Tuberculosis Social Network Project Impact Evaluation 2016-2017

For treatment and control centers, each existing patient was visited by a survey enumerator in a private location such as the patient's home. Enumerators obtained informed consent and administered a baseline survey. Information was collected on the existing patient's socioeconomic characteristics, physical and psychological health, and TB treatment, as well as on information-sharing networks. At the end of the survey, patients at treatment and control centers were prompted to think about individuals outside their households who they believed might be affected by TB ("Please think of people you know who have TB symptoms.") According to RNTCP protocol, immediate family members of TB patients are automatically tested for TB, and as such, were excluded from our referral schemes because they were already known to the system. Then, for treatment centers only, all patients were told, "We are promoting outreach for tuberculosis to encourage more people to get tested and treated, and we invite you to join this effort." They could do this by recommending TB testing for people they knew socially and believed to have symptoms; these new suspects would receive referral cards with information about the screening process. The cards contained information about Operation ASHA, names and addresses of local providers and treatment clinics, a list of TB symptoms, and an ID number used by Operation ASHA and the research team to link the card to the referrer and to distribute incentives according to the study design. New suspects were asked to bring these referral cards to Operation ASHA centers, where they would be screened by health providers and sent for further testing (if required) as per RNTCP mandates.

This process, from a suspect's arrival at an Operation ASHA health center to testing and, if necessary, treatment, was recorded in a referral register at the center that was updated with the relevant outcome at each step, including the result of the screening, whether the new symptomatic got tested, the results of the test (for symptomatics who got tested), and whether the newly identified TB-positive individual enrolled in treatment.

New suspects were always told that they had been targeted for outreach by someone who knew them personally, and shown where their information would be recorded on the card that linked them back to the contact who provided the referral. While they were asked to bring referral cards with them to Operation ASHA, they - like any other individual - could seek care at Operation ASHA (or a public sector facility) without providing a referral card or other documentation. Operation ASHA continued to conduct outreach, screening, and enrollment of new patients following its regular procedures throughout the duration of the study, including enrolling new patients who did not have referral cards. Any new suspect who was approached by or on behalf of an existing patient in this study, but who was concerned about having their visit to Operation ASHA linked to the contact who referred them, could present for screening and receive identical care without submitting the referral card. To the extent that this occurred, we will underestimate the extent of case finding as a result of the outreach and incentive conditions tested in this study.

After the intervention, endline surveys were conducted with existing patients to capture information on health outcomes and satisfaction with Operation ASHA. Intake surveys were also administered to the new suspects identified through the schemes: these measured their characteristics and history of care for TB.