Barriers to Pediatric and Youth Tuberculosis Treatment Initiation in Sub-Saharan Africa: A Systematic Review

Sullivan, Brittney J.

Purpose: Timely initiation and correct treatment of tuberculosis (TB) are critical to reduce disease transmission and improve patient outcomes. Barriers to treatment initiation exist at the patient- and system-level for adults and children; however, barriers to treatment initiation in younger individuals are less understood. Therefore, the aim of this study is to determine patient- and system-level barriers to treatment initiation for pediatric and youth diagnosed with TB in sub-Saharan Africa through systematic review of the literature.

Methods: This review was conducted in October 2015 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Databases searched include PubMed, Embase, CINAHL, Global Health, SCOPUS, and African Medicus Index for all literature pertaining to pediatric and youth TB in sub-Saharan Africa. Studies were eligible for inclusion if the primary or secondary objectives of the study were related to pediatric or youth barriers to TB treatment initiation. Two reviewers independently assessed articles.

Results: A total of 1,490 unique articles met criteria for screening; 152 studies met criteria for full text review; 56 articles were included for final analysis. Both patient-level and system-level barriers exist across sub-Saharan Africa for pediatric and youth diagnosed with TB and impede treatment initiation. Examples of patient-level barriers include limited knowledge, poor attitudes and beliefs regarding TB, and economic burdens causing delays in seeking care for diagnosis of TB symptoms and treatment of TB disease. System-level barriers include laboratory and healthcare provider delays between diagnosis and treatment, lack of integration of TB/HIV services, and lack of flexibility in treatment provision (i.e. centralization of services and Directly Observed Therapy). Barriers to diagnosis were more frequently studied than barriers to treatment initiation. Many barriers for children and youth overlapped with adults; however, additional barriers existed for children and youth such as a parent being diagnosed with TB and more difficulty in confirming diagnosis due to delayed or inconclusive diagnostics.

Conclusion: Patient- and system-level barriers to TB treatment initiation are common in sub-Saharan Africa for children and youth. More research aimed at addressing the specific needs of children and youth is urgently needed in sub-Saharan Africa particularly around improved diagnosis and treatment initiation. Improving the recognition of TB in children and reducing the time from symptom onset to treatment initiation is imperative. Targeting patient- and system-level barriers together must be addressed to improve patient outcomes.