Experiences and meanings of integration of TCAM (Traditional, Complementary and Alternative Medical) providers in three Indian states: results from a cross-sectional, qualitative implementation research study.

OBJECTIVES: Efforts to engage Traditional, Complementary and Alternative Medical (TCAM) practitioners in the public health workforce have growing relevance for India's path to universal health coverage. We used an action-centred framework to understand how policy prescriptions related to integration were being implemented in three distinct Indian states. SETTING: Health departments and district-level primary care facilities in the states of Kerala, Meghalaya and Delhi. PARTICIPANTS: In each state, two or three districts were chosen that represented a variation in accessibility and distribution across TCAM providers (eg, small or large proportions of local health practitioners, Homoeopaths, Ayurvedic and/or Unani practitioners). Per district, two blocks or geographical units were selected. TCAM and allopathic practitioners, administrators and representatives of the community at the district and state levels were chosen based on publicly available records from state and municipal authorities. A total of 196 interviews were carried out: 74 in Kerala, and 61 each in Delhi and Meghalaya. PRIMARY AND SECONDARY OUTCOME MEASURES: We sought to understand experiences and meanings associated with integration across stakeholders, as well as barriers and facilitators to implementing policies related to integration of Traditional, Complementary and Alternative (TCA) providers at the systems level. RESULTS: We found that individual and interpersonal attributes tended to facilitate integration, while system features and processes tended to hinder it. Collegiality, recognition of stature, as well as exercise of individual personal initiative among TCA practitioners and of personal experience of TCAM among allopaths enabled integration. The system, on the other hand, was characterised by the fragmentation of jurisdiction and facilities, intersystem isolation, lack of trust in and awareness of TCA systems, and inadequate infrastructure and resources for TCA service delivery. CONCLUSIONS: State-tailored strategies that routinise interaction, reward individual and system-level individual integrative efforts, and are fostered by high-level political will are recommended.

Cash transfer and microfinance interventions for tuberculosis control: review of the impact evidence and policy implications.

OBJECTIVE: To quantify the impact of cash transfer and microfinance interventions on a selected list of tuberculosis (TB) risk factors and assess their potential role in supporting TB control. DATA SOURCE: Published and unpublished references identified from clinical and social electronic databases, grey literature and web sites. METHODS: Eligible interventions had to be conducted in middle- or low-income countries and document an impact evaluation on any of the following outcomes: 1) TB or other respiratory infections; 2) household socio-economic position; and 3) factors mediating the association between low household socio-economic position and TB, including inadequate health-seeking behaviours, food insecurity and biological TB risk factors such as human immunodeficiency virus (HIV) and adult malnutrition. Interventions targeting special populations were excluded. RESULTS: Fifteen cash transfer schemes (four unconditional and 11 conditional) and seven microfinance programmes met the eligibility criteria. No intervention addressed TB or any other respiratory infection. Of 11 cash transfer and four microfinance interventions, respectively seven and four reported a positive impact on indicators of economic well-being. A positive impact on household food security was documented in respectively eight of nine and three of five cash transfer and microfinance interventions. Improved health care access was documented respectively in 10 of 12 cash transfer and four of five microfinance interventions. The only intervention evaluating impact on HIV incidence was a microfinance project that found no effect. No cash transfer or microfinance interventions had an impact on adult malnutrition. CONCLUSIONS: Cash transfer and microfinance interventions can positively impact TB risk factors. Evaluation studies are urgently needed to assess the impact of these social protection interventions on actual TB indicators.

The association between school attendance, HIV infection and sexual behaviour among young people in rural South Africa.

OBJECTIVES: To investigate whether the prevalence of HIV infection among young people, and sexual behaviours associated with increased HIV risk, are differentially distributed between students and those not attending school or college. DESIGN: A random population sample of unmarried young people (916 males, 1003 females) aged 14-25 years from rural South Africa in 2001. METHODS: Data on school attendance and HIV risk characteristics came from structured face-to-face interviews. HIV serostatus was assessed by oral fluid ELISA. Logistic regression models specified HIV serostatus and high-risk behaviours as outcome variables. The primary exposure was school attendance. Models were adjusted for potential confounders. RESULTS: HIV knowledge, communication about sex and HIV testing were similarly distributed among students and non-students. The lifetime number of partners was lower for students of both sexes (adjusted odds ratio (aOR) for more than three partners for men 0.67; 95% CI 0.44 to 1.00; aOR for more than two partners for women 0.69; 95% CI 0.46 to 1.04). Among young women, fewer students reported having partners more than three years older than themselves (aOR 0.58; 95% CI 0.37 to 0.92), having sex more than five times with a partner (aOR 0.57; 95% CI 0.37 to 0.87) and unprotected intercourse during the past year (aOR 0.60; 95% CI 0.40 to 0.91). Male students were less likely to be HIV positive than non-students (aOR 0.21; 95% CI 0.06 to 0.71). CONCLUSIONS: Attending school was associated with lower-risk sexual behaviours and, among young men, lower HIV prevalence. Secondary school attendance may influence the structure of sexual networks and reduce HIV risk. Maximising school attendance may reduce HIV transmission among young people.

Local research ethics committees of the Mexican Institute of Social Security: results of a national survey.

OBJECTIVE: To identify the structure, composition and work of the local research ethics committees (LRECs) of the Mexican Institute of Social Security (IMSS) in Mexico. DESIGN: A descriptive cross-sectional study was performed that included all LRECs of the IMSS. METHODS: A total of 335 questionnaires coded in advance were posted to each LREC secretary. The requested information was from January to December 2001. RESULTS: The response rate was 100%. Two hundred and thirty-eight (71%) LRECs were reported as 'active' during the evaluation period. Although almost all LRECs were composed of diverse professionals, physicians dominated the LRECs' membership. The rejection rate for research projects was lower than 1 per 1000, and less than half of the LRECs held meetings to issue a report of projects' evaluation. CONCLUSIONS: LRECs need to foster good ethical research; implementation of an audit system to examine their work might help improve LRECs' performance and accountability.

Undiagnosed pulmonary tuberculosis deaths in rural South Africa.

This research explores death from pulmonary tuberculosis (PTB) using a verbal autopsy (VA) tool within the established Agincourt Health and Demographic Surveillance System site in South Africa's rural northeast. Previous work on active case finding in the area highlighted a modest burden of undiagnosed PTB in the community. This VA research confirms the existence of undiagnosed PTB deaths, with 13 (46%) of 28 PTB deaths among the permanent adult population (n = 38,251) going undetected by the health service. There was a median duration of coughing in the community of 16 weeks among these undiagnosed PTB deaths. As most undiagnosed cases present to the health service at some point during their illness, intervention strategies to support early diagnosis at this level can only be re-emphasised by this work.

Tuberculosis control in rural India: lessons from public-private collaboration.

SETTING: A rural tuberculosis (TB) Unit (population 350 794) in Pune district, Maharashtra State, India. OBJECTIVE: To develop a 'model' partnership between rural private medical practitioners (PMPs) and the Revised National Tuberculosis Control Programme (RNTCP). DESIGN: A partnership was developed between 100 PMPs in the study area and the district health and tuberculosis staff through facilitation by a non-governmental organisation (NGO). Participatory research methods were used to plan and implement the partnership. The process of creation and implementation of the partnership was analysed using quantitative and qualitative research methods. RESULTS: The partnership contributed to 30% of the cases detected in the TB Unit over a 5-month period. Six months after withdrawal of the NGO, referrals from the private sector to the RNTCP were continuing to a lesser extent, but there was a breakdown of the communication and documentation systems. CONCLUSION: The project highlights the importance of organisational and individual commitment to these partnerships, the key roles of the District Health Officer and the District Tuberculosis Officer in guiding and supporting these initiatives from the public sector, the potential role of process and outcome 'indicators' in monitoring partnerships and the important role of NGOs as intermediaries and facilitators.

Introducing operations research into management and policy practices of a non-governmental organization (NGO): a partnership between an Indian leprosy NGO and an international academic institution.

This paper reports on a partnership between LEPRA, a non-governmental organization (NGO), and the London School of Hygiene and Tropical Medicine (LSHTM) to explore the feasibility and appropriateness of incorporating operations research into the management and decision-making of a leprosy NGO. A pilot study in Orissa was used to determine the advantages and disadvantages of introducing operations research to assist in decision-making and programme implementation within the organization. The results highlight the difficulty and complexity of the process, but point to several important themes: partnership, changing perspectives, use of time and priority-setting, identification of gaps in systems, and building institutional and personal capabilities. The results of the study provide support to encourage NGOs to become actively involved in research. Because of their work and service to local communities, NGOs have the opportunity to collect information about the perceptions, resources and constraints of individuals, families and the communities themselves in accessing appropriate care. Their proximity to communities gives them a feeling of responsibility for ensuring that this information is translated to the district, national and ultimately international level. This will help to ensure the creation of appropriate infectious disease control policies that support the needs of patients. 'Outside' academic institutions can help NGOs to facilitate this up-stream flow of information from the local to the national and international level, to help to ensure that international disease control policies are appropriately serving local communities.

Adherence to tuberculosis treatment: lessons from the urban setting of Delhi, India.

The Revised National Tuberculosis Control Programme (RNTCP), which incorporated the WHO DOTS strategy was introduced in India in the mid-1990s. An operational research project was conducted between 1996 and 1998 to assess the needs and perspectives of patients and providers in two chest clinics in Delhi, Moti Nagar and Nehru Nagar, during the introduction of the new strategy. This paper reports on the findings of the project, concentrating on information collected from 40 in-depth interviews with patient defaulters and from non-participant observations in clinics and directly observed treatment centres. In Moti Nagar chest clinic, 117 of 1786 (6.5%) patients and 195 of 1890 (10%) patients in Nehru Nagar left care before their treatment was complete. It was argued that the reasons for default stem from a poor correlation between patient and programme needs and priorities, and from particular characteristics of the disease and its treatment. Patient needs that were not met by the health system included convenient clinic timings, arrangements for the provision for treatment in the event of a family emergency and provision for complicated cases like alcoholics. The problems facing the provider were poor interpersonal communication with the health staff, lack of attention and support at the clinic, difficulty for patients to re-enter the system if they missed treatment and, in certain areas, long distances to the clinic. Problems related to diseases were inability of the staff to deal with drug side-effects, and patients' conception of equating well-being with cure. Simple, practical measures could improve the provision of tuberculosis (TB) treatment: more flexible hours, allowances for poor patients to reach the clinics and training health care staff for respectful communication and monitoring drug side-effects. The findings indicate a need to rethink the label of 'defaulter' often given to the patients. The important areas for future operational research is also highlighted.

Tuberculosis treatment in complex emergencies: are risks outweighing benefits?

Tuberculosis (TB) is a major public health problem in complex emergencies. Humanitarian agencies usually postpone the decision to offer TB treatment and opportunities to treat TB patients are often missed. This paper looks at the problem of tuberculosis treatment in these emergencies and questions whether treatment guidelines could be more flexible than international recommendations. A mathematical model is used to calculate the risks and benefits of different treatment scenarios with increasing default rates. Model outcomes are compared to a situation without treatment. An economic analysis further discusses the findings in a trade-off between the extra costs of treating relapses and failures and the savings in future treatment costs. In complex emergencies, if a TB programme could offer 4-month treatment for 75% of its patients, it could still be considered beneficial in terms of public health. In addition, the proportion of patients following at least 4 months of treatment can be used as an indicator to help evaluate the public health harm and benefit of the TB programme.

Transfusion medicine in India: a survey of current practice.

The new Indian National Blood Policy intends to improve the provision of easily accessible safe blood and blood components, available according to need. There is a requirement for information on patterns of blood transfusion in India, to help understand the potential for changes in transfusion practice and the organization of blood services, and to help ensure optimal use of this valuable and limited human resource. This study involved a questionnaire survey of blood transfusion practice with reference to Indian National AIDS Control Organisation clinical guidelines at selected blood centres in four study areas (Delhi, Bangalore, Nasik District and Imphal). Information on 1062 transfusion episodes was analysed. Adult recipients accounted for 87% of transfusions, and amongst the age group of 25-34, 73% of transfusions were to women. Anaemia was listed as a reason for 60% of transfusions, surgery for 42%, acute haemorrhage for 26% and pregnancy for 16%. Seventy-four per cent of adult transfusions were inappropriate when assessed against criteria derived from government transfusion guidelines. Possible common proximate causes for inappropriate transfusions include unnecessary transfusion for iron-deficiency anaemia and transfusion as a first choice for volume replacement. Options to promote good transfusion practice in India should be appraised.

Intervention to promote appropriate blood use in India.

The decision to transfuse should be guided by information on the risks and benefits of transfusion. Safer alternatives should be considered. Properly screened blood or components from a reputable source should be used. In this study, a simple, self-educating transfusion request form was developed, and its effects on transfusion practice were assessed, using a cluster-randomized trial. Transfusions at six study hospitals and six control hospitals at four locations in India (Delhi, Bangalore, Nasik and Imphal) were monitored over a 4-month pre-intervention period and a 5-month post-intervention period. During the trial, 56 171 units were transfused to in-patients at the participating hospitals. Among the six intervention hospitals, there was some evidence of a nonsignificant post-intervention reduction in all the three main outcome measures: number of transfusion requests per admission (P = 0.09), number of units transfused per admission (P = 0.11) and number of crossmatches per admission (P = 0.06). No such changes were seen at control sites over the same period. Simple interventions to promote good clinical practice can have an effect, but may be better placed within longer term, broad-based strategies that are able to consider some of the background factors. Lack of clinical training, the hospital environment and fragmented blood bank services influence the way blood is used in India. It is thought that the intervention was ultimately unsuccessful because these factors remained as detrimental influences. A focus on education, policy and infrastructure in line with the new National Blood Policy will be important in coming years.

Lessons in integration--operations research in an Indian leprosy NGO.

Since the Alma Ata Declaration in 1978, health systems supporting the treatment and control of infectious diseases like leprosy and tuberculosis have been encouraged to 'integrate' into the primary health care structure within countries. Now, more than 20 years later, countries are still grappling with the concept of integration and looking for ways to achieve it. This study reports findings from a leprosy/Tuberculosis/AIDS awareness pilot project conducted by LEPRA India, a leprosy non-governmental organization (NGO), between 1996 and 2000 in Koraput district, Orissa. The project addressed the issue of integration on two levels. On the one hand LEPRA used the context of the project to explore ways in which to integrate TB services into their existing leprosy control structure. On the other hand, lessons from the pilot study were intended to help the organization find ways of linking with the government health care structure. Following a 'qualitative approach', this operations research project assessed the perceptions of communities and providers about leprosy and tuberculosis services. Providers across the spectrum of this plural healthcare system were asked to provide comment on developing stronger networks with each other, with NGOs and with government, while patients and communities were asked to describe the resources available to them and the constraints they face in accessing health care in general, and for leprosy and TB in particular. LEPRA staff from top management to the outreach workers were also approached for their views. Patients and communities noted that physical access to treatment was a major constraint, while the existence of local providers and family support structures facilitated health and health care. Providers expressed a willingness to collaborate (with LEPRA and the government), but lacked training, adequate staff support and the appropriate equipment/technical resources. Also lacking were adequate information campaigns to inform the public about these diseases and their treatment. This information has provided LEPRA with an understanding of how they might best fill gaps in the existing system and therefore assist in the process of integrating services in their own organization and through the primary health care structure. To achieve this aim, LEPRA will increasingly become involved in developing relationships and partnerships with government in the delivery of training and services and in infrastructure development.

TB control, poverty, and vulnerability in Delhi, India.

The Revised National Tuberculosis Control Programme (RNTCP), based on the World Health Organization's DOTS strategy,* was introduced in India in the mid-1990s. This paper reports the findings from operational research studies in two pilot sites in New Delhi from 1996 to 1998. A variety of operational research methods were used, including semi-structured interviews, focus group discussions, non-participant observations and collection of data from the tuberculosis registers. The cure rates for the clinics were 71 and 75% with a default rate of 6 and 11%, respectively. An important finding was that health workers screened patients to determine their ability to conform to the direct observation of treatment element of the RNTCP. If the health worker was confident that the patient would comply and/or be easy to trace in the community in the event of 'default', they were provided with short-course treatment under the RNTCP. Other patients, largely those who were in absolute poverty, socially marginalized, itinerant labourers, poorly integrated in the city, were put on standard tuberculosis (TB) treatment as for the previous National TB Programme. The programme was evidently excluding the most vulnerable from the best available care. These findings demonstrate the potential dangers of target-driven programmes where there is an absence of support to both frontline health workers and patients. The paper also highlights the importance of operations research in helping to identify problems within TB programmes.