Assessing the gender responsiveness of tuberculosis interventions: a scoping review (2000-2025).

BACKGROUND: Tuberculosis (TB) is a major public health concern resulting in high rates of morbidity and mortality worldwide, particularly in low- and middle-income countries, despite treatment having been available for over 50 years. It remains a crucial health problem in Thailand. This study aimed to develop a program for building tuberculosis (TB) care competencies of village health volunteers (VHVs) and to examine its effects on the outcomes of care for TB patients.
 
 METHODS: The competency development program (CDP) was developed based on the principles of empowerment and community-based TB care. Forty VHVs in two villages of Khoglor sub-district, Trang, Thailand were recruited. Participants were classified into control and experimental groups equally (n=20) by using a matched pair technique. 
 
 RESULTS: The results showed that the mean scores of TB knowledge, attitude towards TB care, and TB care skills in the experimental group at the baseline and post-intervention were significantly different (p < 0.05). The mean scores of TB knowledge, attitude towards TB care, and TB care skills in the experimental and control groups at the baseline were not different. However, the scores of these three competencies at the post-intervention were significantly higher in the experimental group, compared to the control group (p < .05).
 
 CONCLUSION: Per the findings of the study, healthcare professionals should incorporate the principles of empowerment and community-based TB care in TB training programs in order to enhance TB care competencies of community health volunteers.

Tuberculosis (TB) care cascade is a recently evolved care model for patient retention across the sequential stages of care for a successful treatment outcome. The care cascade is multi-folded and complex in setting where the health system is reforming for its resilience. India, one of the countries with the highest burden of tuberculosis mortality and morbidity, is not an exception to this complexity. With the diverse challenges in the Indian health system and societal diversity, it is essential to understand the factors contributing to this TB care cascade. Thus, this study aims to map all the contributing factors to the TB care cascade in India. Further, it also captures the different patterns of factors explored so far in different countries’ regions. This systematic literature review was conducted between October 2020 and February 2021 in India using PubMed databases, Web of Science, and Google Scholar. Two reviewers extracted the data from eligible studies to summarize and tabulate important findings. Data were extracted and tabulated for study design, location of the study, type of TB patients, methodological approach, system side challenges, and demand-side challenges in the study’s findings. Out of 692 initial hits from the literature search, 28 studies were finally included to synthesize evidence in this review as per the inclusion and exclusion criteria. This review provides an insight into different factors such as the system-side (health workforce, institutional) and the demand-side (individual, societal) contributing towards the care cascade. The prime factors reflected in most of the studies were socio-economic condition, disease awareness, myths/beliefs, addictions among the demand-side factors and accessibility, the attitude of the healthcare staff, delay in referral for diagnosis among the system-side factors. The accountability for addressing these diverse factors is recommended to close the gaps in the TB care cascade.

In 2021, an estimated 10.6 million people fell ill with tuberculosis (TB) globally and 11.3% were children. About 40% of children aged five to fourteen years with TB are missed annually. In Uganda, 44% of adolescents with chronic cough of more than two weeks do not seek care from health facilities. Therefore, strategies to promote health care-seeking behaviour among adolescents were urgently needed to resolve the gap. In regard to this, the research project utilized a before and after design, in which the number of adolescents (10-19years) enrolled in the project health facilities were compared before and after the intervention. The intervention package that comprised of tuberculosis awareness and screening information was developed together with adolescents, thus; a human-centred approach was used. The package consisted of TB screening cards, poster messages and a local song. The song was broadcasted in the community radios. Poster messages were deployed in the community by the village health teams (VHTS). The TB screening cards were given to TB positive and presumptive adults to screen adolescents at home. Adolescents that were found with TB symptoms were referred to the project health facilities. Socio-demographic and clinical characteristics of eligible adolescents were collected in a period of six months from Kawolo, Iganga, Gombe and Kiwoko health facilities. To determine the effectiveness of the package, before and after intervention data were equally collected. A total of 394 adolescents were enrolled, majority (76%) were school going. The intervention improved adolescent TB care seeking in the four project health facilities. The average number of adolescents screened increased from 159 to 309 (incidence rate ratio (IRR) = 1.9, P<0.001, 95% CI [1.9, 2.0]). Those presumed to have TB increased from 13 to 29(IRR = 2.2, P<0.001, 95% CI [1.9, 2.5]). The ones tested with GeneXpert increased in average from 8 to 28(IRR = 3.3, P<0.001, 95% CI [2.8, 3.8]). There was a minimal increase in the average monthly number of adolescents with a positive result of 0.8, from 1.6 to 2.4(p = 0.170) and linkage to TB care services of 1.1, from 2 to 3.1(p = 0.154). The project improved uptake of TB services among adolescents along the TB care cascade. We recommend a robust and fully powered randomized controlled trial to evaluate the effectiveness of the Package.

Quality matters: Redefining child TB care with an emphasis on quality

BackgroundIn China, tuberculosis (TB) care, traditionally provided through the Centre for Disease Control (CDC), has been integrated into ‘designated’ public hospitals at County level, with hospital staff taking on delivery of TB services supported by CDC staff. Little is known about the impact of this initiative on the hospital-based health workers who were delegated to manage TB. Drawing on a case study of two TB ‘designated’ hospitals in Zhejiang province, we explored factors influencing hospital-based health workers’ motivation in the context of integrated TB service delivery.MethodsWe conducted 47 in-depth interviews with health officials, TB/hospital managers, clinicians, radiologists, laboratory staff and nurses involved in the integrated model of hospital-based TB care. Thematic analysis was used to develop and refine themes, code the data and assist in interpretation.ResultsHealth workers tasked with TB care in ‘designated’ hospitals perceived their professional status to be low, related to their assessment of TB treatment as lacking need for professional skills, their limited opportunities for professional development, and the social stigma surrounding TB. In both sites, the integrated TB clinics were under-staffed: health workers providing TB care reported heavy workloads, and expressed dissatisfaction with a perceived gap in their salaries compared with other clinical staff. In both sites, health workers were concerned about poor infection control and weak risk management assessment systems.ConclusionsInadequate attention to workforce issues for TB control in China, specifically the professional status, welfare, and development as well as incentivization of infectious disease control workers has contributed to dissatisfaction and consequently poor motivation to serve TB patients within the integrated model of TB care. It is important to address the failure to motivate health workers and maximize public good-oriented TB service provision through improved government funding and attention to the professional welfare of health workers providing TB care in hospitals.

Pathways to care for people with chronic respiratory diseases (CRDs) remain inadequate in many low- and middle-income countries (LMICs). In this opinion piece we describe opportunities for the integration of tuberculosis (TB) and respiratory care, as a means of improving patient outcomes.TB and CRDs are intricately linked in many LMICs. People with pulmonary TB (PTB) and CRDs experience similar symptoms, including breathlessness, cough, and chest pain. They may have similar risk factors for disease, including smoking and occupational exposures. PTB is a direct cause of lung damage in the form of post-TB lung disease. Both groups are often directed to TB services as a first point of contact, where they are known as ‘people with presumptive TB’. However, despite the overlap in risk factors, symptoms, and harms described above, public health and clinical care pathways for TB and CRDs remain almost entirely separate in many LMICs.It is likely that co-ordinated approaches to prevention, diagnosis and care would improve patient outcomes. Strategies may include upstream public health interventions to address shared risk factors, the use of shared diagnostic pathways, the provision of decentralised access to both TB and CRD care, and co-ordinated information provision about the risk factors and symptoms of both conditions. Health-related benefits may include more timely diagnosis of CRDs, improved CRD treatment and care, and reduced inappropriate empirical TB treatment or retreatment. Integrated approach may be particularly timely, given increasing scarcity in global health donor funding.However, we also highlight the need for further data in this space. Robust approaches to the design and evaluation of integrated services are lacking. Observational work describing the core components and potential impact of integrated care, and pilot models of integrated care are much needed to inform person-centred approaches to TB and respiratory care in LMICs.

SETTING: Nine high-burden public tuberculosis (TB) clinics in Gaborone, Botswana.OBJECTIVE: To evaluate the challenges encountered, healthcare worker (HCW) approaches, and supported interventions in TB and TB-HIV (human immunodeficiency virus) care for adolescents and young adults (AYA, aged 10-24 years).DESIGN: Semi-structured interviews with HCW in TB clinics, analyzed using thematic analysis.RESULTS: Sixteen HCWs were interviewed. AYA developmental needs included reliance on family support for care, increasing autonomy, attending school or work, building trust in HCWs, and intensive TB education and adherence support. Stigma strongly influenced care engagement, including clinic attendance and HIV testing. Health system barriers to optimal AYA TB care included limited staffing and resources to follow-up or support. HCWs utilized intensive education and counseling, and transitioned AYA to community-based directly observed therapy whenever feasible. HCWs supported implementation of youth-friendly services, such as AYA-friendly spaces or clinic days, training in AYA care, use of mobile applications, and peer support interventions, in addition to health system strengthening.CONCLUSION: HCWs utilize dedicated approaches for AYA with TB, but have limited time and resources for optimal care. They identified several strategies likely to improve care and better retain AYAs in TB treatment. Further work is needed to study interventions to improve AYA TB care and outcomes.

<h2>Abstract</h2><h3>Background</h3> Tuberculosis (TB) remains significant public health issue in India, particularly in high-burden areas. Understanding factors associated with adverse treatment outcomes and delays in TB care pathway is crucial for improving TB control efforts. Hence, this study aimed to identify the determinants of delay in TB care pathway and adverse treatment outcomes in Chennai, South India. <h3>Methods</h3> We conducted retrospective cohort study among 497 newly diagnosed, drug-sensitive TB patients at ESIC Medical College & PGIMSR, Chennai, from April 2020 to April 2022. Data were collected from the National TB Elimination Programme portal and supplemented via phone interviews. Patients were assessed for sociodemographic, behavioral, and clinical characteristics, and delays in TB care cascade. Logistic regression models identified predictors of patient delay, total delay, non-adherence, and adverse treatment outcomes and interpreted as adjusted odds ratio (AOR). <h3>Results</h3> The study found median patient delay of 18 days and total delay of 28 days in TB care pathway. Females and patients without fever at baseline had significantly longer delays. Extrapulmonary TB was associated with longer total delay. Non-adherence to medication was prevalent (26.6 %) and was the strongest predictor of adverse treatment outcomes (AOR:39.18, 95 %CI: 21.56–71.20, p < 0.001). <h3>Conclusion</h3> Our study found significant delays in care-seeking, especially among females and individuals without fever at baseline. Non-adherence to treatment was prevalent and associated with adverse treatment outcomes. Implementation of community-based adherence support programs that include regular patient follow-ups and counseling sessions will address barriers to treatment adherence, especially tailored for women and individuals with extrapulmonary TB.

Situational analysis of tuberculosis control programs in the Eastern Mediterranean Region: Gaps and solutions

BackgroundLow- and middle-income countries (LMICs) are facing a combined affliction from both tuberculosis (TB) and noncommunicable diseases (NCDs), which threatens population health and further strains the already stressed health systems. Integrating services for TB and NCDs is advantageous in tackling this joint burden of diseases effectively. Therefore, this systematic review explores the mechanisms for service integration for TB and NCDs and elucidates the facilitators and barriers for implementing integrated service models in LMIC settings.Methods and findingsA systematic search was conducted in the Cochrane Library, MEDLINE, Embase, PubMed, Bibliography of Asian Studies, and the Global Index Medicus from database inception to November 4, 2021. For our search strategy, the terms “tuberculosis” AND “NCDs” (and their synonyms) AND (“delivery of healthcare, integrated” OR a range of other terms representing integration) were used. Articles were included if they were descriptions or evaluations of a management or organisational change strategy made within LMICs, which aim to increase integration between TB and NCD management at the service delivery level. We performed a comparative analysis of key themes from these studies and organised the themes based on integration of service delivery options for TB and NCD services. Subsequently, these themes were used to reconfigure and update an existing framework for integration of TB and HIV services by Legido-Quigley and colleagues, which categorises the levels of integration according to types of services and location where services were offered. Additionally, we developed themes on the facilitators and barriers facing integrated service delivery models and mapped them to the World Health Organization’s (WHO) health systems framework, which comprises the building blocks of service delivery, human resources, medical products, sustainable financing and social protection, information, and leadership and governance.A total of 22 articles published between 2011 and 2021 were used, out of which 13 were cross-sectional studies, 3 cohort studies, 1 case–control study, 1 prospective interventional study, and 4 were mixed methods studies. The studies were conducted in 15 LMICs in Asia, Africa, and the Americas. Our synthesised framework explicates the different levels of service integration of TB and NCD services. We categorised them into 3 levels with entry into the health system based on either TB or NCDs, with level 1 integration offering only testing services for either TB or NCDs, level 2 integration offering testing and referral services to linked care, and level 3 integration providing testing and treatment services at one location. Some facilitators of integrated service include improved accessibility to integrated services, motivated and engaged providers, and low to no cost for additional services for patients. A few barriers identified were poor public awareness of the diseases leading to poor uptake of services, lack of programmatic budget and resources, and additional stress on providers due to increased workload. The limitations include the dearth of data that explores the experiences of patients and providers and evaluates programme effectiveness.ConclusionsIntegration of TB and NCD services encourages the improvement of health service delivery across disease conditions and levels of care to address the combined burden of diseases in LMICs. This review not only offers recommendations for policy implementation and improvements for similar integrated programmes but also highlights the need for more high-quality TB–NCD research.

BackgroundThere is a paucity of empiric data evaluating whether Tuberculosis (TB) is a useful surrogate measure for Universal Health Coverage (UHC), despite recognition of the importance of TB control efforts as part of the broader UHC agenda. We hypothesized that indicators of TB burden and coverage are sensitive tracers of UHC, when compared to other disease-specific indicators of service provision.MethodsLinear regression models were used to determine the extent to which variability in UHC Service Coverage Index (SCI) was accounted for by (1) TB incidence rates and (2) TB mortality rates across 183 countries. Dominance analyses, stratifying countries by World Bank income criteria and TB burden, were used to determine the importance of TB treatment coverage in predicting UHC SCI scores, relative to other disease-specific indicators of service provision.ResultsAcross 183 countries, TB incidence rate and TB mortality rate were negatively correlated, with UHC SCI score, (r = -0.67 and r = -0.74, respectively). In linear regression models including all 183 countries, TB incidence rates explained 45% of the variability in SCI scores; TB mortality rate explained 55% of variability. Restricting models to the 30 highest TB burden countries, both incidence and mortality explained less of the variability in SCI score (16% and 36%, respectively). In dominance analysis, comparing 13 disease-specific indicators of service provision, TB effective treatment coverage, ranked ninth overall. In dominance analysis stratified by TB burden, the TB treatment coverage estimate was ranked ninth in the 30 high burden countries and sixth in the 153 non-high burden countries. In separate analyses stratified by world bank income status, TB coverage ranked as third most important variable in LICs and fifth in LMICs and UMICs, but was less important in analysis restricted HICs (ranked seventh).ConclusionsCompared to other disease-specific indicators of service provision, TB coverage was an important indicator of overall UHC service coverage, especially in low-income countries. These findings highlight that national-level inequities in TB-coverage may be an important tracer of universal health coverage.

World Tuberculosis Day 2022: aligning COVID-19 and tuberculosis innovations to save lives and to end tuberculosis

Although tuberculosis (TB) affects people worldwide, particularly those of lower socioeconomic status, the vast majority of the burden is felt in low- and middle-income countries (LMICs). In turn, the ethical challenges posed by TB care and control are especially salient in LMICs faced with acute and chronic resource constraints. For some of these challenges, there is broad agreement about what ought to be done. TB prevention among close contacts of contagious patients, for example, is essential. Other challenges, however, are either new or refractory and require greater consideration. This chapter discusses three such key ethical challenges posed by TB care and control, particularly within the context of LMICs: isolation and involuntary isolation, third-party notification, and the introduction of new antitubercular drugs.

Characteristics, knowledge, attitude, and practice of pharmacy personnel in supporting tuberculosis treatment: A multicenter cross-sectional study in a high-burden tuberculosis country

There is a high burden of both diabetes (DM) and tuberculosis (TB) in China, and as DM increases the risk of TB and adversely affects TB treatment outcomes, there is a need for bidirectional screening of the two diseases. How this is best performed is not well determined. In this pilot project in China, we aimed to assess the feasibility and results of screening DM patients for TB within the routine healthcare setting of five DM clinics. Agreement on how to screen, monitor and record was reached in May 2011 at a national stakeholders meeting, and training was carried out for staff in the five clinics in July 2011. Implementation started in September 2011, and we report on 7 months of activities up to 31 March 2012. DM patients were screened for TB at each clinic attendance using a symptom-based enquiry, and those positive to any symptom were referred for TB investigations. In the three quarters, 72% of 3174 patients, 79% of 7196 patients and 68% of 4972 patients were recorded as having been screened for TB, resulting in 7 patients found who were already known to have TB, 92 with a positive TB symptom screen and 48 of these newly diagnosed with TB as a result of referral and investigation. All patients except one were started on anti-TB treatment. TB case notification rates in screened DM patients were several times higher than those of the general population, were highest for the five sites combined in the final quarter (774/100 000) and were highest in one of the five clinics in the final quarter (804/100 000) where there was intensive in-house training, special assignment of staff for screening and colocation of services. This pilot project shows that it is feasible to carry out screening of DM patients for TB resulting in high detection rates of TB. This has major public health and patient-related implications.