Coverage, delivery models, and implementation challenges of the community driven nutritional supplementation initiative for people with TB: A mixed methods study from Puducherry, India

Ni-kshay Mitras are volunteers who provide monthly food baskets worth 7.5-10 USD to people with tuberculosis as a part of India's recent community-driven nutritional support initiative. We assessed the initiative's coverage and implementation challenges in Puducherry, India. This mixed-methods study involved secondary data of adults with TB notified from public facilities between April 2023 and March 2024. This was followed by 42 in-depth interviews (qualitative) with the stakeholders from January to February 2025. Data analysis was done using the R software. Manual thematic analysis was done to derive qualitative insights using Kurt Lewin's framework. A total of 131 Ni-kshay Mitras were registered. Of the 1055 adults with TB who consented to receive nutritional support, 517(49%) received at least three food baskets during their treatment period, similar across different socioeconomic and nutritional statuses. Duration between the diagnosis and receipt of the first food basket (N = 852) was 41(IQR 26,71) days. Facilitators, barriers, and suggested solutions were grouped under major categories such as donor-related, health system-related, and those related to the perception of patients with TB. Facilitators included an established protocol for distributing food baskets, home delivery for sick/older adults, quality check of food baskets, and patient feedback receptiveness. Donor-related challenges included a lack of consistency, reminder requisition, and an inclination for distribution within their geographical settings. Health provider-related challenges were difficulties in monthly collection and transportation of the supplies, hesitancy to approach the donors, poor peer support, and challenges in data documentation on the reporting portal. Nearly half of the adults with TB received at least three food baskets over their treatment period, with prolonged latency in initiating the first food basket. Gaps were observed in prioritizing food basket distribution to the vulnerable group of patients with TB.