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Factors influencing diagnosis and treatment initiation for multidrug-resistant/rifampicin-resistant tuberculosis in six sub-Saharan African countries: a mixed-methods systematic review
  1. Charity Oga-Omenka1,2,3,
  2. Azhee Tseja-Akinrin4,
  3. Paulami Sen3,5,
  4. Muriel Mac-Seing1,2,
  5. Aderonke Agbaje6,
  6. Dick Menzies3,5,
  7. Christina Zarowsky1,2,7
  1. 1École de santé publique de l’Université de Montréal (ESPUM), Montréal, Quebec, Canada
  2. 2Centre de recherche en santé publique, Université de Montréal (CReSP), Montréal, Quebec, Canada
  3. 3McGill International TB Centre, Montreal, Quebec, Canada
  4. 4Azhee Akinrin Consulting, Lagos, Nigeria
  5. 5Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
  6. 6Institute of Human Virology, Abuja, Nigeria
  7. 7School of Public Health, University of the Western Cape, Cape Town, South Africa
  1. Correspondence to Ms Charity Oga-Omenka; omenkac{at}


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.

  • tuberculosis
  • health services research
  • public health
  • systematic review

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  • Handling editor Alberto L Garcia-Basteiro

  • Twitter @omenkac, @MMacSeing

  • 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.

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