Barriers to engagement in the care cascade for tuberculosis disease in India: A systematic review of quantitative studies

• Published in: PLoS medicine 2024-05, Vol.21 (5), p.e1004409
• Main Authors: Jhaveri, Tulip A, Jhaveri, Disha, Galivanche, Amith, Lubeck-Schricker, Maya, Voehler, Dominic, Chung, Mei, Thekkur, Pruthu, Chadha, Vineet, Nathavitharana, Ruvandhi, Kumar, Ajay M V, Shewade, Hemant Deepak, Powers, Katherine, Mayer, Kenneth H, Haberer, Jessica E, Bain, Paul, Pai, Madhukar, Satyanarayana, Srinath, Subbaraman, Ramnath
• Format: Article
• Language: English
• Subjects: Biology and Life Sciences; Care and treatment; Diagnosis; Estimates; Health Services Accessibility; Humans; India - epidemiology; Male; Medical research; Medicine and Health Sciences; Medicine, Experimental; People and Places; Physical Sciences; Social aspects; Survival; Systematic review; Treatment Outcome; Tuberculosis; Tuberculosis - diagnosis; Tuberculosis - epidemiology; Tuberculosis - therapy; Undernutrition; Variables
• ISSN: 1549-1676; 1549-1277; 1549-1676
• DOI: 10.1371/journal.pmed.1004409

India accounts for about one-quarter of people contracting tuberculosis (TB) disease annually and nearly one-third of TB deaths globally. Many Indians do not navigate all care cascade stages to receive TB treatment and achieve recurrence-free survival. Guided by a population/exposure/comparison/outcomes (PECO) framework, we report findings of a systematic review to identify factors contributing to unfavorable outcomes across each care cascade gap for TB disease in India. We defined care cascade gaps as comprising people with confirmed or presumptive TB who did not: start the TB diagnostic workup (Gap 1), complete the workup (Gap 2), start treatment (Gap 3), achieve treatment success (Gap 4), or achieve TB recurrence-free survival (Gap 5). Three systematic searches of PubMed, Embase, and Web of Science from January 1, 2000 to August 14, 2023 were conducted. We identified articles evaluating factors associated with unfavorable outcomes for each gap (reported as adjusted odds, relative risk, or hazard ratios) and, among people experiencing unfavorable outcomes, reasons for these outcomes (reported as proportions), with specific quality or risk of bias criteria for each gap. Findings were organized into person-, family-, and society-, or health system-related factors, using a social-ecological framework. Factors associated with unfavorable outcomes across multiple cascade stages included: male sex, older age, poverty-related factors, lower symptom severity or duration, undernutrition, alcohol use, smoking, and distrust of (or dissatisfaction with) health services. People previously treated for TB were more likely to seek care and engage in the diagnostic workup (Gaps 1 and 2) but more likely to suffer pretreatment loss to follow-up (Gap 3) and unfavorable treatment outcomes (Gap 4), especially those who were lost to follow-up during their prior treatment. For individual care cascade gaps, multiple studies highlighted lack of TB knowledge and structural barriers (e.g., transportation challenges) as contributing to lack of care-seeking for TB symptoms (Gap 1, 14 studies); lack of access to diagnostics (e.g., X-ray), non-identification of eligible people for testing, and failure of providers to communicate concern for TB as contributing to non-completion of the diagnostic workup (Gap 2, 17 studies); stigma, poor recording of patient contact information by providers, and early death from diagnostic delays as contributing to pretreatment loss to follow-up (Gap 3, 1