Abstract
Introduction and rationale: Gender significantly shapes health and wellbeing, interacting with social, economic, and individual factors to influence both health and equitable access to quality healthcare services. Globally, adult men account for 55% of all people who develop TB, and two out of every three individuals with TB who go undiagnosed or undetected are men. Health policies that are not gender-specific reinforce biological, social and behavioural factors that predispose men to TB. A prolonged period with undiagnosed and untreated TB not only impacts men’s health but also contributes to onward TB transmission within communities and may increase the risk for negative socioeconomic consequences such as catastrophic costs and loss of income. There have been calls for national TB programs to recognise the unique barriers among men and introduce patient-centred strategies to address them. However, limited evidence exists on gender-specific approaches, and there are no specific guidelines targeting TB screening among men in health facilities within Uganda. To address this, I led a study that co-created and evaluated a gender-specific intervention.Objectives: The overall objective of this study was to co-create and evaluate a health facility-based TB screening intervention designed to increase TB notifications by improving access to TB screening and care services among men over a one-year study period. The specific objectives are:
1) To co-create a health facility-based TB screening intervention targeting men
2) To evaluate the effectiveness of a health facility-based TB screening intervention targeting men in increasing the number of people with TB notified and initiated on treatment disaggregated by sex over a one-year study period
3) To evaluate the acceptability, appropriateness, feasibility and implementation processes of a health facility-based TB screening intervention targeting men
Methods: I led a sequential exploratory mixed methods study called IGNITE (Improving TB Case Detection Using a Gender-Specific TB Screening Intervention in Urban Public Health Facilities in Uganda). The study employed both quantitative methods (quasi-experimental multiple time series design and questionnaires) and qualitative methods (participatory workshops, observation and key informant interviews) across two phases. In phase one, I engaged stakeholders in participatory workshops to co-create the proposed intervention, develop its theory of change and map TB care processes (Objective 1). The resulting multi-faceted intervention included the use of symptom-based checklist stamps for TB screening, distribution of TB educational materials, and the introduction of male-friendly TB clinics with extended evening service hours, health education by male champions in ‘men’s corners’, and integrated TB, HIV, diabetes, and hypertension screening. During phase two, I coordinated the implementation of the intervention and explored its effectiveness (Objective 2), feasibility and implementation processes (Objective 3). To assess effectiveness, I compared TB notification data before (January-June 2023) and after (July-December 2023) IGNITE at intervention (Gombe and Mityana hospitals) and control (Luwero and Kiboga hospitals) sites, applying a quasi-Poisson regression model. I explored the feasibility and implementation processes of the intervention using mixed methods, applying thematic analysis for qualitative data and reporting average quantitative scores.
Results: The number of people presumed to have TB increased in Gombe but declined in Mityana. Gombe's TB notifications rose by 46.3% driven entirely by male notifications (Female 0%, Male 88.4%), while Mityana reported a 36.4% increase across both genders (Female 26.3%, Male 45.1%). Notifications declined in control facilities. The intervention significantly increased TB case notification rates (RR: 1.51, 95% CI: 1.03-2.22), and males had a higher notification rate than females (RR: 1.5, 95% CI: 1.23-1.83). Treatment initiation rates ranged from 97.4% to 100% in women and 91.4% to 97.7% in men before and after the intervention. The intervention had no impact on treatment initiation.
Healthcare workers had mixed perceptions of the intervention: some found the intervention burdensome, while others reported that it simplified their work and contributed to increased TB notifications. Checklist stamps were perceived to simplify TB screening and improve documentation, while TB educational materials increased patient engagement. Positive experiences among people with TB, including improved access to additional health services and shorter waiting times, enhanced the overall acceptability of the intervention. Intervention implementation varied, with Gombe achieving higher coverage with the stamp and integrated screening, while Mityana had higher coverage with other components.
Conclusion: The participatory approach facilitated the co-creation of context-specific, person-centred TB interventions for men and enhanced stakeholders’ support during implementation. Gender-specific interventions for screening and diagnosing people with TB and linking them to care can significantly improve notifications among men without decreasing notifications among women.
| Date of Award | 10 Nov 2025 |
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| Original language | English |
| Awarding Institution |
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| Supervisor | Justin Pulford (Supervisor), Rachael Thomson (Supervisor), Tom Wingfield (Supervisor) & Bruce Kirenga (Supervisor) |