Tuberculosis

Projects

Patient pathways to Tuberculosis care in Mumbai & Patna. Invited by Bill & Melinda Gates Foundation.

Funding Agency Bill & Melinda Gates Foundation

Collaborating Institute Sambodhi Research & Communication Pvt. Ltd (SR)

Principal Investigator Dr. Nerges Mistry, FMR & Mr. Kultar Singh, SR

Project team A team of consultants comprising of clinical consultants Dr.YatinDholakia, Dr. Sheela Rangan (MAAS) and Dr. David Osrin (SNEHA) is closely working with the qualitative researchers. The field qualitative team comprises of 12 (six male & six female) researchers. Six each for Mumbai and Patna respectively. The team in Mumbai includes three researchers from PUKAR as well.

Duration of the Project December 2013 to August 2014

Background

Delayed or incorrect diagnosis and treatment is a major driver of the TB epidemic. Reduction in TB transmission will require interventions to shorten delays and improve quality of care. A substantial proportion (46%) of all TB patients in India are estimated to be treated in the private sector, it is imperative to engage with private providers to shorten delays and reduce transmission. The private engagement strategy as enshrined in the National Strategic Plan (NSP) and referred to as Public Private Interface Agency (PPIA) is envisaged to reduce diagnostic delays and shorten patient pathways as well as improve quality of TB care. To ascertain the effectiveness of intervention and generate evidence on the impact of the PPIA approach the Bill & Melinda Gates Foundation, along with partners is supporting a PPIA intervention in two pilot sites (Mumbai & Patna).  The pathway to care is defined as the sum total of events for seeking care from appearance of first symptom to the initiation of appropriate treatment.

The main objective of the project is to ascertain the pathways to care of TB cases in the cities of Patna and Mumbai on treatment, quality and cost till final diagnosis and beginning of anti-TB therapy. This project is undertaken in collaboration with SR. Overall design is a repeated cross-sectional, population based surveys to identify known TB and chest symptomatic cases, followed by in-depth qualitative interviews of 120-150 known TB cases on pathways and costs and 100 chest symptomatics using a parallel schedule to gather real time information which would be free from recall bias.

Role of Sambodhi Research & Communications Pvt. Ltd

Primary quantitative "house hold" survey to enumerate patients who have undertaken anti TB treatment in the past six months will be conducted across 10000 households consisting of ~50000 individuals in each city i.e. Mumbai and Patna to identify ~125-150 TB and ~100 chest symptomatic cases.

Role  of FMR

(Above: FMR staff interviewing a tuberculosis patient as part of operations research into pathways of care in Patna in 2013.)

  • Qualitative in depth interviews of identified TB patients for establishing pathways to care and costs
  • Qualitative in-depth interviews of identified chest symptomatics to gain insight on health care seeking behavior and direct/in direct costs incurred
  • Identification of the preferred providers from whom treatment has been sought and the confirmation of their location by the researchers

Key findings:

After a comprehensive training programme of all the researchers,rigorous pilot was undertaken in both the cities to detect and remedy a wide range of potential problems with the instruments and in order to ensure the validity with respect to questionnaire: layout of questionnaire and validity of question wording, technology related: Functioning of mobile, the app, data transfer and receipt, logistical issues like, team deployment, study timings, non-response rate etc.

The pilot testing began 11th March 2014 onwards, in Mumbai the in-depth interviews of TB and chest symptomatic (CS) cases were conducted at NargisDutt Nagar and Maharashtra Transit camp in Ward H/West  Bandra; and in Patna at Danapur Cantonment, DanapurNijamat and Khagaul areas as per the lists received from Sambodhi after their piloting of the household survey.

The final baseline survey was initiated from 6th May 2014. Till date we have received 7 lists in Patna and 9 lists in Mumbai from Sambodhi team since the initiation of household survey. So far the completed interviews of TB cases are 45 and CS cases are 85 in Mumbai and in Patna the TB cases are 22 and CS cases are 40.

Regular qualitative team meetings are being conducted every fortnight in order to discuss cases, learn the field challenges and troubleshooting as well as update the team with any changes.

The process of data entry is currently being discussed with the operation modelling team from the Gates Foundation - Mr. SarangDeo and Mr. NimPathy. The first meeting discussing the same was held on 21st March 2014, and was attended by the operation modelling team, Dr. Sheela Rangan, Ms. Shimoni Shah (Data manager) and Ms. AkshayaPatil. Finalization of the same will be done in the follow-up meeting which will be scheduled in the coming weeks. Data entry into the CS-Pro Database created by our Data Manager (Ms. Shimoni Shah) will begin after finalization of the same.

Field visit by the Gates Foundation team was conducted on 14th May 2014 by Dr. SrinathSatyanarayan and Dr. AnupamaHazarika in order to attend the in-depth interviews in Dharavi and Bandra areas in Mumbai.

Every month an “All hands meet” consisting of Gates Foundation, Sambodhi Research & Communication Pvt. Ltd, PPIA agencies and FMR team takes place in either Mumbai or Delhi to discuss the progress of the study.

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