ASCOT: Addressing the Social Determinants and Consequences of Tuberculosis in Nepal

In this invited "SDG 3 and me" blog , Bhola Rai, Kritika Dixit, and Tom Wingfield of Birat Nepal Medical Trust and Liverpool School of Tropical Medicine explain how their team's mixed methods research to address tuberculosis informs -and is informed by- the Sustainable Development Goals framework.
Published in Sustainability
ASCOT: Addressing the Social Determinants and Consequences of Tuberculosis in Nepal
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A confluence of crises is challenging the goals set out in the 2030 Agenda for Sustainable Development. Covid-19 has killed more than 15 million people and pushed – or pushed further - more than 250 million people into extreme poverty. Conflict has forced millions from their homes with a quarter of the world’s population living in conflict-affected countries. Climate change is predicted to cause 250,000 additional deaths per year, from malnutrition, malaria, diarrhoea and heat stress alone between 2030 and 2050, and greenhouse gases to rise by up to 14% by 2030 – woefully short of Paris Agreement targets. On this backdrop, it is abundantly clear that good health and wellbeing of both people and planet will not be attained by strategies focused on achieving individual Sustainable Development Goals (SDG). The SDGs are inextricably linked and must be considered and addressed in concert.

Tuberculosis (TB), the quintessential disease of poverty, is a leading cause of death from an infectious disease and also deaths related to antimicrobial resistance. Key socioeconomic determinants driving the global TB epidemic include undernutrition and food insecurity, poor housing conditions and ventilation, overcrowding and high population density, and limited healthcare access - especially with relation to coverage and uptake of the BCG vaccine, TB diagnosis and treatment, and TB preventive therapy.

To address these broader determinants and accelerate progress towards ending TB, the World Health Organization produced the Multisectoral Accountability Framework (MAF) (2019). The framework emphasizes the need for multisectoral collaborations and partnerships across research, implementation, monitoring and evaluation, and policy in order to achieve key SDGs such as alleviating poverty, enhancing social protection coverage, ensuring food security, and improving living conditions (Figure 1).

Figure 1:  The relationship between TB and the SDGs (reproduced from Satyanaranaya et al, Tropical Medicine and Infectious Diseases, 2020)

In Nepal, a low-income country with a high TB burden, our international, interdisciplinary team including a well-established Nepalese NGO, Birat Nepal Medical Trust (BNMT, www.bnmt.org.np), has been working over the past five years to design, implement, and evaluate socioeconomic interventions to end TB and its broader consequences – in line with both MAF and SDG targets.

Our Academy of Medical Sciences, Wellcome Trust and Stop TB Partnership funded research in Nepal showed that 61% of TB-affected households experienced “catastrophic costs” and identified modifiable socioeconomic barriers, including stigma and mental illness, and facilitators (Figure 2) to accessing TB services. Then, with key multisectoral stakeholders in Nepal, including the Nepal TB Control Center (NTCC), people with TB, and TB survivors, we co-designed a locally-appropriate socioeconomic support package for TB-affected households for trial evaluation in Nepal.

Figure 2: Barriers and facilitators to accessing TB services in Nepal (reproduced with permission from Dixit et al, BMJ Open 2021)

In 2021, we began our United Kingdom Research and Innovation (UKRI) fundedASCOT: Addressing the Social Consequences and Determinants of TB” pilot trial (ISRCTN 17025974). The primary aim of the ASCOT pilot trial was to use mixed methods research to evaluate the feasibility and acceptability of the co-designed socioeconomic support package for TB-affected households in Nepal. The pilot trial recruited 128 participants in four districts of Nepal randomised to four study arms:

 

 

The interventions were designed to be aligned with specific SDGs (Figure 3):

Social support consisted of enhanced TB information, education, and counselling (IEC) including an illustrated wall calendar during a household visit; and TB survivor-led mutual support groups called “TB Clubs”- adapted from research in Ethiopia, which included a novel, locally-made animated TB stigma video.

The social support was aligned with: SDG-4 (Quality Education) with a focus on TB-focused health education as a form of patient-centred health promotion; and SDG-10 (Reduced Inequalities) through empowerment of underserved people with TB and their households to make informed, autonomous health choices.

Economic support consisted of unconditional monthly cash transfers (~£20GBP/month) for six months. The economic support was aligned with SDG-1 (Reduced Poverty) with cash transfer representing a form of TB-specific social protection to reduce catastrophic costs of TB; and SDG-2 (Zero Hunger) given that, in diverse settings, cash transfers have been found to be predominantly used by impoverished households to buy food and reduce food insecurity.

Socioeconomic support consisted of a combination of social and economic support. Similar integrated socioeconomic support packages have previously been shown to improve TB treatment outcomes and mitigate catastrophic costs in Peru but their impact in low-income high TB burden settings like Nepal remains unknown.

 

Figure 3: ASCOT Pilot Trial field photography (consent obtained from all featured participants)

 

 

Preliminary results from the ASCOT pilot trial were recently presented at the 53rd Union World Conference on Lung Health. These interim analyses showed high intervention fidelity except for low TB Club attendance in the Social Arm (Table). TB Club was rated as “good/very good” by 47/50 (94%) attendees with requests from local TB programme staff and communities to continue TB Clubs beyond the duration of the ASCOT project in the study sites. High recruitment, participation and follow-up rates with minimal attrition suggest good acceptability of support packages and final acceptability analysis is due to be completed by February 2023. Based on these findings, the ASCOT team has applied for large-scale funding to conduct a well-powered randomised-controlled two-arm trial of the integrated socioeconomic support package vs standard of care.

Table: ASCOT Pilot Trial Recruitment, Follow-up (FU), and support activities

Thanks to the learning and collaboration arising from ASCOT, new research projects and partnerships have arisen based on working towards specific SDG targets such as increasing access to care and addressing mental illness and stigma. These include: the Medical Research Foundation Dorothy Temple Cross International Collaboration Award funded “SAFEST-MDR-TB-1” study to evaluate the feasibility and acceptability of video-observed therapy for people with multi-drug resistant TB in Mozambique, led by Dr Celso Khosa; and the Royal Society of Tropical Medicine and Hygiene-fundedCharacterising and Addressing the Psychosocial Impact of Tuberculosis in Indonesia (CAPITA)” mixed methods study led by Dr Ahmad Fuady.

TB is a prime example of an ancient poverty-related illness that would benefit from a modern eradication strategy nested within the SDG framework. While increased international spending and domestic resource mobilisation are still required to achieve SDG-3, our research and ASCOT trial illuminate the importance of considering the SDGs in the design, implementation, and evaluation of interventions to address the social determinants and consequences of ill health.

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Bhola Rai, Project Manager, Birat Nepal Medical Trust, Nepal. ORCID: https://orcid.org/0000-0002-7421-4891  Twitter: @BholaRai30  Email: bhola@bnmt.org.np

Kritika Dixit, Co-Investigator, Birat Nepal Medical Trust, Nepal, and World Health Organization Collaborating Centre on Tuberculosis and Social Medicine, Karolinksa Institutet, Sweden. ORCID: https://orcid.org/0000-0002-7957-8109 Twitter: @_KritikaDixit  Email: kritika@bnmt.org.np

Tom Wingfield, Principal Investigator, LIV-TB Collaboration, Liverpool School of Tropical Medicine, UK, and SPARKS network, World Health Organization Collaborating Centre on Tuberculosis and Social Medicine, Karolinksa Institutet, Sweden. ORCID: https://orcid.org/0000-0001-8433-6887. Twitter: @drtomwingfield  Email: tom.wingfield@lstmed.ac.uk

We would like to thank the Nepal National Tuberculosis Control Centre, Province Health Directorate, Health Offices, Nepal Health Research Council, colleagues from the Birat Nepal Medical Trust team, and the people affected by tuberculosis and their household who gave their time to participate in this research.

We are also grateful to the Department of Health and Social Care (DHSC), the Foreign, Commonwealth & Development Office (FCDO), the Medical Research Council (MRC) and Wellcome UK for a  JGHT Development grant to conduct the ASCOT Pilot Trial.

For more information on the challenges to achieving SDG3, see this World Bank blog.

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