Background Tuberculosis (TB) is a major public health concern in South Africa and TB-related mortality remains unacceptably high. Numerous clinical studies have examined the direct causes of TB-related mortality, but its wider, systemic drivers are less well understood. Applying systems thinking, we aimed to identify factors underlying TB mortality in South Africa and describe their relationships. At a meeting organised by the ‘Optimising TB Treatment Outcomes’ task team of the National TB Think Tank, we drew on the wide expertise of attendees to identify factors underlying TB mortality in South Africa. We generated a causal loop diagram to illustrate how these factors relate to each other. Results Meeting attendees identified nine key variables: three ‘drivers’ (adequacy & availability of tools, implementation of guidelines, and the burden of bureaucracy); three ‘links’ (integration of health services, integration of data systems, and utilisation of prevention strategies); and three ‘outcomes’ (accessibility of services, patient empowerment, and socio-economic status). Through the development and refinement of the causal loop diagram, additional explanatory and linking variables were added and three important reinforcing loops identified. Loop 1, ‘Leadership and management for outcomes’ illustrated that poor leadership led to increased bureaucracy and reduced the accessibility of TB services, which increased TB-related mortality and reinforced poor leadership through patient empowerment. Loop 2, ‘Prevention and structural determinants’ describes the complex reinforcing loop between socio-economic status, patient empowerment, the poor uptake of TB and HIV prevention strategies and increasing TB mortality. Loop 3, ‘System capacity’ describes how fragmented leadership and limited resources compromise the workforce and the performance and accessibility of TB services, and how this negatively affects the demand for higher levels of stewardship. Conclusions Strengthening leadership, reducing bureaucracy, improving integration across all levels of the system, increasing health care worker support, and using windows of opportunity to target points of leverage within the South African health system are needed to both strengthen the system and reduce TB mortality. Further refinement of this model may allow for the identification of additional areas of intervention.

Aim: In the face of increasing tobacco consumption in Sub-Saharan Africa, it is crucial to not only curb the uptake of tobacco, but to ensure that tobacco users quit. Considering the minimal attention that tobacco cessation interventions receive in Sub-Saharan Africa, this review aims to describe studies that evaluated tobacco cessation interventions in the region. Methods: A search of studies published till December 2019 that evaluated tobacco cessation interventions in Sub-Saharan Africa and examined tobacco quit rates was conducted in PubMed-Medline, Web of Science and Scopus. Study designs were not limited to randomised control trials but needed to include a control group. Results: Of the 454 titles and abstracts reviewed, eight studies, all conducted in South Africa, were included. The earliest publication was from 1988 and the most recent from 2019. Five studies were randomised control trials, two were quasi-experimental and one was a case–control study. Populations studied included community-based smokers (four studies) and university students, while the relevant clinic-based studies were conducted in pregnant women, tuberculosis patients and HIV-infected patients. Sample sizes were 23 in the case–control study, 87–561 in randomised control trials, and 979 (pregnant women) and 4090 (three rural communities) in the quasi-experimental studies. Four studies included nicotine replacement therapy in the interventions while four utilised only psychotherapy without adjunct pharmacotherapy. Quit rates were evaluated by exhaled carbon monoxide levels (five studies), blood carbon monoxide, urinary cotinine levels and self-reported quit rates. Four studies (two each with and without pharmacotherapy) reported significantly better outcomes in the intervention versus the control groups while one study findings (without pharmacotherapy) were significant in women but not men. Conclusion: This review highlights that scant attention has been paid to tobacco cessation intervention in Sub-Saharan Africa. The heterogeneity of these studies precluded comparisons across interventions or populations. There is a need for evidence-based low-cost tobacco cessation intervention that target high-risk population in Sub-Saharan Africa.

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