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）：耻辱是阻碍控制传染病努力的一个主要社会问题。先前的许多医学和社会科学研究都集中在个人的耻辱经历上，而很少关注耻辱是如何以及为何产生的。拟议的研究采用了一种新方法，并将耻辱概念化为社区层面的现象。利用经济学的最新进展，发展了一种结构理论（目标 1），该理论认为，至少在最初，耻辱可以通过减少感染的传播来使社区受益。一旦治疗方法被开发出来，耻辱感在一些社区仍然存在，导致动态低效率，而在其他社区则消失。 该理论将使用印度农村地区独特的主要和行政数据进行检验，印度农村地区正在进行一项由 NIH 资助的研究 (HD 058831)，该研究正在评估社区志愿者（村庄或种姓成员）对结核病患者坚持治疗的影响。实证分析的第一步是确定社区的定义（村庄、种姓或 村庄内的种姓），这与印度背景下的耻辱分析相关（目标 2）。第二步是确定耻辱是社区层面而非个人层面的现象（目标 3）。该理论表明，一旦开发出一种治疗方法，社区将要么保持污名化平衡，要么转向非污名化平衡，具体取决于其基本特征。财富或教育水平高于阈值的社区，由于拥有健康的成员而受益匪浅，因此很容易变得不再受到污名化。获得医疗服务的门槛水平以上的社区可以降低治疗成本，也将不再受到侮辱。然而，在低于这些阈值的社区中，耻辱规范将持续存在。实证分析的第三步是统计确定社区从污名化均衡向非污名化均衡不连续转变的阈值（目标 4）。最后一步将检查健康结果（检测延迟和不坚持结核病治疗）是否在同一阈值下发生不连续变化，这将为理论以及耻辱与这些健康结果之间的因果关系提供支持（目标 5） 。拟议分析的大部分数据已经收集完毕，例如一系列耻辱措施、社区特征和治疗结果。补充项目将从整个研究区域的中心收集额外的结核病检测数据。总体而言，这项创新研究为污名分析带来了全新的基于社区的理论视角和最先进的非线性计量经济学技术。除了对基础社会科学的贡献外，研究结果还将为未来的政策干预措施提供信息，这些政策干预措施旨在通过以下方式减少耻辱并改善健康结果：（1）表明这些干预措施的最佳设计应在社区（而不是个人）层面进行，并且（ 2）确定最容易从污名化平衡推向非污名化平衡的特定社区。