Leaving no-one behInd: Transforming Gendered pathways to Health for TB (LIGHT)

Globally, the World Health Organization (WHO) reported an estimated of 10.6 million people fell ill with tuberculosis (TB) in 2021, up from 10.1 million in 2020. The latest figures estimated 1.6 million deaths globally in 2021 from this communicable disease, ranking TB as the second leading cause of death from a single infectious disease after COVID-19. Men accounted for the highest TB burden (56.5% of all TB cases in 2021 compared to 32.5% among adult women and 11% among children).

The COVID-19 pandemic has reversed years of progress in the fight against TB with fewer people diagnosed and treated or provided with TB preventive treatment, and fewer resources allocated for essential TB services and TB research and development.

Gender has a powerful influence on the health and well-being of people and communities affected by TB, intersecting with other individual, social, structural, and economic factors and impacting on their right to health and well-being and whether they have equitable access to quality healthcare. People of different genders face different challenges and thus need different solutions. A strong and sustained focus on strengthening health systems and putting health equity, gender and human rights at the core of a person-centred TB response is key to achieving global health goals for healthier people and ensuring that no-one is left behind.

The LIGHT consortium aims to support a more effective, gender-sensitive health policy and practice response to reduce TB transmission, morbidity, mortality and associated catastrophic costs for sustainable, gender equitable access to quality TB prevention and care.

A particular challenge in the fight against TB is that men account for more than half of the total estimated TB cases annually, and two out of every three cases which go undetected or untreated are in men. This has an impact on the efficacy of public health responses with tremendous personal, familial, social, and economic consequences for their families and the wider community. The evidence base argues for including, not replacing, men in the gender and health agenda, discourse, policies, and programmes.

LIGHT will conduct research; strengthen capacity for research, research management and research uptake; ensure uptake of evidence generated by the programme into policy discussions; and monitor, evaluate and apply learning from our work.

Research

We will conduct research within and across our partner countries (Nigeria, Uganda, Malawi and Kenya) to co-create relevant, timely new evidence that will help inform policy and practice through developing, implementing and evaluating novel interventions to improve access and reduce disparities in access to TB diagnosis, treatment and outcomes for underserved groups, particularly men. The overall aim of implementing, evaluating and comparing different approaches across the LIGHT consortium is to examine the applicability of such approaches in other similar contexts such as low-and-middle-income settings; as well as investigating their effectiveness in improving health outcomes for underserved groups, particularly men across all age groups.

In-country research

Uganda

LIGHT partners at MLI will investigate the feasibility, acceptability and effectiveness of TB screening among men reached by health sector interventions. They will do so by conducting research that aims to “improve TB case detection using a gender transformative TB screening package in formal and informal health systems in Uganda”.

This research will:

• Determine gender-related factors preventing men from accessing services for TB diagnosis and treatment in Uganda.
• Identify interventions that aim to increase the detection of TB among individuals attending health facilities in Uganda.
• Assess whether the inclusion of gender-sensitive approaches into interventions aiming to increase the detection of men with TB and treatment uptake improves their effectiveness and acceptability.
• Identify gender-sensitive lessons for good practice in the design of interventions aiming to increase the detection of TB among people attending health services in Uganda.
• Evaluate the cost effectiveness of gender-sensitive interventions to increase the detection of TB among patients attending health services in Uganda.

Nigeria

LIGHT partners at ZRC will investigate the acceptability, convenience, effectiveness and costs of new TB diagnostics and linkage to care interventions while working in formal and informal settings, where men congregate within densely populated urban communities, to identify missing cases. They will do so by conducting research on the “Development and Evaluation of gender-Sensitive TB Interventions for community settings in NigEria (DESTINE)”.

The research will:

• Determine gender-related factors preventing men from accessing services for TB diagnosis and treatment in Nigeria.
• Identify outreach or community-based approaches that aim to increase the detection of people with presumptive TB in Nigeria.
• Assess whether the inclusion of gender-sensitive approaches into outreach and community-based interventions increases their effectiveness to detect men with TB and improves TB treatment uptake.
• Identify gender-sensitive lessons for good practice in the design of community-based and outreach services for TB.
• Evaluate the cost effectiveness of gender-sensitive community-based and outreach interventions.

Kenya

The research carried out by LIGHT partners at ReSoK aims to “understand the burden of TB among young people, especially men, and to eventually develop and test interventions to address this burden”. They will conduct:

• TB care cascade analysis to determine risk factors for non-completion of screening, diagnostic and treatment steps among young people in Kenya to allow for prioritization of resources and optimisation of TB care in the population of young people.
• Systematic review of qualitative studies on TB care related challenges and opportunities experienced by young people in sub-Saharan Africa and other LMICs settings.
• Participatory research to design a theory-informed TB care related intervention for young people in sub-Saharan Africa that would be formally tested in a future RCT (depending on funding availability).

Malawi

LIGHT partners at MLW will evaluate adapted active case-finding approaches in all settings (at the community level where people live and socialise, in occupational settings, in learning institutions, and at the health facility level) to increase inclusion of youths and young adult men and have epidemiological impact for the wider community. They will do so by conducting research on the “potential epidemiological impact of increasing uptake of TB active case finding interventions among men and youth on transmission, morbidity and mortality in Africa”.

This research will:

• Use Bayesian multi-level statistical modelling of TB prevalence survey data from low- and middle-income countries, synthesise available data and estimate the male-to-female gender-gap in engagement with TB screening activities; and using partial-pooling of data, investigate how this varies by age group, district and country.
• Work with key stakeholders (community members, National TB programmes, researchers, policymakers) to identify intervention strategies that would be feasible and acceptable to increase male and youth engagement with community-based TB active case finding activities.
• Use mathematical transmission modelling, investigate the potential epidemiological impact of interventions that increase male and youth engagement in community-based TB active case finding interventions.
• Develop and pilot interventions to increase male and youth engagement with TB active case finding interventions, evaluating feasibility, acceptability, and potential impact to inform scale up of interventions and implementation evaluation, with the overall objective of changing gendered norms and rapidly improving TB care and prevention.

Cross-cutting research

The LIGHT consortium recognises that robust cross-disciplinary research is urgently needed to devise and implement optimal prevention, diagnosis, treatment and health system approaches that address challenges across the TB care cascade. This will also enable rapid deployment of new tools for TB control (vaccines, new drugs and shorter drug regimens, diagnostics). Accordingly, cross-consortium research activities and analyses will be carried out by the different partners in the UK (i.e., LSTM & LSHTM) and Africa to complement in-country research through consolidating data from multiple settings and assessing the impact and effectiveness of various research interventions. Such research activities include:

• Modelling the potential epidemiological impact of improving men’s access to care, primarily conducted by LSTM, LSHTM and MLW research teams, will be applied across the projects to deepen understanding of implications of scaling up or modifying interventions.
• Gender and intersectionality framework analysis of TB burden and care, primarily carried out by LSTM, MLW and MLI research teams, and will be applied across all projects to ensure a consistent approach and build on existing country gender assessments
• Health economics and cost effectiveness studies, primarily conducted by LSTM, and will be applied across all projects to allow comparisons of the in-country intervention, through analysing the economic consequences of TB and generating evidence to inform national policies.
• Community-participatory research will be carried out across all four countries. This research approach aims at establishing a deeper understanding of the real issues/problems and barriers facing people with TB and those affected by TB (i.e. their families and communities) in relation to accessing TB services and care, as well as involving the community in identifying solutions and ways to overcome these barriers.

Capacity Strengthening

LIGHT aims to leave a sustainable legacy within partner countries of individual and institutional high-quality research, research management and research uptake capacity and multi-stakeholder use of evidence. Drawing on technical advice from relevant thematic Working Groups, we will undertake capacity strengthening along the dynamic spectrum of knowledge creation and use, focusing on individuals, institutions and networks/platforms. We will draw on and strengthen existing know-how, resources, networks/platforms and programmes where relevant and build on previous training and experience.

Research Uptake

LIGHT aims to maximise the impact of research generated by the consortium to help guide research development at the national and regional level and strengthen evidence-informed approaches to TB care as well as to support the strengthening of the systematic use of learning and evidence. The team will seek opportunities to engage and effectively communicate with a range of influential stakeholders to enable the research findings to be taken up by decision-makers and used to achieve positive development outcomes.

Monitoring, evaluation and learning

LIGHT team will monitor, evaluate and apply learning in support of partner organisational objectives and contribute to the accountability mechanisms of the consortium including a focus on value for money.

LIGHT aims to contribute to real-world change through new evidence generated by the consortium. We will support in-country partners and key stakeholders to ensure that global and public health policies, programmes, organisations and initiatives are gender-sensitive, pro-poor and ready to support the introduction and scale-up of new TB-related products by 2030 to meet global TB targets.

For LIGHT, success will be reflected by:

• New research evidence on how to increase the detection and cure of males (adults and adolescents) with TB that take into account the needs of women, girls and boys; the COVID-19 context; and the urban contexts in Malawi, Kenya, Uganda and Nigeria.
• Policy and practice on TB treatment and care that has been informed by the new research evidence in each country and regionally, drawing out common themes which are relevant in multiple settings.
• Increased individual, institutional and stakeholder capacity to conduct, manage and use multi-disciplinary, policy-relevant research.

LIGHT is funded by UK aid and led by the Liverpool School of Tropical Medicine working with partners in Kenya, Malawi, Nigeria, Uganda, and the UK.

LIGHT’s partners are:

• African Institute for Development Policy (AFIDEP), Kenya & Malawi
• Liverpool School of Tropical Medicine (LSTM), UK
• London School of Hygiene and Tropical Medicine (LSHTM), UK
• Makerere University Lung Institute (MLI), Uganda
• Malawi-Liverpool-Wellcome Trust Research Programme (MLW), Malawi
• Respiratory Society of Kenya (ReSOK), Kenya
• Zankli Research Centre (ZRC), Nigeria