Using Community Participation to Improve the Health System in South India

利用社区参与改善印度南部的卫生系统

• 批准号: 8727209
• 负责人: Kaivan Munshi
• 金额: $ 43.63万
• 依托单位: PENNSYLVANIA STATE UNIVERSITY, THE
• 依托单位国家: 美国
• 财政年份: 2013
• 资助国家: 美国
• 起止时间: 2013-09-01 至 2015-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8727209
• 关键词: Adherence; Adult; Area; Biological Markers; Caring; Case Management; Castes; Cause of Death; Censuses; Characteristics; Communicable Diseases; Communities; Community Health; Community Participation; Confidentiality; Cooperative Behavior; Country; Data; Decentralization; Economics; Employee; Ensure; Exclusion; Experimental Games; Future; Generations; Government; Health; Health Personnel; Health system; Home environment; Household; Human Resources; India; Individual; Institution; Intervention; Laboratories; Lead; Literature; Measures; Methods; Monitor; Motivation; Neighborhoods; Outcome Measure; Patients; Performance; Pharmaceutical Preparations; Policies; Population; Public Health; Pulmonary Tuberculosis; Questionnaires; Randomized; Randomized Controlled Trials; Regimen; Research; Research Infrastructure; Role; Rural; Social Interaction; Social Network; Social Welfare; Social support; Sociology; Source; Study Section; Surveys; System; Techniques; Testing; Time; Treatment Protocols; Treatment outcome; Tuberculosis; Work; arm; base; burden of illness; cost; density; experience; improved; insight; interdisciplinary collaboration; member; population based; preconditioning; programs; response; rural area; social; social capital; solidarity; success; theories; trait; volunteer; willingness

DESCRIPTION (provided by applicant): The unsatisfactory performance of public health systems, particularly in poor rural areas, has lead to calls for decentralization and greater community participation throughout the developing world. This project rigorously investigates where and why community health volunteers will be motivated to effectively carry out their assigned tasks. The project focuses on tuberculosis, a leading contributor to the global burden of disease, and proposes to use community volunteers as Directly Observed Treatment (DOT) providers to ensure that TB patients adhere to their extended treatment regimen. Social solidarity-the selfless willingness to help another without receiving direct benefits in return-is seen as the primary motivation for community volunteers when strict confidentiality must be maintained, as with TB case management. The new theory of solidarity formation that is developed indicates that spatially dispersed communities with less dense social networks will compensate for their limited ability to enforce cooperation among their members by investing in solidarity. The theory predicts that these communities should therefore produce more effective DOT providers. This hypothesis will be tested in a unique social laboratory in rural South India with a population of 1.2 million, covering 420 villages (neighborhoods) and including 50 kin-groups (sub-castes); kin-groups span a much larger area than the village and are an important source of economic and social support in the rural Indian context. Data will be collected from three sources. First, a randomized control trial will assign the 4000 adult pulmonary TB patients who enter the public health system over a 2.5-year period to one of four arms: (1) community DOT provider within the patient's kin-group in the same village; (2) community DOT provider within the patient's kin-group from a nearby village; (3) community DOT provider outside the patient's kin-group in the same village; (4) government DOT provider, the current method of care (control arm). DOT provider performance will be based on objective measures of treatment success as well as assessment of the patient's (and DOT provider's) experience. Second, a survey of 10,500 households will collect measures of solidarity using multiple techniques (questionnaire responses and experimental games). Third, historical census data on community spatial dispersion will be matched to TB patient outcomes and measures of community solidarity. Based on the theory, patients assigned to TB volunteers from their own kin-group are expected to enjoy relatively high levels of treatment success (Aim 1) and solidarity is expected to be greater within kin-groups than within villages (Aim 2). Looking across kin-groups, more spatially dispersed kin-groups are expected to generate better volunteer performance (conditional on the patient being assigned within kin-group) (Aim 3) and greater levels of solidarity (Aim 4). Given current efforts to decentralize the health system in India and other countries, research aiming to systematically evaluate successful community participation and understand its underlying preconditions comes at a particularly opportune time.

说明(申请人提供)：公共卫生系统的表现不令人满意，特别是在贫穷的农村地区，这导致了在整个发展中世界要求权力下放和更多社区参与的呼声。这个项目严格调查社区卫生志愿者将在哪里以及为什么被激励有效地执行他们分配的任务。该项目侧重于结核病，这是全球疾病负担的主要贡献者，并建议使用社区志愿者作为直接观察治疗(DOT)提供者，以确保结核病患者坚持延长治疗方案。社会团结--帮助他人而不获得直接利益的无私意愿--被视为社区志愿者的主要动机，因为必须严格保密，例如结核病病例管理。形成团结的新理论表明，社会网络密度较低的分散在空间上的社区将通过投资团结来弥补其有限的能力，以加强成员之间的合作。该理论预测，这些社区应该因此产生更有效的DOT提供商。这一假设将在南印度农村的一个独特的社会实验室中得到检验，该农村有120万人口，覆盖420个村庄(社区)，包括50个亲属群体(亚种姓)；亲属群体的面积比村庄大得多，在印度农村背景下是经济和社会支持的重要来源。数据将从三个来源收集。首先，一项随机对照试验将在2.5年期间进入公共卫生系统的4000名成年肺结核患者分配到四个分支机构中的一个：(1)同一村庄患者亲属组内的社区DOT提供者；(2)来自附近村庄的患者亲属组内的社区DOT提供者；(3)同一村庄患者亲属组外的社区DOT提供者；(4)政府DOT提供者，即当前的护理方法(对照手臂)。DOT提供者的表现将基于对治疗成功的客观衡量以及对患者(和DOT提供者)体验的评估。其次，对10,500个家庭的调查将使用多种技术(问卷调查和实验游戏)收集团结的衡量标准。第三，关于社区空间分散的历史普查数据将与结核病患者的结果和社区团结的衡量标准相匹配。根据这一理论，从自己的亲属组分配给结核病志愿者的患者预计将享受相对较高的治疗成功水平(目标1)，预计亲属组内的团结程度将大于村庄内(目标2)。纵观亲属组，更多空间分散的亲属组有望产生更好的志愿者表现(条件是病人被分配到亲属组中)(目标3)和更大程度的团结(目标4)。鉴于印度和其他国家目前正在努力下放卫生系统的权力，旨在系统评估成功的社区参与并了解其基本前提条件的研究恰逢其时。