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: 8131143
• 负责人: Kaivan Munshi
• 金额: $ 46.93万
• 依托单位: BROWN UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2010
• 资助国家: 美国
• 起止时间: 2010-09-01 至 2015-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8131143
• 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; public health relevance; 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. PUBLIC HEALTH RELEVANCE: Using Community Participation to Improve the Health System in South India Project Narrative The major objective of this project is to rigorously investigate where and why community participation in the health system in rural South India can be successful. The project explores the feasibility of using community volunteers for case management of tuberculosis, a serious infectious disease and a leading cause of death worldwide.

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的表现不令人满意，这导致人们呼吁在整个发展中世界实行权力下放和加强社区参与。该项目严格调查了社区卫生志愿者在哪里以及为什么会被激励有效地执行分配给他们的任务。该项目的重点是结核病，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其扩展治疗方案。社会团结--无私地愿意帮助他人而不获得直接的回报--被视为社区志愿者在必须严格保密时的主要动机，如结核病病例管理。团结形成的新理论表明，空间分散的社区与不太密集的社交网络将弥补其有限的能力，加强其成员之间的合作，投资于团结。该理论预测，这些社区因此应该产生更有效的DOT提供者。这一假设将在印度南部农村的一个独特的社会实验室进行测试，该实验室有120万人口，覆盖420个村庄（社区），包括50个亲属团体（次种姓）;亲属团体的面积比村庄大得多，是印度农村经济和社会支持的重要来源。将从三个来源收集数据。首先，一项随机对照试验将在2.5年的时间里将4000名进入公共卫生系统的成年肺结核患者分配到四个组中的一个：（1）患者在同一村庄的亲属组中的社区DOT提供者;（2）患者在附近村庄的亲属组中的社区DOT提供者;（3）社区DOT提供者，不在同一村庄的患者亲属组;（4）政府DOT提供者，当前的护理方法（对照组）。DOT提供者的表现将基于治疗成功的客观衡量标准以及对患者（和DOT提供者）经验的评估。第二，对10，500户家庭进行调查，使用多种技术（问卷答复和实验游戏）收集团结措施。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措施相匹配。根据这一理论，从其亲属群体中分配到结核病志愿者的患者预计将享有相对较高的治疗成功率（目标1），预计亲属群体内的团结程度将高于村庄内的团结程度（目标2）。纵观亲属群体，空间分散的亲属群体预计将产生更好的志愿者表现（条件是患者被分配在亲属群体内）（目标3）和更高水平的团结（目标4）。鉴于目前印度和其他国家正在努力下放卫生系统，旨在系统地评估成功的社区参与并了解其基本先决条件的研究恰逢其时。 公共卫生关系：利用社区参与改善南印度卫生系统项目叙述本项目的主要目标是严格调查在哪里以及为什么社区参与南印度农村卫生系统可以成功。该项目探讨了利用社区志愿人员进行结核病病例管理的可行性，结核病是一种严重的传染病，也是全世界的主要死因。