We are not on course to achieve the End TB Strategy goal of ending TB – a problem that has been worsened by the COVID-19 pandemic. To accelerate progress towards this goal, we need a paradigm shift that moves us beyond the current, narrow focus on development of health technologies to emphasise access to diagnosis, care, and treatment by patients. This will require more inclusive strategies to address the social determinants of TB, so that diagnosis, treatment, and care are affordable, appropriate, of high quality, sustainable and, importantly, available, and accessible to people where and when they need them.
Social determinants are “conditions in which people are born, grow, live, work and age” and the “systems put in place to deal with illness”, which give rise to stark health inequalities. As we recently summarised in ourfirst blog of this series examining how addressing the social determinants of TB can accelerate ending TB, the linkage between social determinants and TB is well described. Gender - the characteristics of women, men, girls and boys that are socially constructed - is a key determinant of health, and indeed TB, that interacts with broader social determinants and is a cross-cutting theme across the SDG agenda.
Gender plays a crucial role in the likelihood of developing TB disease, seeking and engaging with care, and achieving treatment success. TB disease has severe consequences for different sexes and age groups. There is a body of evidence showing inequitable outcomes for women, highlighting delays in care-seeking behaviour and the impacts of these on children and families as well as gender-specific issues around stigma and discrimination.
In recent years, there has been an appropriate focus on improving public health systems to reach underserved women and children and significant learning from this work across the public health policy and TB practitioner communities.
It is important to reflect these insights broadly across the gender spectrum. Women face specific risks associated with TB such as higher HIV prevalence, higher rates of malnutrition and care roles within homes and within the health workforce. The socio-economic status may contribute to a delay in seeking care. Gendered response within TB has previously been linked to women’s health, within the framework of gender equality and development. However, gender-related determinants also deleteriously affect men. Globally, men have a life expectancy nearly five years lower than women and a significantly higher burden of ill-health as measured by Disability Adjusted Life Years (DALYs) and this is mirrored in outcomes for TB. There have been relatively few interventions developed and assessed to address this, despite the direct and indirect impacts of poor ill-health among men on the wider community. Little is known about the burden of TB in other genders, and there is a notable evidence gap concerning men and people with non-binary identities. This in turn is reflected on the dearth of gender-sensitive policies and practices related to the effort to end TB.
It is time to widen the spotlight to include developing specific interventions that target men to improve outcomes for women, children, and the wider communities in which they live, learning from efforts already made targeting women. In this blog post, we explore why a focus now on men, in addition to women and children, will be a vital element of any comprehensive strategy to end the TB pandemic.
Men and the TB epidemic
Globally, more men than women are diagnosed with and die from TB. In 2019, men aged 15 and above accounted for 56% of people diagnosed to have TB for the first time, and more than half of TB deaths. Importantly, this imbalance is not sufficiently addressed by active searches (or ‘active case-finding’) for people with TB: recent national prevalence survey data suggest that men are more likely than women to have undiagnosed TB or be “missed”.
“Within the healthcare system, more men than women are treated for TB but fewer men complete treatment. This goes some way to explain why, in low- and middle-income countries (LMICs), two thirds of TB transmission can be attributed to men.”
Dr Tom Wingfield
We know now that men are fuelling the spread of TB across the community, affecting everyone, no matter what gender. Tackling TB in men is critical to promoting the health and wellbeing of all.
The intersectionality of gender and TB
In seeking to understand the disproportionate TB burden in men, we need first to examine how gender interacts with broader social determinants of health and inequity. Gender influences health and wellbeing in three ways: (i) interacting with the social determinants of health such as age, education level, occupation, tobacco use, indoor air pollution, geographical location, and socio-economic status; (ii) influencing health behaviours that affect health outcomes; and (iii) through the health system response to gender, including how gender affects the financing and design of health interventions that in turn impact access to quality health care.
At the individual level, men are more likely than women to engage in lifestyle factors such as smoking, alcohol and other substance use, which are associated with both TB illness and delayed TB care-seeking. In addition, diabetes, a known risk factor for TB disease, is more prevalent in men than women. At the social and community level, male-dominated occupations (e.g. mining), rates of incarceration, and socialization patterns in crowded settings (e.g. bars, shebeens), may predispose them to a higher risk of TB exposure and transmission. Moreover, the role of ‘masculinity’ and related social-cultural norms contribute to delayed health seeking among men and reinforce habits that may negatively impact upon their health. These perceived and/or expected sociocultural roles and norms of men within the home, community, or workplace are complex, culturally and age specific, and difficult to unpick and address.
From the health system perspective, men are underserved and take longer to access care compared to women. When they do seek care, men are more likely than women to initially use private healthcare, where the organisation of TB services may not be well coordinated to offer timely and efficient diagnosis, notification, and treatment. Pressures on men to reduce time away from work and lost income may be exacerbated by clinic opening times during prime labouring hours. In Kenya, coverage by the National Health Insurance Fund (NHIF) is limited, and the workforce is largely informal, with men predominantly occupying casual labour positions in quarries (mines), the fishing industry, and in the privately-owned public transportation system. These conditions create challenges and barriers to taking time off work. While men often occupy a higher socioeconomic position than women in high TB burden countries, the psychosocial consequence of job loss and unemployment on men due to ill health can be severe and have serious knock-on effects for women and children.
The way forward
Despite the disproportionate and ongoing TB burden in men, there are few gender-sensitive interventions targeting men for TB diagnosis, treatment and care and we know relatively little about what works or how to improve. To end TB, there is need to develop evidence-informed interventions that consider how gender intersects with other social determinants of health to end preventable deaths for women, children, men, and people with non-binary identities.
Crucial research and implementation questions to be answered include:
- How do we identify and address the gendered social determinants of TB for men?
- How do we make health systems more men-friendly and accessible?
- What might gender-based active identification of people with TB look like for men?
- How might social protection, care and adherence strategies be adapted for men?
- How can we engage different stakeholders including the men, TB affected people, healthcare workers, policy makers and the research community in this process?
Authors: Beatrice Kirubi, Tom Wingfield and Chakaya Muhwa
This is the second blog in a series that examines how addressing the social determinants of TB can accelerate ending TB, drawing on the research and engagement of The LIGHT consortium