title: Gender-related barriers and delays in accessing tuberculosis diagnostic and treatment services: a systematic review of qualitative studies.
abstract: Background. Tuberculosis (TB) remains a significant global public health problem with known gender-related (male versus female) disparities. We reviewed the qualitative evidence (written/spoken narrative) for gender-related differences limiting TB service access from symptom onset to treatment initiation. Methods. Following a systematic process, we searched 12 electronic databases, included qualitative studies that assessed gender differences in accessing TB diagnostic and treatment services, abstracted data, and assessed study validity. Using a modified "inductive coding" system, we synthesized emergent themes within defined barriers and delays limiting access at the individual and provider/system levels and examined gender-related differences. Results. Among 13,448 studies, 28 studies were included. All were conducted in developing countries and assessed individual-level barriers; 11 (39%) assessed provider/system-level barriers, 18 (64%) surveyed persons with suspected or diagnosed TB, and 7 (25%) exclusively surveyed randomly sampled community members or health care workers. Each barrier affected both genders but had gender-variable nature and impact reflecting sociodemographic themes. Women experienced financial and physical dependence, lower general literacy, and household stigma, whereas men faced work-related financial and physical barriers and community-based stigma. Conclusions. In developing countries, barriers limiting access to TB care have context-specific gender-related differences that can inform integrated interventions to optimize TB services.
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
authors.forename: Lakshmi
authors.identifier: 0000-0002-1224-7380
authors.initials: L
authors.lastname: Krishnan
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
authors.forename: Tokunbo
authors.initials: T
authors.lastname: Akande
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
authors.forename: Anita V
authors.initials: AV
authors.lastname: Shankar
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
authors.forename: Katherine N
authors.initials: KN
authors.lastname: McIntire
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
authors.forename: Celine R
authors.initials: CR
authors.lastname: Gounder
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA ; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA ; Center for Clinical Global Health Education, Johns Hopkins University, 600 North Wolfe Street, Phipps 540B, Baltimore, MD 21287, USA.
authors.forename: Amita
authors.initials: A
authors.lastname: Gupta
authors.affiliation: Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
authors.forename: Wei-Teng
authors.initials: WT
authors.lastname: Yang