 Good morning all. So today I'm here before you presenting our study on the health-related quality of life among drug-resistant tuberculosis patients which was done in Mumbai. So just to give you a brief about, we all know that India has a very high burden of tuberculosis and a very high burden of drug-resistant tuberculosis also. And Mumbai, which you can see here is on the western part of this country, is a mega-police economic hub. But it also has a very high burden of tuberculosis along with very severe drug-resistant strains in the community there. So now we had already seen, Philip mentioned before me that the treatment for drug-resistant tuberculosis, the 20 month old with injectables, a lot of side effects. So one of the questions is how did it affect the quality of life? So before that let's actually see what is health-related quality of life. So health-related quality of life, it's a patient reported outcome measure. It's the perceived illness of the patient. How does the patient actually perceive the illness that he has from the disease that a doctor sees in the clinic? And it includes how the illness has affected the physical, psychological, emotional, social and the role functioning of this patient. What exactly are the effects of the illness, how he perceives the effect of the illness on all these different factors? And why is it important to study the quality of life? Well, as a patient, their functional capacity, well-being and the experience of their illness, it's much more important to the patient than just getting a bacteriological cure. So this background and just have to say that to put it in very short term, in very short, patients want to live and not just merely survive and that's what quality of life is all about. So with background, what we aimed was to assess the quality of life among drug-resistant tuberculosis patients. What were the factors associated with it? And we also to explore the patient's perspectives about the quality of life. The methods that we use, we use the mixed method study. Actually today I won't be presenting the quantitative part in detail. So we used the cross-sectional interviews for quantitative and we did in-depth interviews for qualitative. We conducted the study in two different settings in Mumbai. One is MSF, Private Clinic and other is Jupiter Hospital which is a multi-speciality hospital in Mumbai. Both these settings have a multidisciplinary teams of nurses, psychologists, counsellors, social workers and psychiatrists who are on board and all the patients are provided individualized tailored treatment with a very patient-centered treatment modules are used. So all the participants in the study are drug-resistant TB patients and they are more than 18 years of age. For in-depth interviews, what we have done is we have selected a subset of patients who actually represent like to get the highest data that we can actually get from it. And for data collection, for quantitative use, a WHOQL graph that's the World Health Organization's quality of life brief questioner. It has 26 questions with four different domains and for in-depth interviews we used an interview guide. In the patient characteristics, we enrolled 95 patients in total 12 of whom were enrolled for the qualitative phase and if we look at the bottom the TB resistance pattern, half of our patients are XDR-TBR, like which is one of the worst resistance patterns that you can have. A brief about the quantitative part of this, so what we see here is like the zero, the minimum score for WHOQL graph can be zero, range up to 100 which is the maximum score and these are the four domains that we have and if we look here in the physical and the psychological domains are the ones which were most affected. One interesting thing about quantitative that I would like to mention is that having to quit your job because of tuberculosis, if a patient actually had to quit their job because of taking TB treatment or before because of their disease, it affected a lot quantitatively a significant association with the social relations, it really affected that domain very badly. Now going into the quantitative or the brief framework of this study, so we have four domains which you can see that we have focused which affect the quality of life, the physical domain I am not going to concentrate today due to lack of time. Let's go to the second one here which is the psychological domain, so in the psychological domain the most affected we see that yes we had patients who were suffered from lot of anxiety, lot of depression, also what we had seen was that TB affected the self-image, the side effects and all the other things, it affected the way the patients perceived about themselves and all of this in turn led that the uncertainty with the treatment about the disease, it led that they had no hopes from their self, from their career or from their children, the only thing that they wanted, the only hope which they had was that I want to get better and I should never get this disease again. One of our patients said that I have asked my husband to remarry and not to expect anything from me, that was the situation in the region and there was a different aspect also to this part where one patient said that yes TB did slow down my life to a certain extent but it also gave me time to think about what's important for me. He says that earlier it was more of quantity but now it's more of quality of my life. The next part is the social and the role functioning which we have seen was affecting and one of the main thing was the fear of stigmatization and the treatment side effects which led to self-imposed psychological and social isolation of the patients from all the other and this affected even their psychological domain at the end of the day. One of a 23-year-old female young girl she said that I have failed as a daughter and a sister. However we have seen that if a patient was able to assume the role of a supporter that if the patient could actually go and support someone, it helped them cope with their own illness. A 52-year-old female she said that helping others with their problems helped me. I get courage from that. The next part that I would like to focus on are the environmental factors which included knowledge, finance and health systems. So in this I would like to focus first on the health system part of this. And the health system factor the support that the patients received from the health system from the doctors that they say every day from the nurses was seen to be very important factor which affected a patient's quality of life. One of our patients 55-year-old male he said doctors would not even touch me or talk directly with me at times. I was made to sit far away from the doctor's desk. I felt untouchable. When I came here the doctor kept his hand on my shoulder and assured me that you would get better and I felt half cured. So just simple reassurance, humane treatment at the health facilities for the patient can actually go a long way in helping the patients complete this very hardest treatment of DRTB. Other environmental factors I would like to focus is the directly observed therapy. So going every day to take their pills was seen to be something that interfered with their daily life and especially work and this was a major stressor for all of the participants. The other factor is pill burden. Philip said how long the treatment is injections. Just to give an idea DRTB patient takes about 14 and a half thousand pills to get his treatment cured and I cannot put it better than one of my participants what is the effect of pill burden on their quality of life. She said a 29-year-old female. My entire schedule revolves around medicine timings. I cannot do anything for myself or anyone else. It's like my injections, my pills, then pills, then food, then I sleep and on waking up again it's injections and pills and food that's all that is left in my life now. Last and very important part I would like to focus and spend some time as the support component. So the support from family, from close friends, help patients in overcoming the negativity or the oppression that they had about the treatment and this helped them to take the treatment regularly and still continue on medicines and the other part was the support at workplace. As I mentioned even earlier with the quantitative results, whenever the patients could actually continue their job they got support from the workplace, from their boss or from their colleagues to complete their treatment. This gave a much higher motivation to them and purpose to complete this treatment. Social support in the form of counselling was also mentioned, some patients also needed psychiatric care and it was seen to be something that helped patients. So what do these results actually mean? So all the quantitative part, so yes the quality of life scores were reduced, it was lower than what you would expect in normal people. But what was surprising even for us was that the quality of life scores were not actually as low as what had been reported in the literature earlier and the quality part really helped us to get a hang on why the scores could have been better. So I would like to say that DRTB patients who have received good standards of comprehensive patient-centered care who are empowered and knowledgeable about their disease and who receive support from family workplace and the health systems can have a reasonable quality of life despite the grave challenges imposed upon them by their disease and treatment. I would like to acknowledge all my participants, all my colleagues and everyone who has helped me with the study. Thank you. Thank you Chinmay for focusing on such an important part of the management of the DRTB cases. Usually it is missed in the hospitals, in the national programs and elsewhere. So we have time for taking one or two quick questions. Yes. More of a comment than a question, would like to share our experience, I'm from basically from Kerala. Please if I can interrupt you, we are here to ask questions. There's something called treatment support groups which we have experimented in Patananda district of Kerala. With the local self-government, we provide for most of the things that a PTB patient wants in the course of treatment and with that treatment support group, it's a formalized system whereby the local self-government, civil society, everybody is engaged at the Punjayat level. With that we have been able to reduce the initial loss to follow-up rates to zero, loss to follow-up rates to zero. The paper has been published in 2015. So if we can scale it up to a national level probably, you know, be helpful. Thank you so much. And again, emphasize please if you have questions you can ask because we have limited time. Yes. I am Dr. Dhyan. My question is as far as you mentioned, the support, family support and the social support, was there any study which shows was there any bias in the support between a male and a female patient, which is a common problem in our society? Is there any data which shows that this gender got this much support? Thank you. Wonderful point actually and we have not studied this and I am not actually not even aware of a literature which distinguishes between the support that the males and the females receive. So thank you. So I think you can take it in your next project but this is a very important part about this study. Yes. Last question please. Hi. My name is Yogish. My interest is you consider even XDR TB patients. So have you noticed any difference in the quality of life between among different resistance groups like MDR, pre-XDR and XDR? Yes, we have done that analysis and there is no difference actually with the resistance pattern. The resistance pattern was not seen to affect the quality of life in any of the four domains which we have seen. So as I said, it's something more than it's like a patient perceived thing and we do not, the quantitative or the qualitative reader do not show that the resistance pattern make a difference. Okay. Thank you, Chennai. Thank you very much on focusing for this very important point in the management. Thank you.