# Behaviour change solutions driven by cognitive insights for improving TB health care seeking among vulnerable population: an exploratory multi-state qualitative study in India

## TL;DR

This study explores how behavior change solutions based on cognitive insights can improve tuberculosis care-seeking among vulnerable populations in India.

## Contribution

The study introduces and evaluates novel behavior change solutions tailored to cognitive biases to improve TB healthcare seeking in vulnerable groups.

## Key findings

- Health auto and jaanch coupon improved TB awareness and reduced diagnostic delays.
- Starter-kit and TB mukt certificate enhanced treatment adherence and community acceptance.
- BCSs empowered TB patients and addressed cognitive barriers like decision fatigue and loss aversion.

## Abstract

Tuberculosis disproportionately affects vulnerable groups due to low health awareness and suboptimal care-seeking behaviour. Individualised person-centric approaches are scarce in India’s national TB program. This study assessed the usefulness of behaviour change solutions (BCS) in improving TB case identification and treatment adherence among mining/industrial workers, migrants, tea-garden workers, tribals, and urban vulnerable.

In this qualitative study we conducted 147 in-depth interviews (IDI) with adult (78 men, 69 women) BCS beneficiaries, facilitators (auto drivers, community leaders) and healthcare providers between May–August, 2023 in Karnataka, Telangana, Assam, and Bihar. We explored the usefulness of four BCSs — health auto (addressing decision fatigue and healthcare costs), jaanch coupon (addressing the loss aversion bias), TB starter-kit (reducing ambiguity aversion), and TB mukt certificate (reinforcing positive perceptions), through user experience. Interviews were conducted in local language (Kannada, Telugu, Hindi and Assamese), audio recorded, transcribed, and analysed using a deductive approach. A thematic analysis was done, focusing on participants’ knowledge of the solutions, their experiences using them, perceived benefits and challenges, and recommendations for improvement. Thematic saturation was reached through a process of collaborative analysis, where the research team iteratively reviewed and discussed emerging patterns. The study received ethics approval from the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore.

The initial codes were merged into major themes based on their similarity. Findings indicated that health auto and jaanch coupon enhanced TB related awareness at the community level, reduced diagnostic delay, and facilitated increased case finding. On the other hand, use of starter-kit and TB mukt certificate led to improved treatment adherence. BCSs also supported timely decision-making, promoted treatment adherence, and empowered persons with TB by fostering a sense of entitlement. Moreover, BCSs attempted to address multifaceted vulnerabilities: while case finding solutions were able to facilitate accessibility and affordability by addressing physical barriers, the case holding solutions reduced stigma and improved community acceptance. However, the data also indicated that the solutions had challenges related to acceptability, and scalability.

Findings from this study underscored that BCS catalysed TB healthcare seeking by addressing cognitive barriers. It suggests that designing targeted cognitive interventions could potentially be a promising approach to alter cognitive biases, inculcate behavioural changes, and improve TB care-seeking and treatment outcomes.

The online version contains supplementary material available at 10.1186/s12889-026-26542-x.