Food support helps people with tuberculosis—lessons from the RATIONS trial

Tuberculosis care does not stop at medicines. During the Reducing Activation of Tuberculosis by Improvement of Nutritional Status (RATIONS) trial, researchers led by Madhavi Bhargava set out to understand how people living with TB and the health workers around them experienced a food-based support package. Rather than measuring only biological outcomes, the team carried out a qualitative study to hear directly from those affected: patients with TB, their household contacts, and frontline and program staff. The goal was to learn whether the food intervention felt acceptable, whether people saw real benefits, and whether it could be delivered in routine program settings. This approach treats the experiences and practical views of recipients and implementers as essential evidence. By exploring perceptions, experiences and expectations, the study aimed to guide how nutritional support might be designed, scaled, or adjusted so it works in the everyday lives of people facing TB and the systems that care for them.

The team recruited 58 people for in-depth interviews (IDI) and focus group discussions (FGDs) using referential sampling. Participants included patients with TB (PwTB), household contacts (HHCs), trial team members, government frontline workers called the Sahiyas, and National TB Elimination Program (NTEP) staff. All interviews and discussions were audio-recorded, transcribed and translated. Researchers generated codes by an inductive process and manually grouped them into themes, using direct quotes to illustrate findings. The food intervention was widely seen as acceptable—participants cited cultural compatibility, adequate quality, quantity and duration. Reported benefits included helping people tolerate the adverse effects of medications, gaining weight, improving health and resuming work; many said the support was life-saving during the COVID-19 pandemic. The study also noted food-sharing in the control arm and that some people did not regain their pre-disease functional status despite weight gain. Preferences varied between support in kind, cash, or a mix. Sahiyas observed fewer TB deaths, better adherence and improved functional recovery, expressed confidence in feasibility and willingness to help implement the intervention. Field staff found trial duties demanding because of rigorous data collection but meaningful, while NTEP staff called the approach feasible if resources were provided. Many interviewees favored extending food support to HHCs.

Taken together, these findings point to several practical implications. The qualitative inquiry concluded that a food-based intervention for PwTB and their HHCs was acceptable, feasible and beneficial for recipients and for the National TB Elimination Program, provided resources are committed. Participants suggested expanding nutritional support in some areas, strengthening cash assistance where needed, and offering food or combined cash-plus-food options; views were divided but many preferred food over cash, while others wanted both. The study also highlights implementation realities: frontline Sahiyas appear willing and able to take on delivery, but trial teams face extra workload from rigorous data collection, and household food-sharing can dilute targeted support. Finally, weight gain did not always translate into full functional recovery, suggesting that programs should pair nutrition with other supports for rehabilitation. These insights can help policymakers and program managers design nutritional components that are culturally acceptable, operationally feasible and aligned with the needs of people living with TB.