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Factors influencing diagnosis and treatment initiation for ...Drug- resistant tuberculosis (DR- TB)...
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1 Oga-Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280 Factors influencing diagnosis and treatment initiation for multidrug- resistant/rifampicin-resistant tuberculosis in six sub-Saharan African countries: a mixed-methods systematic review Charity Oga-Omenka , 1,2,3 Azhee Tseja-Akinrin, 4 Paulami Sen, 3,5 Muriel Mac-Seing , 1,2 Aderonke Agbaje, 6 Dick Menzies, 3,5 Christina Zarowsky 1,2,7 Original research To cite: Oga-Omenka C, Tseja-Akinrin A, Sen P, et al. Factors influencing diagnosis and treatment initiation for multidrug-resistant/rifampicin- resistant tuberculosis in six sub-Saharan African countries: a mixed-methods systematic review. BMJ Global Health 2020;5:e002280. doi:10.1136/ bmjgh-2019-002280 Handling editor Alberto L Garcia-Basteiro ► Additional material is published online only. To view, please visit the journal online (http://dx.doi.org/10.1136/ bmjgh-2019-002280). Received 6 January 2020 Revised 10 April 2020 Accepted 15 April 2020 For numbered affiliations see end of article. Correspondence to Ms Charity Oga-Omenka; [email protected] © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. ABSTRACT Background Drug-resistant tuberculosis burdens fragile health systems in sub-Saharan Africa (SSA), complicated by high prevalence of HIV. Several African countries reported large gaps between estimated incidence and diagnosed or treated cases. Our review aimed to identify barriers and facilitators influencing diagnosis and treatment for drug- resistant tuberculosis (DR-TB) in SSA, which is necessary to develop effective strategies to find the missing incident cases and improve quality of care. Methods Using an integrative design, we reviewed and narratively synthesised qualitative, quantitative and mixed-methods studies from nine electronic databases: Medline, Global Health, CINAHL, EMBASE, Scopus, Web of Science, International Journal of Tuberculosis and Lung Disease, PubMed and Google Scholar (January 2006 to June 2019). Results Of 3181 original studies identified, 55 full texts were screened, and 29 retained. The studies included were from 6 countries, mostly South Africa. Barriers and facilitators to DR-TB care were identified at the health system and patient levels. Predominant health system barriers were laboratory operational issues, provider knowledge and attitudes and information management. Facilitators included GeneXpert MTB/RIF (Xpert) diagnosis and decentralisation of services. At the patient level, predominant barriers were patients being lost to follow-up or dying due to lengthy diagnostic and treatment delays, negative public sector care perceptions, family, work or school commitments and using private sector care. Some patient-level facilitators were HIV positivity and having more symptoms. Conclusion Case detection and treatment for DR -TB in SSA currently relies on individual patients presenting voluntarily to the hospital for care. Specific interventions targeting identified barriers may improve rates and timeliness of detection and treatment. INTRODUCTION Drug-resistant tuberculosis (DR-TB) is a major threat to global health as it undermines gains in TB control, and is especially burdensome to health systems in resource-limited settings. 1 Defined as TB resistant to both isoniazid and rifampicin, it is the leading cause of deaths Summary box What is already known? ► Globally, only 39% and 32% of the estimated drug-resistant tuberculosis (DR-TB) patients are diagnosed and started on appropriate treatment, respectively. ► Ten high burden countries in Africa contributed 12% of the estimated global incident cases in 2018, with 54% of these in only Nigeria and South Africa. ► For patients who are diagnosed and placed on treat- ment, delays in access to diagnosis and treatment were up to several months in some sub-Saharan African countries. What are the new findings? ► Laboratory operational challenges as well as inad- equate healthcare worker knowledge, attitude and skills were the predominant barriers noted at the health system level. ► Predominant patient-level barriers included loss to follow-up and death, as well as inability to pay care- related costs. ► Availability of newer diagnostic tools was the pre- dominant health-level facilitator of quicker diagnosis and treatment; however, this did not always trans- late to significantly higher rates of diagnosis and treatment. What do the new findings imply? ► Implementers and policymakers need to better un- derstand and address various issues that impact DR-TB care at different levels, in order to maximise the impact of new care innovations. on August 10, 2021 by guest. Protected by copyright. http://gh.bmj.com/ BMJ Glob Health: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. Downloaded from
Transcript of Factors influencing diagnosis and treatment initiation for ...Drug- resistant tuberculosis (DR- TB)...
1Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280
Factors influencing diagnosis and treatment initiation for multidrug- resistant/rifampicin- resistant tuberculosis in six sub- Saharan African countries: a mixed- methods systematic review
Charity Oga- Omenka ,1,2,3 Azhee Tseja- Akinrin,4 Paulami Sen,3,5 Muriel Mac- Seing ,1,2 Aderonke Agbaje,6 Dick Menzies,3,5 Christina Zarowsky1,2,7
Original research
To cite: Oga- Omenka C, Tseja- Akinrin A, Sen P, et al. Factors influencing diagnosis and treatment initiation for multidrug- resistant/rifampicin- resistant tuberculosis in six sub- Saharan African countries: a mixed- methods systematic review. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280
Handling editor Alberto L Garcia- Basteiro
► Additional material is published online only. To view, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjgh- 2019- 002280).
Received 6 January 2020Revised 10 April 2020Accepted 15 April 2020
For numbered affiliations see end of article.
Correspondence toMs Charity Oga- Omenka; omenkac@ gmail. com
© Author(s) (or their employer(s)) 2020. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.
AbsTrACTbackground Drug- resistant tuberculosis burdens fragile health systems in sub- Saharan Africa (SSA), complicated by high prevalence of HIV. Several African countries reported large gaps between estimated incidence and diagnosed or treated cases. Our review aimed to identify barriers and facilitators influencing diagnosis and treatment for drug- resistant tuberculosis (DR- TB) in SSA, which is necessary to develop effective strategies to find the missing incident cases and improve quality of care.Methods Using an integrative design, we reviewed and narratively synthesised qualitative, quantitative and mixed- methods studies from nine electronic databases: Medline, Global Health, CINAHL, EMBASE, Scopus, Web of Science, International Journal of Tuberculosis and Lung Disease, PubMed and Google Scholar (January 2006 to June 2019).results Of 3181 original studies identified, 55 full texts were screened, and 29 retained. The studies included were from 6 countries, mostly South Africa. Barriers and facilitators to DR- TB care were identified at the health system and patient levels. Predominant health system barriers were laboratory operational issues, provider knowledge and attitudes and information management. Facilitators included GeneXpert MTB/RIF (Xpert) diagnosis and decentralisation of services. At the patient level, predominant barriers were patients being lost to follow- up or dying due to lengthy diagnostic and treatment delays, negative public sector care perceptions, family, work or school commitments and using private sector care. Some patient- level facilitators were HIV positivity and having more symptoms.Conclusion Case detection and treatment for DR -TB in SSA currently relies on individual patients presenting voluntarily to the hospital for care. Specific interventions targeting identified barriers may improve rates and timeliness of detection and treatment.
InTroduCTIonDrug- resistant tuberculosis (DR- TB) is a major threat to global health as it undermines gains
in TB control, and is especially burdensome to health systems in resource- limited settings.1 Defined as TB resistant to both isoniazid and rifampicin, it is the leading cause of deaths
summary box
What is already known? ► Globally, only 39% and 32% of the estimated drug- resistant tuberculosis (DR- TB) patients are diagnosed and started on appropriate treatment, respectively.
► Ten high burden countries in Africa contributed 12% of the estimated global incident cases in 2018, with 54% of these in only Nigeria and South Africa.
► For patients who are diagnosed and placed on treat-ment, delays in access to diagnosis and treatment were up to several months in some sub- Saharan African countries.
What are the new findings? ► Laboratory operational challenges as well as inad-equate healthcare worker knowledge, attitude and skills were the predominant barriers noted at the health system level.
► Predominant patient- level barriers included loss to follow- up and death, as well as inability to pay care- related costs.
► Availability of newer diagnostic tools was the pre-dominant health- level facilitator of quicker diagnosis and treatment; however, this did not always trans-late to significantly higher rates of diagnosis and treatment.
What do the new findings imply? ► Implementers and policymakers need to better un-derstand and address various issues that impact DR- TB care at different levels, in order to maximise the impact of new care innovations.
on August 10, 2021 by guest. P
rotected by copyright.http://gh.bm
j.com/
BM
J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
2 Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280
BMJ Global Health
Figure 1 Study selection. SSA, sub- Saharan Africa; TB, tuberculosis.
due to antimicrobial resistance and took an estimated 214 000 lives in 2018.2 The 2018 United Nations High- Level resolution to ‘end TB including DR- TB’ by acceler-ating access to affordable prevention and care, is in line with earlier goals including the Sustainable Development Goals (SDGs) and The End TB Strategy.3–5 To meet these goals, it is essential to synthesise the growing evidence on barriers and facilitators to DR- TB care.
DR- TB is more difficult to diagnose and treat than drug- susceptible TB and is often associated with up to 5.5 times higher treatment costs, longer treatment courses and lower treatment success rates.1 2 6 Glob-ally, only 39% and 32% of the estimated patients diag-nosed with DR- TB are started on appropriate treatment, respectively.2 Ten high burden countries (HBCs) in sub- Saharan Africa (SSA) contributed 12% of the 484 000 estimated incident cases in 2018, mostly in Nigeria and
South Africa. Nigeria and Mozambique were among 10 countries contributing 75% of the global treatment enrolment gap.2
Gaps in TB care were notedly higher in Africa, where the HIV- associated TB incidence is highest, as HIV further complicates TB care. Of 14 countries classi-fied by WHO as HBCs for TB, DR- TB and HIV, 8 are in Africa.2
For patients with DR- TB who are diagnosed and treated, several studies have reported delays in access running into several months in several SSA countries.7–10 These delays, occurring at patient and health system (provider) levels, contribute to increased morbidity, infection transmission, loss to follow- up and poorer treat-ment outcomes.11 12 This review examines any synthe-sised qualitative and quantitative literature, with a view to inform policy and practice in SSA.
on August 10, 2021 by guest. P
rotected by copyright.http://gh.bm
j.com/
BM
J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280 3
BMJ Global Health
Tab
le 1
O
verv
iew
of s
elec
ted
stu
die
s
Stu
dy
ID
num
ber
Stu
dy
(yea
r),
coun
try
Res
earc
h d
esig
n an
d
met
hod
sP
erio
dP
op
ulat
ions
(n
umb
er)
Stu
dy
ob
ject
ives
Leve
l of
care
(d
iag
nosi
s/tr
eatm
ent)
Dim
ensi
ons
o
f ac
cess
Sum
mar
y o
f fi
ndin
gs
Ass
essm
ent
of
stud
y q
ualit
y (s
core
)
Qua
litat
ive
stud
ies
1B
ieh
(201
7)N
iger
ia
Qua
litat
ive
FGD
s, ID
Is a
nd
KIIs
2014
Pat
ient
s (1
1)
and
hea
lth
wor
kers
(4)
NA
Trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Trea
tmen
t d
elay
s d
ue t
o st
igm
a an
d d
iscr
imin
atio
n,
as w
ell a
s a
lack
of r
equi
red
ho
spita
l too
ls.
B
2N
aid
oo(2
015)
Sou
th A
fric
a
Qua
litat
ive
IDIs
(par
t of
a
big
ger
stud
y in
clud
ing
a re
tros
pec
tive
coho
rt20
10–2
012
Pat
ient
s (2
6)N
AD
iagn
osis
and
tr
eatm
ent
Str
uctu
ral
and
pat
ient
d
imen
sion
s
Pat
ient
s b
elie
fs a
nd k
now
led
ge
of T
B s
ymp
tom
s, w
rong
p
erce
ptio
ns o
f hea
lthca
re
and
fam
ily c
omm
itmen
ts,
com
pou
nded
by
heal
th
syst
ems
mis
sed
op
por
tuni
ties
and
del
ays,
imp
act
acce
ss.
A
Qua
ntit
ativ
e st
udie
s
3C
ox(2
015)
Sou
th A
fric
a
Ret
rosp
ectiv
e tr
end
an
alys
is20
09–
2013
Pat
ient
s (1
58)
Tim
e to
tre
atm
ent
initi
atio
n (T
TI)
bef
ore
the
dec
entr
alis
atio
n,
dur
ing
dec
entr
alis
atio
n an
d a
fter
d
ecen
tral
isat
ion.
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l d
imen
sion
sD
ecen
tral
isat
ion
and
in
trod
ucin
g X
per
t w
ere
asso
ciat
ed w
ith s
igni
fican
t re
duc
tions
in T
TI, a
fter
initi
al
gain
s w
ith t
he L
PA.
B
4C
ox(2
017)
Sou
th A
fric
a
Ret
rosp
ectiv
e co
hort
stu
dy
2011
–201
3P
atie
nts
(250
8 in
201
1)(2
528
in 2
013)
Trea
tmen
t in
itiat
ion
wer
e as
sess
ed a
mon
g la
bor
ator
y-
dia
gnos
ed p
atie
nts
bef
ore
and
af
ter
Xp
ert
imp
lem
enta
tion.
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Pat
ient
s ag
e an
d H
IV
stat
us, a
s w
ell a
s d
iagn
ostic
tim
elin
ess
del
ay a
cces
s.
A
5D
lam
ini-
M
vela
se(2
014)
Sou
th A
fric
a
Ret
rosp
ectiv
e co
hort
stu
dy
2011
–201
2P
atie
nts
(637
)A
vaila
bili
ty o
f con
firm
ator
y D
ST
and
TTI
with
Xp
ert
com
par
ed
with
phe
noty
pic
and
gen
otyp
ic
DS
T.
Dia
gnos
isS
truc
tura
l d
imen
sion
sP
oor
adhe
renc
e to
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ert
algo
rithm
was
due
to
rollo
ut
of X
per
t p
rece
din
g tr
aini
ng o
f cl
inic
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A
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ntit
ativ
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udie
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6E
bon
wu
(201
3)S
outh
Afr
ica
Cro
ss- s
ectio
nal s
tud
y20
11P
atie
nts
(942
)E
valu
atio
n of
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atm
ent
upta
ke,
loss
to
follo
w- u
p a
nd r
eten
tion
of
new
ly d
iagn
osed
pat
ient
s.
Trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Ref
erra
ls fr
om h
osp
itals
, som
e he
alth
dis
tric
ts, b
eing
HIV
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gativ
e an
d t
owns
hip
pla
ce
of r
esid
ence
wer
e as
soci
ated
w
ith t
reat
men
t no
n- in
itiat
ion.
A
7E
vans
et
al(2
018)
Sou
th A
fric
a
Ret
rosp
ectiv
e co
hort
stu
dy:
Firs
t co
hort
: 201
1–20
12 (3
5%
Xp
ert
imp
lem
enta
tion)
Sec
ond
coh
ort:
201
3201
4 (>
90%
imp
lem
enta
tion)
Pat
ient
s:Fi
rst
coho
rt
(594
)S
econ
d
coho
rt 7
13
Com
par
ed t
reat
men
t in
itiat
ion
and
TTI
forla
bor
ator
y- co
nfirm
ed
pat
ient
s w
ith (fi
rst
vs s
econ
d
coho
rt).
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Xp
ert
imp
lem
enta
tion
incr
ease
d d
iagn
ostic
cap
acity
an
d t
reat
men
t ra
tes.
A
Con
tinue
d
on August 10, 2021 by guest. P
rotected by copyright.http://gh.bm
j.com/
BM
J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
4 Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280
BMJ Global Health
Stu
dy
ID
num
ber
Stu
dy
(yea
r),
coun
try
Res
earc
h d
esig
n an
d
met
hod
sP
erio
dP
op
ulat
ions
(n
umb
er)
Stu
dy
ob
ject
ives
Leve
l of
care
(d
iag
nosi
s/tr
eatm
ent)
Dim
ensi
ons
o
f ac
cess
Sum
mar
y o
f fi
ndin
gs
Ass
essm
ent
of
stud
y q
ualit
y (s
core
)
8H
anra
han
et a
l(2
012)
Sou
th A
fria
Ob
serv
atio
nal c
ohor
t st
udy:
2007
– 20
08 w
ith M
GIT
p
heno
typ
ic D
ST
2009
– 20
10 w
ith L
PA
Pat
ient
s (n
=11
76
MG
IT) a
nd
(n=
1177
LPA
)
Com
par
ed d
ata
on p
atie
nts
regi
stra
tion
bef
ore
and
aft
er a
n ex
pan
ded
DS
T al
gorit
hm.
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Intr
oduc
ing
the
fast
er L
PA
DS
T te
stin
g cu
t d
own
time
to
dia
gnos
is a
nd in
crea
sed
cas
e d
etec
tion
with
out
the
exp
ecte
d
imp
act
on T
TI d
ue t
o ot
her
heal
th s
yste
m b
ottle
neck
s.
A
9H
anra
han
(201
3)S
outh
Afr
ica
Pro
spec
tive
coho
rt s
tud
yJu
l–S
ep 2
011
Pat
ient
s (6
41)
Eva
luat
ed d
iagn
ostic
follo
w- u
p
and
out
com
es fo
r a
coho
rt o
f p
resu
mp
tive
pat
ient
s sc
reen
ed
usin
g a
sing
le p
oint
- of-
care
X
per
t.
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Poi
nt- o
f- ca
re X
per
t p
rovi
ded
q
uick
er t
reat
men
t in
itiat
ion,
m
ostly
sam
e d
ay t
reat
men
t.Th
is w
as 2
wee
ks fa
ster
tha
n fo
r th
ose
star
ted
em
piri
cally
or
bas
ed o
n su
gges
tive
ches
t X
- ra
y, a
nd 2
0 w
eeks
fast
er t
han
for
cultu
re d
iagn
osis
.
A
10Ir
ued
o(2
017)
Sou
th A
fric
a
Ret
rosp
ectiv
e co
hort
stu
dy
Jan
2009
–Dec
201
4P
atie
nts
(342
)A
naly
sed
rec
ord
s of
dia
gnos
ed
pat
ient
s, c
omp
arin
g d
iagn
ostic
m
odal
ities
to
asse
ss t
he X
per
t ef
fect
on
TTI.
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Xp
ert
sign
ifica
ntly
red
uced
th
e tim
e to
dia
gnos
is a
nd T
TI.
This
was
sig
nific
antly
sho
rter
co
mp
ared
with
LPA
and
cu
lture
/phe
noty
pic
DS
T.
A
11Ja
cob
son
(201
2)S
outh
Afr
ica
Ret
rosp
ectiv
e co
hort
stu
dy
2007
–201
1P
atie
nts
(197
)C
omp
ared
rec
ord
s of
pat
ient
s te
sted
usi
ng t
he M
TBD
Rp
lus
and
with
cul
ture
- bas
ed D
ST
to
det
erm
ine
if TT
I fro
m s
pec
imen
co
llect
ion
was
sho
rten
ed.
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
The
use
of L
PA fo
r d
iagn
osis
d
ram
atic
ally
imp
rove
d T
TI
but
lab
orat
ory
and
clin
ical
op
erat
iona
l del
ays
rem
aine
d a
p
rob
lem
.
A
Qua
ntit
ativ
e st
udie
s
12Ja
cob
son
et a
l(2
017)
Sou
th A
fric
a
Ret
rosp
ectiv
e co
hort
in
Wes
tern
Cap
e: t
wo
sam
ple
s at
bas
elin
e— fo
r X
per
t; a
nd
for
LPA
plu
s D
ST
2011
– 20
13.
Pro
spec
tive
coho
rt in
thr
ee
othe
r p
rovi
nces
: one
sam
ple
co
llect
ed a
t b
asel
ine
for
Xp
ert;
a s
ubse
que
nt o
ne fo
r LP
A p
lus
cultu
re- b
ased
DS
T on
ly w
ith d
etec
tion
of R
R- T
B.
2012
– 20
13
Pat
ient
s (1
332)
*Wes
tern
C
ape
Pro
vinc
e:
(835
)*E
aste
rn
Cap
e, F
ree
Sta
te a
nd
Gau
teng
P
rovi
nce:
(4
97)
Qua
ntifi
ed t
he t
ime
to D
ST
resu
lts a
nd p
rop
ortio
n of
pat
ient
s p
oten
tially
pla
ced
on
sub
optim
al
ther
apy.
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Inco
mp
lete
and
dec
reas
ing
adhe
renc
e to
Nat
iona
l re
qui
rem
ents
for
DS
Tim
ped
es
dia
gnos
is r
ates
.Lo
ng t
urna
roun
d t
ime
for
DS
T re
sults
follo
win
g R
R- T
B
dia
gnos
is.
A
Tab
le 1
C
ontin
ued
Con
tinue
d
on August 10, 2021 by guest. P
rotected by copyright.http://gh.bm
j.com/
BM
J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280 5
BMJ Global Health
Stu
dy
ID
num
ber
Stu
dy
(yea
r),
coun
try
Res
earc
h d
esig
n an
d
met
hod
sP
erio
dP
op
ulat
ions
(n
umb
er)
Stu
dy
ob
ject
ives
Leve
l of
care
(d
iag
nosi
s/tr
eatm
ent)
Dim
ensi
ons
o
f ac
cess
Sum
mar
y o
f fi
ndin
gs
Ass
essm
ent
of
stud
y q
ualit
y (s
core
)
13Jo
kwiro
et
al(2
018)
Zim
bab
we
Cro
ss- s
ectio
nal s
tud
y.20
16–
2017
with
tw
o p
hase
s:X
per
t on
ly fo
r p
resu
mp
tive
DR
- TB
and
HIV
coi
nfec
tion:
2016
;X
per
t re
com
men
ded
for
all
pre
sum
ptiv
e p
atie
nts:
2017
.
. Thirt
een
Xp
ert
assa
ys
(13
137
tota
l as
says
):*2
016:
(455
6)*2
017:
(858
1)
Com
par
ed t
he u
se o
f dep
loyi
ng
Xp
ert
only
for
pre
sum
ptiv
e D
R-
TB a
nd H
IV c
oinf
ectio
n vs
Xp
ert
for
all p
resu
mp
tive
TB p
atie
nts.
Dia
gnos
isS
truc
tura
l d
imen
sion
sIn
crea
sed
acc
ess
to X
per
t ut
ilisa
tion
bey
ond
hig
h- ris
k gr
oup
s sl
ight
ly in
crea
sed
d
etec
tion
of d
rug
susc
eptib
le
TB, b
ut n
ot D
R- T
B s
trai
ns.
Per
sist
ent
HS
cha
lleng
es
imp
eded
Xp
ert
utili
satio
n.
A
14K
wez
a(2
018)
Sou
th A
fric
a
Cro
ss- s
ectio
nal s
urve
y20
15P
atie
nts
(125
5)E
stim
ated
the
pro
por
tion
of
pat
ient
s m
isse
d b
y P
HC
s us
ing
surv
eys
and
tes
ting.
Dia
gnos
isS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
HS
mis
sed
mos
t p
atie
nts
with
TB
att
end
ing
PH
Cs
for
TB- r
elat
ed s
ymp
tom
s an
d fo
r ot
her
reas
ons.
A
15M
cLar
en(2
017)
Sou
th A
fric
a
Hea
lthca
re e
valu
atio
n20
04–2
011
26 m
illio
n te
sts
in 4
29
hosp
itals
Ass
esse
d q
ualit
y of
car
e in
pub
lic
heal
th fa
cilit
ies
by
anal
ysin
g N
atio
nal H
ealth
Lab
orat
ory
Ser
vice
dat
abas
e fo
r TB
tes
ts .
Dia
gnos
isS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Faci
litie
s no
t ad
herin
g to
na
tiona
l sta
ndar
ds
for
TB
test
ing.
How
ever
, DS
T ra
tes
imp
rove
d s
tead
ily o
ver
time.
Test
ing
rate
s w
ere
tran
sien
tly
affe
cted
by
pol
icy
and
gu
idel
ine
chan
ges.
B
Qua
ntit
ativ
e st
udie
s
16M
etca
lfe e
t al
(201
6)Z
imb
abw
e
Pro
spec
tive
stud
y:20
11–
2014
Pat
ient
s (3
52)
Dia
gnos
tic a
ccur
acy
and
TTI
fo
r X
per
t w
ere
com
par
ed w
ith
cultu
re a
nd D
ST.
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Rap
id d
iagn
osis
with
Xp
ert
was
not
, in
itsel
f, en
ough
to
rem
ove
heal
th s
yste
m d
elay
s to
tre
atm
ent
initi
atio
n.
A
17M
ohr
(201
7)S
outh
Afr
ica
Ret
rosp
ectiv
e co
hort
stu
dy
2012
– 20
14P
atie
nts
(543
)A
naly
sed
rec
ord
s of
dia
gnos
ed
pat
ient
s to
ass
ess
pro
por
tion
that
cou
ld h
ave
bee
n d
iagn
osed
ea
rlier
.
Dia
gnos
isS
truc
tura
l d
imen
sion
sLa
ck o
f gui
del
ine
adhe
renc
e le
d t
o p
atie
nts
not
bei
ng
dia
gnos
ed.
A
18M
oyo
et a
l(2
015)
Sou
th A
fric
a
Ret
rosp
ectiv
e an
alys
is s
tud
y:20
08–2
013
Ad
oles
cent
p
atie
nts
(71)
Ana
lyse
d d
ata
for
adol
esce
nts
pat
ient
s to
des
crib
e fr
eque
ncy
of
trea
tmen
t su
cces
s or
failu
re, l
oss
to fo
llow
- up
and
dea
ths.
Trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Trea
tmen
t re
fusa
l and
lo
ss t
o fo
llow
- up
wer
e th
e p
red
omin
ant
reas
ons
for
non-
in
itiat
ion
of t
reat
men
t.
A
19N
aid
oo(2
014)
Sou
th A
fric
a
Ob
serv
atio
nal a
naly
sis
of 1
0 fa
cilit
ies
2008
– 20
12
Pat
ient
s (5
41)
Stu
dy
com
par
ed T
TI in
M
DR
TBP
lus
Line
Pro
be
Ass
ay v
s X
per
t- b
ased
alg
orith
ms.
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Xp
ert
red
uced
TTI
by
red
ucin
g LT
AT. H
owev
er, p
atie
nts
wer
e b
eing
del
ayed
by
othe
r st
eps
need
ed b
efor
e tr
eatm
ent
initi
atio
n.
A
20N
kosi
(201
3)S
outh
Afr
ica
Cro
ss- s
ectio
nal s
urve
y20
08P
atie
nts
(148
)D
eter
min
ed r
easo
ns fo
r no
n-
refe
rral
of D
R- T
B p
atie
nts.
Trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Poo
r H
CW
kno
wle
dge
of t
he
natio
nal D
R- T
B g
uid
elin
es,
and
pat
ient
s lo
ss t
o fo
llow
- up
co
ntrib
uted
to
non-
refe
rral
s.
A
Tab
le 1
C
ontin
ued
Con
tinue
d
on August 10, 2021 by guest. P
rotected by copyright.http://gh.bm
j.com/
BM
J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
6 Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280
BMJ Global Health
Stu
dy
ID
num
ber
Stu
dy
(yea
r),
coun
try
Res
earc
h d
esig
n an
d
met
hod
sP
erio
dP
op
ulat
ions
(n
umb
er)
Stu
dy
ob
ject
ives
Leve
l of
care
(d
iag
nosi
s/tr
eatm
ent)
Dim
ensi
ons
o
f ac
cess
Sum
mar
y o
f fi
ndin
gs
Ass
essm
ent
of
stud
y q
ualit
y (s
core
)
21O
ga- O
men
ka
et a
l(2
019)
Nig
eria
Ret
rosp
ectiv
e co
hort
stu
dy.
2015
– 20
17P
atie
nts
(996
)E
xam
ined
tre
atm
ent
rate
s an
d T
TI u
sing
201
5 th
e TB
p
rogr
amm
e re
cord
s.
Trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Geo
grap
hic
loca
tion
and
le
vel o
f hea
lthca
re in
fluen
ced
p
atie
nt t
reat
men
t in
itiat
ion
with
in t
he t
ime
reco
mm
end
ed
by
the
Nat
iona
l gui
del
ines
.
A
Qua
ntit
ativ
e st
udie
s
22O
liwa
et a
l(2
018)
Ken
ya
Cro
ss- s
ectio
nal s
tud
y:20
15P
atie
nts
(82
313)
Ana
lyse
d N
atio
nal T
B p
rogr
amm
e d
ata
for
case
not
ifica
tion
rate
s, a
nd c
apac
ity t
o p
erfo
rm
dia
gnos
tic t
ests
.
Dia
gnos
isS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Des
pite
gui
del
ine
spec
ifica
tions
, Xp
ert
use
was
sub
optim
al, n
egat
ivel
y af
fect
ing
dia
gnos
is, e
spec
ially
in
chi
ldre
n an
d lo
w r
isk
grou
ps.
A
23Ti
mire
et
al(2
019)
Zim
bab
we
Coh
ort
stud
y20
17–
2018
Pat
ient
s (1
33)
Det
erm
ined
the
imp
act
of t
he
Hai
n te
chno
logy
(tim
elin
ess
and
p
rop
ortio
n of
DS
T te
sts)
.
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Whi
le d
ecen
tral
isat
ion
and
tr
eatm
ent
acce
ss p
ositi
vely
im
pac
ted
TTI
, dis
tanc
e fr
om
the
NR
L hi
nder
ed t
imel
y co
llect
ion
and
ret
urn
of D
ST.
A
24Va
n D
en
Han
del
(201
5)S
outh
Afr
ica
Pro
spec
tive
eval
uatio
n of
diff
eren
t d
iagn
ostic
ap
pro
ache
s20
11–
2013
Pat
ient
s (1
449)
Det
erm
ined
the
imp
act
of X
per
t an
d d
ecen
tral
isat
ion
on p
atie
nt
care
in a
reas
with
poo
r ac
cess
to
lab
orat
ory
serv
ices
.
Dia
gnos
isS
truc
tura
l d
imen
sion
sX
per
t in
trod
uctio
n an
d
dec
entr
alis
atio
n im
pac
ted
tr
eatm
ent
rate
s an
d t
imel
ines
, b
ut d
id n
ot s
igni
fican
tly
incr
ease
rat
es o
f det
ectio
n.
A
Mix
ed- m
etho
ds
stud
ies
25D
oulla
et
al(2
019)
Tanz
ania
Qua
litat
ive
FGD
s, ID
Is: 2
012
Qua
ntita
tive
cros
s- se
ctio
nal
sam
ple
ana
lysi
s:20
11–
2013
Qua
litat
ive
45
HC
WQ
uant
itativ
e 27
59 s
amp
les
Eva
luat
ed t
he e
ffect
iven
ess
and
st
akeh
old
er p
erce
ptio
n of
rou
tine
surv
eilla
nce
syst
em fo
r p
revi
ousl
y tr
eate
d T
B c
ases
.
Dia
gnos
isS
truc
tura
l d
imen
sion
sD
elay
edsp
ecim
en
tran
spor
tatio
n, la
ck o
f re
sour
ces
and
oth
er
lab
orat
ory
chal
leng
es
(eg,
mis
com
mun
icat
ion,
in
cons
iste
nt t
rain
ing,
etc
) d
elay
ed d
iagn
osis
.
A
26M
pag
ama
et a
l(2
019)
Tanz
ania
Ret
rosp
ectiv
e co
hort
stu
dy
and
cro
ss- s
ectio
nal s
tud
y:
2015
28 T
B
dis
tric
ts39
9 p
atie
nts
Iden
tified
hea
lthca
re b
arrie
rs
to im
ple
men
tatio
n of
mol
ecul
ar
dia
gnos
tics
and
TB
col
lab
orat
ive
pra
ctic
es in
HIV
clin
ics.
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Ove
rall,
un
der
dia
gnos
esoc
curr
ed
whe
re d
rug
resi
stan
ce is
ex
pec
ted
to
be
pre
vale
nt.
HC
Ws
lack
ed t
he t
ools
, ex
per
tise
and
kno
wle
dge
to
app
rop
riate
ly m
anag
e p
atie
nts
with
TB
.
B
Mix
ed- m
etho
ds
stud
ies
Tab
le 1
C
ontin
ued
Con
tinue
d
on August 10, 2021 by guest. P
rotected by copyright.http://gh.bm
j.com/
BM
J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280 7
BMJ Global Health
Stu
dy
ID
num
ber
Stu
dy
(yea
r),
coun
try
Res
earc
h d
esig
n an
d
met
hod
sP
erio
dP
op
ulat
ions
(n
umb
er)
Stu
dy
ob
ject
ives
Leve
l of
care
(d
iag
nosi
s/tr
eatm
ent)
Dim
ensi
ons
o
f ac
cess
Sum
mar
y o
f fi
ndin
gs
Ass
essm
ent
of
stud
y q
ualit
y (s
core
)
27M
nyam
bw
a et
al
(201
8)Ta
nzan
ia
Ret
rosp
ectiv
e co
hort
stu
dy:
20
13–
2016
Qua
litat
ive:
IDIs
Cha
rt r
evie
w:
pat
ient
s (7
82)
Qua
litat
ive
inte
rvie
ws:
TB
co
ord
inat
ors
(27)
Ass
esse
d t
he e
ffect
iven
ess
of t
he
Xp
ert
GxA
lert
pla
tfor
mon
link
age
of p
atie
nts
to c
are.
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Alth
ough
the
GxA
lert
p
latf
orm
imp
rove
d d
iagn
osis
, he
alth
care
inco
nsis
tenc
ies
imp
aire
d c
orre
ct m
anag
emen
t of
pat
ient
s.
B
28W
esth
uize
n et
al
(201
7)S
outh
Afr
ica
Cro
ss- s
ectio
nal s
tud
y: 2
015
Med
ical
st
uden
ts (1
2)D
eter
min
ed t
he fr
eque
ncy
and
imp
act
of o
ccup
atio
nal
TB d
isea
se in
cur
rent
med
ical
st
uden
ts a
nd r
ecen
tly g
rad
uate
d
doc
tors
.
Dia
gnos
is a
nd
trea
tmen
tS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
Ove
rall,
med
ical
stu
den
ts d
id
not
have
ad
equa
te a
cces
s to
the
sup
por
t an
d s
ervi
ces
need
ed fo
r al
l TB
car
e,
incl
udin
g D
R- T
B.
B
29Z
imri
(201
2)S
outh
Afr
ica
Qua
litat
ive
FGD
s an
d
qua
ntita
tive
case
con
trol
2011
10 F
GD
with
p
aren
tsan
d
pro
vid
ers;
Cas
e co
ntro
l: 50
pat
ient
s ea
ch a
rm
Car
egiv
ers
of c
hild
ren
refe
rred
to
a sp
ecia
list
pae
dia
tric
MD
R- T
B
clin
ic t
o d
eter
min
e w
hy m
any
child
con
tact
s w
ere
not
bro
ught
fo
r as
sess
men
t.
Dia
gnos
isS
truc
tura
l an
d p
atie
nt
dim
ensi
ons
HC
W a
ttitu
de,
col
oure
d
ethn
icity
, the
mot
her
bei
ng
the
sour
ce c
ase,
hav
ing
a sm
oker
in t
he h
ouse
, tra
nsp
ort
time,
cos
t an
d n
umb
er
of t
rans
ition
s, a
nd fe
ar o
f in
fect
ion
wer
e id
entifi
ed a
s b
arrie
rs.
A
DR
- TB
, dru
g- re
sist
ant
TB; D
ST,
dru
g- se
nsiti
vity
tes
ting;
FG
Ds,
focu
s gr
oup
dis
cuss
ions
; HC
W, h
ealth
care
wor
ker;
HS
, hea
lth s
yste
m; I
DI,
in- d
epth
inte
rvie
ws;
KIIs
, key
info
rman
t in
terv
iew
s; L
PA, l
ine
pro
be
assa
y; L
TAT,
Lab
orat
ory
turn
- aro
und
tim
e; M
DR
, mul
tidru
g- re
sist
ant
TB; M
GIT
, myc
obac
teria
gro
wth
ind
icat
or t
ube;
NA
, not
ap
plic
able
; NR
L, N
atio
nal o
r C
entr
al R
efer
ence
Lab
orat
ory;
PH
C,
Prim
ary
Hea
lth C
linic
s; R
R- T
B, r
ifam
pic
in- r
esis
tant
TB
; TB
, tub
ercu
losi
s; T
TI, t
ime
to t
reat
men
t in
itiat
ion;
Xp
ert,
Gen
eXp
ert
MTB
/RIF
Ass
ay.
Tab
le 1
C
ontin
ued
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BMJ Global Health
Our review question was ‘What are the patient or provider factors associated with delays in tuberculosis diagnosis and treatment in sub- Saharan Africa?’.
MeTHodsWe used a mixed- methods systematic review with an integrative approach13 to analyse data from qualitative, quantitative and mixed- methods literature and assessed quality using the COnsolidated criteria for REporting Qual-itative research for qualitative studies (COREQ), Strength-ening the Reporting of Observational Studies in Epidemiology -Combined tool (STROBE) and Mixed Methods Appraisal Tool (MMAT) tools, respectively.14–16
We registered the systematic review protocol in the PROSPERO database (https://www. crd. york. ac. uk/ PROSPERO/ display_ record. php? RecordID= 106875).
search strategyUsing a combination of key terms, we searched nine electronic databases: CINAHL, Medline, Embase, Global Health, Scopus, Web of Science, International Journal of Tuberculosis and Lung Disease, PubMed and Google Scholar between January 2006 and June 2017, updating the search in June 2019. The year 2006 was used as this was the date of the first WHO publication guiding the programmatic management of DR- TB.
The Population, Intervention, Comparator and Outcomes (PICO) framework17 and key search terms used are summarised in online supplementary annex 1. The initial search terms were piloted and refined in CINAHL, and replicated in other databases, using appro-priate strategies specific to each. The public health librarian at the University of Montreal School of Public Health validated this process.
study selection and inclusion criteriaWe selected studies (figure 1) based on our inclusion criteria and PICO framework (online supplementary annex 1). Search results were downloaded into EndNote X7.7 and deduplicated. Titles and abstracts were screened, and full texts reviewed to determine studies for inclusion, and reasons for exclusion. All discrepancies or uncertainties were discussed and resolved by consensus during the final review.
data extractionDescriptive and analytical data were extracted (table 1). Study findings and outcomes were grouped quantita-tively and qualitatively (table 2). Paired access dimen-sions and recommendations for some identified barriers, drawn from the studies themselves, were presented in the context of the healthcare access model by Levesque et al (table 3).18 Finally, a summary of access factors based on perceived importance and frequency of appearance19 are presented in figure 2, online supplementary annex 3.
Quality assessmentWe assessed the quality of studies through different critical quality appraisal tools based on study designs.
Consensus was reached by discussion. For quantitative studies, we used the STROBE combined tool.14 The COREQ15 and the MMAT was used to appraise mixed- methods studies.16 The quality assessment are provided in online supplementary annex 2.
The overall quality assessments of ‘A’ for high (>70%), ‘B’ (50%–69%) for medium or ‘C’ (<50%) for low were assigned based on independent evaluation by at least two reviewers for each study. The STROBE, COREQ and MMAT tools have been used in several systematic reviews as a basis for excluding low quality studies.20–22
Conceptual frameworkWe adapted a conceptual framework, mapping the TB care continuum from symptom onset to treatment initi-ation23 to four corresponding dimensions of access at the provider and patient levels,18 24 and aligned these to identified barriers and facilitators from our review (figure 3). We explained provider factors using the six health systems building blocks described by WHO.25 Patient- level barriers and facilitators were described using the Andersen and Newman individual determinants of healthcare utilisation.26
data analysisWe used an integrative approach13 to develop a narrative analysis of key findings from qualitative, quantitative and mixed- methods studies, due to the high heterogeneity of selected studies. We repeatedly screened, coded and cate-gorised data from each study in four ways: table 1 gives the selected study overview—first author (year) and country, research design, population, intervention (when appli-cable), summary of barriers and facilitators, the level of care (diagnosis or treatment) in which they occurred and the dimensions of care (provider or patient), the main findings and the quality assessment score.
In table 2, we separated quantitative and qualitative findings for each identified factor. We reported associ-ations that were statistically significant or relevant to our analysis and included representative quotes where available.
In table 3, we used the healthcare access model by Levesque et al18 24 to categorise data into four provider and patient paired dimensions: approachability/ability to perceive; acceptability/ability to seek; availability/ability to reach; affordability/ability to pay and finally appropriateness/ability to engage. The paired dimen-sion of approachability and ability to perceive relates mostly to knowledge of providers and patients about services. Acceptability and the corresponding ability to seek focuses on cultural and social aspects that influence people’s decisions to use health service and the personal autonomy and agency to make these decisions. Avail-ability and the ability to reach refers to the physical exis-tence of health systems and health workers, as well as the physical mobility and work flexibility of patients to reach available health resources. The dimensions of afford-ability and the corresponding ability to pay reflects the
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ownloaded from
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BMJ Global Health
Tab
le 2
Q
uant
itativ
e an
d q
ualit
ativ
e fin
din
gs
Fact
or
Qua
ntit
ativ
e fi
ndin
gs
95%
CI (
stud
y ID
)Q
ualit
ativ
e fi
ndin
gs
(stu
dy
ID)
Bar
rier
Faci
litat
or
Bar
rier
Faci
litat
or
Hea
lthc
are
syst
em le
vel b
arri
ers
(bas
ed o
n th
e W
HO
Hea
lth
Sys
tem
s Fr
amew
ork
)
Lead
ersh
ip a
nd g
over
nanc
e
Gui
del
ines
ava
ilab
ility
an
d in
clus
ion
of lo
w-
risk
grou
ps
►
Pat
ient
ref
erra
l ham
per
ed a
s m
ost
HC
Ws
wer
e un
awar
e of
the
nat
iona
l gui
del
ines
.42
►Te
stin
g ra
tes
wer
e tr
ansi
ently
res
pon
sive
to
cha
nges
in c
linic
al g
uid
elin
es a
nd w
ith
incr
ease
d a
war
enes
s47
►
Imp
lem
entin
gan
exp
and
ed a
lgor
ithm
si
gnfic
antly
incr
ease
d D
ST
use
and
rat
es
of d
iagn
osis
51
Ser
vice
del
iver
y
Infr
astr
uctu
re a
nd
equi
pm
ent
►
Xp
ert
and
che
st X
- ray
wer
e un
even
ly
dis
trib
uted
.44
►
Few
dis
tric
ts h
ad la
bor
ator
y ca
pac
ity29
►
Non
- fun
ctio
nal X
per
t m
achi
nes
rep
orte
d,
vary
ing
by
regi
on67
►
The
GxA
lert
not
ifica
tion
syst
em s
end
ing
shor
t te
xts
mes
sage
s to
TB
coo
rdin
ator
s w
hen
a M
DR
- TB
cas
e w
as d
etec
ted
. Th
e co
ord
inat
ors
also
com
mun
icat
ed
this
info
with
the
res
pec
tive
dis
tric
t co
ord
inat
ors31
►
Lack
of n
eces
sary
infr
astr
uctu
re a
nd
tool
s28 4
5
►
HC
W b
lam
ed fo
r la
ck o
f eq
uip
men
t an
d
del
ays45
►
“… t
hey
take
it o
ut o
n th
e he
alth
wor
kers
b
ecau
se, t
hey
are
the
peo
ple
the
y se
e. If
th
ere
is a
ny fo
rm o
f dis
satis
fact
ion
with
se
rvic
e, if
… p
ower
out
age,
…th
ey t
ake
it ou
t on
you
and
its
very
pai
nful
… ”
45
►
Unr
elia
ble
eq
uip
men
t m
aint
enan
ce a
nd
elec
tric
al fl
uctu
atio
ns67
Dec
entr
alis
atio
n an
d
inte
grat
ion
►
Pre
- tre
atm
ent
del
ays
per
sist
aft
er X
per
t im
ple
men
tatio
n d
ue t
o ce
ntra
lisat
ion
of
clin
ical
req
uire
men
ts li
ke X
- ray
, liv
er fu
nctio
n te
sts,
and
aud
iom
etry
19
►
sign
ifica
ntly
incr
ease
d t
reat
men
t ra
tes.
35
►
Dec
entr
alis
atio
n an
d X
per
t im
ple
men
tatio
n re
duc
ed T
TI a
nd
imp
rove
d p
atie
nt o
utco
mes
.36
►
Dec
entr
alis
atio
n an
d t
reat
men
t av
aila
bili
ty im
pro
ved
tre
atm
ent
rate
s30
►
Dec
entr
alis
ed X
per
t re
duc
ed L
TAT
and
im
pro
ved
rat
es o
f dia
gnos
is.37
►
Dec
entr
alis
atio
n re
duc
ed T
TI;38
►
A la
ck in
inte
grat
ion
resu
lted
in s
hort
age
of m
ater
ials
28 “
Our
pro
gram
me
is v
ertic
al,
…th
ere
is a
sho
rtag
e of
[sup
plie
s]; t
hey
shou
ld in
tegr
ate
so t
hat
som
e of
the
se
thin
gs c
ould
als
o b
e b
udge
ted
for…
”28
►
Ava
ilab
le, d
ecen
tral
ised
DR
- TB
tr
eatm
ent
a fa
cilit
ator
to
early
ca
re32
Lab
orat
ory
oper
atio
nal
issu
es: s
put
um
tran
spor
tatio
n,
turn
- aro
und
tim
e,
mis
dia
gnos
is,
com
mun
icat
ion
and
lin
kage
to
care
►
Rea
sons
for
DS
T no
t d
one
wer
e co
ntam
inat
ion,
failu
re t
o gr
ow /
loss
of
viab
ility
27
►
Lab
orat
ory
oper
atio
nal i
ssue
s re
sulte
d
in o
nly
half
of D
ST
resu
lts, e
ven
thou
gh
sput
um w
as c
olle
cted
, and
mos
t of
the
sa
mp
les
reac
hed
the
NR
L. O
nly
very
few
re
sults
got
bac
k to
req
uest
ing
faci
litie
s.30
►
Onl
y 32
.4%
of s
amp
les
wer
e re
ceiv
ed a
t th
e N
RL
in 3
yea
rs; 5
8% a
nd 9
7% o
f cul
ture
and
D
ST
had
LTA
T lo
nger
tha
n re
com
men
ded
28
►
25%
of s
ubm
itted
sp
ecim
ens
did
not
hav
e re
sults
com
mun
icat
ed b
ack
to t
he c
linic
67
►
Onl
y 32
.3%
of n
ewly
dia
gnos
ed
pat
ient
s w
ere
trea
ted
, due
to
inco
mp
lete
re
cord
s on
the
GxA
lert
dat
abas
e an
d
mis
com
mun
icat
ion31
►
Mea
n d
iagn
ostic
del
ay o
f 8.1
wee
ks29
►
Diffi
culty
in p
acka
ging
, con
tam
inat
ion,
b
atch
ing
and
tra
nsp
ortin
g sa
mp
les
resu
lting
in p
rolo
nged
del
ays
in d
iagn
osis
.28
“In
a p
arce
l of s
pec
imen
s, y
ou c
ould
find
on
e sp
ecim
en …
15
day
s ol
d a
nd a
noth
er
3 d
ays
old
…. I
thi
nk t
hey
[rec
ieve
] but
the
y d
on’t
send
it o
n tim
e. In
stea
d t
hey
wai
t fo
r th
em t
o b
e m
any
bef
ore
send
ing28
►
Sp
ecim
ens
rece
ived
at
late
hou
rs o
r no
t in
suf
ficie
nt n
umb
ers
affe
ct la
bor
ator
y op
erat
ions
67
►
An
initi
al n
egat
ive
test
res
ult
del
ayed
d
iagn
ostic
pro
cess
32
►
Pro
long
ed d
elay
in r
ecei
ving
res
ults
from
th
e la
bor
ator
y32
►
The
use
of t
he E
xped
ited
M
ail S
ervi
ces
for
sam
ple
tr
ansp
orta
tion
help
ful i
f su
stai
ned
28
Con
tinue
d
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rotected by copyright.http://gh.bm
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J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
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BMJ Global Health
Fact
or
Qua
ntit
ativ
e fi
ndin
gs
95%
CI (
stud
y ID
)Q
ualit
ativ
e fi
ndin
gs
(stu
dy
ID)
Bar
rier
Faci
litat
or
Bar
rier
Faci
litat
or
Clin
ic o
per
atio
nal
issu
es: p
atie
nt
trac
king
and
follo
w-
up, l
ong
wai
ting
times
►
Hig
h ra
tes
(76%
) of l
oss
to fo
llow
- up
led
to
non-
refe
rral
s 42
►
Ref
erra
ls a
s p
er g
uid
elin
es w
ere
not
imp
lem
ente
d d
ue t
o no
t ha
ving
con
tact
in
form
atio
n fo
r tr
eatm
ent
faci
lity42
►
Inad
equa
te t
rack
ing
of p
atie
nts
and
un
avai
lab
le r
esul
ts fo
r fo
llow
- up
ap
poi
ntm
ents
at
ham
per
ed a
cces
s32
►
"…Th
e cl
inic
pho
ned
me
[but
] did
not
say
w
hy. I
onl
y w
ent
[two
wee
ks la
ter]
and
was
in
form
ed…
that
I ha
ve M
DR
- TB
. … I
was
ve
ry d
istu
rbed
tha
t th
e cl
inic
(had
) not
to
ld m
e [e
arlie
r]…
of t
his
very
con
tagi
ous
dis
ease
…I t
hink
thi
s w
as v
ery
irres
pon
sib
le
of t
he c
linic
…”.
Del
ays
in c
omm
unic
atin
g re
sults
of u
p t
o 3
mon
ths.
32
►
A la
ck o
f sp
ecim
en r
efer
ral m
echa
nism
no
ted
as
a ch
alle
nge
by
43%
of H
CW
s 67
►
Long
wai
ting
times
in p
ublic
fact
ilitie
s,32
45
resu
lting
in p
atie
nts
seek
ing
care
in t
he
priv
ate
sect
or w
here
TB
car
e op
tions
wer
e of
ten
not
as e
ffici
ent45
.
Leve
l of c
are
►
Pat
ient
s re
ferr
ed fr
om a
hos
pita
l wer
e 8
times
mor
e lik
ely
not
to in
itiat
e tr
eatm
ent
than
clin
ic r
efer
rals
50
►
Pat
ient
s ac
cess
ing
care
in h
ighe
r le
vel
faci
litie
s ha
d s
light
ly lo
wer
od
ds
of g
ettin
g te
sted
com
par
ed w
ith t
hose
in lo
wer
leve
ls44
►
The
trea
tmen
t ra
te w
as h
ighe
st in
TB
ho
spita
ls, w
ith P
HC
rat
es h
ighe
r th
an fo
r se
cond
ary
or t
ertia
ry h
osp
itals
.43
►
Acc
essi
bili
ty o
f car
e at
a P
HC
faci
litat
ed
trea
tmen
t ac
cess
. Mos
t ad
oles
cent
s st
arte
d t
reat
men
t at
a P
HC
com
par
ed
with
oth
er le
vels
36
►
In- p
atie
nts
wer
e m
ore
likel
y th
an
outp
atie
nts
to e
xper
ienc
e tim
ely
trea
tmen
t33
►
Varia
ble
tes
ting
rate
s b
etw
een
clin
ics
and
hos
pita
lsfo
r al
l thr
ee c
omp
aris
ons47
Pub
lic v
s p
rivat
e se
ctor
car
e
►P
atie
nts
in p
rivat
e se
ctor
had
sig
nific
antly
lo
wer
od
ds
of g
ettin
g te
sted
com
par
ed w
ith
thos
e in
pub
lic s
ecto
r44
►P
rivat
e se
ctor
as
entr
y- p
oint
,32 p
oor
per
cep
tion
of p
ublic
sec
tor
care
,32 a
nd lo
w
ind
ex o
f sus
pic
ion
at p
rivat
e fa
cilit
ies29
as
bar
riers
to
care
.
►“I
wen
t b
ack
agai
n an
d a
gain
to
the
pha
rmac
y an
d g
ot d
iffer
ent
med
icat
ion
ever
y tim
e. I
mus
t ha
ve g
one
ther
e fiv
e tim
es”.
32
►
Pub
lic s
ecto
r ca
re id
entifi
ed
as h
avin
g m
ore
DR
- TB
car
e op
tions
32
►
“…. T
here
are
muc
h b
ette
r op
tions
at
the
(pub
lic) c
linic
tha
n th
e p
rivat
e d
octo
rs…
lots
of t
est
whi
ch c
an b
e ta
ken…
”32
Tab
le 2
C
ontin
ued
Con
tinue
d
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rotected by copyright.http://gh.bm
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BM
J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
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BMJ Global Health
Fact
or
Qua
ntit
ativ
e fi
ndin
gs
95%
CI (
stud
y ID
)Q
ualit
ativ
e fi
ndin
gs
(stu
dy
ID)
Bar
rier
Faci
litat
or
Bar
rier
Faci
litat
or
Loca
tion
and
co
vera
ge (r
ural
/urb
an)
►
Wid
e re
gion
al v
aria
tions
in s
taff
trai
ning
, sa
mp
le c
olle
ctio
n,te
stin
g ca
pac
ity, r
ates
and
m
onito
ring27
47
67
►
Geo
grap
hic
loca
tion
of r
efer
ral w
as n
ot
asso
ciat
ed w
ith t
reat
men
t in
itiat
ion
time48
►
Faci
litie
s >
250
km a
way
from
NR
L to
ok
long
er t
o re
ceiv
e D
ST
resu
lts c
omp
ared
with
fa
cilit
ies
<50
km
30
►
Sig
nific
ant
regi
onal
diff
eren
ces
in
trea
tmen
t ra
tes
and
TTI
acr
oss
the
nine
S
outh
Afr
ican
pro
vinc
es .43
►
Wes
tern
Cap
e p
atie
nts
wer
e m
ore
likel
y to
hav
e se
cond
- lin
e D
ST
resu
lts t
han
the
rem
aini
ng p
rovi
nces
, due
to
the
spec
ific
pro
vinc
ial g
uid
elin
es 27
►
Util
isat
ion
of X
per
t in
crea
sed
bet
wee
n 20
16 a
nd 2
017
(88%
incr
ease
), an
d w
as
sign
ifica
ntly
hig
her
in p
rovi
ncia
l tha
n in
ru
ral h
osp
itals
.49
►
Faci
litie
s th
at w
ere
<50
km
aw
ay fr
om t
he
NR
L w
ere
mor
e lik
ely
to h
ave
DS
Ts d
one
com
par
ed w
ith t
hose
>25
0 km
aw
ay.30
►
Tran
spor
tatio
n of
sam
ple
s m
ore
diffi
cult
in
rura
l are
as28
►
“the
tra
nsp
orta
tion
…to
the
NR
L is
not
a
pro
ble
m…
. Act
ually
, big
gest
pro
ble
m is
re
ferr
ing
sam
ple
s fr
om p
erip
hera
l lab
orat
ory
to d
istr
ict
lab
orat
ory
whe
re p
ost
serv
ices
is
not
avai
lab
le”.
28
Hea
lth w
orkf
orce
Ad
here
nce
to
guid
elin
es
►D
esp
ite c
omp
lete
rol
lout
of X
per
t te
stin
g,
only
59%
of n
ew c
ases
wer
e d
iagn
osed
43
►
Less
tha
n ha
lf of
RR
- TB
pat
ient
s ha
d D
ST
resu
lts, a
s re
com
men
ded
by
the
guid
elin
es27
►
Poo
r gu
idel
ine
adhe
renc
e w
as a
mon
g re
ason
s fo
r in
corr
ect
pat
ient
scr
eeni
ng a
nd
Xp
ert
und
er- u
tilis
atio
n 34
44 .
►
Gui
del
ines
not
imp
lem
ente
d d
ue t
o p
atie
nt
follo
w- u
p p
erce
ived
as
diffi
cult
42
►
44 ►
Inco
mp
lete
ad
here
nce
to N
atio
nal g
uid
elin
es
(51%
of p
atie
nts
had
DS
T).30
►
Hea
lth p
rovi
der
s’ fa
ilure
to
follo
w
dia
gnos
tic a
lgor
ithm
s d
elay
ed D
R-
TB t
estin
g an
d le
d t
o w
rong
(firs
t- lin
e)
trea
tmen
t re
gim
ens32
►
“Whe
n th
e re
sults
cam
e b
ack
they
tol
d m
e I d
o no
t ta
ke m
y ta
ble
ts. I
tol
d t
hem
‘but
I t
ake
my
pill
s ev
ery
day
’. Th
ey c
ould
not
un
der
stan
d w
hy m
y re
sults
wer
e 3-
plu
s p
ositi
ve…
The
tre
atm
ent
did
not
hel
p…
I st
arte
d t
o gi
ve u
p h
ope”
(Xp
ert-
6—a
high
- ris
k p
atie
nt w
ith D
R- T
B e
xper
ienc
ed
5- m
onth
del
ay d
ue t
o no
t ha
ving
a t
est
don
e an
d in
itiat
ion
on fi
rst-
line
trea
tmen
t).32
Wor
kloa
d a
nd s
taff
num
ber
s
►La
bor
ator
y st
aff s
hort
ages
con
trib
utin
g to
d
elay
s28 4
5
►
“NR
L st
aff h
ave
bee
n tr
ying
to
per
form
the
ir w
ork
but
the
y ar
e ov
erlo
aded
with
man
y sp
ecim
ens
from
eac
h si
de
of t
he c
ount
ry.
”.28
►
Sho
rtag
e of
tra
ined
lab
orat
ory
staf
f to
man
th
e X
per
t m
achi
nes
note
d a
s a
chal
leng
e b
y he
ads
of la
bor
ator
ies10
Tab
le 2
C
ontin
ued
Con
tinue
d
on August 10, 2021 by guest. P
rotected by copyright.http://gh.bm
j.com/
BM
J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
12 Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280
BMJ Global Health
Fact
or
Qua
ntit
ativ
e fi
ndin
gs
95%
CI (
stud
y ID
)Q
ualit
ativ
e fi
ndin
gs
(stu
dy
ID)
Bar
rier
Faci
litat
or
Bar
rier
Faci
litat
or
HC
W k
now
led
ge,
trai
ning
, exp
erie
nce
and
sup
ervi
sion
►
Poo
r ad
here
nce
to X
per
t al
gorit
hm
attr
ibut
ed t
o X
per
t ro
llout
pre
ced
ing
trai
ning
of
clin
icia
ns; o
nly
half
of p
atie
nts
test
ed
rece
ived
con
firm
ator
y re
sults
.41
►
HC
W k
now
led
ge, a
pp
licat
ion
and
in
terp
reta
tion
of m
olec
ular
dia
gnos
tics
bel
ow e
xpec
ted
leve
ls. 67
►
Freq
uenc
y of
unt
rain
ed la
bor
ator
y st
aff
per
form
ing
Xp
ert
was
com
mon
in a
ll re
gion
s67
►
Onl
y 41
.7%
of i
nitia
l dia
gnos
es w
ere
corr
ect
and
a p
atie
nt w
as s
tart
ed e
mp
irica
lly o
n a
DS
- TB
reg
imen
with
out
cultu
re, d
elay
ed
dia
gnos
is.29
►
Mos
t H
CW
s w
ere
mor
e co
mfo
rtab
le a
nd
know
led
geab
le u
sing
Xp
ert
than
oth
er
test
typ
es a
nd it
was
the
mos
t co
mm
on
test
use
d (7
2%)67
►
HC
W lo
w in
dex
of s
usp
icio
n fo
r TB
re
sulti
ng in
del
ayed
dia
gnos
is32
►
“I w
as a
t (th
e C
HC
) for
24
hour
s …
they
tol
d
me
that
I ha
d in
fect
ion
in m
y lu
ngs
and
ga
ve m
e th
e d
rip a
nd a
ntib
iotic
s…In
the
sa
me
mon
th I
did
n’t
feel
so
wel
l so
I wen
t b
ack…
and
the
y ga
ve m
e th
e sa
me
drip
an
d a
ntib
iotic
s”.32
►
“I ju
st fe
el s
ome
of t
he s
taff
at
the
clin
ic is
in
exp
erie
nced
.”40
►
Poo
r su
per
visi
on le
adin
g to
dem
otiv
atio
n28
►
Pro
vid
er s
ched
ulin
g ea
rly r
etur
n vi
sits
for
DR
- TB
tes
t re
sults
id
entifi
ed a
s a
faci
litat
or32
►
Sup
por
t to
the
dis
tric
ts b
y th
e N
atio
nal p
rogr
amm
e he
lpfu
l if
sust
aine
d28
►
“the
re is
a n
eed
to
stre
ngth
en
sup
ervi
sion
, mak
e it
mor
e fr
uitf
ul
not
just
a v
ehic
le v
isiti
ng. I
t ne
eds
to b
e su
pp
ortiv
e, g
et
ther
e, s
tay
with
the
sta
ff, f
or
them
to
reco
gniz
e an
d li
sten
to
thei
r p
rob
lem
s …
the
n p
rovi
de
solu
tion”
28
HC
W m
otiv
atio
n an
d a
ttitu
de,
in
clud
ing
stig
ma
and
d
iscr
imin
atio
n
►
Pre
- tre
atm
ent
asse
ssm
ent
test
s w
ere
ofte
n no
t p
erfo
rmed
as
othe
r H
CW
s d
ista
nced
th
emse
lves
from
DR
- TB
ser
vice
s45
►
Fear
of i
nfec
tion
lead
ing
to s
tigm
a an
d
dis
crim
inat
ion
affe
ctin
g b
oth
DR
- TB
H
CW
s an
d p
atie
nts.
Del
iber
ate
pat
ient
s ap
poi
ntm
ents
can
cella
tion
note
d45
►
"…so
me
nurs
es a
nd m
edic
al w
orke
rs
trea
ted
us
like
we
are
not
fit t
o liv
e. T
hey
keep
a d
ista
nce
whe
n th
ey [t
alk]
with
us.
If
you
com
e cl
oser
, the
y w
ill s
hout
go!
go!
! go
!!! …
I fe
lt lik
e th
e w
orst
per
son
on e
arth
ha
ving
MD
R- T
B”45
►
HC
W b
lam
ed fo
r la
ck o
f eq
uip
men
t an
d
del
ays45
►
A la
ck o
f HC
W m
otiv
atio
n no
ted
as
a ch
alle
nge
to c
are67
►
HC
W a
ttitu
de
and
pat
ient
co
unse
lling
exp
edite
d t
reat
men
t ac
cep
tanc
e an
d p
roce
ss32
►
Pro
vid
er r
esp
onsi
vene
ss a
t fir
st
cont
act
and
com
mun
icat
ing
conc
ern
abou
t p
atie
nts’
wel
l-
bei
ng fa
cilit
ated
ear
ly c
are32
►
"I …
had
mix
ed fe
elin
gs(w
hen
I w
as t
old
ab
out
MD
R- T
B).
…. I
th
ough
t it
was
the
end
of t
ime
for
me,
but
whe
n th
e tr
eatm
ent
pro
cess
was
exp
lain
ed t
o m
e,
I fel
t m
uch
bet
ter
and
look
ed
forw
ard
to
the
trea
tmen
t”32
Hea
lth in
form
atio
n sy
stem
s
Dat
a m
anag
emen
t
►O
nly
68%
of s
pec
imen
s re
ceiv
ed b
y th
e la
bor
ator
y ha
d r
etrie
vab
le r
eque
st fo
rms34
►
56%
of p
atie
nts
with
con
firm
ator
y sa
mp
les
wer
e un
trac
eab
le w
ithin
3 m
onth
s of
Xp
ert
sam
ple
s,41
21%
not
foun
d a
t al
l33
►
Dat
a er
rors
mis
sing
dat
a an
d 2
1.2%
of
trea
ted
pat
ient
s no
t lin
ked
to
dia
gnos
tic
regi
ster
like
ly in
dic
ativ
e of
mis
sing
pat
ient
s33
►
Inco
mp
lete
rec
ord
s lik
ely
cont
ribut
ed t
o w
hy m
ost
pat
ient
s (6
7%) o
f pat
ient
s w
ere
untr
eate
d31
►
Inco
rrec
tly fi
lled
lab
orat
ory
req
uest
s fo
rms
lead
ing
to m
isp
lace
d r
esul
ts28
►
“Thi
s is
a lo
ng- s
tand
ing
pro
ble
m la
bor
ator
y re
que
st fo
rms
not
fille
d in
wel
l, a
lot
of
info
rmat
ion
is m
issi
ng. W
e se
e fo
rms
com
ing
with
eith
er o
ne n
ame
or ju
st in
itial
s an
d t
he r
est
of t
he in
form
atio
n no
t fil
led
in
”.28
►
Unr
elia
ble
pat
ient
ad
dre
sses
a c
halle
nge
for
HC
Ws67
Acc
ess
to s
econ
d- l
ine
dia
gnos
tics,
med
icat
ions
and
tec
hnol
ogie
s
Tab
le 2
C
ontin
ued
Con
tinue
d
on August 10, 2021 by guest. P
rotected by copyright.http://gh.bm
j.com/
BM
J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280 13
BMJ Global Health
Fact
or
Qua
ntit
ativ
e fi
ndin
gs
95%
CI (
stud
y ID
)Q
ualit
ativ
e fi
ndin
gs
(stu
dy
ID)
Bar
rier
Faci
litat
or
Bar
rier
Faci
litat
or
T yp
e of
dia
gnos
tic
test
►
Med
ian
time
to t
reat
men
t re
duc
ed t
o 0
day
s fo
r X
per
t- p
ositi
ve p
atie
nts,
com
par
ed w
ith
14 d
ays
for
emp
iric
TB a
nd s
ugge
stiv
e ch
est
X- r
ay fi
ndin
gs, a
nd 1
44 fo
r cu
lture
- pos
itive
, X
per
t- ne
gativ
e p
atie
nts38
►
Use
of L
PA w
as a
ssoc
iate
d w
ith d
elay
s in
dia
gnos
is a
nd t
reat
men
t, m
ostly
due
to
pro
long
ed la
bor
ator
y TA
T39
►
LPA
intr
oduc
tion
asso
ciat
ed w
ith
red
uced
TTI
(76
to 5
0 d
ays)
. Xp
ert
asso
ciat
ed w
ith a
furt
her
red
uctio
n to
8
day
s .7
►
LTAT
red
uced
from
38
to 2
day
s fo
r ne
w p
atie
nts;
and
to
1 d
ay fo
r p
atie
nts
dia
gnos
ed w
ith X
per
t, 43
►
LPA
dia
gnos
is v
s liq
uid
cul
ture
red
uced
la
bor
ator
y TA
T fr
om 5
2 to
26
day
s, a
nd
TTI f
rom
79
to 5
4 d
ays;
and
from
89
to 7
3.5
day
s fo
r sm
ear
pos
itive
s an
d
nega
tives
, res
pec
tivel
y51
►
Com
par
ed w
ith c
ultu
re, p
atie
nts
dia
gnos
ed w
ith L
PA w
ere
73.3
% le
ss
likel
y to
be
initi
ated
late
on
trea
tmen
t52
►
Pat
ient
s d
iagn
osed
with
Xp
ert
wer
e m
ore
likel
y to
hav
e an
ear
lier
TTI w
hen
com
par
ed w
ith D
ST
cultu
re a
nd w
ere
less
like
ly t
o ha
ve la
te T
TI (a
fter
60
day
s)53
►
TTI i
n th
e X
per
t- b
ased
alg
orith
m w
as 1
7 d
ays,
with
a m
edia
n la
bor
ator
y TA
T of
1
day
. The
re w
as a
dec
reas
e of
25
day
s in
med
ian
MD
R- T
B T
TI in
the
Xp
ert-
b
ased
alg
orith
m.39
►
Old
er d
iagn
ostic
tes
ts p
rolo
nged
d
iagn
ostic
pro
cess
28
►
“I w
ould
say
the
met
hod
s us
ed t
o ex
amin
e th
e sp
ecim
ens
… I
thin
k it
is a
big
ch
alle
nge
bec
ause
we
need
to
be
able
to
get
thes
e re
sults
qui
cker
, for
inst
ance
, the
y co
uld
be
exam
ined
by
liqui
d c
ultu
re a
nd
dru
g su
scep
tibili
ty t
estin
g is
don
e us
ing
mol
ecul
ar m
etho
ds
thes
e co
uld
giv
e re
sults
q
uick
er”28
New
er d
iagn
ostic
s im
pac
t on
rat
es
►*
Trea
tmen
t ra
tes
rem
aine
d u
ncha
nged
with
X
per
t.7
39 4
3
►
Cas
e d
etec
tion
rate
s d
id n
ot in
crea
se
follo
win
g th
e in
trod
uctio
n of
Xp
ert37
►
The
pro
por
tion
of R
R- T
B c
ases
d
iagn
osed
by
Xp
ert
incr
ease
d fr
om
43%
to
61%
with
incr
ease
d X
per
t im
ple
men
tatio
n. T
he p
rop
ortio
n w
ho
initi
ated
tre
atm
ent
incr
ease
d fr
om 4
3%
to 6
0% a
lso.
35
Acc
ess
to t
estin
g p
rod
ucts
►
Una
vaila
ble
dia
gnos
tic s
ervi
ces
in c
amp
us
heal
th fa
cilit
ies
and
stu
den
ts w
ere
refe
rred
to
priv
ate
or p
ublic
hos
pita
ls.29
►
Full
imp
lem
enta
tion
of X
per
t re
sulte
d
in in
crea
sed
dia
gnos
is r
ates
(20%
) and
tim
elin
ess
(92%
), tr
eatm
ent
refe
rral
and
in
itiat
ion
(15%
), in
crea
sed
tre
atm
ent
timel
ines
s (4
9%) a
nd d
ecre
ased
dea
ths
bef
ore
trea
tmen
t (6
6.9%
)35
►
Sto
ck o
uts
of X
per
t ca
rtrid
ges
and
rea
gent
s re
por
ted
as
a ch
alle
nge
by
HC
Ws67
Hea
lth fi
nanc
ing
TB
hea
lth fi
nanc
ing
►
Inad
equa
te h
ealth
fina
ncin
g re
sulte
d in
a
poo
r ac
cess
to
care
or
cata
stro
phi
c co
sts
for
pat
ient
s.29
►
Fund
ing
for
sam
ple
tra
nsp
orta
tion29
►
“… W
ho w
ill t
ake
the
spec
imen
s to
the
st
atio
ns a
nd …
pic
k [th
em] u
p …
and
who
w
ill p
ay t
he c
osts
for
send
ing
…?
…”29
Pat
ient
leve
l (b
ased
on
the
And
erse
n an
d N
ewm
an h
ealt
h se
rvic
es u
tilis
atio
n m
od
el)
Tab
le 2
C
ontin
ued
Con
tinue
d
on August 10, 2021 by guest. P
rotected by copyright.http://gh.bm
j.com/
BM
J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
14 Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280
BMJ Global Health
Fact
or
Qua
ntit
ativ
e fi
ndin
gs
95%
CI (
stud
y ID
)Q
ualit
ativ
e fi
ndin
gs
(stu
dy
ID)
Bar
rier
Faci
litat
or
Bar
rier
Faci
litat
or
Pre
dis
pos
ing
char
acte
ristic
s
Sex
►
Sex
not
ass
ocia
ted
with
hav
ing
a D
ST
don
e,27
30 n
or w
ith t
reat
men
t in
itiat
ion
rate
s or
tim
elin
ess33
43
48 5
4
►
Fem
ales
less
like
ly t
o ha
ve T
B s
cree
ning
on
hos
pita
l pre
sent
atio
n w
ith T
B- r
elat
ed
sym
pto
ms,
OR
=0.
646
►
LTAT
was
for
fem
ales
was
1.0
9 tim
es
long
er.27
►
The
mot
her
bei
ng t
he T
B s
ourc
e ca
se
resu
lted
in c
hild
ren
bei
ng m
ore
likel
y to
mis
s cl
inic
ap
poi
ntm
ents
OR
=3.
7840
►
Bei
ng m
ale
was
ass
ocia
ted
with
in
crea
sed
od
ds
of g
ettin
g an
d X
per
t te
st
in a
ll ag
e gr
oup
s.44
►
Fem
ales
mor
e lik
ely
to h
ave
timel
y d
iagn
osis
as
mal
es w
ere
89.3
% m
ore
likel
y to
be
dia
gnos
ed a
fter
12
day
s co
mp
ared
with
tho
se d
iagn
osed
in 2
d
ays
or le
ss, e
ven
whe
n ad
just
ed fo
r th
e H
IV s
tatu
s.52
Age
►
Pat
ient
s ag
ed ≥
55
year
s a
had
low
er
trea
tmen
t ra
tes
than
tho
se 4
5–54
yea
rs43
►
Ad
ults
(age
d 2
0–59
yea
rs) w
ere
less
like
ly
than
chi
ldre
n (a
ged
0–1
9 ye
ars)
to
be
initi
ated
on
trea
tmen
t33
►
TTI w
as lo
nger
for
child
ren
aged
0–1
5 ye
ars
com
par
ed w
ith t
hose
age
d 1
6–24
yea
rs43
►
Pat
ient
s ag
e ≤1
0 ye
ars
wer
e le
ss li
kely
to
have
a D
ST
resu
lt27
►
Few
pat
ient
s ag
ed 0
–14
year
s (5
%) a
nd
≥15
year
s (1
2.2%
) had
an
Xp
ert
test
don
e44
►
Age
was
not
ass
ocia
ted
with
tim
e to
d
iagn
osis
,52 n
or h
avin
g a
DS
T d
one,
30 n
or
with
rat
es o
f tre
atm
ent36
or
timel
ines
s.39
►
Ad
ults
age
d 5
5 ye
ars
and
ab
ove
wer
e m
ore
likel
y to
be
scre
ened
for
TB o
n ho
spita
l pre
sent
atio
n fo
r ot
her
reas
ons
than
tho
se a
ged
18–
24 y
ears
46
►
Mid
dle
- age
d a
dul
ts 3
5–44
yea
rs h
ad
high
er c
ase
notifi
catio
n ra
tes,
whe
reas
it
was
the
low
est
for
child
ren
aged
5–9
ye
ars44
Pre
gnan
cy
►B
eing
pre
gnan
t m
ade
it m
ore
diffi
cult
to
acce
ss T
B c
are,
res
ultin
g in
tra
nsm
issi
on t
o fa
mily
mem
ber
s32
►
"I w
as c
ough
ing
and
hav
ing
shar
p p
ains
…
They
sai
d t
hey
coul
d n
ot h
elp
me
bec
ause
I am
pre
gnan
t…It
was
a v
ery
bad
p
regn
ancy
”32
Tab
le 2
C
ontin
ued
Con
tinue
d
on August 10, 2021 by guest. P
rotected by copyright.http://gh.bm
j.com/
BM
J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280 15
BMJ Global Health
Fact
or
Qua
ntit
ativ
e fi
ndin
gs
95%
CI (
stud
y ID
)Q
ualit
ativ
e fi
ndin
gs
(stu
dy
ID)
Bar
rier
Faci
litat
or
Bar
rier
Faci
litat
or
HIV
►
Inco
nclu
sive
: HIV
- neg
ativ
e (a
OR
=0.
6)50
or
with
unk
now
n st
atus
43 p
atie
nts,
and
in o
rthe
r ca
ses
HIV
pos
itive
,43 w
ere
less
like
ly t
o st
art
trea
tmen
t50
►
HIV
sta
tus
was
not
ass
ocia
ted
with
ha
ving
a D
ST
don
e,30
nor
with
tre
atm
ent
timel
ines
s48 5
3
►
Od
ds
of r
ecei
ving
TB
dia
gnos
is h
ighe
r if
HIV
- pos
itive
usi
ng X
per
t th
an fo
r A
RT-
naïv
e38
►
HIV
- pos
itive
pat
ient
s ha
d n
early
tw
ice
the
odd
s of
rec
eivi
ng a
n X
per
t te
st.44
►
Fear
of a
n H
IV d
iagn
osis
del
ayed
ca
re- s
eeki
ng32
►
“My
mot
her
said
I m
ust
go t
o th
e cl
inic
for
a TB
tes
t. S
he w
as w
orrie
d t
hat
I may
hav
e TB
bec
ause
my
(rel
ativ
e) a
lso
had
TB
. I d
id
not
wan
t to
go
…to
o sc
ared
tha
t if
I go
for
a TB
tes
t, t
hey
will
als
o te
st m
e fo
r H
IV”32
►
Som
e H
IV- i
nfec
ted
pat
ient
had
an
aw
aren
ess
of t
heir
incr
ease
d
risk
of T
B32
►
“I w
as c
ough
ing,
my
bon
es
pai
ned
and
I w
as lo
sing
wei
ght…
I th
ough
t I h
ad T
B …
I wen
t to
the
A
RV
doc
tor
bec
ause
I ha
d a
n ap
poi
ntm
ent
… a
nd t
old
him
how
I f
eel.
I ask
ed h
im t
o se
nd m
e fo
r a
TB t
est”
32
►
“I k
new
I w
as H
IV p
ositi
ve, a
nd
that
mad
e m
e m
ore
wor
ried
w
hen
I fel
t si
ck. E
ven
whe
n m
y TB
res
ults
wer
e ne
gativ
e…I w
ent
agai
n fo
r a
TB t
est”
32
Pre
sent
ing
sym
pto
ms
and
his
tory
►
Pat
ient
s w
ith s
mea
r- ne
gativ
e d
isea
se w
ere
less
like
ly t
o ha
ve D
ST
resu
lts 27
►
Pat
ient
s fr
om t
he W
este
rn C
ape
had
mor
e fo
rms
of r
esis
tanc
e th
an p
atie
nts
from
th
e ot
her
pro
vinc
es; l
ead
ing
to in
crea
sed
lik
elih
ood
of i
neffe
ctiv
e D
R- T
B t
reat
men
t.27
►
Pat
ient
s w
ith fe
ver
and
any
tw
o sy
mp
tom
co
mb
inat
ion
(cou
gh, f
ever
, wei
ght
loss
, nig
ht
swea
ts) w
ere
less
like
ly t
o b
e sc
reen
ed fo
r TB
46
►
Pat
ient
s w
ith a
ny t
hree
or
four
sym
pto
m
com
bin
atio
n (c
ough
, fev
er, w
eigh
t lo
ss, n
ight
sw
eats
) wer
e m
ore
likel
y to
be
scre
ened
for
TB o
n ho
spita
l p
rese
ntat
ion46
►
Ret
reat
men
t ca
ses
(ie, f
ailu
res,
rel
apse
s/re
curr
ence
s, d
efau
lters
) had
the
hig
hest
od
ds
of g
ettin
g an
Xp
ert44
►
Bei
ng u
nder
wei
ght,
esp
ecia
lly in
chi
ldre
n ag
ed 0
–14
year
s d
oub
led
the
od
ds
of
rece
ivin
g an
Xp
ert
test
.44
►
Hal
f the
pat
ient
s ha
d p
revi
ousl
y b
een
trea
ted
for
TB b
ut t
hat
did
not
alw
ays
tran
slat
e to
sym
pto
m r
ecog
nitio
n or
tim
ely
heal
th s
eeki
ng “
I did
not
bel
ieve
it c
ould
b
e TB
aga
in b
ecau
se I
com
ple
ted
my
trea
tmen
t th
e fir
st t
ime”
.32
►
Hal
f the
pat
ient
s w
ere
pre
viou
sly
trea
ted
for
TB a
nd s
ever
al
reco
gnis
ed t
he s
ymp
tom
s as
a
recu
rren
ce, r
esp
ond
ing
by
qui
ckly
se
ekin
g he
lp a
t a
PH
C fa
cilit
y “I
ha
d a
ll th
e sy
mp
tom
s th
at I
had
th
e la
st t
ime
whe
n I h
ad T
B. S
o I
wan
ted
the
m t
o ch
eck
(for
TB)”
.32
Sel
f- d
enia
l and
non
- dis
clos
ure
Life
styl
e an
d e
thni
city
►
Pat
ient
s ha
d a
hig
her
likel
ihoo
d o
f mis
sing
cl
inic
ap
poi
ntm
ents
whe
n ci
gare
ttes
wer
e sm
oked
in t
he h
ouse
40
►
Col
oure
d p
atie
nts
whe
n co
mp
ared
with
X
hosa
wer
e le
ss li
kely
to
atte
nd c
linic
ap
poi
ntm
ents
and
mor
e lik
ely
del
ayed
d
iagn
osis
40
Tab
le 2
C
ontin
ued
Con
tinue
d
on August 10, 2021 by guest. P
rotected by copyright.http://gh.bm
j.com/
BM
J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
16 Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280
BMJ Global Health
Fact
or
Qua
ntit
ativ
e fi
ndin
gs
95%
CI (
stud
y ID
)Q
ualit
ativ
e fi
ndin
gs
(stu
dy
ID)
Bar
rier
Faci
litat
or
Bar
rier
Faci
litat
or
Pat
ient
age
ncy ,
p
erce
ptio
ns, a
nd
attit
udes
►
Pat
ient
s co
ncer
ned
ab
out
the
risk
of D
R- T
B
infe
ctio
n at
the
clin
ic: O
R=
2.45
; an
d t
hose
w
ith p
erce
ptio
n of
long
wai
ting
times
not
at
tend
ing
clin
ic O
R=
2.47
40
►
Failu
re t
o re
cogn
ise
TB s
ymp
tom
s or
lack
of
aw
aren
ess
that
TB
can
rec
ur r
esul
ted
in
del
ayed
car
e- se
ekin
g32
►
“I w
as h
avin
g a
terr
ible
cou
gh a
nd I
was
sw
eatin
g at
nig
ht, b
ut …
I st
ill t
houg
ht t
his
was
just
a fe
ver
and
the
cha
nge
of s
easo
n an
d t
hat
ever
ythi
ng w
as g
oing
to
be
fine”
32
►
Neg
ativ
e p
erce
ptio
ns o
f the
pub
lic s
ecto
r (o
ver-
bur
den
ed; r
ight
s in
frin
gem
ent;
ne
gativ
e st
aff a
ttitu
des
; lac
k of
priv
acy)
32 45
►
“I w
as e
xpec
ting
long
que
ues
and
sitt
ing
for
ages
bef
ore
gett
ing
help
, but
… t
here
w
as n
o q
ueue
and
I go
t he
lped
with
in
10 m
in…
t”32
►
Bel
iefs
in s
uper
stiti
ons
31 a
mon
g p
atie
nts,
no
n- d
iscl
osur
e d
elay
ed p
rop
er c
are45
“A
n ill
ness
tha
t w
ill m
ake
doc
tors
and
nur
ses
to
run
away
, if y
ou t
ell a
non
- med
ic, w
ill t
hey
stay
with
you
? . …
…I c
anno
t te
ll th
em. N
ot
even
my
girlf
riend
”45
►
Ear
lier
care
- see
king
was
ena
ble
d
by
sym
pto
m r
ecog
nitio
n or
an
awar
enes
s of
incr
ease
d r
isk
of T
B
amon
g H
IV p
atie
nts32
“I k
new
I w
as H
IV p
ositi
ve, a
nd t
hat
mad
e m
e m
ore
wor
ried
… E
ven
whe
n m
y TB
res
ults
wer
e ne
gativ
e…I
wen
t ag
ain
for
a TB
tes
t”.32
►
Per
cep
tions
of g
ood
qua
lity
serv
ice
and
fam
iliar
ity w
ith
serv
ice32
32
►
Pat
ient
’s a
genc
y in
sp
ecifi
cally
re
que
stin
g TB
scr
eeni
ng s
ervi
ces
that
wer
e no
t of
fere
d fa
cilit
ated
ea
rly d
iagn
osis
32
►
Pat
ient
pat
ienc
e in
wai
ting
for
care
32
►
“I w
aite
d fo
r a
long
tim
e …
I ju
st t
old
mys
elf t
hat…
I am
sic
k al
read
y an
d I
need
hel
p a
nd in
or
der
for
me
to g
et h
elp
I m
ust
be
pat
ient
”.32
Ena
blin
g ch
arac
teris
tics
Fam
ily, s
choo
l or
wor
k su
pp
ort/
com
mitm
ents
►
Hea
lth s
eeki
ng d
elay
was
3.2
wee
ks (0
–16
wee
ks, S
D 4
.6) d
ue t
o fe
ar o
f mis
sing
ac
adem
ic t
each
ing
and
clin
ical
dut
ies29
►
Fam
ily/
wor
k/ s
choo
l com
mitm
ents
or
dis
satis
fact
ion
with
the
ser
vice
pre
vent
ing
a re
turn
to
faci
litie
s or
inte
rrup
tions
to
the
dia
gnos
tic p
roce
ss.29
32
40
►
“The
day
… I
was
tol
d I
have
MD
R- T
B, m
y fa
mily
pho
ned
… t
hat
my
sist
er p
asse
d
away
. Eve
ryth
ing
then
wen
t cr
azy.
All
I co
uld
thi
nk a
bou
t th
en w
as t
he fa
stes
t w
ay
to g
et (h
ome.
) …no
t th
inki
ng a
bou
t m
y M
DR
- TB
tre
atm
ent,
may
be
bec
ause
my
min
d w
as v
ery
occu
pie
d w
ith m
y fa
mily
re
spon
sib
ilitie
s …
”.32
►
Fam
ily s
upp
ort
enab
led
ear
ly
care
- see
king
32
Loss
to
follo
w- u
p o
r d
eath
►
31.2
% o
f pat
ient
s d
ied
bef
ore
trea
tmen
t in
itiat
ion
and
46.
4% lo
st t
o fo
llow
- up
50
►
Mai
n re
ason
for
pat
ient
s’ n
on- r
efer
ral w
as
LFTU
42
►
Sev
eral
pat
ient
s (1
9% v
s 33
% in
hos
pita
l an
d P
HC
res
pec
tivel
y) d
ied
bef
ore
refe
rral
.42
►
Onl
y 32
% n
ew d
iagn
osed
pat
ient
s w
ere
trea
ted
; 38%
wer
e un
trac
eab
le a
nd 2
6%
die
d b
efor
e tr
eatm
ent31
►
Of s
ix u
ntre
ated
pat
ient
s, o
ne o
utm
igra
ted
an
d o
ne d
ied
bef
ore
trea
tmen
t.36
►
Sym
pto
ms
wor
seni
ng a
nd d
eath
bef
ore
trea
tmen
t‘…
this
pat
ient
…d
ecid
ed t
o co
ntac
t R
TLC
for
help
. … b
ut t
he p
atie
nt
die
d b
efor
e [b
eing
] tak
en t
o K
IDH
’.31
►
Pat
ient
s re
luct
ant
to d
iscl
ose
thei
r co
rrec
t ad
dre
sses
due
to
confi
den
tialit
y co
ncer
ns29
Tab
le 2
C
ontin
ued
Con
tinue
d
on August 10, 2021 by guest. P
rotected by copyright.http://gh.bm
j.com/
BM
J Glob H
ealth: first published as 10.1136/bmjgh-2019-002280 on 2 July 2020. D
ownloaded from
Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280 17
BMJ Global Health
Fact
or
Qua
ntit
ativ
e fi
ndin
gs
95%
CI (
stud
y ID
)Q
ualit
ativ
e fi
ndin
gs
(stu
dy
ID)
Bar
rier
Faci
litat
or
Bar
rier
Faci
litat
or
Dire
ct a
nd in
dire
ct
cost
s of
car
e
►M
ore
than
one
min
ibus
tra
nsfe
r to
get
to
clin
ic w
as a
ssoc
iate
d w
ith c
hild
ren
mis
sing
ap
poi
ntm
ents
40
►
Pat
ient
s in
curr
ed s
ubst
antia
l hea
lthca
re
cost
s an
d t
rans
por
t co
sts.
29
►
Lack
of t
rans
por
tatio
n co
st t
o ke
ep
app
oint
men
ts32
►
Par
ticip
ants
rep
orte
d s
ubst
antia
l exp
ense
s,
incl
udin
g sp
ecia
list
app
oint
men
ts,
inve
stig
atio
ns, t
reat
men
t co
sts29
Geo
grap
hic
loca
tion
►
Info
rmal
set
tlem
ents
, (aO
R=
0.4)
sub
urb
(0.3
) an
d p
rison
(0.1
) les
s lik
ely
to s
tart
tre
atm
ent
com
par
ed w
ith t
owns
hip
res
iden
ce50
►
Late
DR
- TB
tre
atm
ent
Initi
atio
n (a
fter
60
day
s) w
as le
ss li
kely
in p
atie
nts
havi
ng a
to
wn
add
ress
.53
►
Varia
ble
tre
atm
ent
initi
atio
n p
atte
rns
with
in
regi
ons
and
with
in s
tate
s in
the
sam
e re
gion
; and
bet
wee
n se
mi-
urb
an a
nd u
rban
lo
catio
ns.33
►
City
/tow
n re
sid
ence
was
mor
e lik
ely
to in
itiat
e tr
eatm
ent
com
par
ed w
ith
tow
nshi
p r
esid
ence
50
►
Pat
ient
s liv
ing
in s
emi-
urb
an a
reas
wer
e m
ore
likel
y to
exp
erie
nce
timel
y in
itiat
ion
of t
reat
men
t th
an t
hose
in u
rban
are
as.33
►
Con
veni
ence
of f
ree,
acc
essi
ble
lo
cal s
ervi
ces
enab
led
ear
ly
care
- see
king
32
Nee
d c
hara
cter
istic
s an
d h
ealth
see
king
pra
ctic
e
Trea
tmen
t re
fusa
l or
sym
pto
m
min
imiz
atio
n
►
Of s
ix p
atie
nts
who
wer
e no
t p
lace
d o
n tr
eatm
ent,
tw
o w
ere
due
to
trea
tmen
t re
fusa
ls.36
►
Sym
pto
m m
inim
isat
ion
or d
enia
l,res
ulte
d
in d
elay
ed c
are-
seek
ing32
“B
ut a
t al
l the
se
times
I w
as n
ot s
ick.
It w
as ju
st a
cou
gh,
swea
t at
nig
ht a
nd I
felt
that
I w
as a
lso
losi
ng w
eigh
t, n
othi
ng e
lse,
not
a d
ay I
ever
fe
lt lik
e I w
as s
ick”
.32
Alte
rnat
ive
care
►
Pat
ient
s op
t fo
r tr
aditi
onal
med
icin
e an
d d
o no
t re
turn
for
resu
lts67
►
Cul
tura
l bel
iefs
and
see
king
tra
diti
onal
he
alth
care
32
►
Pat
ient
s op
ting
for
trad
ition
al m
edic
ine
and
not
ret
urni
ng fo
r re
sults
not
ed a
s a
chal
leng
e to
car
e b
y H
CW
s67
#1—
even
tho
ugh
a st
udy
of p
atie
nts
alre
ady
on t
reat
men
t, s
ome
issu
es li
ke d
iscr
imin
atio
n ha
ve b
een
show
n in
oth
er s
tud
ies
to im
pac
t p
atie
nt a
cces
s to
car
e.#2
8—d
istin
guis
hing
bet
wee
n fa
ctor
s re
late
d t
o d
iagn
osis
/tre
atm
ent
acce
ss fr
om im
pac
t of
tre
atm
ent.
aOR
, ad
just
ed O
R; D
R- T
B, d
rug-
resi
stan
t TB
; DS
T, d
rug-
sens
itivi
ty t
estin
g; H
CW
, hea
lthca
re w
orke
r; L
PA, l
ine
pro
be
assa
y; L
TAT,
Lab
orat
ory
turn
arou
nd t
ime;
LTF
U, l
ost
to fo
llow
- up
; NR
L, N
atio
nal o
r C
entr
al T
B R
efer
ence
La
bor
ator
y; R
R- T
B, r
ifam
pic
in- r
esis
tant
TB
; SE
, Sou
thE
ast;
SW
, Sou
thW
est;
TB
, tub
ercu
losi
s; T
TI, t
ime
to t
reat
men
t in
itiat
ion;
Xp
ert,
Gen
eXp
ert
MTB
/RIF
Ass
ay.
Tab
le 2
C
ontin
ued
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18 Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280
BMJ Global Health
financial implications of health services and the capacity on the side of patients to bear these costs.18
To synthesise the factors identified across the variety of studies, we ranked each barrier and facilitator based on its importance within each study and the number of studies where it appeared (figure 2, online supplementary annex 3). A factor is assigned the maximum score of 3 if it affects >50% of participants or has an OR of <0.65 or >1.5 for quantitative studies; and deemed as being of high impor-tance or repeatedly mentioned across participant types. Factors are assigned a 2 if they affect 25%–50% of partici-pants, or OR 0.65–0.8 or 1.25–1.5 for quantitative studies; or were deemed of moderate importance or by default when mentioned but not rated in qualitative studies. Factors were assigned 1 if affecting few participants and a zero if not mentioned. These scores were added for each study where the factor appeared. A similar method for synthesising mixed- methods reviews has been previously described.19
Patient and public involvementPatients or members of the public were not involved in this research.
resulTsAfter an initial search yield of 3181 unique studies, 55 full texts met screening criteria, and a final selection of 30 articles were retained (figure 1).
study characteristicsThe majority of the included studies were conducted in South Africa (n=20), with Zimbabwe (n=3), Tanzania (n=3), Nigeria (n=2), Kenya (n=1) and Gabon (n=1) making up the rest. These six countries represent 49.5% of the 77 000 estimated DR- TB incident cases in Africa in 2018.2 There were 3 qualitative, 22 quantitative and 5 mixed- methods studies. Among the quantitative studies, there were 13 retrospective, 3 prospective and 1 mixed cohort studies, and 5 cross- sectional surveys. All of the three qualitative studies employed in- depth interviews, with one study including focus group discussions. Five studies examined access factors related to DR- TB treat-ment only, 9 on DR- TB diagnosis only and 16 focused on both diagnosis and treatment. Factors impacting access were identified at provider (n=30) and patient (n=24) levels. Sixteen studies explored the influence of diag-nostic tools on laboratory turnaround time and on treat-ment initiation. Table 1 summarises the study character-istics for this review.
Quality appraisalThe results of our quality assessment are shown in online supplementary annex 2. Out of a total of 22 quantitative studies, 20 were classified as A, with 2 scoring B based on the STROBE criteria.14 The two qualitative studies scored A and B using the COREQ tool,15 with one study, graded a C, excluded. Using the MMAT tool,16 four studies were graded A and one as B in mixed methodology.
Provider factors affecting dr-Tb diagnosis and treatmentIn all 29 retained studies, the most dominant factors affecting DR- TB care were provider- related (table 2, figure 3). Our study highlighted a wide range of specific problems reflecting nearly all aspects of service delivery and health workforce with a few issues related to leader-ship and governance, and management of health prod-ucts and information.
Service delivery was, by far, the most predomi-nant provider- related barrier. Laboratory10 27–32 and clinic10 28 31 33 34 operational challenges, as well as centrali-sation of services7 28 30 32 35–39 and poor linkage between the public and private sector,29 32 hampered care. Inadequate provider knowledge, skill and adherence to national guidelines were also recurring themes.10 27–30 32 34 40–44 These are discussed in more detail in the context of the paired dimensions of access.
Patient-level factors influencing dr-Tb diagnosis and treatmentMost patient- level barriers were related to predis-posing characteristics including knowledge and percep-tions,29 39 40 45 HIV status,7 38 43 44 presenting symptoms,44 46 gender44 46 and age27 43 44 46; and enabling characteristics including geographic location,10 27 28 30 43 47–49 life commit-ments29 32 40 and the ability to pay for transportation or services.29 32 39 40 A few need and health- seeking character-istics were also identified relating to treatment refusal,36 and choosing private sector care.10 32
Paired access dimensionsWe have summarised access factors and recommenda-tions from the reviewed studies into four paired dimen-sions (table 3).18
Approachability/ability to perceiveWe found that provider and patient knowledge about DR- TB services18 were hindered by inadequate leader-ship and governance, provider training, service delivery, patients’ predisposing and need characteristics.18 25 26 At the systems level, inadequate patient tracking, refer-rals and follow- up, poor provider knowledge about the service requirements and inadequate guideline availability and non- adherence were identified chal-lenges.10 28 31 32 34 35 40–43 46 50 Patients’ ability to perceive the right services were hampered by health illiteracy, poor perceptions of services, distrust and unmet expec-tations.31 39 40
At the health systems level, the consequences of poor leadership and governance were reflected in patient non- referral, misdiagnosis and treatment with ineffec-tive regimens.32 42 Guidelines awareness, availability and expansion to include low- risk groups were shown to improve access.32 42 47 51
Provider knowledge, skills and attitude were repeatedly shown to influence access and was a predominant theme (figure 3). Delayed or inadequate training, inexperi-ence and poor supervision of health workers influenced
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rotected by copyright.http://gh.bm
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Oga- Omenka C, et al. BMJ Global Health 2020;5:e002280. doi:10.1136/bmjgh-2019-002280 19
BMJ Global Health
Tab
le 3
P
aire
d a
cces
s d
imen
sion
s an
d r
ecom
men
dat
ions
Str
uctu
ral a
cces
s d
imen
sio
ns a
nd b
arri
ers
(stu
dy
ID #
)P
atie
nts
acce
ss d
imen
sio
ns a
nd b
arri
ers
(stu
dy
ID #
)R
eco
mm
end
atio
ns(s
tud
y ID
#)
Ap
pro
acha
bili
ty:
►
Out
reac
h—la
ck o
f pat
ient
tra
ckin
g an
d fo
llow
- up
35 4
2 50
►
Ref
erra
ls fr
om c
linic
s or
priv
ate
faci
litie
s to
DR
TB c
are
cent
res
not
don
e42 4
3 50
►
Poo
r H
CW
info
rmat
ion
or k
now
led
ge o
f TB
, res
ista
nce,
gui
del
ines
or
algo
rithm
s31 3
5 39
–41
46 6
7
►
Lack
of g
uid
elin
e kn
owle
dge
and
ad
here
nce28
31
34 4
2
Ab
ility
to
per
ceiv
e:
►P
oor
know
led
ge o
f dis
ease
and
per
cep
tions
of s
ervi
ce31
32
40
►
Dis
trus
t an
d u
nmet
exp
ecta
tions
31 3
2
►
Rai
se p
ublic
aw
aren
ess
of s
ymp
tom
s an
d t
he n
eed
for
early
car
e32 4
0
►
Imp
rove
HC
W k
now
led
ge/t
rain
ing
and
sup
ervi
sion
on
TB s
urve
illan
ce,
resi
stan
ce m
onito
ring,
gui
del
ines
and
alg
orith
ms.
27 2
9 31
39
41 4
2 44
46
47 5
3
►
Imp
rove
sur
veill
ance
, dat
a m
anag
emen
t, r
efer
ral a
nd s
cree
ning
, eg,
in
tens
ified
cas
e fin
din
g, a
pp
oint
men
t of
ded
icat
ed li
nkag
e of
ficer
s in
ea
ch d
istr
ict.
28 3
0 32
34
35 3
9 41
43
44 4
6 47
50
51
►
Incr
ease
acc
ess
to n
ewer
, rap
id d
iagn
ostic
s p
oint
- of-
care
Xp
ert
and
en
sure
pro
per
dep
loym
ent
and
use
.7 36
38
41 4
4 49
51–
53 6
7
►
Use
of h
ome
visi
ts o
r al
ert
syst
ems
to fo
llow
- up
pat
ient
s35 4
0–42
►
Bro
ad- b
ased
pol
icie
s an
d s
trat
egie
s to
imp
rove
scr
eeni
ng41
47
51
Acc
epta
bili
ty:
►
Pro
fess
iona
l val
ues,
nor
ms
and
att
itud
e45
►
Car
e at
trib
utes
—in
fect
ion
cont
rol,
long
dur
atio
n of
hos
pita
lisat
ion/
trea
tmen
t40 4
5
Ab
ility
to
seek
:
►P
erso
nal a
nd s
ocia
l val
ues32
36
►
Dis
clos
ure
and
con
fiden
tialit
y31 4
5
►
Cul
ture
and
gen
der
nor
ms32
►
Wor
k an
d fa
mily
com
mitm
ents
32
►
Pat
ient
soc
iod
emog
rap
hic
char
acte
ristic
, tre
atm
ent
hist
ory
and
com
orb
iditi
es27
30
33 3
9 43
44
50 5
1
►
Cho
osin
g al
tern
ativ
e ca
re32
►
Fear
of i
nfec
tion,
del
ays
or s
ide
effe
cts29
32
40
►
Imp
rove
ser
vice
del
iver
y in
clud
ing
inte
grat
ion
and
ret
entio
n in
car
e, e
g,
app
oint
men
t of
link
age
offic
ers
in e
ach
dis
tric
t.2
4 6
20
►
Red
uce
hosp
italis
atio
n d
urat
ion45
►
- S
tren
gthe
n in
fect
ion
cont
rol m
easu
res
and
occ
upat
iona
l hea
lth
serv
ices
.29 3
1 40
45
►
Incr
ease
hom
e- b
ased
car
e of
DR
- TB
42 4
5
►
Imp
rove
vis
itatio
n p
olic
ies
for
hosp
italis
ed p
atie
nts45
►
Mor
e at
tent
ion
to p
atie
nt- l
evel
bar
riers
.29 3
3
Str
uctu
ral a
cces
s d
imen
sio
ns a
nd b
arri
ers
(stu
dy
ID #
)P
atie
nts
acce
ss d
imen
sio
ns a
nd b
arri
ers
(stu
dy
ID #
)R
eco
mm
end
atio
ns(s
tud
y ID
#)
Ava
ilab
ility
: cov
erag
e/ce
ntra
lisat
ion
of s
ervi
ces7
37
►
Bed
sp
aces
for
hosp
italis
atio
n p
hase
51
►
Hea
lth p
rod
ucts
: ina
deq
uate
sup
plie
s of
dia
gnos
tics
and
dru
gs67
►
Per
sonn
el: s
hort
ages
in H
CW
qua
ntity
and
qua
lity45
47
►
Lab
orat
ory
and
clin
ic o
per
atio
nal e
rror
s an
d d
elay
s27 2
8 31
34
37 4
7 51
53
54
►
Inad
equa
te a
cces
s to
or
low
util
isat
ion
of n
ewer
dia
gnos
tic
inst
rum
ents
7 27
32
35 3
8 49
52
54 6
7
►
Reg
iona
l op
erat
iona
l diff
eren
ces27
33
Ab
ility
to
reac
h:
►P
oor
sput
um s
pec
imen
27
►
Diffi
cult
tran
spor
tatio
n to
faci
lity37
39
40 4
9
►
Lack
of s
ocia
l sup
por
t45
►
Geo
grap
hic
loca
ted
far
from
car
e27 3
3 37
40
50 5
1
►
Out
mig
ratio
n or
dea
th36
42
►
Dec
entr
alis
ing,
link
ing
and
inte
grat
ing
serv
ices
7 33
37
40 4
1 51
►
Imp
rove
soc
ial a
nd p
sych
osoc
ial s
upp
ort45
►
Incr
ease
HC
W q
uant
ity a
nd q
ualit
y.47
►
Ena
ble
sam
e d
ay t
reat
men
t in
itiat
ion
afte
r X
per
t37
►
Two
sput
um s
pec
imen
at
bas
elin
e27
►
Incr
ease
cap
acity
and
qua
lity
of in
pat
ient
and
com
mun
ity- b
ased
car
e51
►
Ens
urin
g co
ntin
uous
sup
ply
of h
ealth
pro
duc
ts.49
►
Exp
and
ed a
nd t
imel
y ac
cess
to
trea
tmen
t re
gim
ens,
faci
litie
s an
d
stra
tegi
es.8
21 2
3
Affo
rdab
ility
:
►P
rogr
amm
e st
ruct
ure29
32
40
►
Lack
of f
und
ing
for
sput
um t
rans
por
tatio
n an
d c
onsu
mab
les28
Ab
ility
to
pay
:
►In
abili
ty t
o p
ay fo
r tr
ansp
ort
or t
reat
men
t re
qui
rem
ents
; op
por
tuni
ty c
osts
40
►
Incr
ease
d g
over
nmen
t in
vest
men
t28
HC
W, h
ealth
care
wor
ker;
TB
, tub
ercu
losi
s.
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BMJ Global Health
Figure 2 Summary of barriers and facilitators influencing drug- resistant tuberculosis (DR- TB) diagnosis and treatment in sub- Saharan Africa (SSA), ranked both on frequency of appearance and perceived importance.HCW, healthcare worker; KSA, knowledge, skills and attitude. *Inconclusive results; see table 2.
product availability, diagnosis and treatment.10 28 29 32 40 41 Poor adherence to DR- TB testing algorithm, treatment guidelines or referral procedures hampered diagnosis and treatment,27 30 32 34 42–44 with patients often left undi-agnosed, untreated, treated with ineffective drugs or only after serious complications.32 42
At the patient level, poor perception of the public sector (overburdened, long waiting times, negative staff attitudes, poor confidentiality, lack of privacy, risk of infection) were some reasons why patients were avoiding the public sector hospitals where DR- TB services could be accessed.29 39 40 45
Wrong disease attribution, symptom minimisation, non- disclosure, treatment refusal and choosing traditional care were also noted as delaying care- seeking.10 32 36 45
Patients seeking care first in the private sector (private hospitals, pharmacies, patent medicine vendors, tradi-tional healers), where the index of suspicion was lower, instead of public sector, where services were available, had lower odds of getting tested.44
Acceptability/ability to seekOur review found that although provider attitudes and practice were implicated, patients’ predisposing charac-teristics were predominant in influencing their decisions to use health services.18 25 26 Acceptability challenges were related to poor healthcare worker norms and attitude including confidentiality concerns, stigma and how the care patients received were influenced by their symp-toms7 43 44 46 or sociodemographic characteristics.40 45 Patient’s ability to seek were influenced by their sociode-mographic characteristics, personal, cultural and social values, disclosure, work and family commitments, use
of private sector alternatives and fear of poor infection control.27 29–33 36 39 40 44 50 51
At the provider level, stigma and discrimination towards providers from other hospital workers, and from provider to patients compromised access to and quality of care.10 32 45
At the patient level, living with HIV had conflicting results. Some studies found no association between HIV status and having a DST done, nor with time to treat-ment.48 52 However, two studies found patients with HIV having overall higher odds of receiving a TB diagnosis.38 44 However, HIV- positive patients had longer times to treat-ment or were less likely to initiate treatment,7 43 except in one study where treatment initiation rates were higher than in HIV- negative patients.50 In qualitative studies, the fear of an HIV diagnosis delayed health- seeking, and some patients with HIV were seen to have an increased awareness of TB risk.32
Patients presenting with more than any two of TB symp-toms (cough, fever, weight loss, night sweats), retreatment cases and undernourished children were more likely to be screened for TB on hospital presentation for other reasons than those presenting with fewer symptoms, new cases and well- nourished children, respectively.44 46 Smear- positive cases and more symptomatic patients were more likely to have a DST done.27 47 Half of the time, previous TB led to faster symptom recognition and care- seeking.32 In one study, being pregnant made accessing DR- TB care more difficult as providers refused to initiate any DR- TB- related care.32
Patient agency and persistence in demanding DR- TB testing where none was offered was noted as a facilitator to DR- TB healthcare, and this was linked to HIV positivity
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Figure 3 An adapted conceptual framework of identified barriers and facilitators to to DR- TB care.
or prior knowledge of the disease, either through an earlier TB infection or knowing another patient with DR- TB.32
Results linking access to patient gender and age were largely inconclusive. In several studies, neither patient gender nor age were found to be associated with diag-nosis timeliness or rates,27 30 52 nor with treatment initiation rates or timeliness.36 39 43 48 There were some indications that females44 46 or children whose mothers are the primary TB source,40 or younger age27 43 44 46 were less like to be diagnosed or treated (table 2). One study33 found children to be more likely to initiate treatment than adults.
One study noted other contextual patient factors that were seen to influence DR- TB care. In South Africa, ethnicity and cigarette smoking—with children failing to attend clinic appointments more frequently from coloured ethnicity and homes with cigarette smokers. No particular reason was given for these differences, however, it was acknowledged that these were markers for other socioeconomic and cultural factors needing further research.40
Availability/ability to reachThese were mostly related to service delivery, access to health products and patient tracking on the provider
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side and geographic access and life commitments on the patient side.18 25 26 Specific health system barriers were related to coverage, bed spaces and centralisation of services; inadequate availability and coverage of health products—equipment and technology, advanced diag-nostics and medications; shortages of health personnel; clinic and laboratory errors.7 10 27 28 30–35 37–40 45 47 49 51–53 Patients were prevented from reaching health services when they lived in inaccessible locations or faraway distances, lack of social support and difficulty in trans-portation, poor sputum specimen, out- migration or death.27 32 33 36 37 40 42 45 49–51
Laboratory operational challenges were the most reoc-curring barriers to care (figure 3). Specimen contami-nation, loss of viability, difficulty in packaging, batching, transportation and delivery of samples10 27 28 delayed diag-nosis. Not requesting tests, incomplete records, delayed results were other barriers preventing patients form accessing care.10 28–32 Staff shortages, especially laboratory staff, contributed to diagnostic delays and patient waiting times.10 28 45 There were significant geographical varia-tions, mostly in laboratory operations, which impacted referral, diagnosis and treatment rates.10 27 28 30 33 43 47–49 National programme support to health centres and using expedited mail service for sample transportation were helpful in reducing laboratory delays.28
Poor data management affected patient linkage to care and reporting. Errors including missing patient records in diagnosis or treatment registers, irretrievable request forms, incomplete data entry led to misplaced results, untraceable patients and poor linkage to care.10 28 31 33 34
Inadequate coverage and maintenance of diagnostic equipment, as well as power outages hampered diag-nostic capacity10 28 44 45 and staff motivation.45 Where available, using the Xpert notification system improved team communication and facilitated diagnosis.31
Centralisation (in few specialised health centres) of GeneXpert MTB/RIF (Xpert) or other pretreatment requirements like X- rays, and a lack of integration, increased diagnosis time28 39 and resulted in negative patient experiences.45 Service decentralisation (wide-spread availability of services, and at the different health-care levels) was, consequently shown to be a major facilitator of access (figure 3), reducing time to diagnosis and treatment and increasing diagnosis rates.7 30 32 35–38 However, patients initiating care at higher facilities had lower odds of getting tested or initiating treatment.36 44 50 Treatment initiation rate was highest among patients diag-nosed directly through TB hospitals.43 In one setting, timeliness of treatment was higher among patients initi-ated as inpatients compared with outpatients.33
The public sector had longer waiting times pushing patients to access care in the private sector, with poor linkages between the two.29 32 Failure or delay in tracking patients, and unavailability of results at appointments prevented access.10 32
Access to newer diagnostics was the principal facili-tator of access identified (figure 3). There was an overall
consensus that the use of older diagnostic tests (eg, X- rays, drug susceptibility testing (DST) or line probe assay (LPA)), when compared with Xpert, was associated with longer times to diagnosis and treatment.7 28 37–39 41 43 51–53 With the exception of one study,35 Xpert implementa-tion did not result in corresponding increases in diag-nosis and treatment rates.7 37 43 54 Also, the average time to DR- TB care remained significantly higher than the national targets in most settings.33 39 41 43 52 53
At the patient level, several studies noted high rates of patients being lost to follow- up or dying before treatment due to non- referrals, data errors, prolonged pretreat-ment processes and delayed care- seeking.31 42 50
Geographical location of patients was also identified as an access barrier. Patients in an urban/formal settlement accessed care more compared with those in rural, informal settlements or prison. Other variations were likely linked to the healthcare location, as noted above.32 33 50 53 Signifi-cant variations in accessing diagnosis and treatment were due to geographical locations of the patients, with urban residence or proximity to care facility increasing likeli-hood of testing and treatment, as well as reducing time to results and treatment.10 27 28 30 43 47–49
Family, work or school commitments were seen to prevent or interrupt the care process, while the presence of family support enabled care- seeking.29 32 40
Affordability/ability to payThe financial implications of services were mostly related to the enabling characteristics of patients to pay for care including transportation costs.18 25 26 In our review, we found difficulties in paying for transport to health facil-ities, and high opportunity costs borne by patients.32 40
Ease of access and cost of health services were some reasons for choice of facility. A lack of money for trans-port, travel time and numerous bus transfers influ-enced whether they returned to the facility after initial visit.29 39 40 Seeking care in the private sector was noted as contributing to the high costs of care for patients, as some go the public sector, where care was perceived as poor, only when they could no longer afford private care.32 In another study where high costs of care was noted, majority of the patients sought care in the private sector.29
DiscussionOur review synthesises the diverse knowledge base about obstacles to DR- TB care in SSA to create a consolidated understanding to inform practice. It highlighted several health system and patient barriers.
Our key findings include the role of rapid diagnostics and laboratory operational issues play in facilitating or impeding access. Rapid diagnostic tools, particularly Xpert, play a central role in accessing DR- TB diagnosis and treatment, and their absence would constitute a significant barrier to receiving care.28 38 39 The introduc-tion of these tools has led to a significant reduction in times to care for DR- TB.7 38 39 43 51–53 However, although
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times were shortened, patients still experienced unneces-sary delays in accessing care. The gains of rapid diagnostic technology have, so far, not translated into a commensu-rate increase in rates of detection and treatment.7 37 39 43 These were likely due to the range of laboratory oper-ational errors identified,10 27–32 and which need to be targeted to improve case finding and treatment rates.
Our review data reveal several missed opportunities for screening and treatment initiation.7 32 34 46 These contribute to the global ‘missing cases’, perpetuate trans-mission and highlight critical gaps in the care cascade. For example, the inadequate linkage between the private and the public sector occur before access to testing and are beyond the scope of rapid diagnostics. They contribute to the persistence of low diagnostic and treatment rates despite Xpert implementation.
Results for age and sex were found to be divergent, as many studies found both factors not significant in impacting care. In the studies where age was significant, younger age was mostly a barrier,27 43 44 46 except in one study33 where the programme prioritised children and other high- risk groups for Xpert diagnosis and inpatient care. Where most studies found sex not associated with DR- TB care, some found being female or a child or a female patient with DR- TB to be a barrier to care.27 40 44 46 One study found females more likely to have earlier diag-nosis, likely due to care- seeking behaviours.52
Several contextual factors like language, religion and culture were not identified by the studies included in this review. Geographic locations of the health centres and of the patients themselves were identified as influ-encing access to care, and this has been reported by other authors.55 56 Ethnicity and lifestyle were identified in one study to influence access, likely due to socioeco-nomic and cultural implications.40 The lack of qualitative data on the influence of sex and age on access makes it difficult to draw conclusions about whether the effects seen were due to contextual factors.
To improve patient- level barriers calls for a close examination of social determinants like poverty and geographic access as an addition to biomedical approaches, as recommended by the Commission on Social Determinants of Health (CSDH).57–59 The burdens of infectious diseases like TB are disproportion-ately borne by patients with certain sociodemographic characteristics. For example, rural patients bear higher treatment costs and report more difficulty with trans-port to health centres for treatment.60 61 Demographic characteristics such as gender, poverty or ethnicity often interact in complex ways, further increasing vulnera-bility and disadvantage.62 63 Inadequate knowledge of DR- TB disease and health services was also identified as a major cause of poor health- seeking behaviour among patients. Raising public awareness of symptoms and available resources may contribute to reducing these delays.
The biomedical approach, which focuses more on the use of technology to manage diseases needs to be
combined with efforts to tackle root causes and social determinants of DR- TB disease.60 64
Our findings indicate that, in order to overcome prevailing barriers to care, innovative diagnostic tools and treatment require functional, efficient and accessible health systems to reach and track patients who are, them-selves, informed and motivated. The high susceptibility of individuals getting harmed from DR- TB, due to the complex interaction between risk factors and available resources, is manifested in their inability to manage risks or recover from the disease effectively.63 This is corrobo-rated by many of the reviewed studies in which diagnosed patients died before they could be initiated on life- saving treatment.31 36 42 50 This highlights the fact that DR- TB continues to be characterised by avoidable morbidity and deaths, especially in SSA, and must be treated with urgency. The raison d’être of rapid diagnostic methods is to improve these outcomes by facilitating quicker diagnosis and treatment. Xpert implementation did not translate to universal increases in diagnosis and treatment rates, presenting a significant setback and missed opportunity in the control of DR- TB.
Gaps in the capacity of the health system to deliver care need to be closed. This would require significant invest-ments at lower levels of care towards more decentralised and ambulatory models of care. In order to fund these efforts, SSA governments need to prioritise and increase health investments and mobilise resources to fund TB control.
strengths and limitationsThe strengths of this review include the adaptation of our conceptual framework to align factors influencing DR- TB care with other well- known frameworks in the field of healthcare access and systems strengthening,18 25 26 using a mixed- methods approach.
This review has a few limitations. First, due to the hetero-geneity of study methods and outcome variables, neither summary measures (eg, effect size) nor pooled analysis for specific interventions were determined, as the studies were not sufficiently comparable to each other. Another limitation is related to the location of the studies. Our search showed a dominance of studies from South Africa, with only two from Nigeria, and none from Angola, DR Congo, Ethiopia, Kenya, Mozambique, the other TB/DR- TB/HIV HBCs in the region. This may have affected the generalisability of our findings within the region, as there are likely other barriers in the different other settings that were not identified. However, the relatively higher HIV burden in South Africa, and the country’s quick adoption of newer diagnostics and medications could serve as an example for these other countries as they scale- up services for DR- TB.
ConClusIonsThe implications of these findings are sobering; they suggest that despite significant progress in cutting down
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time to diagnosis and treatment by using rapid diagnos-tics, this is not enough, in itself, to remove all delays to diagnosis, as other barriers persist in the health system.
WHO recognises that DR- TB is a social justice problem and as a threat to global health security, requiring universal access to the tools and services needed for rapid diagnosis, treatment and care.65 Diagnosis and treatment for DR- TB is a complex and multifaceted socioeconomic problem that needs to be addressed using a multisectoral approach.66 Provider- level and patient- level barriers need to be addressed to maximise the impact of advanced diagnostics. Most of the oper-ational problems identified, such as the poor provider knowledge and implementation of DR- TB guidelines or inefficient screening or laboratory processes, are recti-fiable, although with a substantial amount of effort and investment. We have identified this review as a call to action for all relevant players.
There is a need for more studies focusing on contex-tual access dimensions and care cascades from more HBCs in SSA, as this review has highlighted a dominance of studies from South Africa.
Author affiliations1École de santé publique de l’Université de Montréal (ESPUM), Montréal, Quebec, Canada2Centre de recherche en santé publique, Université de Montréal (CReSP), Montréal, Quebec, Canada3McGill International TB Centre, Montreal, Quebec, Canada4Azhee Akinrin Consulting, Lagos, Nigeria5Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada6Institute of Human Virology, Abuja, Nigeria7School of Public Health, University of the Western Cape, Cape Town, South Africa
Twitter Charity Oga- Omenka @omenkac and Muriel Mac- Seing @MMacSeing
Acknowledgements The authors would like to thank the University of Montreal librarian Sylvie Fontaine for her valuable assistance in conducting the search strategy.
Contributors CO- O, MM- S and CZ conceived the study, DM and CZ supervised the study. CO- O, AT- A and MM- S collected data. CO- O, AT- A, PS and AA analysed the data. All coauthors reviewed and provided feedback on the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not- for- profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.
open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
orCId idsCharity Oga- Omenka http:// orcid. org/ 0000- 0003- 0779- 570XMuriel Mac- Seing http:// orcid. org/ 0000- 0001- 5966- 6702
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