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Health Impact Framework Paper: Tuberculosis in India

Emily Rittenhouse

Delaware Technical Community College

NUR 310 Global Health

Dr. Rosati

February 19, 2023

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Health Impact Framework Paper: Tuberculosis in India

The health of a country or community can have a global effect. Different issues in global

health, such as communicable diseases like tuberculosis, are not impacted by borders. One of the

seventeen Sustainable Development Goals (SDGs) is SDG 3, which focuses on good health and

well-being (Skolnik, 2021). Part of the global plan for this goal is that communicable diseases

like tuberculosis will no longer be a global health issue by the year 2030 (Skolnik, 2021). India is

noted to have about 1.4 billion people, and tuberculosis has been number seven on the list of top

ten causes of mortality both in 2009 and 2019 (IHME, 2023). Gupta et al (2020) list India as one

of the countries with increased tuberculosis prevalence. The authors further discuss that the

burden of tuberculosis in the middle to lower-income countries is still a significant issue. In

contrast, in more developed countries, it is no longer considered a threat (Gupta et al, 2020).

Tuberculosis affects the burden of disease in India through three major areas of health, including

disability, morbidity, and mortality. India was noted to have around 10 million tuberculosis cases,

and the cases in India encompass 27% of the global tuberculosis cases reported (Gupta et al,

2020). Tuberculosis has also become resistant to certain drugs, making it more complex and

expensive to treat (Skolnik, 2021). The health impact pyramid contains five components that

impact the overall health of individuals (Frieden, 2010). This paper will discuss the impact and

burden of tuberculosis in India and examine several interventions to promote education and

prevent communicable disease spread to promote better health.

The foundation or the first tier of the health impact pyramid is about determinants of

health in a population or country (Frieden, 2010). Different socioeconomic factors impact the

health of a country. India is considered a lower-middle-income country. Several countries have

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moved toward universal healthcare, but this has yet to happen in India (Skolnik, 2021). Their

health system is very similar to that of the United States. The health system contains public and

private sectors, but most may opt for private facilities if the public ones are overrun and

overcrowded (Skolnik, 2021). Increased financial struggle can result when the population is

burdened with out-of-pocket healthcare costs and from choosing a private sector over a public

one (Skolnik, 2021). This correlation indicates that healthcare costs can be associated with

poverty in India (Skolnik, 2021). Migliori et al (2020) list poverty as a risk factor for

tuberculosis. Education is also linked to socioeconomic status and health. Notably, literacy in

India is around 74.4% of the inhabitants (CIA, 2023). Higher morbidity and mortality have been

linked to populations with lower socioeconomic status and education levels (Sharma et al, 2022).

The next tier of the health impact pyramid involves changing an environment to promote

healthy choices (Frieden, 2010). IHME (2023) lists malnutrition and air pollution as India's top

two leading causes of morbidity and mortality. Skolnik (2021) stresses the need to ensure air

pollution in the home is alleviated as it has been linked to tuberculosis as well as cataracts.

Alcohol consumption, tobacco use, and malnutrition have been associated with individuals

becoming more likely to develop active tuberculosis (Skolnik, 2021). Another source also

attributes overcrowding as a risk factor for tuberculosis (Migliori et al, 2020). India's urban

population is currently around 36% (CIA, 2023). However, the urban population is expected to

increase because the anticipated rate of urban growth is expected to be doubled by 2050

(Ramaiah & Avtar, 2019). Gupta et al (2020) note that people with tuberculosis are more likely

to be coping with other diseases, such as other communicable diseases like HIV and
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non-communicable diseases like diabetes mellitus. When people have had tuberculosis, they can

become more likely to develop COPD (Mohan et al, 2019).

For the third tier of the pyramid, it is important to determine long-lasting protective

interventions (Frieden, 2010). Vaccinations provide lasting benefits for the population. The

Bacillus Calmette-Guerin, or BCG vaccine, is a critical childhood vaccine because it can

alleviate the severity of tuberculosis (Skolnik, 2021). This becomes very important regarding

child morbidity and mortality. However, Skolnik (2021) notes that the BCG vaccine does not

significantly affect tuberculosis's total prevalence. One source urged the need to find a new

vaccination for tuberculosis with the new collaboration of resources and methods that are now

available, just as resources were used to develop COVID-19 vaccinations (Chakaya et al, 2021).

The fourth tier of the pyramid aims at clinical interventions that can be implemented and

can significantly influence better health and wellness (Frieden, 2010). Three components have

been identified to have the highest impact on alleviating the burden of tuberculosis, starting with

preventive measures and patient-centered care, ensuring strong support and policies are

implemented, and promoting advanced research (Migliori et al, 2020). The authors also stress the

importance of establishing effective prevention methods as well as an effective vaccination. The

article argues that early diagnosis and treatment are essential but would not be sufficient alone

for the overall management of tuberculosis (Migliori et al, 2020). For diagnosis, the molecular

test Xpert MTB/RIF is crucial for individuals presumed to have tuberculosis and is endorsed by

WHO (Skolnik, 2021). This test is considered more effective because it can diagnose as well as

assess for drug resistance compared to what has been done historically by simply looking at the

patient's sputum under microscopy (Skolnik, 2021). When tuberculosis is diagnosed, it is

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followed by a treatment of taking several medications, including rifampicin, isoniazid,

pyrazinamide, and ethambutol, on a routine daily basis for six months (Skolnik, 2021). Upon

completion of the tuberculosis treatment, the patient should be evaluated to see how the

individual is functioning and is encouraged to pursue pulmonary rehabilitation (Migliori et al,

2020).

The final tier of the health impact pyramid calls for counseling and education, which is

especially important for nurses (Frieden, 2010). The US Public Health Service utilized the

Health Belief Model to recognize factors influencing an individual's health behavior and choices

(Skolnik, 2021). Regarding tuberculosis, these factors may entail the individual's view of how

likely they are to develop tuberculosis and how bad tuberculosis could be if they get it (Skolnik,

2021). The first priority would be to educate the different communities in India that tuberculosis

is spread through the air around someone with active tuberculosis infection (Skolnik, 2021).

Another vital component of exposure for individuals to understand is that tuberculosis is higher

in urban or city regions in comparison to rural regions of India (Gupta et al, 2020). It is also

essential to provide education on the risk factors such as comorbid conditions such as diabetes

and HIV, as well as other factors, including crowded housing or environments, malnutrition, and

tobacco and alcohol usage (Skolnik, 2021). Other components of this model include the

individual recognizing the positive impact prevention could provide as well as ensuring the

individual is self-aware of what is preventing them from pursuing better health prevention and

practices (Skolnik, 2021). Tuberculosis can affect the individual not just on a physical level but

also on an emotional, social, financial, and psychological level (Aggarwal, 2019). Skolnik (2021)

discusses how the financial burden of tuberculosis can affect 60% of an individual's yearly
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income. The emotional, psychological, and social well-being can be affected both by the

isolation and stigma that comes with tuberculosis (Aggarwal, 2019). The author suggests that the

caregiver's role is to improve the quality of life by providing education about tuberculosis and

ensuring proper support (Aggarwal, 2019). It is imperative for the healthcare provider to ensure

the individual sticks to the daily treatment regime in order to ensure successful management of

the disease as well as limit drug resistance (Skolnik, 2021). Since there are multiple options for

treatment schedules and locations, it is also the priority of the healthcare provider to give the

patient autonomy by allowing them to choose which type of treatment would work best for that

individual after the risks and benefits have been adequately explained to ensure compliance

(Migliori et al, 2020).

Cultural factors are vital to consider when discussing the health of a specific community,

region, or country. In India, women are noted to be discriminated against in regard to many

areas, especially in healthcare (Moradhvaj & Saikia, 2019). It was found that males have a higher

prevalence of tuberculosis, but females experience more mortality (Skolnik, 2021). One article

states that herbal medicine usage in India accounts for about 80% of the population (Krupa et al,

2019). The source discusses how many herbal treatments can be applied to multiple ailments and

added to their meals (Krupa et al, 2019). As part of healthcare providers' culturally competent

practice and patient-centered care, it is crucial to consider incorporating herbal treatments when

appropriate.

Many research articles recommend future interventions for the common goal of ending

tuberculosis and other communicable diseases. Two areas identified were to build up health

systems as well as promote universal healthcare which would address the first tier of the health
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impact pyramid (Skolnik, 2021). Another source urges that governments need to be supported

with appropriate funding and resources to decrease the morbidity and mortality of communicable

and non-communicable diseases (Mohan et al, 2019). Advocacy for changes in policies and a

call for action are required to support the need to decrease the burden of poverty and lack of food

supply which also addresses the first tier of the health impact pyramid (Aggarwal, 2019). When

considering the regional disparities of healthcare in India, it was identified that underdeveloped

regions should receive more recognition and interventions to promote better health (Singha &

Roy, 2022). Pandey et al (2020) suggest that addressing the issue of air pollution will do two

things for India, including providing a good overall health and economic future for the country as

well as aid in reaching other SDG goals. This overall goal of improving air pollution addresses

the second tier of the health impact pyramid. As stated previously, Chakaya et al (2021) strongly

urges the collaboration of resources to develop a more improved vaccination for tuberculosis

addressing the third tier of the pyramid. In terms of clinical interventions, one study completed in

India encourages the use of CT scans and bronchoscopy for diagnostic treatment (Thakur et al,

2022). These authors state that, especially since the COVID-19 pandemic, chest x-rays are more

likely to be misdiagnosed and strongly recommend the need for India to have institutions with

bronchoscopy and CT scan availability (Thakur et al, 2022). Good communication, counseling,

support, education programs, as well as reducing the stigma of tuberculosis is encouraged for the

management of the final tier of the health impact pyramid (Aggarwal, 2019).

There are many professional opportunities available in the global health field. Nurses can

seek out opportunities to be active in their hospitals, communities, as well as globally. One

source provides several options for the nurse to become leaders and be actively involved in
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promoting global health, including joining professional nursing organizations and assisting with

making or adjusting organizational policies (Edmondson et al, 2017). Some professional

organizations also make medical trips to countries in need to help support the community's

needs. Nursing Beyond Borders is a professional organization that makes trips abroad to promote

better health among children as well as in the community (Nurses Beyond Borders, n.d.).

Whether becoming involved in one's local community as an educator or policy advocator or

traveling abroad to provide support to other communities, it is crucial for the nurse to find ways

to be actively involved in the education and implementation of better health and well-being for

all people.

 
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