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Jeyashree K, Thangaraj JWV, Shanmugasundaram D, Sri Lakshmi Priya G, Pandey S, Janagaraj V, Shanmugasundaram P, Ts S, Ramasamy S, Chadwick J, Arunachalam S, Sharma R, Shah V, Chowdhury A, Iyer S, Rao R, Mattoo SK, Murhekar MV, Evaluation Group NPY. Ni-kshay Poshan Yojana: receipt and utilization among persons with TB notified under the National TB Elimination Program in India, 2022. Glob Health Action 2024; 17:2363300. [PMID: 39034827 PMCID: PMC11265306 DOI: 10.1080/16549716.2024.2363300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 05/28/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND Ni-kshay Poshan Yojana (NPY), a direct benefit transfer scheme under the National Tuberculosis Elimination Program (NTEP) in India, provides a monthly benefit of INR500 for nutritional support of persons with TB (PwTB). OBJECTIVES To determine the proportion of PwTB receiving atleast one NPY instalment and pattern of utilisation; to ascertain factors associated with NPY non-receipt and association of NPY receipt with TB treatment outcome. METHODS In our cross-sectional study, we used multi-stage sampling to select PwTB whose treatment outcome was declared between May 2022 and February 2023. A cluster-adjusted, generalized linear model was used to identify factors associated with the non-receipt of NPY and determine association between NPY receipt and TB treatment outcome. RESULTS Among 3201 PwTB, 2888 (92.7%; 95% CI 89.8%, 94.8%) had received at least one NPY instalment, and 1903 (64.2%; 95% CI 58.9%, 69.2%) self-reported receipt of benefit. The median (IQR) time to receipt of first instalment was 105 (60,174) days. Non-receipt was significantly higher among PwTB from states with low TB score (aPR = 2.34; 95%CI 1.51, 3.62), who do not have bank account (aPR = 2.48; 95%CI 1.93, 3.19) and with unknown/missing diabetic status (aPR = 1.69; 95%CI 1.11, 2.55). Unfavorable treatment outcomes were associated with non-receipt of NPY (aPR 4.93; 95%CI 3.61,6.75) after adjusting for potential confounders. CONCLUSION Majority of the PwTB received atleast one NPY instalment, but they experience significant delays. Most of the recipients utilised NPY for nutrition. Longitudinal follow-up studies are required to study the impact of NPY on treatment outcomes.
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Affiliation(s)
- Kathiresan Jeyashree
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology, Chennai, India
| | - Jeromie W V Thangaraj
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology, Chennai, India
| | - Devika Shanmugasundaram
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology, Chennai, India
| | - G Sri Lakshmi Priya
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology, Chennai, India
| | - Sumit Pandey
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology, Chennai, India
| | | | - Prema Shanmugasundaram
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology, Chennai, India
| | - Sumitha Ts
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology, Chennai, India
| | - Sabarinathan Ramasamy
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology, Chennai, India
| | - Joshua Chadwick
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology, Chennai, India
| | | | - Rahul Sharma
- TB Support Network, WHO Country Office for India, New Delhi, India
| | - Vaibhav Shah
- TB Support Network, WHO Country Office for India, New Delhi, India
| | - Aniket Chowdhury
- TB Support Network, WHO Country Office for India, New Delhi, India
| | - Swati Iyer
- TB Support Network, WHO Country Office for India, New Delhi, India
| | - Raghuram Rao
- Central TB Division, Ministry of Health and Family Welfare, New Delhi, India
| | - Sanjay K Mattoo
- Central TB Division, Ministry of Health and Family Welfare, New Delhi, India
| | - Manoj V Murhekar
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology, Chennai, India
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Rupani MP, Vyas S, Shah IA. Cohort study on association between catastrophic costs and unfavorable tuberculosis treatment outcomes among TB-HIV and TB-diabetes comorbid patients in India. BMC Public Health 2024; 24:2028. [PMID: 39075416 PMCID: PMC11285260 DOI: 10.1186/s12889-024-19609-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 07/26/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND India grapples with an alarming burden of tuberculosis (TB), reporting 2.6 million incident cases in 2023, necessitating intensified efforts toward TB elimination. The prevalence of catastrophic costs, defined as expenses exceeding 20% of annual household income, varies widely. Our objective was to determine the association between catastrophic costs from TB-HIV and TB-diabetes care and unfavorable TB treatment outcomes. METHODS We conducted a cohort study in Bhavnagar, India, from July 2019 to January 2021, involving 234 TB-HIV and 304 TB-diabetes patients. Catastrophic costs were assessed using the World Health Organization's tool. Unfavorable TB treatment outcomes included positive results from sputum smear, nucleic acid amplification, or culture tests at treatment completion, death during treatment, or treatment cessation for a month (for drug-sensitive TB) or two months (for drug-resistant TB). Firth regression was employed to address quasi-separation issues and identify predictors. RESULTS Among TB-HIV patients, 12% faced catastrophic costs, with 20% experiencing unfavorable TB outcomes. In this group, significant predictors included weight (OR: 0.93, 95% CI: 0.89-0.98), family type (OR: 2.5, 95% CI: 1.2-5.5), and initial hospitalization (OR: 2.6, 95% CI: 1.1-6.3). For TB-diabetes patients, 5% faced catastrophic costs, and 14% had unfavorable outcomes, with significant predictors being below the poverty line (BPL) (OR: 2.9, 95% CI: 1.5-5.9) and initial hospitalization (OR: 3.4, 95% CI: 1.1-11.1). Catastrophic cost incidence was higher in TB-HIV (12% vs. 4% in TB only) and TB-diabetes (5% vs. 4% in TB only) patients. However, catastrophic costs did not show a direct association with unfavorable outcomes in either group. CONCLUSIONS Our study found no direct association between catastrophic costs and unfavorable TB outcomes among TB-HIV/TB-diabetes patients. Instead, factors such as weight, family type, BPL status, and initial hospitalization were significant predictors. These findings underscore the importance of socio-economic conditions and initial hospitalization, advocate for enhanced support mechanisms including nutritional and financial aid, especially for BPL families.
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Affiliation(s)
- Mihir P Rupani
- Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Near ST Bus Stand, Jail Road, Bhavnagar, Gujarat, 364001, India.
- Clinical Epidemiology (Division of Health Sciences), ICMR - National Institute of Occupational Health (NIOH), Raksha Shakti University, Indian Council of Medical Research (ICMR), Meghaninagar, Ahmedabad, Gujarat, 380016, India.
- Gujarat University, Ahmedabad, Gujarat, 380009, India.
| | - Sheetal Vyas
- Gujarat University, Ahmedabad, Gujarat, 380009, India
- Department of Community Medicine, Narendra Modi Medical College, Maninagar, Ahmedabad, Gujarat, 380008, India
| | - Immad A Shah
- Clinical Epidemiology (Division of Health Sciences), ICMR - National Institute of Occupational Health (NIOH), Raksha Shakti University, Indian Council of Medical Research (ICMR), Meghaninagar, Ahmedabad, Gujarat, 380016, India
- Division of Agricultural Statistics, Sher-E-Kashmir University of Agricultural Sciences & Technology of Kashmir, Jammu & Kashmir, Srinagar, 190025, India
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Musiimenta A, Tumuhimbise W, Atukunda E, Mugaba A, Linnemayr S, Haberer J. Digital Adherence Technologies Linked to Mobile Money Incentives for Medication Adherence Among People Living With Tuberculosis: Mixed Methods Feasibility and Acceptability Study. JMIR Hum Factors 2024; 11:e47996. [PMID: 38819905 PMCID: PMC11179015 DOI: 10.2196/47996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 10/30/2023] [Accepted: 04/07/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Complementing digital adherence technologies (DATs) with mobile money incentives may improve their utility in supporting tuberculosis medication adherence, yet the feasibility and acceptability of this integrated approach remain unclear. OBJECTIVE This study aims to describe the feasibility and acceptability of a novel DAT intervention called My Mobile Wallet composed of real-time adherence monitoring, SMS text message reminders, and mobile money incentives for tuberculosis medication adherence in a low-income setting. METHODS We purposively recruited people living with tuberculosis from the Mbarara Regional Referral Hospital in Mbarara, Uganda, who (1) were starting tuberculosis treatment at enrollment or within the past 4 weeks, (2) owned a mobile phone, (3) were able to use SMS test messaging, (4) were aged ≥18 years, and (5) were living in Mbarara district. At study exit (month 6), we used interviews and questionnaires informed by the unified theory of acceptance and use of technology (UTAUT) to collect feasibility and acceptability data, reflecting patients' experiences of using each component of My Mobile Wallet. Feasibility also included tracking the functionality of the adherence monitor (ie, an electronic pillbox) as well as SMS text message and mobile money delivery. We used a content analytical approach to inductively analyze qualitative data and Stata (version 13; StataCorp LLC) to analyze quantitative data. RESULTS All 39 participants reported that the intervention was feasible because it was easy for them to use (eg, access and read SMS text messages) and worked as expected. Almost all SMS text messages (6880/7064, 97.4%) were sent as planned. The transmission of adherence data from the monitor worked well, with 98.37% (5682/5776) of the data transmitted as planned. All participants additionally reported that the intervention was acceptable because it helped them take their tuberculosis medication as prescribed; the mobile money incentives relieved them of tuberculosis-related financial burdens; SMS text message reminders and electronic pillbox-based alarms reminded them to take their medication on time; and participants perceived real-time adherence monitoring as "being watched" while taking their medication, which encouraged them to take their medication on time to demonstrate their commitment. The intervention was perceived as a sign of care, which eventually created emotional support and a sense of connectedness to health care. Participants preferred daily SMS text message reminders (32/39, 82%) to reminders linked to missed doses (7/39, 18%), citing the fact that tuberculosis medication is taken daily. CONCLUSIONS The use of real-time adherence monitoring linked to SMS text message reminders and mobile money incentives for tuberculosis medication adherence was feasible and acceptable in a low-resource setting where poverty-based structural barriers heavily constrain tuberculosis treatment and care.
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Affiliation(s)
- Angella Musiimenta
- Faculty of Computing and Informatics, Mbarara University of Science and Technology, Mbarara, Uganda
- Angels Compassion Research and Development Initiative, Mbarara, Uganda
| | - Wilson Tumuhimbise
- Faculty of Computing and Informatics, Mbarara University of Science and Technology, Mbarara, Uganda
- Angels Compassion Research and Development Initiative, Mbarara, Uganda
| | - Esther Atukunda
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Aaron Mugaba
- Faculty of Computing and Informatics, Mbarara University of Science and Technology, Mbarara, Uganda
- Angels Compassion Research and Development Initiative, Mbarara, Uganda
| | | | - Jessica Haberer
- Harvard Medical School, Boston, MA, United States
- Massachusetts General Hospital Center for Global Health, Boston, MA, United States
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Mohan M, Thangaraj JWV, Pandey S, Sri Lakshmi Priya G, Arunachalam S, Sharma R, Shewade HD, Aishwarya B, Afeeq K, Khatoon A, Gokulvijay B, Sireesha G, Chandra K, Nandhakumar S, Samuel P, Nanditha Viswanathan C, Shanmugasundaram D, Rao R, Murhekar MV, Jeyashree K. Need for operational simplicity and timely disbursal of benefits-a qualitative exploration of the implementation of a direct benefit transfer scheme for persons with tuberculosis in India. Infect Dis Poverty 2024; 13:36. [PMID: 38783334 PMCID: PMC11112885 DOI: 10.1186/s40249-024-01206-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Ni-kshay Poshan Yojana (NPY) is a direct benefit transfer scheme of the Government of India introduced in 2018 to support the additional nutritional requirements of persons with TB (PwTB). Our recent nationwide evaluation of implementation and utilization of NPY using programmatic data of PwTB from nine randomly selected Indian states, reported a 70% coverage and high median delay in benefit credit. We undertook a qualitative study between January and July 2023, to understand the detailed implementation process of NPY and explore the enablers and barriers to effective implementation and utilization of the NPY scheme. METHODS We followed a grounded theory approach to inductively develop theoretical explanations for social phenomena through data generated from multiple sources. We conducted 36 in-depth interviews of national, district and field-level staff of the National Tuberculosis Elimination Programme (NTEP) and NPY beneficiaries from 30 districts across nine states of India, selected using theoretical sampling. An analytical framework developed through inductive coding of a set of six interviews, guided the coding of the subsequent interviews. Categories and themes emerged through constant comparison and the data collection continued until theoretical saturation. RESULTS Stakeholders perceived NPY as a beneficial initiative. Strong political commitment from the state administration, mainstreaming of NTEP work with the district public healthcare delivery system, availability of good geographic and internet connectivity and state-specific grievance redressal mechanisms and innovations were identified as enablers of implementation. However, the complex, multi-level benefit approval process, difficulties in accessing banking services, perceived inadequacy of benefits and overworked human resources in the NTEP were identified as barriers to implementation and utilization. CONCLUSION The optimal utilization of NPY is enabled by strong political commitment and challenged by its lengthy implementation process and delayed disbursal of benefits. We recommend greater operational simplicity in NPY implementation, integrating NTEP activities with the public health system to reduce the burden on the program staff, and revising the benefit amount more equitably.
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Affiliation(s)
- Malu Mohan
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Jeromie W V Thangaraj
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Sumit Pandey
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - G Sri Lakshmi Priya
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | | | - Rahul Sharma
- TB Support Network, WHO Country Office for India, New Delhi, India
| | - Hemant Deepak Shewade
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - B Aishwarya
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - K Afeeq
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Afsana Khatoon
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - B Gokulvijay
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Gude Sireesha
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Kavita Chandra
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - S Nandhakumar
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Prince Samuel
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - C Nanditha Viswanathan
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Devika Shanmugasundaram
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Raghuram Rao
- Central Tuberculosis Division, Government of India, New Delhi, India
| | - Manoj V Murhekar
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Kathiresan Jeyashree
- Indian Council of Medical Research-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India.
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Jeyashree K, Shanmugasundaram P, Shanmugasundaram D, Priya G SL, Thangaraj JWV, Ts S, Pandey S, Ramasamy S, Sharma R, Arunachalam S, Shah V, Janagaraj V, Sundari S S, Chadwick J, Shewade HD, Chowdhury A, Iyer S, Rao R, Mattoo SK, Murhekar MV. Direct benefit transfer for nutritional support of patients with TB in India-analysis of national TB program data of 3.7 million patients, 2018-2022. BMC Public Health 2024; 24:299. [PMID: 38273246 PMCID: PMC10811802 DOI: 10.1186/s12889-024-17777-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/15/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Patients with TB have additional nutritional requirements and thus additional costs to the household. Ni-kshay Poshan Yojana(NPY) is a Direct Benefit Transfer (DBT) scheme under the National Tuberculosis Elimination Programme(NTEP) in India which offers INR 500 monthly to all notified patients with TB for nutritional support during the period of anti-TB treatment. Five years after its implementation, we conducted the first nationwide evaluation of NPY. METHODS In our retrospective cohort study using programmatic data of patients notified with TB in nine randomly selected Indian states between 2018 and 2022, we estimated the proportion of patients who received at least one NPY instalment and the median time to receive the first instalment. We determined the factors associated (i) with non-receipt of NPY using a generalised linear model with Poisson family and log link and (ii) with time taken to receive first NPY benefit in 2022 using quantile regression at 50th percentile. RESULTS Overall, 3,712,551 patients were notified between 2018 and 2022. During this period, the proportion who received at least one NPY instalment had increased from 56.9% to 76.1%. Non-receipt was significantly higher among patients notified by private sector (aRR 2.10;2.08,2.12), reactive for HIV (aRR 1.69;1.64,1.74) and with missing/undetermined diabetic status (aRR 2.02;1.98,2.05). The median(IQR) time to receive the first instalment had reduced from 200(109,331) days in 2018 to 91(51,149) days in 2022. Patients from private sector(106.9;106.3,107.4days), those with HIV-reactive (103.7;101.8,105.7days), DRTB(104.6;102.6,106.7days) and missing/undetermined diabetic status (115.3;114,116.6days) experienced longer delays. CONCLUSIONS The coverage of NPY among patients with TB had increased and the time to receipt of benefit had halved in the past five years. Three-fourths of the patients received at least one NPY instalment, more than half of whom had waited over three months to receive the first instalment. NTEP has to focus on timely transfer of benefits to enable patients to meet their additional nutritional demands, experience treatment success and avoid catastrophic expenditure.
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Affiliation(s)
- Kathiresan Jeyashree
- ICMR-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India.
| | - Prema Shanmugasundaram
- ICMR-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Devika Shanmugasundaram
- ICMR-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Sri Lakshmi Priya G
- ICMR-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Jeromie W V Thangaraj
- ICMR-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Sumitha Ts
- ICMR-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Sumit Pandey
- ICMR-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Sabarinathan Ramasamy
- ICMR-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Rahul Sharma
- TB support network, WHO Country Office for India, New Delhi, India
| | | | - Vaibhav Shah
- TB support network, WHO Country Office for India, New Delhi, India
| | | | - Sivakami Sundari S
- ICMR-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Joshua Chadwick
- ICMR-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Hemant Deepak Shewade
- ICMR-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
| | - Aniket Chowdhury
- TB support network, WHO Country Office for India, New Delhi, India
| | - Swati Iyer
- TB support network, WHO Country Office for India, New Delhi, India
| | | | | | - Manoj V Murhekar
- ICMR-National Institute of Epidemiology, R-127, TNHB, Ayapakkam, Chennai, Tamil Nadu, 600077, India
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Ferreira MRL, Bonfim RO, Bossonario PA, Maurin VP, Valença ABM, Abreu PDD, Andrade RLDP, Fronteira I, Monroe AA. Social protection as a right of people affected by tuberculosis: a scoping review and conceptual framework. Infect Dis Poverty 2023; 12:103. [PMID: 37993962 PMCID: PMC10664497 DOI: 10.1186/s40249-023-01157-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 11/09/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND Tuberculosis is an infectious disease strongly influenced by social determinants closely associated with cycles of poverty and social exclusion. Within this context, providing social protection for people affected by the disease constitutes a powerful instrument for reducing inequalities and enhancing inclusion and social justice. This study aimed to identify and synthesize strategies and measures aimed at ensuring social protection as a right of people affected by tuberculosis. METHODS This is a scoping review, with searches conducted in six databases in February 2023. We included publications from 2015 onwards that elucidate strategies and measures of social protection aimed at safeguarding the rights to health, nutrition, employment, income, housing, social assistance, and social security for people affected by tuberculosis. These strategies could be implemented through policies, programs, and/or governmental agreements in any given context. The data extracted from the articles underwent descriptive analysis and a narrative synthesis of findings based on the dimensions of social protection. Additionally, we developed a conceptual framework illustrating the organizational and operational aspects of measures and strategies related to each dimension of social protection identified in this review. RESULTS A total of 9317 publications were retrieved from the databases, of which sixty-three publications were included. The study's results highlighted measures and strategies concerning the social protection of people affected by tuberculosis. These measures and strategies revolved around the rights to proper nutrition and nourishment, income, housing, and health insurance, as well as expanded rights encompassing social assistance and social welfare. It was reported that ensuring these rights contributes to improving nutritional status and the quality of life for individuals with tuberculosis, along with reducing catastrophic costs, expanding access to healthcare interventions and services, and fostering TB treatment adherence, thereby leading to higher rates of TB cure. CONCLUSIONS Our findings identify social protection measures as a right for people affected by tuberculosis and have the potential to guide the development of evidence-based social and health policies through collaboration between tuberculosis control programs and governmental entities.
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Affiliation(s)
| | - Rafaele Oliveira Bonfim
- University of Sao Paulo at Ribeirao Preto College of Nursing, Ribeirao Preto, Sao Paulo, Brazil
| | | | | | | | - Paula Daniella de Abreu
- University of Sao Paulo at Ribeirao Preto College of Nursing, Ribeirao Preto, Sao Paulo, Brazil
| | | | - Inês Fronteira
- Global Health and Tropical Medicine, Institute of Hygiene and Tropical Medicine, NOVA University Lisbon, Lisbon, Portugal
- National School of Public Health, Public Health Research Center, Comprehensive Health Research Center, NOVA University Lisbon, Lisbon, Portugal
| | - Aline Aparecida Monroe
- University of Sao Paulo at Ribeirao Preto College of Nursing, Ribeirao Preto, Sao Paulo, Brazil
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Dave JD, Rupani MP. Advancing Social Protection and Tuberculosis Elimination in India - Beyond Cash Transfers and Towards Addressing Social and Structural Determinants for a Healthier Future; A Response to the Recent Commentaries. Int J Health Policy Manag 2023; 12:8130. [PMID: 37579372 PMCID: PMC10462078 DOI: 10.34172/ijhpm.2023.8130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/25/2023] [Indexed: 08/16/2023] Open
Affiliation(s)
- Jigna D. Dave
- Department of Respiratory Medicine, Government Medical College Bhavnagar, Maharaja Krishnakumarsinhji Bhavnagar University, Bhavnagar, India
| | - Mihir P. Rupani
- Department of Community Medicine, Government Medical College Bhavnagar, Maharaja Krishnakumarsinhji Bhavnagar University, Bhavnagar, India
- Department of Clinical Epidemiology, Division of Health Sciences, ICMR-National Institute of Occupational Health (NIOH), Indian Council of Medical Research (ICMR), Ahmedabad, India
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Bhaumik S, Beri D, Zwi AB, Jagnoor J. Snakebite care through the first two waves of COVID-19 in West Bengal, India: a qualitative study. Toxicon X 2023; 18:100157. [PMID: 37089517 PMCID: PMC10091724 DOI: 10.1016/j.toxcx.2023.100157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 04/25/2023] Open
Abstract
Snakebite is a public health problem in many countries, with India having the highest number of deaths. Not much is known about the effect of the COVID-19 pandemic on snakebite care. We conducted 20 in-depth interviews with those bitten by venomous snakes through the two waves of COVID-19 (March-May 2020; May-November 2021), their caregivers, health care workers and social workers in two areas (Sundarbans and Hooghly) of West Bengal, India. We used a constructivist approach and conducted a thematic analysis. We identified the following themes: 1. Snakebite continued to be recognised as an acute emergency during successive waves of COVID-19; 2. COVID-19 magnified the financial woes of communities with high snakebite burden; 3. The choice of health care provider was driven by multiple factors and consideration of trade-offs, many of which leaned toward use of traditional providers during COVID-19; 4. Rurality, financial and social disadvantage and cultural safety, in and beyond the health system, affected snakebite care; 5. There is strong and shared felt need for multi-faceted community programs on snakebite. We mapped factors affecting snakebite care in the three-delay model (decision to seek care, reaching appropriate health facility, receiving appropriate care), originally developed for maternal mortality. The result of our study contextualises and brings forth evidence on impact of COVID-19 on snakebite care in West Bengal, India. Multi-faceted community programs, are needed for addressing factors affecting snakebite care, including during disease outbreaks - thus improving health systems resilience. Community programs for increasing formal health service usage, should be accompanied by health systems strengthening, instead of an exclusive focus on awareness against traditional providers.
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Affiliation(s)
- Soumyadeep Bhaumik
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Injury Division, The George Institute for Global Health, New Delhi, India
| | - Deepti Beri
- Injury Division, The George Institute for Global Health, New Delhi, India
| | - Anthony B Zwi
- School of Social Sciences, University of New South Wales, Sydney, Australia
| | - Jagnoor Jagnoor
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Injury Division, The George Institute for Global Health, New Delhi, India
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Shah H. Challenges and Strategic Solutions to Guarantee Last Mile Reach for an Indian TB Patient's Nikshay Poshan Yojana; A Conditional Cash Transfer Scheme Comment on "Does Direct Benefit Transfer Improve Outcomes Among People With Tuberculosis? - A Mixed-Methods Study on the Need for a Review of the Cash Transfer Policy in India". Int J Health Policy Manag 2023; 12:7668. [PMID: 37579406 PMCID: PMC10461863 DOI: 10.34172/ijhpm.2023.7668] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 03/26/2023] [Indexed: 08/16/2023] Open
Abstract
India has put efforts into the prevention and control of tuberculosis (TB) for more than 50 years. Nikshay Poshan Yojna (NPY) is one of the schemes of conditional cash transfers (CCTs) by the Government of India. The CCT schemes mostly address the demand side constraints. Governments could use this in developing nations as a tool to divert financial resources toward societal development. In India, NPY is more directed toward providing monetary support for a nutritional diet and reducing the catastrophic expenditure of TB patients. Several studies highlighted challenges in implementing cash transfer schemes and provided different operational models. A country like India should address the challenges with defined strategies to ensure its last-mile reach. A present commentary discussing challenges and possible solutions that policy-makers can adapt and set up a support structure to ensure that supportive actions are implemented in response to patient and system side issues.
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Affiliation(s)
- Harsh Shah
- Department of Public Health Science, Indian Institute of Public Health - Gandhinagar, Gujarat, India
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10
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Schraufnagel AM, Shete PB. Evaluating Social Protection Policies With an Implementation Science Framework: India's Direct Benefit Transfer for Tuberculosis Comment on "Does Direct Benefit Transfer Improve Outcomes Among People With Tuberculosis? - A Mixed-Methods Study on the Need for a Review of the Cash Transfer Policy in India". Int J Health Policy Manag 2023; 12:7698. [PMID: 37579424 PMCID: PMC10461881 DOI: 10.34172/ijhpm.2023.7698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/28/2023] [Indexed: 08/16/2023] Open
Abstract
Addressing the social and structural determinants of tuberculosis (TB) through social protection programs is a central feature of global public health policy and disease elimination strategies. However, how best to implement such programs remains unknown. India's direct benefit transfer (DBT) program is the largest cash transfer program in the world dedicated to supporting individuals affected by TB. Despite several studies aimed at evaluating the impact of DBT, many questions remain about its implementation, mechanisms of action, and effectiveness. Dave and Rupani's mixed-methods evaluation of this program previously published in this journal offers valuable insights into the strengths and limitations of the DBT program in improving TB treatment outcomes. Their results also provide an opportunity for demonstrating how systematically collected data may be further analyzed and presented using implementation science, a field of study using methods to promote the systematic uptake of evidence-based interventions to support sustainable program scale-up.
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Affiliation(s)
- Ann M. Schraufnagel
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA, USA
- Center for Tuberculosis, University of California-San Francisco, San Francisco, CA, USA
| | - Priya B. Shete
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA, USA
- Center for Tuberculosis, University of California-San Francisco, San Francisco, CA, USA
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11
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Rubinstein F, Blumenfeld A. Conditional Cash Transfer to Improve TB Outcomes: Necessary but Not Sufficient Comment on "Does Direct Benefit Transfer Improve Outcomes Among People With Tuberculosis? - A Mixed-Methods Study on the Need for a Review of the Cash Transfer Policy in India". Int J Health Policy Manag 2023; 12:7643. [PMID: 37579479 PMCID: PMC10125050 DOI: 10.34172/ijhpm.2022.7643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/12/2022] [Indexed: 08/16/2023] Open
Abstract
Tuberculosis (TB) still represents a major public health problem in many regions of the world. TB control can only be achieved through a comprehensive and inclusive response which takes into account both upstream and downstream coordinated interventions related to structural determinants such as poverty, nutrition, sanitation, housing and access to healthcare as well as timely diagnosis and support throughout the course of treatment. Several social and financial support strategies have been proposed to improve TB treatment adherence, including conditional cash transfers (CCTs). In this context, demonstrating that social protection directly improves a specific health outcome using routinely collected data, incomplete registries or surveillance reports brings about many methodological challenges. We briefly discuss this paper and some limitations, describe main findings from our own research in this area and make a call to expand social protection interventions to address structural conditions of those most affected.
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Affiliation(s)
- Fernando Rubinstein
- Institute of Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
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12
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Rupani MP, Vyas S. A sequential explanatory mixed-methods study on costs incurred by patients with tuberculosis comorbid with diabetes in Bhavnagar, western India. Sci Rep 2023; 13:150. [PMID: 36600031 PMCID: PMC9811877 DOI: 10.1038/s41598-023-27494-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 01/03/2023] [Indexed: 01/05/2023] Open
Abstract
Diabetes is one of the commonest morbidity among patients with tuberculosis (TB). We conducted this study to estimate the costs incurred by patients with TB comorbid with diabetes and to explore the perspectives of program managers as well as patients on the reasons and solutions for the costs incurred due to TB-diabetes. We conducted a descriptive cross-sectional study to estimate costs among 304 patients with TB-diabetes comorbidity registered in the public health system during 2017-2020 in the Bhavnagar region of western India, which was followed by in-depth interviews among program functionaries and patients to explore solutions for reducing the costs. Costs, when exceeded 20% of annual household income, were defined as catastrophic as this cut-off was most significantly related to adverse TB outcomes. Among the 304 patients with TB-diabetes comorbidity, 72% were male and the median (interquartile IQR) monthly family income was Indian rupees (INR) 9000 (8000-11,000) [~ US$ 132 (118-162)]. The median (IQR) total costs due to combined TB-diabetes were INR 1314 (788-3170) [~ US$ 19 (12-47)], while that due to TB were INR 618 (378-1933) [~ US$ 9 (6-28)]. Catastrophic costs due to TB were 4%, which increased to 5% on adding the costs due to diabetes. Health system strengthening, an increase in cash assistance, and other benefits such as a nutritious food kit were suggested for reducing the costs incurred. We conclude that, in addition to a marginal increase in the percentage of catastrophic costs, co-existent diabetes nearly doubled the median total costs incurred among patients with TB. Strengthening the TB-diabetes bi-directional activities, tailoring the cash transfer scheme for comorbid patients, and making the common two-drug combination diabetes tablets available at government drug stores would help TB-diabetes comorbid patients cope with the costs of care.
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Affiliation(s)
- Mihir P. Rupani
- grid.413227.10000 0004 1801 0602Department of Community Medicine, Government Medical College Bhavnagar (Maharaja Krishnakumarsinhji Bhavnagar University), Near ST Bus Stand, Jail Road, Bhavnagar, Gujarat 364001 India ,grid.411877.c0000 0001 2152 424XGujarat University, Ahmedabad, Gujarat 380009 India ,grid.415578.a0000 0004 0500 0771Present Address: Clinical Epidemiology, Division of Health Sciences, ICMR - National Institute of Occupational Health (NIOH), Indian Council of Medical Research, Meghaninagar, near Raksha Shakti University, Ahmedabad, Gujarat 380016 India
| | - Sheetal Vyas
- grid.411877.c0000 0001 2152 424XGujarat University, Ahmedabad, Gujarat 380009 India ,grid.411494.d0000 0001 2154 7601Department of Community Medicine, AMC-MET Medical College, Maninagar, Ahmedabad, Gujarat 380008 India
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13
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Fuady A. Closing the Evidence Gap of Cash Transfer for Tuberculosis-Affected Households Comment on "Does Direct Benefit Transfer Improve Outcomes Among People With Tuberculosis? - A Mixed-Methods Study on the Need for a Review of the Cash Transfer Policy in India". Int J Health Policy Manag 2022; 12:7658. [PMID: 37579478 PMCID: PMC10125063 DOI: 10.34172/ijhpm.2022.7658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/26/2022] [Indexed: 08/16/2023] Open
Abstract
Achieving the targets of eliminating tuberculosis (TB) requires a combination of biomedical, epidemiological, and social approaches. Having hitted by the coronavirus disease 2019 (COVID-19) pandemic which diminishes the financial capacity of TB-affected households, the importance of delivering socioeconomic support to TB-affected household emerges. However, the evidence of TB-related socioeconomic support is still scarce, and some questions are left unanswered. A sequential explanatory mixed-methods study by Dave and Rupani shows that the direct benefit transfer (DBT), a form of cash transfer, to TB-affected households improves TB treatment outcomes in India despite the challenges. Some critical issues remain to be discussed: trading-off between the amount of cash and its sustainability, choosing the most appropriate support packages, detecting, and reaching the target population, and arranging the most effective delivery strategy. Knowledge gap remains to be answered, and a global research agenda and political commitment are critical to encourage more evidence in delivering socioeconomic support for TB control.
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Affiliation(s)
- Ahmad Fuady
- Department of Community Medicine, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
- Primary Health Care Research and Innovation Center, Indonesian Medical Education and Research Institute, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
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