Using Community Participation to Improve the Health System in South India

描述（由申请人提供）：公共卫生系统，特别是贫困农村地区的公共卫生系统表现不理想，这导致了在整个发展中国家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在哪里以及为什么会被激励有效地执行他们分配的任务。该项目将重点放在结核病这一造成全球疾病负担的主要因素上，并建议利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——无私地帮助他人而不获得直接利益的意愿——被视为社区志愿者在必须严格保密的情况下（如结核病病例管理）的主要动机。发展起来的新的团结形成理论表明，空间分散的社会网络密度较低的社区将通过投资于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提供者。这一假设将在拥有120万人口的南印度农村的一个独特的社会实验室进行检验，该实验室覆盖420个村庄（社区），包括50个亲属群体（次种姓）；亲属群体的范围比村庄大得多，是印度农村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年的时间内将4000名进入公共卫生系统的成年肺结核患者分配到四组中的一组：(1)同一村庄患者亲属群体内的社区DOT提供者；(2)附近村庄的患者亲属群体内的社区DOT提供者；(3)患者同村亲属群以外的社区DOT提供者；(4)政府DOT供应商，目前的护理方法（控制臂）。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）经验的评估。其次，对10500个家庭的调查将使用多种技术（问卷调查和实验游戏）收集团结措施。第三，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措施相匹配。根据这一理论，分配给来自其自身亲属群体的结核病志愿者的患者有望获得相对较高的治疗成功率（目标1），亲属群体内部的团结程度有望高于村庄内部（目标2）。纵观亲属群体，更多空间分散的亲属群体有望产生更好的志愿者表现（条件是患者被分配到亲属群体中）（目标3）和更高水平的团结（目标4）。鉴于印度和其他国家目前正在努力分散卫生系统，旨在系统地评估成功的社区参与并了解其潜在先决条件的研究恰逢其时。

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.