatment (PMTPT) guidelines issued by India's Central TB Division in 2021, all under-five household contacts of bacteriologically confirmed, drug-sensitive pulmonary tuberculosis patients are eligible for IPT following exclusion of active disease.⁶ This policy is implemented through the NTEP as part of the National Strategic Plan 2017–2025. Despite a clearly defined policy framework, coverage of IPT among eligible under-five contacts remains suboptimal. The India TB Report 2024 documents that only 60% of eligible under-five contacts received tuberculosis preventive therapy (TPT), underscoring persistent gaps in service delivery.⁷ Attrition occurs across multiple cascade stages—identification, screening, initiation, and completion—yet few studies have systematically quantified losses at each step or examined the underlying determinants. Mixed-methods approaches are particularly well suited to this research context because they combine programme-level measurement with caregiver and health-system perspectives, thereby generating both explanatory depth and practical utility.⁸ This study aimed to evaluate the IPT care cascade among under-five household contacts of pulmonary tuberculosis patients in urban Kalaburagi district, Karnataka, to identify sociodemographic predictors of IPT completion, and to explore the barriers and facilitators that influence IPT uptake and adherence at the caregiver and health-system levels. Methods Study design and setting A sequential explanatory mixed-methods design was employed, in which a quantitative cross-sectional investigation was conducted first, followed by an in-depth qualitative component intended to explain and contextualise the quantitative findings.⁸ The study was conducted at two urban tuberculosis units (TUs) in Kalaburagi district, Karnataka, India. Kalaburagi district has a total of 12 TUs, of which the remaining ten serve predominantly rural areas; the two urban TUs selected represent the principal service-delivery points for the urban population. Study participants The quantitative component included all under-five children residing in the same household as a pulmonary tuberculosis index case registered at either study TU between 1 January and 31 December 2022. Children with confirmed active tuberculosis at the time of contact tracing, or with known contraindications to isoniazid, were excluded. From district TB office records, 207 child contacts were initially identified; after applying exclusion criteria, 179 contacts from 91 index cases were enrolled. For the qualitative component, 10 caregivers of eligible child contacts—five from each TU—were purposively selected to ensure diversity with respect to IPT initiation and completion status, family structure, and socioeconomic background. Data collection Quantitative data were collected through structured telephonic interviews with caregivers, using a pre-tested, semi-structured questionnaire administered in the local language (Kannada/Urdu) following receipt of written informed consent. All responses were verified against NTEP records maintained at the respective TUs. In-depth interviews for the qualitative component were conducted by a postgraduate medical student with proficiency in the local language and training in qualitative research methods. Interviews were conducted at participants' homes or at the TU according to the participant's preference, averaged 30 minutes in duration, and were audio-recorded with explicit participant consent. Transcripts were prepared verbatim and data collection continued until thematic saturation was achieved. Statistical analysis Data were entered and analysed using OpenEpi software (version 3.01). Cascade indicators were expressed as proportions with 95% CIs where appropriate. Associations between sociodemographic variables and IPT completion were assessed using the chi-square test or Fisher's exact test, as dictated by expected cell frequencies; a two-tailed p-value < 0.05 was considered statistically significant. Crude odds ratios and their 95% confidence intervals were calculated for all variables. Qualitative analysis Interview transcripts were subjected to thematic analysis following the framework described by Braun and Clarke. Initial codes were generated inductively from the data, iteratively refined, grouped into categories, and synthesised into overarching themes. Investigator triangulation, involving independent coding by two researchers followed by consensus discussion, was employed to enhance analytical rigour and credibility. Mixed-methods integration was performed at the interpretation stage, whereby qualitative themes were used to explain, contextualise, and extend the quantitative cascade findings. Ethical considerations Ethical approval was obtained from the Institutional Ethics Committee of ESIC Medical College and PGIMSR, Kalaburagi (Reference No. ESICMC/GLB/IEC/18/2023). Participation was voluntary; written informed consent was obtained from all caregivers prior to data collection. Confidentiality was maintained throughout the study, and all data were anonymised prior to analysis. Results Sociodemographic characteristics of index cases Of the 91 index cases, 44.0% resided in three-generation households, 33.0% in nuclear families, and 23.1% in joint families. Approximately 54.9% of households comprised five or fewer members (mean family size 6 ± 2 members). The majority of households (83.5%) contained one or two under-five children. With respect to socioeconomic status, 58.2% of index cases were classified as Kuppuswamy Class III, and 29.7% as Class II (Table 1 ). Table 1 Sociodemographic profile of index cases (N = 91) Sociodemographic Variable Frequency (N = 91) Percentage (%) Type of family Nuclear 30 33.0 Joint 21 23.1 Three-generation 40 44.0 Family size 1–5 members 50 54.9 ≥6 members 41 45.1 Mean ± SD 6 ± 2 — Number of under-five children per household 1–2 76 83.5 3–4 14 15.4 5–6 1 1.1 Mean ± SD 1.6 ± 0.8 — Socioeconomic status (Kuppuswamy scale) Class I 2 2.2 Class II 27 29.7 Class III 53 58.2 Class IV 9 9.9 IPT care cascade Among the 179 enrolled child contacts (mean age 3.5 ± 1.1 years; 56.4% male; all BCG-vaccinated), caregiver awareness of tuberculosis preventive care was reported in 73.2% of cases. Tuberculosis screening was completed in 70.9% of contacts (127/179). Of those screened, IPT was initiated in 49.6% (63/127). Among children who initiated IPT, 49.2% (31/63) completed the full six-month course. The overall cascade completion rate from identification to IPT completion was therefore 17.3% (31/179), indicating marked attrition at both the initiation and completion stages (Table 2 ). Table 2 Demographic profile of child contacts and IPT care cascade indicators (N = 179) Variable Frequency Percentage (%) Age of child contact (years) 1 6 3.4 2 27 15.1 3 57 31.8 4 40 22.3 5 49 27.4 Mean ± SD 3.5 ± 1.1 — Sex Male 101 56.4 Female 78 43.6 Relation to index case Son/daughter 96 53.6 Grandchild 54 30.2 Sibling 7 3.9 Cousin 5 2.8 Other 17 9.5 BCG vaccination received 179 100.0 IPT Care Cascade (N = 179) Screened for tuberculosis 127/179 70.9 IPT initiated (of those screened, n = 127) 63/127 49.6 IPT completed (of those initiated, n = 63) 31/63 49.2 Determinants of IPT completion Child age and sex were not significantly associated with IPT completion (p = 0.90 for both). In contrast, several household-level factors demonstrated strong and statistically significant associations. Children residing in nuclear families were significantly more likely to complete IPT compared with those from joint or three-generation households (OR 4.62; 95% CI: 1.49–14.35; p = 0.006). Smaller household size (1–5 members) was strongly associated with completion (OR 7.54; 95% CI: 2.45–23.25; p = 0.0002). Higher socioeconomic status (Kuppuswamy Class I or II) emerged as the strongest independent predictor of completion (OR 12.35; 95% CI: 2.50–60.97; p = 0.001). Households with fewer under-five child contacts ( 1 – 2 ) also showed significantly higher completion rates than those with three or more contacts (OR 5.60; 95% CI: 1.40–22.46; p = 0.020) (Table 3 ). Table 3 Factors associated with IPT completion among child contacts who initiated therapy(n = 63) Variable IPT Completed n (%) IPT Not Completed n (%) Crude OR (95% CI) p-value Age of child (years) 1–3 15 (50.0) 15 (50.0) 1.06 (0.40–2.86) 0.90 4–5 (Ref) 16 (48.5) 17 (51.5) Reference — Sex Male 17 (48.6) 18 (51.4) 0.91 (0.45–1.84) 0.90 Female (Ref) 14 (50.0) 14 (50.0) Reference — Family type Nuclear 16 (72.7) 6 (27.3) 4.62 (1.49–14.35) 0.006* Joint/three-generation (Ref) 15 (36.6) 26 (63.4) Reference — Household size 1–5 members 24 (70.6) 10 (29.4) 7.54 (2.45–23.25) 0.0002* ≥6 members (Ref) 7 (24.1) 22 (75.9) Reference — Socioeconomic status Class I & II 14 (87.5) 2 (12.5) 12.35 (2.50–60.97) 0.001* Class III & IV (Ref) 17 (36.2) 30 (63.8) Reference — Number of child contacts 1–2 28 (58.3) 20 (41.7) 5.60 (1.40–22.46) 0.020* 3–6 (Ref) 3 (20.0) 12 (80.0) Reference — OR: odds ratio; CI: confidence interval; *p < 0.05 Qualitative findings Thematic analysis of the ten caregiver in-depth interviews yielded five themes that provided mechanistic explanations for the observed cascade gaps. Theme 1 — Limited understanding of tuberculosis transmission and preventive therapy Caregivers demonstrated substantial misconceptions regarding tuberculosis transmission, variously attributing infection to shared food, dietary habits, or poor personal hygiene, rather than to airborne droplet nuclei. Awareness of asymptomatic childhood infection and the rationale for preventive treatment was especially low among caregivers whose children had not initiated IPT. “If someone is having TB and if he coughs or spits and food is kept there, then we might get TB.” (Caregiver 1) Theme 2 — Diagnostic delay and initial reliance on the private sector Several caregivers recounted prolonged periods of undiagnosed symptoms and multiple consultations in the private sector prior to receiving a tuberculosis diagnosis. This delay imposed considerable financial hardship on families, diverting resources that might otherwise have supported engagement with public-sector preventive services. “We spent nearly one lakh in private hospital before knowing medicines are free in government.” (Caregiver 5) Theme 3 — Trust in frontline healthcare workers as a facilitator Confidence in government frontline workers—particularly Anganwadi workers, ASHA workers, and clinic nurses—emerged consistently as a key facilitator of IPT acceptance and adherence. This finding aligned with the higher completion rates observed in better-supported households in the quantitative analysis. “Anganwadi people used to call us monthly… they helped us a lot.” (Caregiver 1) Theme 4 — Practical barriers and elder-mediated social pressure Caregivers commonly described challenges in administering daily tablets to young children due to tablet refusal, perceived bitterness, and generalised parental anxiety about daily medication. Additionally, in multigenerational households, elders frequently questioned the necessity of treating a visibly well child, exerting social pressure that undermined caregiver motivation to continue IPT. “Many people told not to give tablets daily to children without disease.” (Caregiver 1) Theme 5 — Missed opportunities and inadequate counselling A subset of caregivers relied exclusively on physical separation of young children from the index case as a preventive measure, without initiating IPT. In several instances, healthcare providers had not clearly communicated the indication for preventive therapy or had not prioritised it during clinical encounters, contributing directly to attrition at the initiation stage. “Doctor said keep children away, so we sent them to mother-in-law house.” (Caregiver 5) Integration of quantitative and qualitative findings Integrated analysis revealed that household- and caregiver-level factors, rather than child-specific characteristics, were the principal drivers of cascade attrition. The significantly higher completion rates observed in nuclear, smaller, and higher socioeconomic-status households were qualitatively explained by greater caregiver agency, fewer competing priorities, and more consistent engagement with frontline health workers. Conversely, caregiver misconceptions about tuberculosis, social pressure from extended family members, and inadequate provider counselling collectively accounted for the disproportionate losses at both initiation and completion stages in larger, multigenerational, and lower socioeconomic-status households. Discussion This sequential explanatory mixed-methods study documented substantial attrition across the IPT care cascade in urban Kalaburagi, with screening coverage of 70.9%, IPT initiation among those screened of 49.6%, and completion among initiators of 49.2%, yielding an overall cascade completion rate of only 17.3%. These figures are broadly consistent with national data reporting TPT initiation in approximately 60% of eligible under-five contacts⁷ and corroborate the findings of published studies from other high-burden Indian settings that have identified comparable patterns of programmatic attrition at multiple cascade stages.⁵,⁶ The strong and independent associations of nuclear family structure, smaller household size, higher socioeconomic status, and fewer under-five contacts per household with IPT completion underscore the central role of household dynamics in shaping preventive care behaviour. These associations are consistent with evidence from analogous settings in which household complexity and caregiver burden have been identified as impediments to adherence to preventive treatment regimens.⁹,¹⁰ Qualitative data provided a mechanistic explanation for these quantitative associations: in larger, multigenerational households, conflicting health beliefs and elder-driven discouragement of treatment in asymptomatic children created an environment that was actively hostile to IPT adherence—a nuance that would not have been apparent from quantitative analysis alone. Inadequate counselling at the point of initiation, infrequent follow-up, and excessive reliance on caregiver initiative were identified as structural and programmatic contributors to cascade losses. These observations align with a substantial body of literature identifying system-level deficiencies as critical predictors of preventive therapy coverage.¹¹,¹² The facilitating role of Anganwadi and ASHA workers documented in this study corroborates findings from implementation research emphasising the value of patient-centred communication and sustained community engagement in improving preventive therapy outcomes.¹³ A key strength of this study is its mixed-methods design, which enabled the integration of programme-level cascade measurement with rich contextual explanations, thereby enhancing the translational relevance of the findings for programme managers and policymakers. Limitations include the restriction to a single urban district, which may constrain generalisability to rural or other geographic settings, and the relatively small qualitative sample, although thematic saturation was achieved. As a cross-sectional study, temporal relationships between exposures and outcomes cannot be established. Conclusion Despite reasonable tuberculosis screening coverage among under-five household contacts, high rates of attrition at both the IPT initiation and completion stages represent a substantial and largely preventable missed opportunity for tuberculosis elimination in this urban setting. Household structure and socioeconomic status, mediated by caregiver perceptions and differential engagement with frontline health workers, are critical determinants of cascade completion. To address these findings, programmatic interventions should prioritise structured caregiver counselling at the time of index case registration, enhanced community-level follow-up by Anganwadi and ASHA workers, and the development and procurement of child-friendly IPT formulations. Routine monitoring of all stages of the IPT care cascade should be embedded within NTEP reporting frameworks to enable timely identification and remediation of cascade losses at scale. Declarations Funding: No external funding was received for this study. Competing interests: The authors declare no competing interests. Ethics approval and consent to participate: This study was approved by the Institutional Ethics Committee of ESIC Medical College and PGIMSR, Kalaburagi (Reference No. ESICMC/GLB/IEC/18/2023). All procedures were carried out in accordance with the ethical standards of the Institutional Ethics Committee and in accordance with the 1964 Helsinki Declaration and its later amendments. Written informed consent was obtained from all caregivers prior to data collection. Consent to publish: Not applicable. Data availability statement: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Authors’ contributions: LKT conceived the study, collected and analysed the data, and drafted the manuscript. SP supervised the study design and critically revised the manuscript. Both authors read and approved the final version. Acknowledgements: The authors acknowledge the support of the District TB Office, Kalaburagi; the study participants and their caregivers; and the institutional authorities of ESIC Medical College and PGIMSR, Kalaburagi, for facilitating this research. Clinical trial number: Not applicable. References World Health Organization. Global Tuberculosis Report 2024. Geneva: WHO; 2024. Ministry of Health and Family Welfare. India TB Report 2024. New Delhi: Central TB Division, MoHFW; 2024. Park K. Textbook of Preventive and Social Medicine. 27th ed. Jabalpur: Bhanot; 2023. pp. 207–8. World Health Organization. Tuberculosis in Children. Geneva: WHO; 2022. Harries AD, Kumar AMV, Satyanarayana S, et al. The growing importance of tuberculosis preventive therapy and how research can enhance its implementation. Trop Med Infect Dis. 2020;5(2):62. Central TB. Division. Guidelines for Programmatic Management of Tuberculosis Preventive Treatment (PMTPT). New Delhi: MoHFW; 2021. Central TB. Division. India TB Report 2024. New Delhi: MoHFW; 2024. p. 14. Creswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research. 3rd ed. Los Angeles: SAGE; 2018. Obi EN, Amaechi EC, Uchenna NJ, et al. Household contact investigation for TB and determinants of preventive therapy uptake. BMC Infect Dis. 2021;21:893. Muyoyeta M, Moyo M, Kasese N, et al. Implementation of isoniazid preventive therapy in settings with high TB and HIV burden. PLoS ONE. 2015;10(6):e0130733. WHO Consolidated. Guidelines on Tuberculosis — Module 2: Screening. Geneva: WHO; 2021. Getahun H, Matteelli A, Chaisson RE, Raviglione M. Latent Mycobacterium tuberculosis infection. N Engl J Med. 2015;372(22):2127–35. Govindasamy D, Ford N, Kranzer K. Risk factors, barriers and facilitators for linkage to antiretroviral therapy care — application to TB preventive therapy. Int J Tuberc Lung Dis. 2012;16(10):1284–94. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 13 May, 2026 Reviews received at journal 12 May, 2026 Reviews received at journal 07 May, 2026 Reviewers agreed at journal 05 May, 2026 Reviewers agreed at journal 05 May, 2026 Reviewers agreed at journal 04 May, 2026 Reviewers agreed at journal 04 May, 2026 Reviews received at journal 01 May, 2026 Reviewers agreed at journal 01 May, 2026 Reviews received at journal 27 Apr, 2026 Reviewers agreed at journal 24 Apr, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers invited by journal 22 Apr, 2026 Editor invited by journal 21 Apr, 2026 Editor assigned by journal 21 Apr, 2026 Submission checks completed at journal 18 Apr, 2026 First submitted to journal 18 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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The India TB Report 2024 documents that only 60% of eligible under-five contacts received tuberculosis preventive therapy (TPT), underscoring persistent gaps in service delivery.⁷ Attrition occurs across multiple cascade stages\u0026mdash;identification, screening, initiation, and completion\u0026mdash;yet few studies have systematically quantified losses at each step or examined the underlying determinants. Mixed-methods approaches are particularly well suited to this research context because they combine programme-level measurement with caregiver and health-system perspectives, thereby generating both explanatory depth and practical utility.⁸\u003c/p\u003e \u003cp\u003e This study aimed to evaluate the IPT care cascade among under-five household contacts of pulmonary tuberculosis patients in urban Kalaburagi district, Karnataka, to identify sociodemographic predictors of IPT completion, and to explore the barriers and facilitators that influence IPT uptake and adherence at the caregiver and health-system levels.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eA sequential explanatory mixed-methods design was employed, in which a quantitative cross-sectional investigation was conducted first, followed by an in-depth qualitative component intended to explain and contextualise the quantitative findings.⁸ The study was conducted at two urban tuberculosis units (TUs) in Kalaburagi district, Karnataka, India. Kalaburagi district has a total of 12 TUs, of which the remaining ten serve predominantly rural areas; the two urban TUs selected represent the principal service-delivery points for the urban population.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy participants\u003c/h3\u003e\n\u003cp\u003eThe quantitative component included all under-five children residing in the same household as a pulmonary tuberculosis index case registered at either study TU between 1 January and 31 December 2022. Children with confirmed active tuberculosis at the time of contact tracing, or with known contraindications to isoniazid, were excluded. From district TB office records, 207 child contacts were initially identified; after applying exclusion criteria, 179 contacts from 91 index cases were enrolled.\u003c/p\u003e \u003cp\u003eFor the qualitative component, 10 caregivers of eligible child contacts\u0026mdash;five from each TU\u0026mdash;were purposively selected to ensure diversity with respect to IPT initiation and completion status, family structure, and socioeconomic background.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eQuantitative data were collected through structured telephonic interviews with caregivers, using a pre-tested, semi-structured questionnaire administered in the local language (Kannada/Urdu) following receipt of written informed consent. All responses were verified against NTEP records maintained at the respective TUs. In-depth interviews for the qualitative component were conducted by a postgraduate medical student with proficiency in the local language and training in qualitative research methods. Interviews were conducted at participants' homes or at the TU according to the participant's preference, averaged 30 minutes in duration, and were audio-recorded with explicit participant consent. Transcripts were prepared verbatim and data collection continued until thematic saturation was achieved.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were entered and analysed using OpenEpi software (version 3.01). Cascade indicators were expressed as proportions with 95% CIs where appropriate. Associations between sociodemographic variables and IPT completion were assessed using the chi-square test or Fisher's exact test, as dictated by expected cell frequencies; a two-tailed p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Crude odds ratios and their 95% confidence intervals were calculated for all variables.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative analysis\u003c/h3\u003e\n\u003cp\u003eInterview transcripts were subjected to thematic analysis following the framework described by Braun and Clarke. Initial codes were generated inductively from the data, iteratively refined, grouped into categories, and synthesised into overarching themes. Investigator triangulation, involving independent coding by two researchers followed by consensus discussion, was employed to enhance analytical rigour and credibility. Mixed-methods integration was performed at the interpretation stage, whereby qualitative themes were used to explain, contextualise, and extend the quantitative cascade findings.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003e was obtained from the Institutional Ethics Committee of ESIC Medical College and PGIMSR, Kalaburagi (Reference No. ESICMC/GLB/IEC/18/2023). Participation was voluntary; written informed consent was obtained from all caregivers prior to data collection. Confidentiality was maintained throughout the study, and all data were anonymised prior to analysis.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic characteristics of index cases\u003c/h2\u003e \u003cp\u003eOf the 91 index cases, 44.0% resided in three-generation households, 33.0% in nuclear families, and 23.1% in joint families. Approximately 54.9% of households comprised five or fewer members (mean family size 6\u0026thinsp;\u0026plusmn;\u0026thinsp;2 members). The majority of households (83.5%) contained one or two under-five children. With respect to socioeconomic status, 58.2% of index cases were classified as Kuppuswamy Class III, and 29.7% as Class II (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic profile of index cases (N\u0026thinsp;=\u0026thinsp;91)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSociodemographic Variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency (N\u0026thinsp;=\u0026thinsp;91)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNuclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJoint\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThree-generation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;5 members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;6 members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026thinsp;\u0026plusmn;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of under-five children per household\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocioeconomic status (Kuppuswamy scale)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIPT care cascade\u003c/h2\u003e \u003cp\u003eAmong the 179 enrolled child contacts (mean age 3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 years; 56.4% male; all BCG-vaccinated), caregiver awareness of tuberculosis preventive care was reported in 73.2% of cases. Tuberculosis screening was completed in 70.9% of contacts (127/179). Of those screened, IPT was initiated in 49.6% (63/127). Among children who initiated IPT, 49.2% (31/63) completed the full six-month course. The overall cascade completion rate from identification to IPT completion was therefore 17.3% (31/179), indicating marked attrition at both the initiation and completion stages (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic profile of child contacts and IPT care cascade indicators (N\u0026thinsp;=\u0026thinsp;179)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge of child contact (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRelation to index case\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSon/daughter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrandchild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSibling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCousin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBCG vaccination received\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIPT Care Cascade (N\u0026thinsp;=\u0026thinsp;179)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScreened for tuberculosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e127/179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIPT initiated (of those screened, n\u0026thinsp;=\u0026thinsp;127)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63/127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIPT completed (of those initiated, n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31/63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDeterminants of IPT completion\u003c/h2\u003e \u003cp\u003eChild age and sex were not significantly associated with IPT completion (p\u0026thinsp;=\u0026thinsp;0.90 for both). In contrast, several household-level factors demonstrated strong and statistically significant associations. Children residing in nuclear families were significantly more likely to complete IPT compared with those from joint or three-generation households (OR 4.62; 95% CI: 1.49\u0026ndash;14.35; p\u0026thinsp;=\u0026thinsp;0.006). Smaller household size (1\u0026ndash;5 members) was strongly associated with completion (OR 7.54; 95% CI: 2.45\u0026ndash;23.25; p\u0026thinsp;=\u0026thinsp;0.0002). Higher socioeconomic status (Kuppuswamy Class I or II) emerged as the strongest independent predictor of completion (OR 12.35; 95% CI: 2.50\u0026ndash;60.97; p\u0026thinsp;=\u0026thinsp;0.001). Households with fewer under-five child contacts (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) also showed significantly higher completion rates than those with three or more contacts (OR 5.60; 95% CI: 1.40\u0026ndash;22.46; p\u0026thinsp;=\u0026thinsp;0.020) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFactors associated with IPT completion among child contacts who initiated therapy(n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIPT Completed n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIPT Not Completed n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge of child (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.06 (0.40\u0026ndash;2.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;5 (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17 (51.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.91 (0.45\u0026ndash;1.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNuclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (72.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.62 (1.49\u0026ndash;14.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.006*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJoint/three-generation (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (36.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26 (63.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;5 members\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (70.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.54 (2.45\u0026ndash;23.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.0002*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;6 members (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (75.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocioeconomic status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass I \u0026amp; II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (87.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.35 (2.50\u0026ndash;60.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClass III \u0026amp; IV (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (36.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (63.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of child contacts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (58.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (41.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.60 (1.40\u0026ndash;22.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.020*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;6 (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eOR: odds ratio; CI: confidence interval; *p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eQualitative findings\u003c/h2\u003e \u003cp\u003eThematic analysis of the ten caregiver in-depth interviews yielded five themes that provided mechanistic explanations for the observed cascade gaps.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTheme 1 \u0026mdash; Limited understanding of tuberculosis transmission and preventive therapy\u003c/strong\u003e \u003cp\u003eCaregivers demonstrated substantial misconceptions regarding tuberculosis transmission, variously attributing infection to shared food, dietary habits, or poor personal hygiene, rather than to airborne droplet nuclei. Awareness of asymptomatic childhood infection and the rationale for preventive treatment was especially low among caregivers whose children had not initiated IPT.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If someone is having TB and if he coughs or spits and food is kept there, then we might get TB.\u0026rdquo; (Caregiver 1)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTheme 2 \u0026mdash; Diagnostic delay and initial reliance on the private sector\u003c/strong\u003e \u003cp\u003eSeveral caregivers recounted prolonged periods of undiagnosed symptoms and multiple consultations in the private sector prior to receiving a tuberculosis diagnosis. This delay imposed considerable financial hardship on families, diverting resources that might otherwise have supported engagement with public-sector preventive services.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We spent nearly one lakh in private hospital before knowing medicines are free in government.\u0026rdquo; (Caregiver 5)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTheme 3 \u0026mdash; Trust in frontline healthcare workers as a facilitator\u003c/strong\u003e \u003cp\u003eConfidence in government frontline workers\u0026mdash;particularly Anganwadi workers, ASHA workers, and clinic nurses\u0026mdash;emerged consistently as a key facilitator of IPT acceptance and adherence. This finding aligned with the higher completion rates observed in better-supported households in the quantitative analysis.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Anganwadi people used to call us monthly\u0026hellip; they helped us a lot.\u0026rdquo; (Caregiver 1)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTheme 4 \u0026mdash; Practical barriers and elder-mediated social pressure\u003c/strong\u003e \u003cp\u003eCaregivers commonly described challenges in administering daily tablets to young children due to tablet refusal, perceived bitterness, and generalised parental anxiety about daily medication. Additionally, in multigenerational households, elders frequently questioned the necessity of treating a visibly well child, exerting social pressure that undermined caregiver motivation to continue IPT.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Many people told not to give tablets daily to children without disease.\u0026rdquo; (Caregiver 1)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTheme 5 \u0026mdash; Missed opportunities and inadequate counselling\u003c/strong\u003e \u003cp\u003eA subset of caregivers relied exclusively on physical separation of young children from the index case as a preventive measure, without initiating IPT. In several instances, healthcare providers had not clearly communicated the indication for preventive therapy or had not prioritised it during clinical encounters, contributing directly to attrition at the initiation stage.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Doctor said keep children away, so we sent them to mother-in-law house.\u0026rdquo; (Caregiver 5)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eIntegration of quantitative and qualitative findings\u003c/h2\u003e \u003cp\u003eIntegrated analysis revealed that household- and caregiver-level factors, rather than child-specific characteristics, were the principal drivers of cascade attrition. The significantly higher completion rates observed in nuclear, smaller, and higher socioeconomic-status households were qualitatively explained by greater caregiver agency, fewer competing priorities, and more consistent engagement with frontline health workers. Conversely, caregiver misconceptions about tuberculosis, social pressure from extended family members, and inadequate provider counselling collectively accounted for the disproportionate losses at both initiation and completion stages in larger, multigenerational, and lower socioeconomic-status households.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis sequential explanatory mixed-methods study documented substantial attrition across the IPT care cascade in urban Kalaburagi, with screening coverage of 70.9%, IPT initiation among those screened of 49.6%, and completion among initiators of 49.2%, yielding an overall cascade completion rate of only 17.3%. These figures are broadly consistent with national data reporting TPT initiation in approximately 60% of eligible under-five contacts⁷ and corroborate the findings of published studies from other high-burden Indian settings that have identified comparable patterns of programmatic attrition at multiple cascade stages.⁵,⁶\u003c/p\u003e \u003cp\u003eThe strong and independent associations of nuclear family structure, smaller household size, higher socioeconomic status, and fewer under-five contacts per household with IPT completion underscore the central role of household dynamics in shaping preventive care behaviour. These associations are consistent with evidence from analogous settings in which household complexity and caregiver burden have been identified as impediments to adherence to preventive treatment regimens.⁹,\u0026sup1;⁰ Qualitative data provided a mechanistic explanation for these quantitative associations: in larger, multigenerational households, conflicting health beliefs and elder-driven discouragement of treatment in asymptomatic children created an environment that was actively hostile to IPT adherence\u0026mdash;a nuance that would not have been apparent from quantitative analysis alone.\u003c/p\u003e \u003cp\u003eInadequate counselling at the point of initiation, infrequent follow-up, and excessive reliance on caregiver initiative were identified as structural and programmatic contributors to cascade losses. These observations align with a substantial body of literature identifying system-level deficiencies as critical predictors of preventive therapy coverage.\u0026sup1;\u0026sup1;,\u0026sup1;\u0026sup2; The facilitating role of Anganwadi and ASHA workers documented in this study corroborates findings from implementation research emphasising the value of patient-centred communication and sustained community engagement in improving preventive therapy outcomes.\u0026sup1;\u0026sup3;\u003c/p\u003e \u003cp\u003eA key strength of this study is its mixed-methods design, which enabled the integration of programme-level cascade measurement with rich contextual explanations, thereby enhancing the translational relevance of the findings for programme managers and policymakers. Limitations include the restriction to a single urban district, which may constrain generalisability to rural or other geographic settings, and the relatively small qualitative sample, although thematic saturation was achieved. As a cross-sectional study, temporal relationships between exposures and outcomes cannot be established.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDespite reasonable tuberculosis screening coverage among under-five household contacts, high rates of attrition at both the IPT initiation and completion stages represent a substantial and largely preventable missed opportunity for tuberculosis elimination in this urban setting. Household structure and socioeconomic status, mediated by caregiver perceptions and differential engagement with frontline health workers, are critical determinants of cascade completion. To address these findings, programmatic interventions should prioritise structured caregiver counselling at the time of index case registration, enhanced community-level follow-up by Anganwadi and ASHA workers, and the development and procurement of child-friendly IPT formulations. Routine monitoring of all stages of the IPT care cascade should be embedded within NTEP reporting frameworks to enable timely identification and remediation of cascade losses at scale.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo external funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis study was approved by the Institutional Ethics Committee of ESIC Medical College and PGIMSR, Kalaburagi (Reference No. ESICMC/GLB/IEC/18/2023). All procedures were carried out in accordance with the ethical standards of the Institutional Ethics Committee and in accordance with the 1964 Helsinki Declaration and its later amendments. Written informed consent was obtained from all caregivers prior to data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement:\u0026nbsp;\u003c/strong\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003eLKT conceived the study, collected and analysed the data, and drafted the manuscript. SP supervised the study design and critically revised the manuscript. Both authors read and approved the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors acknowledge the support of the District TB Office, Kalaburagi; the study participants and their caregivers; and the institutional authorities of ESIC Medical College and PGIMSR, Kalaburagi, for facilitating this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Global Tuberculosis Report 2024. Geneva: WHO; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health and Family Welfare. India TB Report 2024. New Delhi: Central TB Division, MoHFW; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark K. Textbook of Preventive and Social Medicine. 27th ed. Jabalpur: Bhanot; 2023. pp. 207\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Tuberculosis in Children. Geneva: WHO; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarries AD, Kumar AMV, Satyanarayana S, et al. The growing importance of tuberculosis preventive therapy and how research can enhance its implementation. Trop Med Infect Dis. 2020;5(2):62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCentral TB. Division. Guidelines for Programmatic Management of Tuberculosis Preventive Treatment (PMTPT). New Delhi: MoHFW; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCentral TB. Division. India TB Report 2024. New Delhi: MoHFW; 2024. p. 14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell JW, Plano Clark VL. Designing and Conducting Mixed Methods Research. 3rd ed. Los Angeles: SAGE; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eObi EN, Amaechi EC, Uchenna NJ, et al. Household contact investigation for TB and determinants of preventive therapy uptake. BMC Infect Dis. 2021;21:893.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuyoyeta M, Moyo M, Kasese N, et al. Implementation of isoniazid preventive therapy in settings with high TB and HIV burden. PLoS ONE. 2015;10(6):e0130733.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO Consolidated. Guidelines on Tuberculosis \u0026mdash; Module 2: Screening. Geneva: WHO; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGetahun H, Matteelli A, Chaisson RE, Raviglione M. Latent Mycobacterium tuberculosis infection. N Engl J Med. 2015;372(22):2127\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGovindasamy D, Ford N, Kranzer K. Risk factors, barriers and facilitators for linkage to antiretroviral therapy care \u0026mdash; application to TB preventive therapy. Int J Tuberc Lung Dis. 2012;16(10):1284\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Public Health](https://link.springer.com/journal/12982)","snPcode":"12982","submissionUrl":"https://submission.springernature.com/new-submission/12982/3","title":"Discover Public Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tuberculosis, Isoniazid Preventive Therapy, child contacts, IPT care cascade, mixed methods, India, NTEP","lastPublishedDoi":"10.21203/rs.3.rs-9335672/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9335672/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIsoniazid Preventive Therapy (IPT) substantially reduces the risk of progression from latent tuberculosis infection to active disease in children under five years of age who reside with infectious pulmonary tuberculosis patients. Despite robust programmatic guidelines, India's preventive care cascade continues to face significant implementation challenges, with persistent losses at multiple stages from identification to treatment completion.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThis study aimed to (i) characterise the IPT care cascade among under-five household contacts of pulmonary tuberculosis index cases in urban Kalaburagi district, (ii) identify sociodemographic factors associated with IPT completion, and (iii) explore caregiver- and system-level barriers and facilitators influencing IPT initiation and completion.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA sequential explanatory mixed-methods study was conducted at two urban tuberculosis units (TUs) in Kalaburagi district, Karnataka, India. The quantitative component comprised a community-based cross-sectional investigation of 179 under-five child contacts identified from 91 pulmonary tuberculosis index cases registered during 2022. The qualitative component involved in-depth interviews with ten purposively selected caregivers. Cascade indicators were described as proportions; associations between sociodemographic variables and IPT completion were examined using chi-square or Fisher's exact tests, with odds ratios (ORs) and 95% confidence intervals (CIs) calculated. Qualitative data were analysed thematically and integrated with quantitative findings at the interpretation stage.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOf the 179 eligible child contacts, 70.9% underwent tuberculosis screening. Among those screened, only 49.6% initiated IPT, and 49.2% of initiators completed the full six-month course, yielding an overall cascade completion rate of 17.3% (31/179). IPT completion was significantly higher among children from nuclear families (OR 4.62; 95% CI: 1.49\u0026ndash;14.35), smaller households (OR 7.54; 95% CI: 2.45\u0026ndash;23.25), higher socioeconomic strata (OR 12.35; 95% CI: 2.50\u0026ndash;60.97), and households with fewer under-five contacts (OR 5.60; 95% CI: 1.40\u0026ndash;22.46). Qualitative analysis identified five themes: limited caregiver knowledge of tuberculosis transmission and prevention; delayed diagnosis with initial reliance on private healthcare; trust in frontline health workers as a facilitating factor; practical challenges and elder-mediated social pressure; and missed opportunities attributable to inadequate counselling.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSubstantial attrition occurs at both the initiation and completion stages of the IPT care cascade, representing a missed opportunity for tuberculosis prevention in this urban setting. Programmatic responses should prioritise structured caregiver counselling at the point of index case registration, sustained community-level follow-up by Anganwadi and ASHA workers, and the development of child-friendly IPT formulations. Routine cascade monitoring should be incorporated into National Tuberculosis Elimination Programme (NTEP) reporting systems.\u003c/p\u003e","manuscriptTitle":"Isoniazid Preventive Therapy Care Cascade among Under-Five Child Contacts of Pulmonary Tuberculosis Patients in Urban Kalaburagi District India and Its Associated Determinants","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 14:58:11","doi":"10.21203/rs.3.rs-9335672/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision 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