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Evaluating the impact of cash transfers on tuberculosis (ExaCT TB): a stepped wedge cluster randomised controlled trial
Open accessAbstract
Background: Mitigating financial barriers to tuberculosis (TB) diagnosis and treatment is a core priority of the global TB agenda. We evaluated the impact of a cash transfer intervention on completion of TB testing and treatment initiation in Uganda. Methods: We conducted a pragmatic complete stepped wedge randomised trial of a one-time unconditional cash transfer at 10 health centres between September 2019 and March 2020. People referred for sputum-based TB testing were enrolled to receive UGX 20 000 (∼USD 5.39) upon sputum submission. The primary outcome was the number initiating treatment for micro-bacteriologically confirmed TB within 2 weeks of initial evaluation. The primary analysis included cluster-level intent-to-treat and per-protocol analyses using negative binomial regression. Results: 4288 people were eligible. The number diagnosed with TB initiating treatment was higher in the intervention period versus the pre-intervention period (adjusted rate ratio (aRR)=1.34) with a 95% CI of 0.62–2.91 (p=0.46), indicating a wide range of plausible true intervention effects. More were referred for TB testing (aRR=2.60, 95% CI 1.86–3.62; p<0.001) and completed TB testing (aRR=3.22, 95% CI 1.37–7.60; p=0.007) per National Guidelines. Results were similar but attenuated in per-protocol analyses. Surveys revealed that while the cash transfer supported testing completion, it was insufficient to address long-term underlying social/economic barriers. Interpretation: While it is uncertain whether a single unconditional cash transfer increased the number of people diagnosed and treated for TB, it did support higher completion of diagnostic evaluation in a programmatic setting. A one-time cash transfer may offset some but not all of the social/economic barriers to improving TB diagnosis outcomes.
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The stepped wedge design in Shete et al. 2023 was likely chosen to ensure that all clusters eventually receive the intervention while also allowing for a comparison between pre-intervention and intervention periods.
“The stepped wedge design was likely chosen to ensure that all clusters eventually receive the intervention while also allowing for a comparison between pre-intervention and intervention periods”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [92]
Eligible health centers in Shete et al. 2023 were randomized using a simple, unrestricted two-stage process. First, they were matched into clusters based on pre-randomization data of patient volume. Second, clusters were randomly assigned into the sequence order in which they would switch into the intervention period during a stakeholder-led randomization ceremony whereby health center代表 chose a编号
“Eligible health centers were randomized using a simple, unrestricted two-stage process. First, they were matched into clusters based on pre-randomization data of patient volume. Second, clusters were randomly assigned into the sequence order in which they would switch into the intervention period during a stakeholder-led randomization ceremony whereby health center representatives chose a numbered”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [92]
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Metadata
- Authors
- Shete, P. B., Kadota, J. L., Nanyunja, G., Namale, C., Nalugwa, T., Oyuku, D., Turyahabwe, S., Kiwanuka, N., Cattamanchi, A., & Katamba, A.
- Affiliations
- University of California, San Francisco (US)
- Makerere University (UG)
- Corresponding author
- Shete, Priya B.
- ORCID
- Venue
- ERJ Open Research
- Publisher
- European Respiratory Society (ERS)
- Published
- 2023-05
- Volume
- 9
- Issue
- 3
- Pages
- 00182-2023
- ISSN
- 2312-0541 (ISSN-L)
- PMC
- PMC10277874
- OpenAlex
- W4379053221
- Cited by
- 8
- References
- 30
- Citations by year
- 2026: 3 · 2025: 3 · 2024: 2
- FWCI
- 1.66
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- ERJ Open Research (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- eScholarship (California Digital Library) (submittedVersion, cc-by-nc)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- UCSF-Gladstone Center for AIDS Research Mentored Science Award in HIV/AIDS Research (NIH P30 AI027763 Award A120163)
- Parker B. Francis Fellowship (P0523744)
- National Heart, Lung, and Blood Institute (R01AI121144)
- Topics
- Health Sciences › Medicine › Infectious Diseases › Tuberculosis Research and Epidemiology
- Social Sciences › Development › Poverty, Education, and Child Welfare
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Healthcare Systems and Reforms
- Keywords
- tuberculosis, cash transfers, tuberculosis diagnosis, TB treatment initiation, financial barriers, unconditional cash transfers, socioeconomic barriers, health care financing, Uganda
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