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: 8711927
• 负责人: Kaivan Munshi
• 金额: $ 12.31万
• 依托单位: PENNSYLVANIA STATE UNIVERSITY, THE
• 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 2015-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8711927
• 关键词: AIDS/HIV problem; Adherence; Area; Attention; Behavior Therapy; Castes; Characteristics; Collection; Communicable Disease Control; Communicable Diseases; Communities; Community Participation; Data; Data Analyses; Disease; Economics; Education; Equilibrium; Funding; Future; Health; Health Policy; Health Services Accessibility; Health system; India; Individual; Infection; Intervention; Leprosy; Link; Measures; Medical Research; Modeling; Neighborhoods; Outcome; Patients; Policies; Research; Rural; Site; Social Interaction; Social Problems; Social Sciences; Social Welfare; Source; Techniques; Testing; Theoretical model; Treatment Cost; Treatment outcome; Tuberculosis; United States National Institutes of Health; Variant; base; computer program; design; experience; improved; innovation; member; novel; novel strategies; public health relevance; social norm; social science research; social stigma; theories; therapy design; trait; tuberculosis treatment; volunteer

DESCRIPTION (provided by applicant): Stigma is a major social problem that hinders efforts to control communicable diseases. Much of the previous research from the medical and social sciences focuses on individual experiences with stigma and pays little attention to how and why stigma develops. The proposed research takes a new approach and conceptualizes stigma as a community-level phenomenon. Drawing on recent advances in economics, a structural theory is developed (Aim 1) which argues that, at least initially, stigma serves to benefit the community by reducing the spread of infection. Once a treatment has been developed, stigma nevertheless persists in some communities, giving rise to a dynamic inefficiency, while it dissipates in others. This theory will be tested using unique primary and administrative data from rural India, the site of an ongoing NIH-funded study (HD 058831) that is evaluating the impact of community volunteers (village or caste members) on adherence to treatment among TB patients. The first step in the empirical analysis will be to establish the definition of community (village, caste, or caste within village) that is relevant for the analysis of stigma in the Indian context (Aim 2). Th second step will be to establish that stigma is a community-level rather than individual-level phenomenon (Aim 3). The theory indicates that once a treatment is developed, communities will either remain in the stigmatizing equilibrium or move to a non-stigmatizing equilibrium, depending on their fundamental characteristics. Communities above a threshold level of wealth or education, which benefit disproportionately from having healthy members, will readily become non-stigmatizing. Communities above a threshold level of access to health services, which lowers the cost of treatment, will also become non- stigmatizing. However, the stigma norm will persist in communities below these thresholds. The third step in the empirical analysis will be to statistically identify the threshold at which communities switch discontinuously from the stigmatizing to the non-stigmatizing equilibrium (Aim 4). The final step will be to examine whether health outcomes - testing delays and non-adherence to treatment for TB - change discontinuously at the same threshold, which would provide support for the theory and the causal relationship between stigma and those health outcomes (Aim 5). Much of the data for the proposed analysis is already being collected, e.g., a range of stigma measures, community characteristics, and treatment outcomes. The supplemental project will collect additional TB testing data from centers throughout the study area. Overall, this innovative research brings a fresh community-based theoretical perspective and state-of-the-art non-linear econometric techniques to the analysis of stigma. Apart from the contribution to basic social science, the results will inform future policy interventions that seek to reduce stigma and improve health outcomes by (1) showing that the optimal design of these interventions should be at the community (rather than individual) level and (2) identifying specific communities that could most easily be pushed from the stigmatizing to the non-stigmatizing equilibrium.

描述（由申请人提供）：污名是阻碍控制传染病的努力的主要社会问题。医学和社会科学的先前许多研究都集中在污名化的个人经历上，几乎不关注污名如何以及为何发展。拟议的研究采用了一种新的方法，并将污名化为社区级现象。利用经济学的最新进展，开发了一种结构理论（AIM 1），该理论至少在最初，污名是通过减少感染的传播来使社区受益的。一旦开发了治疗，污名仍然存在于某些社区，导致动态效率低下，而污名会导致其他社区散发出来。 该理论将使用来自印度农村地区的独特主要和行政数据进行测试，印度农村是NIH资助的一项研究（HD 058831）的地点，该研究正在评估社区志愿者（村庄或种姓成员）对结核病患者遵守治疗的影响。经验分析的第一步是建立社区的定义（村，种姓或 种姓在村庄内）与印度背景下的污名分析有关（AIM 2）。第二步将是确定污名是社区级别而不是个人级别的现象（AIM 3）。该理论表明，一旦开发了治疗，社区将保持污名化平衡，或者根据其基本特征转移到非污名化平衡中。高于财富或教育程度高的社区，从健康成员中受益不成比例地受益，将很容易变得污名化。降低治疗成本的诊所服务水平高于阈值水平的社区也将变得污名化。但是，污名规范将持续在这些阈值以下的社区中。经验分析的第三步将是从统计上确定社区从污名化转变为非耻辱平衡的阈值（AIM 4）。最后一步是检查健康结果 - 测试延迟和对结核病治疗的不遵守 - 在相同的阈值下不连续变化，这将为理论和污名与这些健康结果之间的因果关系提供支持（AIM 5）。提出的分析的许多数据已经收集，例如，一系列的污名措施，社区特征和治疗结果。补充项目将从整个研究领域的中心收集其他结核病测试数据。总体而言，这项创新的研究为污名分析带来了新的基于社区的理论观点和最先进的非线性计量经济学技术。除了对基本社会科学的贡献外，结果还将为未来的政策干预措施提供信息，以减少污名和改善健康结果，通过（1）表明这些干预措施的最佳设计应在社区（而不是个人）水平上，以及（2）确定最容易从污名化的特定社区中，将其推向非污名化的平衡。