Facilitators and barriers to TB care during the COVID-19 pandemic

Abstract

BACKGROUND: Knowledge about factors influencing access and adherence to TB care, and on the impact of the COVID-19 pandemic on TB care in resource-restricted settings is scarce. We conducted this study in Atsimo-Andrefana, a rural region in southern Madagascar where TB prevalence, poverty and food insecurity rates are high. We aimed to determine facilitators and barriers to access to and provision of TB care in rural Madagascar during the COVID-19 pandemic.METHODS: We conducted qualitative focus group discussions (FGDs) and in-depth interviews (IDIs) with patients with TB, community health workers, facility-based health workers, public health officials and non-governmental organisation staff. We analysed interviews using thematic analysis.RESULTS: We conducted 11 FGDs and 23 IDIs. We identified three main barriers to access and adherence to TB care: 1) stigma, 2) indirect treatment costs, and 3) food insecurity. The facilitator perceived as most influential was high health worker motivation. The effects of the COVID-19 pandemic on TB care varied between stake-holders; some health workers described delays in TB diagnosis and increased workload.CONCLUSIONS: To improve access and adherence to TB care, both indirect treatment costs and stigma need to be reduced; undernourished patients with TB should receive food support.

Factors associated with low tuberculosis case detection and investigation in public health facilities (PHFs) in Uganda: A case study of Bududa district

“…This ndings where the workload of health workers and lack of technical staff can be a signi cant barrier to effective TB investigation and diagnosis as documented in previous study [22]. Health workers may be overburdened with other responsibilities, which can lead to delays in TB diagnosis and treatment [22]. Similar ndings where there is low TB detection in rural PHFs was recorded other countries in Africa such as Ghana and Ethiopia.…”

“…The health facility factors identi ed included high workload, lack of protective gear, medicine stock outs, equipment breakdown and power shortages, fear of contacting TB by the Health worker, negative attitude of some health workers and low motivation of staff to manage TB cases. This ndings where the workload of health workers and lack of technical staff can be a signi cant barrier to effective TB investigation and diagnosis as documented in previous study [22]. Health workers may be overburdened with other responsibilities, which can lead to delays in TB diagnosis and treatment [22].…”

Barriers to and facilitators of populational adherence to prevention and control measures of COVID-19 and other respiratory infectious diseases: a qualitative evidence synthesis

“…20 studies were from North America [ 32 – 51 ], 17 from Europe and Central Asia [ 52 – 68 ], 13 from East Asia and the Pacific [ 69 – 81 ], five from South Asia [ 82 – 86 ], 11 from Sub-Saharan Africa [ 87 – 97 ], three from the Middle East and North Africa [ 98 – 100 ] and two from Latin America and the Caribbean [ 101 , 102 ]. According to the World Development Indicators 2022–2023 of the World Bank [ 103 ], 45 of the included studies were from high-income countries [ 32 – 69 , 71 – 74 , 77 , 79 , 81 ], five were from upper-middle-income countries [ 70 , 75 , 78 , 101 , 102 ], 10 were from lower-middle-income countries [ 76 , 82 – 86 , 88 , 97 , 99 , 100 ] and 10 were from low-income countries [ 87 , 89 – 96 , 98 ]. Most participants were young and middle-aged adults, and only 10 studies focused on older people [ 33 , 38 , 41 , 45 , 70 , 71 , 74 , 77 – 79 ].…”

“…Most participants were young and middle-aged adults, and only 10 studies focused on older people [ 33 , 38 , 41 , 45 , 70 , 71 , 74 , 77 – 79 ]. Five studies did not report detailed information regarding participants’ age [ 40 , 64 , 96 , 98 , 99 ].…”

Patient level barriers to accessing TB care services during the COVID-19 pandemic in Uganda, a mixed methods study

“…These include barriers that aligned with our phone questionnaire data such as transportation challenges, and costs of medications but also described new barriers such as increasing cost of living, fear of COVID-19 infection at health centers, the stigma of respiratory symptoms, and decreased accessibility of healthcare workers. This builds on the findings from prior qualitative studies in Madagascar and Brazil that identified barriers to TB care during the COVID-19 pandemic as stigma, treatment costs such as transportation and medications, food insecurity [ 23 , 24 ].…”