ObjectivesEarly diagnosis and timely treatment are key elements of a successful healthcare system. We assessed the role of socioeconomic and cultural norms in accelerating or decelerating uptake and utilisation of health technologies into policy and practice.SettingSecondary and tertiary level healthcare facilities (HCFs) in three East African countries. Level of HCF was selected based on the WHO recommendation for implantation of tuberculosis (TB) molecular diagnostics.ParticipantsUsing implementation of TB diagnostics as a model, we purposively selected participants (TB patients, carers, survivors, healthcare practitioners, community members, opinion leaders and policy-makers) based on their role as stakeholders. In-depth interviews, key informant interviews and focus group discussions were held to collect the data between 2016 and 2018. The data were transcribed, translated, coded and analysed by thematic-content analysis.ResultsA total of 712 individuals participated in the study. Socioeconomic and cultural factors such as poverty, stigma and inadequate knowledge about causes of disease and available remedies, cultural beliefs were associated with low access and utilisation of diagnostic and treatment tools for TB. Poverty made people hesitate to seek formal healthcare resulting in delayed diagnosis and resorting to self-medication and cheap herbal alternatives. Fear of stigma made people hide their sickness and avoid reporting for follow-up treatment visits. Inadequate knowledge and beliefs were fertile ground for aggravated stigma and believing that diseases like TB are caused by spirits and thus cured by spiritual rituals or religious prayers. Cultural norms were also the basis of gender-based imbalance in accessing care, ‘I could not go to hospital without my husband’s permission’, TB survivor.ConclusionOur findings show that socioeconomic and cultural factors are substantial ‘roadblocks’ to accelerating the uptake and utilisation of diagnostic and treatment tools. Resolving these barriers should be given equal attention as is to health system barriers.

Tuberculosis (TB), an airborne disease, is among the ten leading deadly diseases worldwide. Despite the efforts of WHO and its partners to eradicate it, it is still a public health issue especially with the rise of multi-drug resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). Commiphora species (Burseraceae family) are known in the Kenyan traditional medicine to treat respiratory diseases including TB. In the search of new anti-TB alternative drugs, plant materials from Commiphora mildbraedii Engl. (root bark and stem bark), Commiphora edulis (Klotzsch) Engl. (stem bark and leaves) and C. ellenbeckii Engl. (Stem bark and leaves) were tested for antimycobacterial activity, cytotoxicity and phytochemistry. 100 g of the powdered plant materials were macerated using the serial method with solvents of increasing polarity. Aqueous extraction was carried out by decoction. The microbroth dilution method was used to determine the antimycobacterial activity (MIC) against a model Mycobacterium smegmatis ATCC607 while the cytotoxicity evaluation (CC 50 ) was carried out using the MTT assay. The most active extract was fractionated using preparative TLC and fractions were analysed by GC-MS. Thirty extracts were obtained from the 6 different plant materials and eleven of them exhibited the antimycobacterial activity with the methanolic extracts of the stem and root bark of C. mildbraedii, and the aqueous extract of the C. ellenbeckii leaves exhibiting high activities (MIC= 0.39, 0.78 and 0.78 mg/L respectively). The MTT assay showed no or low cytotoxicity. The GC-MS analysis of the preparative TLC fractions from the methanolic extract of C. mildbraedii revealed the presence of 42 compounds belonging to 10 different classes of phytochemicals. Lup-20(29)-en-3-one and o-xylene were the most abundant. Except o-xylene and α-terpineol, all the compounds were detected for the first time in the Commiphora genus. These findings justify the ethnomedicinal uses of Commiphora species in TB treatment.

Background Universal access to basic sanitation remains a global challenge, particularly in low- and middle-income countries. Efforts are underway to improve access to sanitation in informal settlements, often through shared facilities. However, access to these facilities and their potential health gains—notably, the prevention of diarrheal diseases—may be hampered by contextual aspects related to the physical environment. This study explored associations between the built environment and perceived safety to access toilets, and associations between the latter and diarrheal infections. Methods A cross-sectional study was carried out between July 2021 and February 2022, including 1714 households in two informal settlements in Abidjan (Côte d’Ivoire) and two in Nairobi (Kenya). We employed adjusted odds ratios (aORs) obtained from multiple logistic regressions (MLRs) to test whether the location of the most frequently used toilet was associated with a perceived lack of safety to use the facility at any time, and whether this perceived insecurity was associated with a higher risk of diarrhea. The MLRs included several exposure and control variables, being stratified by city and age groups. We employed bivariate logistic regressions to test whether the perceived insecurity was associated with settlement morphology indicators derived from the built environment. Results Using a toilet outside the premises was associated with a perceived insecurity both in Abidjan [aOR = 3.14, 95% confidence interval (CI): 1.13–8.70] and in Nairobi (aOR = 57.97, 95% CI: 35.93–93.53). Perceived insecurity to access toilets was associated with diarrheal infections in the general population (aOR = 1.90, 95% CI: 1.29–2.79 in Abidjan, aOR = 1.69, 95% CI: 1.22–2.34 in Nairobi), but not in children below the age of 5 years. Several settlement morphology features were associated with perceived insecurity, namely, buildings’ compactness, the proportion of occupied land, and angular deviation between neighboring structures. Conclusions Toilet location was a critical determinant of perceived security, and hence, must be adequately addressed when building new facilities. The sole availability of facilities may be insufficient to prevent diarrheal infections. People must also be safe to use them. Further attention should be directed toward how the built environment affects safety. Graphical Abstract

BackgroundBillions of dollars are spent on research globally every year, yet little is translated to public use through policy and/or commercialisation. For the few research findings that make it to policy, evidence in most LMICs shows they hardly see the light of implementation. Our EDCTP-funded TWENDE consortium used implementation of tuberculosis (TB) molecular diagnostics as a model to investigate the barriers, and opportunities to unlock them in order to maximise uptake of health research innovations into policy and practice.MethodsMixed methods approach including surveys, audits, in-depth interviews and focus group discussions (FGDs), policymaker dialogues to unravel the bottlenecks and how to overcome them.Results1119 respondents representing from Uganda, Kenya and Tanzania participated in the study. 19% were district/county health officers, 12% healthcare audits, 58% one-on-one interviews and FGDs with healthcare practitioners, community leaders, TB patients and survivors, and care givers, and 11% policymaker workshops. Barriers: government poverty, family/individual poverty, incompatibility of technologies to existing infrastructure, low awareness and socio-cultural beliefs in the community were found. Stigma at community and healthcare levels was rife. Consequently, TB diagnostics were underimplemented and underutilised. Xpert MTB/RIF test was fully utilised in ∼10% of healthcare facilities (conducting 8 tests per day) whilst Line probe assay was implemented in less than 1% of the facilities.ConclusionBased on our findings, we believe overcoming the barriers presents the opportunity to maximise research impact of public healthcare. This could be achieved through sustained public and practitioners’ sensitisation to remove stigma to increase demand and utilisation of services; early interaction of researchers and policymakers to increase sense of ownership and acceptability of research innovations; early communication between developers and end-users to align the tools with the needs and existing infrastructure capacity; and increased affordability of innovations through socioeconomic empowerment programmes.

Background: Tuberculosis (TB), a treatable disease claims over a million lives every year. Accurate rapid diagnosis is crucial for early treatment initiation and prevention of severe disease. Despite over 10 years approval of molecular diagnostics for routine use, an estimated 3 million TB cases go undetected per year. We investigated the barriers and opportunities to maximise uptake and utilization of molecular diagnostics in routine healthcare settings. Methods: We deployed surveys, healthcare facility audits, focus group discussions, in-depth interviews, and policymaker dialogues to unravel factors affecting the uptake and utilization of TB molecular diagnostics in three East African countries. The benchmark was the World Health Organization approved Xpert MTB/RIF and Line Probe Assay (LPA) implemetation at district and regional hospital level respectively. Results: 190 district and county health officers participated in the survey. The survey findings were corroborated by 145 healthcare facility (HCF) audits and 11 policymaker engagement workshops. At 66% coverage, Xpert MTB/RIF fell behind microscopy and clinical diagnosis by 33% and 1% respectively across 190 districts/counties. Stratified by HCF type, Xpert MTB/RIF implementation was 56%, 96% and 95% at district-, regional- and national referral- hospital level. LPA coverage was 4%, 3% below culture across the three countries. Out of 111 HCFs with Xpert MTB/RIF, 37 (33%) utilized it to full capacity, performing ≥8 tests per day of which 51% of these were level five (zonal consultant and national referral) HCFs. Likewise, 75% of LPA test performance was at level five HCFs. Underutilization of Xpert MTB/RIF and LPA was mainly attributed to inadequate- human resource, 22% and utilities, 26% respectively. Absence of the diagnostic services was attributed to under financing. Lack of awareness was second to underfinancing as reason underlying absence of LPA service. Creation of a health tax and decentralising collection and management of this tax to district/county level was proposed by policymakers as means to boost domestic financing for uptake of health technologies. Conclusion Our findings show higher uptake and utilization of molecular and other diagnostics at tertiary- than primary-secondary- level HCFs. Innovative implementation models to ensure quality access at lower level HCFs are urgently needed.