The role of agency in the implementation of Isoniazid Preventive Therapy (IPT): Lessons from oMakoti in uMgungundlovu District, South Africa

Holistic acceptability of an adult levofloxacin formulation in children and adolescents on a tuberculosis preventive treatment trial

Drug-resistant tuberculosis (TB) is threatening global TB control. Although formulations designed for children are a priority, adult levofloxacin formulations are widely used in TB treatment and prevention. TB-CHAMP was a cluster-randomised, placebo-controlled trial evaluating the efficacy and safety of 24 weeks of daily levofloxacin to prevent TB in child and adolescent household contacts of adults with infectious multidrug-resistant TB. Nested in-depth longitudinal qualitative work was conducted in a subset of children and their caregivers to understand broader experiences of treatment acceptability. We conducted 41 interviews with 8 caregivers of children <6 years, and with 6 older children responding for themselves. Children who could not swallow the adult formulation whole, found the tablet unpalatable, although they learnt to tolerate the taste over time. Most caregivers and children came from families with substantial experience of TB, but felt they knew little about TB preventive therapy. Many families experienced challenging socio-economic circumstances. Poor acceptability was mitigated by sympathetic study personnel, assistance with transport and financial compensation. The adult formulation of levofloxacin was disliked by many younger children but was acceptable to children able to swallow the tablet whole. In addition to using acceptable drug formulations, TB preventive treatment implementation models should include patient education and should accommodate patients' socioeconomic challenges.

Gender and equity considerations in AMR research: a systematic scoping review

Research on gender and antimicrobial resistance (AMR) beyond women's biological susceptibility is limited. A gender and equity lens in AMR research is necessary to promote gender equality and support the effectiveness, uptake, and sustainability of real-world AMR solutions. We argue that it is an ethical and social justice imperative to include gender and related intersectional issues in AMR research and implementation. An intersectional exploration of the interplay between people's diverse identities and experiences, including their gender, socio-economic status, race, disability, age, and sexuality, may help us understand how these factors reinforce AMR risk and vulnerability and ensure that interventions to reduce the risk of AMR do not impact unevenly. This paper reports on the findings of a systematic scoping review on the interlinkages between AMR, gender and other socio-behavioural characteristics to identify priority knowledge gaps in human and animal health in LMICs. The review focused on peer-reviewed and grey literature published between 2017 and 2022. Three overarching themes were gendered division of caregiving roles and responsibilities, gender power relations in decision-making, and interactions between gender norms and health-seeking behaviours. Research that fails to account for gender and its intersections with other lines of disadvantage, such as race, class and ability, risks being irrelevant and will have little impact on the continued and dangerous spread of AMR. We provide recommendations for integrating an intersectional gender lens in AMR research, policy and practice.

The community as an active part in the implementation of interventions for the prevention and care of tuberculosis: A scoping review

Interventions involving direct community stakeholders include a variety of approaches in which members take an active role in improving their health. We evaluated studies in which the community has actively participated to strengthen tuberculosis prevention and care programs. A literature search was performed in Pubmed, Scopus, ERIC, Global Index Medicus, Scielo, Cochrane Library, LILACS, Google Scholar, speciality journals, and other bibliographic references. The primary question for this review was: ¿what is known about tuberculosis control interventions and programs in which the community has been an active part?. Two reviewers performed the search, screening, and selection of studies independently. In cases of discrepancies over the eligibility of an article, it was resolved by consensus. 130 studies were selected, of which 68.47% (n = 89/130) were published after 2010. The studies were conducted in Africa (44.62%), the Americas (22.31%) and Southeast Asia (19.23%). It was found that 20% (n = 26/130) of the studies evaluated the participation of the community in the detection/active search of cases, 20.77% (n = 27/130) in the promotion/prevention of tuberculosis; 23.07% (n = 30/130) in identifying barriers to treatment, 46.15% (n = 60/130) in supervision during treatment and 3.08% (n = 4/130) in social support for patient. Community participation not only strengthens the capacities of health systems for the prevention and care of tuberculosis, but also allows a better understanding of the disease from the perspective of the patient and the affected community by identifying barriers and difficulties through of the tuberculosis care cascade. Engaging key community stakeholders in co-creating solutions offers a critical pathway for local governments to eradicate TB.

The community as an active part in the implementation of interventions for the prevention and control of tuberculosis: a scoping review

Interventions involving direct community stakeholders include a variety of approaches in which members take an active role in improving their health. We evaluated studies in which the community has actively participated to strengthen tuberculosis prevention and control programs. A literature search was performed in Pubmed, Scopus, ERIC, Global Index Medicus, Scielo, Cochrane Library, LILACS, Google Scholar, speciality journals, and other bibliographic references. The primary question for this review was: what is known about tuberculosis control interventions and programs in which the community has been an active part?. Two reviewers performed the search, screening and selection of studies independently. In cases of discrepancies over the eligibility of an article, it was resolved by consensus. 130 studies were selected, of which 68.47% (n=89/130) were published after 2010. The studies were conducted in Africa (44.62%), the Americas (22.31%) and Southeast Asia (19.23%). It was found that 20% (n=26/130) of the studies evaluated the participation of the community in the detection/active search of cases, 20.77% (n=27/130) in the promotion/prevention of tuberculosis; 23.07% (n=30/130) in identifying barriers to treatment, 46.15% (n=60/130) in supervision during treatment and 3.08% (n=4/130) in social support for patient. Community participation not only strengthens the capacities of health systems for the prevention and control of tuberculosis, but also allows a better understanding of the disease from the perspective of the patient and the affected community by identifying barriers and difficulties through of the tuberculosis care cascade. Engaging key community stakeholders in co-creating solutions offers a critical pathway for local governments to eradicate TB.

Toward a conceptual framework of the acceptability of tuberculosis treatment in children using a theory generative approach

To describe an early-stage holistic framework towards evaluating factors that impact the overall acceptability of TB treatment along the TB care cascade in children. We developed a conceptual framework utilising a theory generative approach. Domains were developed through review of existing definitions and analysis of existing qualitative data undertaken in acceptability studies of TB treatment in children. Clarity of domain definitions was achieved through iterative refinement among the research team. Three domains, each comprising several dimensions, were identified to holistically evaluate treatment acceptability: (1) usability, which involves the alignment between the requirements of treatment use and caregivers' and children's ability to integrate TB treatment into their everyday routines, (2) receptivity, which describes the end-user's perception and expectations of treatment and its actual use, and (3) integration, which describes the relationship between available health services and caregivers/children's capacity to make use of those services. Our framework addresses the gaps in current research which do not account for the influence of caregivers' and children's contexts on TB treatment uptake and overall acceptability. This approach may support the development of more standard, holistic measures to improve TB treatment delivery and experiences and future research in children.

Practical and psychosocial challenges faced by caregivers influence the acceptability of multidrug-resistant tuberculosis preventive therapy for young children

Drug-resistant (DR) strains of Mycobacterium tuberculosis (M. tb) are increasingly recognised as a threat to global tuberculosis (TB) control efforts. Identifying people with DR-TB exposure/ infection and providing TB preventive therapy (TPT) is a public health priority. TB guidelines advise the evaluation of household contacts of newly diagnosed TB cases, with the provision of TPT to vulnerable populations, including young children (<5 years). Many children become infected with TB through exposure in their household. Levofloxacin is under evaluation as TPT in children exposed to M. tb strains with resistance to rifampicin and isoniazid (multidrug-resistant TB; MDR-TB). Prior to opening a phase 3 prevention trial in children <5 years exposed to MDR-TB, the pharmacokinetics and safety of a novel formulation of levofloxacin given daily was evaluated as part of a lead-in study. We conducted an exploratory qualitative study of 10 caregivers' experiences of administering this formulation. We explored how the acceptability of levofloxacin as TPT is shaped by the broader impacts of MDR-TB on the overall psychological, social, and financial wellbeing of caregivers, many of whom also had experienced MDR-TB. Caregivers reported that the novel levofloxacin formulation was acceptable. However, caregivers described significant psychosocial challenges in the process of incorporating TPT administration to their children into their daily lives, including financial instability, withdrawal of social support and stigma. When caregivers themselves were sick, these challenges became even more acute. Although new child-friendly formulations can ameliorate some of the pragmatic challenges related to TPT preparation and administration, the overall psychosocial burden on caregivers responsible for administering TPT remains a major determinant of effective MDR-TB prevention in children.

Promoting Tuberculosis Preventive Therapy for People Living with HIV in South Africa: Interventions Hindered by Complicated Clinical Guidelines and Imbalanced Patient-Provider Dynamics

Isoniazid preventive therapy (IPT) reduces the risk of active tuberculosis among people living with HIV, but implementation of IPT in South Africa and elsewhere remains slow. The objective of this study was to examine both nurse perceptions of clinical mentorship and patient perceptions of in-queue health education for promoting IPT uptake in Potchefstroom, South Africa. We measured adoption, fidelity, acceptability, and sustainability of the interventions using both quantitative and qualitative methods. Adoption, fidelity, and acceptability of the interventions were moderately high. However, nurses believed they could not sustain their increased prescriptions of IPT, and though many patients intended to ask nurses about IPT, few did. Most patients attributed their behavior to an imbalance of patient-provider power. National IPT guidelines should be unambiguous and easily implemented after minimal training on patient eligibility and appropriate medication durations, nurse-patient dynamics should empower the patient, and district-level support and monitoring should be implemented.