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Background: It is well known that poverty is associated with ill health and that ill health can result in direct and indirect costs that can perpetuate poverty. Social protection, which includes policies and programmes intended to prevent and reduce poverty in times of ill health, could be one way to break this vicious cycle. Social protection, particularly cash transfers, also has the potential to promote healthier behaviours, including healthcare seeking. Although social protection, particularly conditional and unconditional cash transfers, has been widely studied, it is not well known how recipients experience social protection interventions, and what unintended effects such interventions can cause. Objectives: The aim of this review was to explore how conditional and unconditional cash transfer social protection interventions with a health outcome are experienced and perceived by their recipients. Search methods: We searched Epistemonikos, MEDLINE, CINAHL, Social Services Abstracts, Global Index Medicus, Scopus, AnthroSource and EconLit from the start of the database to 5 June 2020. We combined this with reference checking, citation searching, grey literature and contact with authors to identify additional studies. We reran all strategies in July 2022, and the new studies are awaiting classification. Selection criteria: We included primary studies, using qualitative methods or mixed-methods studies with qualitative research reporting on recipients’ experiences of cash transfer interventions where health outcomes were evaluated. Recipients could be adult patients of healthcare services, the general adult population as recipients of cash targeted at themselves or directed at children. Studies could be evaluated on any mental or physical health condition or cash transfer mechanism. Studies could come from any country and be in any language. Two authors independently selected studies. Data collection and analysis: We used a multi-step purposive sampling framework for selecting studies, starting with geographical representation, followed by health condition, and richness of data. Key data were extracted by the authors into Excel. Methodological limitations were assessed independently using the Critical Appraisal Skills Programme (CASP) criteria by two authors. Data were synthesised using meta-ethnography, and confidence in findings was assessed using the Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach. Main results: We included 127 studies in the review and sampled 41 of these studies for our analysis. Thirty-two further studies were found after the updated search on 5 July 2022 and are awaiting classification. The sampled studies were from 24 different countries: 17 studies were from the African region, seven were from the region of the Americas, seven were from the European region, six were from the South-East Asian region, three from the Western Pacific region and one study was multiregional, covering both the African and the Eastern Mediterranean regions. These studies primarily explored the views and experiences of cash transfer recipients with different health conditions, such as infectious diseases, disabilities and long-term illnesses, sexual and reproductive health, and maternal and child health. Our GRADE-CERQual assessment indicated we had mainly moderate- and high-confidence findings. We found that recipients perceived the cash transfers as necessary and helpful for immediate needs and, in some cases, helpful for longer-term benefits. However, across conditional and unconditional programmes, recipients often felt that the amount given was too little in relation to their total needs. They also felt that the cash alone was not enough to change their behaviour and, to change behaviour, additional types of support would be required. The cash transfer was reported to have important effects on empowerment, autonomy and agency, but also in some settings, recipients experienced pressure from family or programme staff on cash usage. The cash transfer was reported to improve social cohesion and reduce intrahousehold tension. However, in settings where some received the cash and others did not, the lack of an equal approach caused tension, suspicion and conflict. Recipients also reported stigma in terms of cash transfer programme assessment processes and eligibility, as well as inappropriate eligibility processes. Across settings, recipients experienced barriers in accessing the cash transfer programme, and some refused or were hesitant to receive the cash. Some recipients found cash transfer programmes more acceptable when they agreed with the programme's goals and processes. Authors' conclusions: Our findings highlight the impact of the sociocultural context on the functioning and interaction between the individual, family and cash transfer programmes. Even where the goals of a cash transfer programme are explicitly health-related, the outcomes may be far broader than health alone and may include, for example, reduced stigma, empowerment and increased agency of the individual. When measuring programme outcomes, therefore, these broader impacts could be considered for understanding the health and well-being benefits of cash transfers. publishedVersion

Additional file 1: Table S1. Final search strategy adopted in this review.

Additional file 3: Appendix 3. Glossary: operational definitions.

Additional file 2: Table S2. Magnitude of positive effect and results interpretationa.

This review aims to provide a quantitative summary of the impact of cash transfers on poor households’ capacity to cope with idiosyncratic health shocks. For this, we will study the effect of cash transfers on household consumption and/or expenditure growth, and use of coping strategies in response to this type of shock.

Additional file 2. Additional information about the European tax-benefit model EUROMOD.

Additional file 3. Additional information about the NINFEA cohort.

Additional file 1. Additional description of the modelling process.

Tuberculosis is the leading cause of deaths from an infectious disease worldwide. WHO's End TB Strategy is falling short of several 2020 targets. Undernutrition is the leading population-level risk factor for tuberculosis. Studies have consistently found that undernutrition is associated with increased tuberculosis incidence, increased severity, worse treatment outcomes, and increased mortality. Modelling studies support implementing nutritional interventions for people living with tuberculosis and those at risk of tuberculosis disease to ensure the success of the End TB Strategy. In this Personal View, we highlight nutrition-related immunocompromisation, implications of undernutrition for tuberculosis treatment and prevention, the role of nutritional supplementation, pharmacokinetics and pharmacodynamics of antimycobacterial medications in undernourished people with tuberculosis, and the role of social protection interventions in addressing undernutrition as a tuberculosis risk factor. To catalyse action on this insufficiently addressed accelerant of the global tuberculosis epidemic, research should be prioritised to understand the immunological pathways that are impaired by nutrient deficiencies, develop tools to diagnose clinical and subclinical tuberculosis in people who are undernourished, and understand how nutritional status affects the efficacy of tuberculosis vaccine and therapy. Through primary research, modelling, and implementation research, policy change should also be accelerated, particularly in countries with a high burden of tuberculosis.

OBJECTIVES: Tuberculosis (TB) is known as a disease of the poor. Despite TB diagnosis and care usually being offered for free, TB patients can still face substantial costs, especially in the context of multi-drug resistance (MDR). The End TB Strategy calls for zero TB-affected families incurring 'catastrophic' costs due to TB by 2025. This paper examines, by MDR status, the level and composition of costs incurred by TB-affected households during care seeking and treatment; assesses the affordability of TB care using catastrophic and impoverishment measures; and describes coping strategies used by TB-affected households to pay for TB care. METHODS: A nationally representative survey of TB patients at public health facilities across Ghana. RESULTS: We enrolled 691 patients (66 MDR). The median expenditure for non-MDR TB was US$429.6 during treatment, vs. US$659.0 for MDR patients (P-value = 0.001). Catastrophic costs affected 64.1% of patients. MDR patients were pushed significantly further over the threshold for catastrophic payments than DS patients. Payments for TB care led to a significant increase in the proportion of households in the study sample that live below the poverty line at the time of survey compared to pre-TB diagnosis. Over half of patients undertook coping strategies. CONCLUSION: TB patients in Ghana incur substantial costs, despite free diagnosis and treatment. High rates of catastrophic costs and coping strategies in both non-MDR and MDR patients show that new policies are urgently needed to ensure TB care is actually affordable for TB patients.

OBJECTIVE: To describe the associations between socio-economic position and prevalent tuberculosis in the 2010 ZAMSTAR Tuberculosis Prevalence Survey, one of the first large tuberculosis prevalence surveys in Southern Africa in the HIV era. METHODS: The main analyses used data on 34 446 individuals in Zambia and 30 017 individuals in South Africa with evaluable tuberculosis culture results. Logistic regression was used to estimate adjusted odds ratios for prevalent TB by two measures of socio-economic position: household wealth, derived from data on assets using principal components analysis, and individual educational attainment. Mediation analysis was used to evaluate potential mechanisms for the observed social gradients. RESULTS: The quartile with highest household wealth index in Zambia and South Africa had, respectively, 0.55 (95% CI 0.33-0.92) times and 0.70 (95% CI 0.54-0.93) times the adjusted odds of prevalent TB of the bottom quartile. College or university-educated individuals in Zambia and South Africa had, respectively, 0.25 (95% CI 0.12-0.54) and 0.42 (95% CI 0.25-0.70) times the adjusted odds of prevalent TB of individuals who had received only primary education. We found little evidence that these associations were mediated via several key proximal risk factors for TB, including HIV status. CONCLUSION: These data suggest that social determinants of TB remain important even in the context of generalised HIV epidemics.

The End TB Strategy mandates that no tuberculosis (TB)-affected households face catastrophic costs due to TB. However, evidence is limited to evaluate socioeconomic support to achieve this change in policy and practice. The objective of the present study was to investigate the economic effects of a TB-specific socioeconomic intervention. The setting was 32 shantytown communities in Peru. The participants were from households of consecutive TB patients throughout TB treatment administered by the national TB programme. The intervention consisted of social support through household visits and community meetings, and economic support through cash transfers conditional upon TB screening in household contacts, adhering to TB treatment/chemoprophylaxis and engaging with social support. Data were collected to assess TB-affected household costs. Patient interviews were conducted at treatment initiation and then monthly for 6 months. From February 2014 to June 2015, 312 households were recruited, of which 135 were randomised to receive the intervention. Cash transfer total value averaged US$173 (3.5% of TB-affected households' average annual income) and mitigated 20% of households' TB-related costs. Households randomised to receive the intervention were less likely to incur catastrophic costs (30% (95% CI 22–38%) versus 42% (95% CI 34–51%)). The mitigation impact was higher among poorer households. The TB-specific socioeconomic intervention reduced catastrophic costs and was accessible to poorer households. Socioeconomic support and mitigating catastrophic costs are integral to the End TB strategy, and our findings inform implementation of these new policies., Socioeconomic intervention defrays costs of accessing TB care in impoverished TB-affected households in Peru http://ow.ly/zXfd302fBFG

Study rationale. While household socioeconomic position (SEP) may be clearly a root cause of tuberculosis\ud (TB), it is more challenging to understand how household SEP affects the risk of TB, how\ud this effect is mediated by risk factors that are on the causal pathway, how this effect differs at\ud different level of analysis and different pathogenic stages of TB, and how this evidence can\ud inform control strategies.\ud Objectives. The aim of this study was to: 1) explore the ecological correlation between community living\ud conditions and TB prevalence rates; 2) quantify the association between household SEP and\ud TB disease and TB infection and, 3) explore the causal mechanism underlying these\ud associations.\ud \ud Methods. This research project was nested within a population-based HIV-TB prevalence survey\ud conducted in 2005-2006 in two Zambian communities, one rural and one urban. Each\ud community is divided into smaller tracts called Census Advisory Areas (CSA). Prevalent TB\ud was diagnosed through culture and molecular testing of sputum samples collected from the\ud prevalence survey participants. The correlation between community living conditions and\ud TB prevalence was assessed through an ecological analysis conducted at CSA level. The\ud association between household SEP and TB disease and infection was assessed respectively\ud through a case-control and a cross-sectional study. CSA living conditions were explored\ud through poverty mapping. Variables accounting for four different domains of household SEP\ud were recorded (human resources; food availability; housing quality; and access to services)\ud and combined into a composite index using principal component analysis. In addition four\ud more SEP indices were developed: one for each household SEP dimension considered. The\ud analysis of the mediation pathway between household SEP and TB (disease and infection)\ud was driven by a pre-defined conceptual framework, including household SEP and individuallevel\ud risk factors. Adjusted Population Attributable Fractions (PAF) were estimated.\ud \ud Main findings. Ecological analysis - The overall cluster-adjusted TB prevalence rates was 870/100,000\ud (95%Cl: 570-1160/100,000) Urban CSA had both significantly higher TB prevalence rates\ud and wealthier living conditions compared to rural CSA. Although not significantly, TB\ud prevalence rates tended to increase with the worsening of urban CSA living conditions.\ud Case control study - At household level, prevalent TB was significantly associated with\ud lower household SEP [aOR = 6.2,95%Cl: 2.0-19.2 and aOR = 3.4,95%Cl: 1.8-7.6\ud respectively for low and medium household SEP compared to the baseline]. The food\ud availability domain was more strongly associated with prevalent TB than the other domains\ud considered [aOR = 4.2,95%Cl: 1.8-9.2]. At individual level, TB prevalent cases were significantly more likely to have a diet poor in proteins [aOR= 3.1,95%Cl: 1.1-8.7], to be\ud not BCG vaccinated [aOR = 7.7,95%CI: 2.8-20.8], to be HIV positive [aOR= 3.1,95%Cl:\ud 1.7-5.8], and to have migrated [aOR = 5.2,95%CI: 2.7-10.2] than controls. These\ud associations all persisted after controlling for household SEP. The association between\ud household SEP and TB appeared to be mainly mediated by inadequate nutrition. Before\ud mediation, PAF for household SEP was equal to 30%. The adjusted PAF for inadequate\ud nutrition and HIV infection was equal to 42% and 36%, respectively.\ud Cross sectional study - TB infection was associated with higher, rather than lower,\ud household SEP [aOR = 0.4,95%Cl: 0.2-0.9 and aOR= 0.4,95%Cl: 0.2-0.8 for high and\ud medium household SEP compared to low SEP]. This association was driven by the\ud household SEP domain on access to community services [aOR = 2.7,95% Cl: 1.0-7.1 ]. None\ud of the investigated risk factors appear to mediate the association between household SEP and\ud TB infection.\ud Conclusions. \ud In this setting, urban communities were wealthier but also had greater prevalence of TB. The\ud low power of the ecological analysis does not allow any conclusions; however - as for other\ud health indicators, even for TB it seems that the apparent advantage of living in an urban\ud setting can mask severe TB inequalities across smaller urban communities.\ud This study revealed an unexpected and counterintuitive result: low household SEP was\ud significantly associated with a higher risk of TB disease, but with a lower risk TB infection.\ud Higher household SEP may be associated with lifestyles increasing social mixing and thus\ud the risk of infection. Among the infected people, poorer individuals may be more likely to\ud progress to TB disease and, therefore, are more likely to be identified in prevalence surveys.\ud In the association with TB disease, household SEP seems to operate mainly through\ud inadequate nutrition. While both 11V and inadequate nutrition were important social\ud determinants of prevalent TB, these findings suggest that interventions addressing food\ud insecurity may prevent more TB cases in this setting.\ud Because of low study power and possible selection biases results this interpretation will have\ud to be confirmed by more powered and better designed studies. In the meantime, this study\ud suggests that interventions addressing household SEP, through food and financial support,\ud may effectively reduce TB prevalence and complement currently control strategies mainly\ud targeted to HIV positive people.\ud To evaluate the impact and cost-effectiveness of this approach is a priority.