TB or not TB? Getting People to Find Out More Quickly

The Challenge

Tuberculosis (TB) is a leading cause of death worldwide. Yet a significant number of people delay going to a doctor, despite having TB-related symptoms — leading to a large number of new infections in India. We wanted to find out why, so we could identify ways to help and stem the new infections.

Our Approach

In India, we worked in partnership with the Clinton Health Access Initiative and the Greater Chennai Corporation to conduct the first prospective study to follow patients with TB-related symptoms in real time. We assessed 85,000 households across the city of Chennai to discover exactly how people respond to their TB symptoms, and why.

Key Results

• We learned that TB awareness is widespread, and not associated with care-seeking delays – suggesting that intervention efforts should focus less on education campaigns.
• We identified a broad spectrum of barriers to care-seeking delays, including age and job type, smoking and drinking, not getting enough sleep or exercise, healthcare facility preferences, and low risk perception of getting TB.
• We identified distinct segments of the population to better understand TB-symptomatic people who do not promptly seek care. This process revealed a key subpopulation in Chennai: employed men who problem-drink and smoke, comprising just over half of this population.
• We learned that we need to make care-seeking as convenient as possible for this important subgroup, while also increasing their perception of the risks of not getting treated.
• Our research was published in the September 2020 edition of BMJ Global Health.

India accounts for more than a quarter of global TB cases every year, with a higher concentration in metropolitan areas, like Chennai in the southern state of Tamil Nadu. Despite significant progress in TB treatment as new, shorter drug regimens are introduced, big gaps still remain: 42% of Indians with TB do not get diagnosed promptly. Delays or avoidance in care-seeking lead to more infections and death. 

In 2018, we saw the perfect opportunity to address India’s struggle with TB through a precision approach, identifying exactly who we need to reach with the right interventions in order to close the care-seeking gap and spur better outcomes. We started by conducting a first-of-its-kind, large-scale, community-level study, surveying over 85,000 households across Chennai to understand why presumptive TB patients do not seek care. We identified 1,700 participants with presumptive TB symptoms and interviewed them in-depth to map their care-seeking journey and identify population segments with similar care-seeking behavior. 

Our study found that awareness of TB information was already high, suggesting that this is not as important a factor as previous research had indicated. Instead, low risk perception around TB symptoms (especially blood in sputum) and time or convenience were the most important predictors of low care-seeking – more influential, in fact, than money or family income. We found that the risk of becoming TB-positive in Chennai is concentrated among employed men, especially those who problem drink and smoke. This population segment also emerged as the least care-seeking (only 42% with symptoms seek care, compared with 70% of retired men).

Our TB care-seeking work combines machine learning and behavioral science to draw out precise insights about TB patients – a novel approach that can be replicated for other global public health programs. With these insights, we can apply a precision public health strategy, targeting specific population segments with customer-centric services that address their biggest barriers to care. We are now deploying this precision approach with partners in Chennai to build risk perception among our target subgroups, using digital channels and providing them with timely, convenient mobile TB testing services.