Abstract
BackgroundTuberculosis (TB) remains a major public health burden in Nigeria, disproportionately affecting socioeconomically disadvantaged and marginalized groups. Despite global commitments to gender-responsive TB strategies, significant inequities persist in TB care access and outcomes. The Development and Evaluation of a Gender-Responsive TB Intervention for Community Settings in Nigeria (DESTINE) research was designed to respond to these gaps. Grounded in intersectionality and masculinities theories, DESTINE aimed to understand how gender-related factors hinder access to TB services, co-create a community-led intervention, and assess its feasibility and acceptability. This research addresses the urgent need for gender-responsive TB strategies in Nigeria and provides evidence to inform national and global TB response.
Methods
Exploratory sequential, mixed-methods design integrating five distinct components was used. First, a retrospective desk review of National TB Programme data (2018–2021) was conducted to analyze gender disparities along the TB care cascade across Nigeria. Afterwards, a scoping review was undertaken to map how gender considerations were integrated into TB interventions globally between 2000 and 2022, using PRISMA-ScR guidelines and WHO’s Gender Responsive Assessment Tool (GRAT). Then, using qualitative research consisting of in-depth interviews and focus group discussions DESTINE explored how gendered experiences shape access to TB care among men in peri-urban communities. Thereafter, participatory research was conducted to co-create a gender-responsive TB intervention with local stakeholders, including community leaders, healthcare workers, TB survivors, and program managers. Finally, the intervention was implemented and evaluated through a non-randomized cluster-based controlled before-and-after study to assess feasibility, acceptability, and preliminary effect on TB knowledge and stigma reduction in the communities.
Results
The desk review revealed important gender disparities across all stages of the TB care cascade. Men were underrepresented in TB screening despite higher TB prevalence with a screening gap of 51%, resulting in missed opportunities for early diagnosis and treatment. Women were more likely to be screened but also bore a disproportionate burden of HIV-associated TB with 4.1% co-infection rate compared to men with 2.8% over the four-year period. The scoping review identified 13 gender-responsive TB interventions globally, two were gender-blind, the majority (9) of which were classified as gender-sensitive, and two were gender-specific. None was transformative, highlighting a significant gap in designing interventions that directly challenge structural gender inequities. Qualitative findings underscored the complex interplay of masculine norms, poverty, stigma, and health system barriers that deterred men from accessing TB services. Men often delayed care-seeking due to fears of stigma, prioritization of work, and lack of awareness of TB and its existing services. Those who sought care resorted to community-embedded informal care providers that provide temporary symptom relief without disrupting their schedules but did not have ability to diagnose TB promptly.
The co-creation phase successfully developed a community-based, gender-responsive TB screening model that integrated male-friendly approaches such as use of male community champions for knowledge dissemination, and mobile chest X-ray outreach services in socio-cultural congregate settings. The implementation of the intervention demonstrated high feasibility (feasibility of intervention measure score = 19.7 [Cronbach’s α: 0.80]) and acceptability (acceptability of intervention measure score = 19.3 [Cronbach’s α:0.94]). The intervention was associated with increased TB knowledge (adjusted OR = 37.94 [95% CI: 37.00 – 53.31]) and reduced stigma (estimate = -24.457 [95% CI: -25.200 - -23.714]) in the intervention communities compared to the control.
Conclusion
DESTINE highlights the importance of integrating gender responsiveness into TB interventions through community-led solutions. This research shows that participatory design, grounded in an understanding of gendered experiences, can yield feasible and acceptable interventions for gender equitable access to TB services. Addressing gender norms, stigma, and socioeconomic barriers is essential for closing gaps in TB detection and care, particularly in high-burden, low-resource settings. Future interventions must move towards approaches that engage key stakeholders, leverage community assets and resources to challenge inequities and enhance access to TB services for all. DESTINE offers a model for how TB programs in similar contexts can operationalize global gender equity commitments and accelerate progress towards the End TB goals.
| Date of Award | 24 Oct 2025 |
|---|---|
| Original language | English |
| Awarding Institution |
|
| Supervisor | Bertie Squire (Supervisor), Tom Wingfield (Supervisor) & John S. Bimba (Supervisor) |