Patient and provider perceptions of the impact of COVID-19 on tuberculosis healthcare access and delivery: A qualitative study of the complexities of a pandemic within a pandemic

Patient and provider perceptions of the impact of COVID-19 on tuberculosis healthcare access and delivery: A qualitative study of the complexities of a pandemic within a pandemic | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patient and provider perceptions of the impact of COVID-19 on tuberculosis healthcare access and delivery: A qualitative study of the complexities of a pandemic within a pandemic Mrs. Katelyn Brehon, Mrs. Pam Hung, Dr. Maxi Miciak, Dr. Angela Lau, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5656441/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: We aimed to explore patient and provider perspectives of the impact of the COVID-19 pandemic on tuberculosis healthcare access and service delivery. Methods: We used Interpretive Description, a qualitative approach with the end-goal of informing decisions and actions in clinical practice. Levesque et al.’s “ Conceptual framework of access to health care” informed the development of our interview guides. Interviews were conducted virtually and confidentially transcribed verbatim. Data generation and analysis occurred concurrently. Analysis was informed by Braun and Clarke’s six phases of reflexive thematic analysis. Strategies to enhance rigour and trustworthiness of the findings were utilized. Results: We completed 15 interviews: 6 with patients and 9 with providers. Three key themes were generated: (a) Diagnostic hurdles created delay; (b) Hybrid services promote health equity; and (c) Navigating the complexities of a pandemic within a pandemic. Diagnosing tuberculosis was challenging even prior to the pandemic since some providers lacked experience and familiarity with the condition. The diagnostic process was further complicated with the onset of the COVID-19 pandemic. However, COVID-19 also introduced streamlined virtual care for patients which was convenient and improved access but was not viewed as being equivalent to in-person care. The intersection of the COVID-19 and tuberculosis pandemics created competition for limited resources while highlighting learnings that may positively impact future tuberculosis care. Conclusions: Our findings can inform health system leadership about how the COVID-19 pandemic impacted care of other public health threats like tuberculosis, helping to prepare more effectively and equitably for future challenges. tuberculosis access healthcare quality interpretive description Figures Figure 1 Contributions to knowledge What does this study add to existing knowledge? Due to the nature of the disease, TB had to remain a public health priority regardless of shifting healthcare priorities to respond to COVID-19. To our knowledge, we conducted the first qualitative study investigating the perceptions of patients with TB and their healthcare providers on access to care and service delivery during the COVID-19 pandemic in a Canadian context. We believe that this study has built scholarship to inform health system leadership about how the COVID-19 pandemic impacted care of other public health threats like TB, helping to prepare more effectively and equitably for future challenges. What are the key implications for public health interventions, practice or policy? The continued use of virtual DOT should be prioritized to ensure patients with TB are met where they are therefore reducing the burden of treatment while improving adherence. This study highlights the opportunity for multilingual TB providers to be part of TB clinics across Canada to ensure ease of communication and facilitate trusting relationships with patients. Given that the TB population in Canada is inequitably impacted by the social determinants of health, this study highlights the need for TB clinics to receive increased social work staffing resources to more effectively manage social needs in this population. 1. Introduction Tuberculosis (TB) is a preventable and curable condition (Long et al., 2015 ) that affects around ten million people every year globally (World Health Organization, 2024 ). The majority of TB cases are found in low- and middle- income countries (World Health Organization, 2024 ) but the condition exists as a global pandemic due to migration. In high income nations with a low overall rate, TB is distributed disproportionately among sub-populations experiencing social inequities. In Canada, the incidence of active TB (per 100,000) was 4.8 in 2021 with people born outside of Canada accounting for the majority of all cases (76.7%), and Indigenous peoples experiencing the highest overall rate of disease (16.6/100,000 population) (Public Health Agency of Canada, 2024 ). In Alberta, Canada, the incidence was higher in 2021 than the national rate at 5.4 per 100,000 population with over 90% of the total annual TB diagnoses occurring among people born outside of Canada (Public Health Agency of Canada, 2024 ). TB is a slow-moving pandemic (Long et al., 2020 ). This is in stark contrast to the fast-moving viral COVID-19 pandemic caused by SARS-CoV-2 (Long et al., 2020 ). As these two pandemics converged, diversion of resources from TB to COVID-19 has had tremendous consequences for TB patients and the global population as a whole. Previous research demonstrated a reduction in TB incidence rates during the COVID-19 pandemic but a greater mortality due to missed and delayed diagnoses (Duarte et al., 2021 ; Hashem et al., 2022 ; Pai et al., 2022 ). Lower incidence rates may have resulted from mandated lockdowns, “stay at home” messaging, fear of visiting healthcare facilities, and increased stigma due to symptom commonalities between COVID-19 and pulmonary TB (Sahu et al., 2022 ). Due to the nature of the disease, TB had to remain a public health priority regardless of shifting healthcare priorities to respond to COVID-19. However, little research has analyzed how shifting priorities during COVID-19 impacted service delivery and created unintended barriers to accessing TB-related healthcare. Further, to our knowledge, perceptions of patients with TB and their healthcare providers on access to care and service delivery during the pandemic have not been explored in a Canadian context. As such, the objective of this study was to explore patient and provider perspectives of the impact of the COVID-19 pandemic on TB healthcare access and service delivery with consideration given to how patient health may have been affected. 2. Methods This study was conducted in Alberta, Canada. Ethics approval was obtained from the University of Alberta’s Health Research Ethics Board (Pro00118367) and the University of Calgary’s Conjoint Health Research Ethics Board (pSite-22-0025). All participants provided informed verbal consent. Verbal consent was documented on a written consent form completed by the researcher and sent to the participant following the interview for their records. 2.1 Researchers’ Positionality The interdisciplinary research team was comprised of clinicians and researchers with diverse levels of experience and various professional backgrounds. Some team members provided pulmonary care during the pandemic whereas others acted as diverse research and clinical experts outside of pulmonary care (Thorne, 2016 ). The various perspectives included during data analysis offered wide-ranging and important insights into data interpretation and clinical relevance (Thorne, 2016 ). 2.2 Methodological Approach We used Interpretive Description (ID), a qualitative approach with the end-goal of generating clinically meaningful findings that inform practice (Hunt, 2009 ; Thompson Burdine et al., 2021 ; Thorne, 2016 ). Findings are co-constructed by combining researchers’ knowledge of the discipline and their inductive interpretations of participants’ experiences within the context (Hunt, 2009 ; Thorne, 2016 ). 2.3 Conceptual Framework We used Levesque et al’s ‘ Conceptual framework of access to health care’ to help conceptualize how patients’ abilities to perceive, seek, reach, pay, and engage in healthcare services interacted with aspects of the health system (Cu et al., 2021 ; Levesque et al., 2013 ). We used the framework to inform development of our semi-structured interview guides. 2.4 Context and Study Population Alberta TB care is delivered out of three public health clinics: a central “virtual” clinic that serves all patients from rural and reserve communities, and two urban clinics, one in each of Calgary and Edmonton (Long et al., 2015 ). Individuals accessing TB clinics in Alberta are mostly born outside of Canada who have either immigrated, or are visiting; Indigenous peoples; or those from other marginalized groups such as those experiencing homelessness. This population is unique as they are disproportionately impacted by social determinants of health, or “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes” (Healthy People 2030). The TB program also provides occupational screening for healthcare workers, volunteers, people in corrections facilities, and patients from other disciplines such as nephrology, organ transplant, or rheumatology. Those that have recently immigrated or are visiting Canada may not have current health insurance, speak English, or be familiar with the Canadian health system. These social determinants make affordability of testing and treatments, communication with healthcare providers, and health literacy more challenging. These populations also may not be employed or be employed in positions with limited time off making it challenging to attend appointments. This is an important consideration given that the gold standard of TB care in Alberta is direct observed therapy (DOT) where a healthcare provider directly observes a patient taking their medication on weekdays to adherance thus reduce potential for transmission. 2.5 Recruitment Recruitment occurred between December 1, 2022 and April 30, 2023. We aimed to recruit 6–10 patient participants and 6–10 provider participants with equal representation from both urban clinics. All participants met the inclusion criteria of: (1) living in Alberta, (2) age ≥ 18 years, (3) willing to participate in research, and (4) able to provide informed consent. We attempted to gain insight from providers with various professional designations. Purposive sampling was used to diversify the sample based on age, gender, and geographical location (rural or urban). A diverse sample of patients who met the inclusion criteria were identified and approached by healthcare providers involved in their care who introduced the study and confirmed consent to share contact information with the research team. The study coordinator (KB) followed up with each eligible and interested patient to provide further information, gain informed consent, and schedule an interview. All providers working in the included clinics were sent an email by a colleague who is also a member of the research team. The email introduced the study and provided contact information for the study coordinator. Providers interested in participating contacted the study coordinator who provided additional information about the study, gained informed consent, and scheduled an interview. 2.6 Data Generation One-on-one semi-structured interviews were completed by videoconference or phone by one interviewer (KB). Separate interview guides (see Appendix 1) were developed for TB patients and providers and focused on factors from the Levesque et al’s conceptual framework (Levesque et al., 2013 ). Probing questions explored topics in greater depth and detail, as needed. Data generation and analysis occurred concurrently, providing opportunity for iterative refinements to the interview guides (Thorne, 2016 ). At the end of the interviews, participants were asked open-ended questions to facilitate self-report of gender, cultural or ethnic background, and the first three digits of their postal code (patients) or years of professional experience (providers). These questions were intentionally open-ended to ensure participants used terminology meaningful to them. Interviews were recorded, transcribed verbatim, reviewed for accuracy, and imported into NVivo for analysis (QSR International Pty Ltd, 2020 ). 2.7 Data Analysis The analysis was guided by Braun and Clarke’s reflexive thematic analysis (Braun & Clarke, 2006 ; Braun & Clarke, 2020a , 2020b ; Braun & Clarke, 2023 ). The primary study analyst (KB) began by familiarizing herself with the data during transcript cleaning and by re-reading all transcripts. Initial analytic thoughts and codes were developed inductively for each transcript. Codes were considered in relation to one another and expanded or collapsed based on patterns of meaning. A relational approach to analysis was used to generate dialogue between KB, PH and MM to advance the analysis and reflexively co-construct findings that were clinically relevant (Thorne, 2016 ). PH was involved at the raw data level by reading each transcript and meeting with KB to discuss important ideas and clinically relevant information as well as to develop iterations of potential themes and subthemes. Themes and subthemes were then named, defined, and exemplary quotes retrieved from the transcripts and shared with MM, who had not read the transcripts. MM provided critical methodological and clinical perspectives on internal coherence within themes and subthemes and external coherence between themes to ensure they were distinct from one another. Further discussion and critique between KB, PH, and MM occurred until the final themes and subthemes had been generated and defined. To further enhance credibility of the analysis, KB contacted each participant to elicit feedback on the resonance of proposed themes and subthemes (Tracy, 2010 ). Two provider participants and two patient participants provided feedback. Proposed themes and subthemes were written in a narrative format that combined images and exemplary quotes. Any questions or concerns were noted and reflected upon. Subsequent changes were made as necessary. Analysis continued while the final report was drafted and included integration of participant feedback. 2.8 Rigour To enhance trustworthiness, strategies to ensure epistemological integrity, representative credibility, analytic logic, and interpretive authority were utilized (Thorne, 2016 ). We ensured epistemological integrity of the study by choosing ID as our method to address our objective since ID acknowledges the importance of both patient and provider perspectives to understand experiences in the clinical context (Hunt, 2009 ; Thompson Burdine et al., 2021 ; Thorne, 2016 ). Representative credibility was enhanced by interviewing both patients and providers to ensure the co-construction of knowledge. Analytic logic was enhanced through thick description to prioritize verbatim participant accounts. Interpretive authority was enhanced through constant reflection during analysis about potential biases or experiences that could impact interpretation. 3. Results 3.1 Participant Characteristics We completed 15 interviews: 6 with patients and 9 with providers. Tables 1 (patient) and 2 (provider) outline participant characteristics. Most patient participants (66.7%) self-identified as male. Most provider participants (88.9%) self-identified as female. All patient participants lived in an urban centre and had a mean (standard deviation) age of 53.0 (23.6) years. Providers had been working in the TB space for a range of 3 to 40 years with a median (interquartile range) of 10.0 (4.0–14.0) years. On average, interviews with providers tended to last slightly longer (39.8 ± 2.8 minutes) than with patients (33.5 ± 3.5 minutes). Table 1 Patient participant characteristics. Variable n (%) or Mean (SD) Gender a Male 4 (66.7%) Female 2 (33.3%) Mean age (years) (SD) 53.0 (23.6) Rural/Urban Rural 0 (0.0%) Urban 6 (100.0%) Ethnicity b Cambodian 1 (16.7%) Trinidadian 1 (16.7%) East Indian 2 (33.3%) Filipino 2 (33.3%) a All participants were asked their gender as an open-ended question in conversation with the interviewer. All responded using sex-based categories of male/female. We are reporting terms that participants used. b All participants were asked to identify their cultural or ethnic background in an open-ended question in conversation with the interviewer. We are reporting terms that the participants used. [INSERT Table 1 AND Table 2 HERE] Table 2 Provider participant characteristics. Variable n (%), Median (IQR), or Mean (standard deviation (SD)) Gender a Male 1 (11.1%) Female 8 (88.9%) Mean age (years) (SD) 41.9 (9.9) Median years of experience (IQR) 10.0 (4.0–14.0) Ethnicity b Asian 4 (44.4%) Caucasian 4 (44.4%) Métis 1 (11.1%) a All participants were asked their gender as an open-ended question in conversation with the interviewer. All responded using sex-based categories of male/female. We are reporting terms that participants used. b All participants were asked to identify their cultural or ethnic background in an open-ended question in conversation with the interviewer. We are reporting terms that the participants used. 3.2 Impact of the pandemic on healthcare access, service delivery, and health of individuals with TB Three key themes were generated: (a) Diagnostic hurdles created delay; (b) Hybrid services promote health equity; and (c) Navigating the complexities of a pandemic within a pandemic. The relationship between the themes and subthemes is depicted in Fig. 1. [INSERT FIGURE 1 HERE] Figure 1 The bi-directional arrow reflects a time axis. Before the start of the COVID-19 pandemic, TB care was delivered mostly in-person (telehealth care available for all rural and reserve communities across the province). After the start of the pandemic, the COVID-19 virus complicated the TB diagnostic process and created competition for healthcare resources. However, the pandemic also introduced streamlined virtual care which helped TB patients access care. Both before and during the pandemic, front-line provider inexperience and unfamiliarity with TB resulted in some diagnostic delays. In-person care has been valued for its ability to foster communication and connection since before the pandemic and that did not change during the pandemic. The intersection of the COVID-19 and TB pandemics highlighted learnings that may impact future TB care: inequitable access to resources and increased understanding and utility of public health practices 3.2.1 Diagnostic hurdles created delay The first theme highlights challenges that were present prior to the COVID-19 pandemic related to diagnosing active TB and the additional challenges that COVID-19 created. These diagnostic challenges subsequently caused delays in patients receiving TB treatment, which is associated with increased morbidity and mortality. Front-line provider inexperience and unfamiliarity with active TB. Given the relatively low rates of TB in Canada, participants perceived that family and emergency department physicians were often unfamiliar and lacked experience to diagnose TB in a prompt manner both before and during the COVID-19 pandemic. “…because [TB is] relatively rare in Canada compared to other places, it’s often a delayed diagnosis because it’s doesn’t come to the forefront of differentials when a patient presents with cough and constitutional symptoms … the symptoms of TB are pretty non-specific” (provider 1, female) “the only things that I’d … recommend is about the family doctor … [to not] forget to notice … TB symptom[s]. Because I know that some … don’t really notice this kind of symptom that regularly because they just don’t think it’s TB, right?” (patient 1, male) This issue was further complicated by the fact that TB can have extrapulmonary manifestations making diagnosis even more challenging and sometimes delayed, subsequently delaying treatment: “…my ankle on the right side was swelling and … I went to my family doctor and [after] going through a couple of rounds of x-rays we didn’t figure out what it [wa]s … and they sent me in for … immediate surgery … after I think almost like a month they realized that it’s … TB.” (patient 3, male) COVID-19 complicated the diagnostic process. The challenges with diagnosing TB were further complicated by the presence of COVID-19. Given the similarities in symptomology between pulmonary TB and COVID-19, some patients were assumed to have COVID-19 before being properly diagnosed with TB, delaying the start of treatment: “Repeatedly [providers thought COVID before TB] and they just aren’t getting better. … so it could be a while before that diagnosis was caught” (provider 5, female). Patients also perceived that the pandemic had an impact on their diagnostic process: “Yeah, … I think the pandemic did impact [my diagnosis] … because … every time you’re coughing, people will think you might have COVID … And some clinics don’t even want you to be in their clinic” (patient 1, male). Limited access to healthcare facilities due to public health restrictions and individuals’ nervousness to seek care also created delays for patients. Some TB screening programs (i.e., immigration screens, screening for those who live in crowded conditions such as nursing homes) were also paused or delayed in response to the pandemic, resulting in some patients’ diagnoses occurring later than they would have been before the pandemic. However, there was also less immigration during the pandemic significantly decreasing the number of individuals who needed to be screened for TB which allowed for prioritization of other areas of the TB program (i.e., active cases and close contacts). 3.2.2 Hybrid services promote health equity The second theme highlights how a combination of virtual and in-person service delivery helped individuals with TB access required healthcare services regardless of social factors. Virtual care improved accessibility by meeting patients where they are. While there was virtual coordination of care for patients with TB living in rural Alberta for over 20 years prior to the pandemic, DOT treatment was still delivered in-person on weekdays at a clinic or a pharmacy. The pandemic introduced virtual DOT which was more convenient and flexible for patients and meant they did not have to take time off work or pay to travel to the clinic every weekday to complete their treatment: “We used … Zoom … [for] my medication … [and] I loved that, because I d[id]n’t have to travel to the clinic … [for] the nurse to see … if I’m taking my medication, so … I … save my gas and my time.” (patient 5, male) However, virtual DOT did not reduce the burden on patients’ support people (who often assisted with language translation during appointments) as they still needed to take time off work to attend the patient’s appointment. Virtual DOT, which was delivered in a synchronous format, also increased the workload for providers in the TB clinic because the service became their responsibility. The public health centres or pharmacies did not provide virtual DOT services: “… in the past … most of the patients would go to a public health centre for their DOT. So once we started doing virtual, that work came back to our clinic … so that affected … staffing that we needed to have.” (provider 7, female) In-person care fosters communication and connection. While virtual DOT appointments were favoured by patients because of their convenience, they still appreciated having some in-person connection with the TB clinic as they viewed it to be easier to ask questions and connect with their provider: “I think it was really helpful that I had to go in. It makes it more comfortable and it gives you more time to … know the doctor and ask better questions” (patient 3, male). Providers also recognized the value of in-person appointments as they perceived that it allowed for better assessment of patients: “We stopped seeing patients in-person for quite a while … Not being able to examine patients … I think severely affected their care” (provider 9, female). In-person appointments were also perceived by providers to help build trust and relationships with patients: “If you can actually see the person to communicate with them, it’s easier to foster that relationship [compared to] just a telephone call” (provider 5, female). Trust and relationship building are essential aspects of TB care as it is sometimes challenging to convince patients that they need to take their medications for the entire treatment period since their symptoms typically resolve prior to the end of treatment. In-person appointments also made communication easier with individuals whose first language was not English, which is a significant amount of the population who typically presents with TB in Canada. However, given pandemic restrictions, patients’ access to their support person was challenged during in-person appointments often causing uncertainty, nervousness, and unclear communication: “… limiting the support person was a negative for sure. … [having] a supportive person there, … someone who just spoke their language … from their community, it was very beneficial and supported them at … clearly communicating, understanding. … because when they’re stressed and not speaking the language … we just noticed there were definitely gaps in information-sharing and understanding.” (provider 8, female) 3.2.3 Navigating the complexities of a pandemic within a pandemic The final theme highlights healthcare system-level changes that did or could impact TB care provision that providers perceived resulted from navigating the TB pandemic within the context of the broader, global COVID-19 pandemic. Competition for finite healthcare resources. The additional stress that COVID-19 put on the healthcare system resulted in there being competition to access air exchanging rooms in hospitals, lab spaces for regular monitoring, and availability of some healthcare providers. Air exchanging rooms are fundamentally important to properly isolate individuals with TB in hospital. However, such rooms became important for managing the spread of COVID-19, which created competition for the limited resource: “…certain patients are usually admitted [to hospital] at the beginning of their treatment, and so there might be an issue around getting a bed … [because] we usually need a bed in a specially ventilated room … [which] were at a premium during COVID.” (provider 6, male) Similarly, access to labs for bloodwork is critical to monitor patients during treatment. Patient participants did not express any challenges accessing labs for monitoring appointments. In comparison, provider participants perceived challenges with access to labs for patients: “patients who are on active therapy require … bloodwork done throughout … active and latent treatment … [and] access to a lab was an issue for everyone … So I think that there was an access component that limited our ability to monitor like we usually would.” (provider 9, female) Due to their specialized skillset and the fact that they were managing a public health priority themselves, TB nurses were prioritized to stay in their positions and were not redeployed to help manage COVID-19 patients. However, there was pressure on doctors who work in the TB space (both TB pulmonologists and infectious disease doctors) to cover COVID-19 wards given their experience with managing an infectious pulmonary condition: “there’s only about a dozen physicians in the province who specialise in the management of TB, and those physicians were also … in high demand during COVID. So, there was pressure on their time to make themselves available to COVID wards … The real work of the program is done by a public health nursing network, which is very strong and was … intact during COVID … because TB is another public health issue. And so … we’d be … robbing Peter to pay Paul if you stripped it of its capacity.” (provider 6, male) The additional stress on the healthcare system also sometimes led to care delays or early hospital discharge which was perceived to negatively impact the health of individuals with TB: “… we did notice that people were being sent home very ill… We had people who were … really sick at home … because they were sent home … before they’re actually ready” (provider 8, female). Illuminated inequitable access to resources. Healthcare providers working in the TB space have always recognized that isolation supports (i.e., paid time off work, isolation facilities) would benefit individuals with TB. However, none of these supports have ever been available. When the COVID-19 pandemic started, isolation resources became available to support those who tested positive for COVID-19. Some providers were frustrated by this inequitable access to isolation resources and felt that supports were put into place rapidly because the entire population was affected, rather than just a small subset: “I think … the whole way that we treated COVID so differently than we treat TB, the resources that we provided for people to isolate, the free testing and all of that, …, it’s a little bit discouraging in the TB world that … when in need, those things are available if we have the political will. But for some reason, we don’t have those same resources available for TB.” (provider 3, female) Inequitable access to resources was further complicated by limited access to social work support, which is fundamentally important to facilitate system navigation and access. However, social work supports were perceived to be lacking even prior to the pandemic: “I certainly think that we need more resources for our patients … We haven’t always had a social worker. And I think … a lot of our patients need a lot of support” (provider 3, female). The limited access to social work supports in a population with “a social disease with a medical aspect” (provider 6, male) seemed to be further complicated during COVID-19 with the part-time position in Edmonton not being filled during a portion of the pandemic. A provider from the Calgary clinic also discussed wishing there was more social work support in general but recognized how funding was the limiting factor. This lack of social work support makes limited resources even harder to access by the often socially vulnerable population of individuals with TB. Increased understanding and utility of public health measures. Since TB is a public health concern and pandemic itself, TB providers were already intimately familiar with the importance of public health measures like hand hygiene, social distancing, isolation/quarantine, masking, and contact tracing. However, it was perceived that individuals with TB did not necessarily follow this public health advice completely because perhaps they did not understand it, did not want to be stigmatized and draw attention to themselves, or did not have the resources to follow such public health measures. The COVID-19 pandemic made these public health measures commonplace for the global population which providers felt helped to normalize the behaviour: “… previously when we would place patients on home isolation … or talked about contact tracing, that was a real foreign concept to most people … But … I think [COVID-19] kind of normalized that behavior” (provider 9, female) Providers also recognized how there were fewer contacts involved for contact tracing in active TB cases due to the public health measures. This helped to somewhat reduce the pressures on the TB clinic that were present due to some staff being redeployed to work in COVID-19 care. 4. Discussion We explored patient and provider perspectives of the COVID-19 pandemic on TB healthcare access and service delivery. Diagnosing TB was challenging prior to the pandemic and was complicated with the onset of the COVID-19. However, the pandemic also introduced streamlined virtual care for patients which was convenient and improved access but cannot supplant in-person care. The intersection of the COVID-19 and TB pandemics created competition for limited resources but also highlighted learnings that may positively impact future TB care. It has been established that there were pre-pandemic challenges with diagnosing TB. In a systematic review (n = 58) conducted before COVID-19, poorly trained personnel and practitioners with low awareness of TB were noted as contributing to the diagnostic delay (Storla et al., 2008 ). The current study also found that diagnoses seemed to be delayed further with the onset of the COVID-19 pandemic. In a cross-sectional multiple methods study (n = 672 survey participants, 28 interview participants), the authors found some TB patients were improperly quarantined in health facilities with presumed COVID-19 due to their pulmonary TB symptoms (Bbuye et al., 2024 ). The rapid shift to virtual service delivery made DOT more accessible, convenient, and flexible for patients in the current study. Similar to our findings, a systematic review (n = 22) found that patients preferred virtual DOT due to convenience as well as the reduction of time- and cost- related barriers (Chen et al., 2024 ). A survey study (n = 842) outlined how virtual DOT is a more person-centered model of care compared to the traditional in-person DOT model as it is more accessible and helps reduce stigma faced by individuals with TB (Zimmer et al., 2021 ). However, our provider participants found that providing virtual services was more resource intensive. Chi Chen and colleagues ( 2024 ) found four articles in their systematic review (n = 22) highlighting how virtual DOT required less staffing time compared to in-person DOT. However, these four articles describe TB care in locations other than Canada where perhaps DOT was already entirely the responsibility of the clinic prior to the pandemic which may explain the differences in perceptions. While virtual DOT was valued for its convenience, our participants did not think that it could completely supplant in-person visits. In a rapid review (n = 20), Chapman and Veras-Estévaz recognized that in-person, comprehensive physical assessments cannot be completely removed from TB care (Chapman & Veras-Estévaz, 2021 ). Our participants felt that in-person visits promoted clear communication as well as connections between patients and providers that contributed to trust, an essential component of TB care. In a qualitative study (n = 59), healthcare workers discussed how a trusting relationship between themselves and their patients allowed patients to be more open which helped improve treatment adherence and satisfaction with care (Franke et al., 2022 ). In our study, trust was especially important for individuals who required language translation services, highlighting how there could be an important role for multilingual doctors in TB care moving forward to help facilitate trusting relationships with patients. Given the swift and substantial financial and governmental response to the COVID-19 pandemic, it is not surprising that the role of ‘political will’ has been discussed in the literature in terms of the differences in responses to the COVID-19 and TB pandemics. Provider participants from the current study described frustration with all the resources that became available to support individuals with COVID-19 to isolate, recover, and manage financially. Other authors have similarly described how the global COVID-19 response has shown that if governments have the will to mobilize necessary resources to combat a pandemic, they can do so promptly and therefore should do so to meet TB elimination goals (Bedingfield et al., 2022 ; Chapman & Veras-Estévaz, 2021 ; Duarte et al., 2021 ; Trajman et al., 2022 ; Zimmer et al., 2022 ). Also discussed by provider participants in the current study, the supports that were made available for COVID-19 patients would go a long way to mitigate some of the inequities experienced by TB patients while also curbing the spread of TB (Bedingfield et al., 2022 ; Chapman & Veras-Estévaz, 2021 ; Zimmer et al., 2022 ). The COVID-19 pandemic also created opportunities for future TB care. Participants in the current study discussed how the normalization of masking and greater understanding of isolation and contact tracing can and will positively impact TB care in the future. Trajman et al . reported that the COVID-19 pandemic has improved awareness and behaviours around respiratory infection prevention and etiquette. The authors also noted that the COVID-19 pandemic has normalized masking and that this normalization should be capitalized on in response to the TB pandemic (Trajman et al., 2022 ). Similarly, Zimmer and colleagues noted that the COVID-19 pandemic normalized the idea of contact tracing which may help address stigma and hesitation around this concept when used in TB care in the future (Zimmer et al., 2022 ). 4.1 Limitations Some limitations may impact the transferability of our results. First, we interviewed more healthcare providers than patients which may skew the results to their perspective. Recruiting individuals with TB was challenging as patients are not routinely followed by the clinic following treatment conclusion and social challenges may impede them from participating in research. However, given that providers and patients discussed similar ideas, we do not believe this had a severe impact on our results. Second, we were not able to recruit rural participants and only interviewed individuals who could speak English. This may have impacted the variety of voices and perspectives we heard given that this is a highly ethnically diverse population and that rural TB patients likely have unique needs. Future research engaging rural perspectives and people whose primary or preferred language is not English should be conducted to ensure that these voices are heard when making decisions about health services. 5. Conclusion We studied the impact of the COVID-19 pandemic on TB healthcare access and delivery by integrating patient and provider perspectives to lay the groundwork to identify implementable strategies for post-pandemic health system improvements. We identified that the COVID-19 pandemic exacerbated challenges in TB diagnosis and management from both patient and provider perspectives and the implementation of virtual care was convenient for patients. Our findings can inform health system leadership about how the COVID-19 pandemic impacted care of other public health threats like TB, helping to prepare more effectively and equitably for future challenges. References Bbuye, M., Muyanja, S. Z., Sekitoleko, I., Padalkar, R., Robertson, N., Helwig, M., Hopkinson, D., Siddharthan, T., & Jackson, P. (2024). Patient level barriers to accessing TB care services during the COVID-19 pandemic in Uganda, a mixed methods study. BMC Health Serv Res , 24 (1), 52. https://doi.org/10.1186/s12913-023-10513-8 Bedingfield, N., Lashewicz, B., Fisher, D., & King-Shier, K. (2022). Systems of support for foreign-born TB patients and their family members. Public Health Action , 12 (2), 79-84. https://doi.org/10.5588/pha.21.0081 Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology (3), 77-101. Braun, V., & Clarke, V. (2020a). Can I use TA? Should I use TA? Should I not use TA? Comparing reflexive thematic analysis and other pattern‐based qualitative analytic approaches. Counselling and Psychotherapy Research , 21 (1), 37-47. https://doi.org/10.1002/capr.12360 Braun, V., & Clarke, V. (2020b). One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative Research in Psychology , 18 (3), 328-352. https://doi.org/10.1080/14780887.2020.1769238 Braun, V., & Clarke, V. (2023). Toward good practice in thematic analysis: Avoiding common problems and be(com)ing a knowing researcher. Int J Transgend Health , 24 (1), 1-6. https://doi.org/10.1080/26895269.2022.2129597 Chapman, H. J., & Veras-Estévaz, B. A. (2021). Lessons Learned During the COVID-19 Pandemic to Strengthen TB Infection Control: A Rapid Review. Global Health: Science and Practice , 9 (4), 964-977. Chen, E. C., Owaisi, R., Goldschmidt, L., Maimets, I. K., & Daftary, A. (2024). Patient perceptions of video directly observed therapy for tuberculosis: a systematic review. J Clin Tuberc Other Mycobact Dis , 35 , 100406. https://doi.org/10.1016/j.jctube.2023.100406 Cu, A., Meister, S., Lefebvre, B., & Ridde, V. (2021). Assessing healthcare access using the Levesque's conceptual framework- a scoping review. Int J Equity Health , 20 (1), 116. https://doi.org/10.1186/s12939-021-01416-3 Duarte, R., Aguiar, A., Pinto, M., Furtado, I., Tiberi, S., Lonnroth, K., & Migliori, G. B. (2021). Different disease, same challenges: Social determinants of tuberculosis and COVID-19. Pulmonology , 27 (4), 338-344. https://doi.org/10.1016/j.pulmoe.2021.02.002 Franke, M. A., Truss, L. M., Wierenga, H., Nordmann, K., Fruhauf, A., Ranaivoson, R., Rampanjato, Z., Ranjaharinony, F., Knauss, S., Muller, N., & Emmrich, J. V. (2022). Facilitators and barriers to TB care during the COVID-19 pandemic. Public Health Action , 12 (4), 174-179. https://doi.org/10.5588/pha.22.0039 Hashem, M. K., Hussein, A. A. R. M., Amin, M. T., Mahmoud, A., & Shaddad, A. M. (2022). The burden of COVID-19 pandemic on tuberculosis detection: a single-center study. The Egyptian Journal of Bronchology , 16 (1). https://doi.org/10.1186/s43168-022-00117-x Healthy People 2030, U. S. D. o. H. a. H. S., Office of Disease Prevention and Health Promotion. Social Determinants of Health . https://health.gov/healthypeople/priority-areas/social-determinants-health#:~:text=What%20are%20social%20determinants%20of,of%2Dlife%20outcomes%20and%20risks. Hunt, M. (2009). Strengths and Challenges in the Use of Interpretive Description: Reflections Arising From a Study of the Moral Experience of Health Professionals in Humanitarian Work. Qualitation Health Research , 19 (9), 1284-1292. Levesque, J. F., Harris, M. F., & Russell, G. (2013). Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health , 12 , 18. https://doi.org/10.1186/1475-9276-12-18 Long, R., Heffernan, C., Gao, Z., Egedahl, M. L., & Talbot, J. (2015). Do "Virtual" and "Outpatient" Public Health Tuberculosis Clinics Perform Equally Well? A Program-Wide Evaluation in Alberta, Canada. PLoS One , 10 (12), e0144784. https://doi.org/10.1371/journal.pone.0144784 Long, R., King, M., Doroshenko, A., & Heffernan, C. (2020). Tuberculosis and COVID-19 in Canada. EClinicalMedicine , 27 , 100584. https://doi.org/10.1016/j.eclinm.2020.100584 Pai, M., Kasaeva, T., & Swaminathan, S. (2022). Covid-19’s Devastating Effect on Tuberculosis Care — A Path to Recovery. N Engl J Med , 386 (16), 1490-1493. https://doi.org/10.1056/NEJMp2119571 Public Health Agency of Canada. (2024). Tuberculosis in Canada: 2012-2021 Expanded Report . Government of Canada. QSR International Pty Ltd. (2020). NVivo (released in March 2020) . Sahu, S., Wandwalo, E., & Arinaminpathy, N. (2022). Exploring the Impact of the COVID-19 Pandemic on Tuberculosis Care and Prevention. J Pediatric Infect Dis Soc , 11 (Supplement_3), S67-S71. https://doi.org/10.1093/jpids/piac102 Storla, D. G., Yimer, S., & Bjune, G. A. (2008). A systematic review of delay in the diagnosis and treatment of tuberculosis. BMC Public Health , 8 , 15. https://doi.org/10.1186/1471-2458-8-15 Thompson Burdine, J., Thorne, S., & Sandhu, G. (2021). Interpretive description: A flexible qualitative methodology for medical education research. Med Educ , 55 (3), 336-343. https://doi.org/10.1111/medu.14380 Thorne, S. (2016). Interpretive description: Qualitative research for applied practice (J. Morse, Ed. 2nd ed.). Routledge. Tracy, S. J. (2010). Qualitative Quality: Eight “Big-Tent” Criteria for Excellent Qualitative Research. Qualitative Inquiry , 16 (10), 837-851. https://doi.org/10.1177/1077800410383121 Trajman, A., Felker, I., Alves, L. C., Coutinho, I., Osman, M., Meehan, S. A., Singh, U. B., & Schwartz, Y. (2022). The COVID-19 and TB syndemic: the way forward. Int J Tuberc Lung Dis , 26 (8), 710-719. https://doi.org/10.5588/ijtld.22.0006 World Health Organization. (2024). Tuberculosis . https://www.who.int/health-topics/tuberculosis#tab=tab_1 Zimmer, A. J., Heitkamp, P., Malar, J., Dantas, C., O'Brien, K., Pandita, A., & Waite, R. C. (2021). Facility-based directly observed therapy (DOT) for tuberculosis during COVID-19: A community perspective. J Clin Tuberc Other Mycobact Dis , 24 , 100248. https://doi.org/10.1016/j.jctube.2021.100248 Zimmer, A. J., Klinton, J. S., Oga-Omenka, C., Heitkamp, P., Nawina Nyirenda, C., Furin, J., & Pai, M. (2022). Tuberculosis in times of COVID-19. J Epidemiol Community Health , 76 (3), 310-316. https://doi.org/10.1136/jech-2021-217529 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5656441","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":391051151,"identity":"6c7168a6-9a9a-4ab2-b2d0-e3ef6a1b01c9","order_by":0,"name":"Mrs. Katelyn Brehon","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIiWNgGAWjYBACAwYGNiBlw8DAzkOaljQGBmaQlgTitRwmQYu59OFjDz7uOJ/Y38x78HHlDzsG/vYD+LVY9qWlG848cztxxmG+ZMMzCckMEmcIWGVwhsdMmrftdmLDYR4zyYYEZqBTCWrh/wbUci5x/mEe858NCfUMBvwPCNrCBtRyIHED0BbGhoTDDAYSBGyx7GEzk5zZlmy8EegXyYa04zwSNwjYYs7D/EziY5ud7LzjvQc/NthUy/H3E7AFAxCbBkbBKBgFo2AU4AMA4nw/CycGKPEAAAAASUVORK5CYII=","orcid":"","institution":"","correspondingAuthor":true,"prefix":"Mrs.","firstName":"Katelyn","middleName":"","lastName":"Brehon","suffix":""},{"id":391051152,"identity":"f70d7eb9-3d9c-4755-bc91-05cd1d83ac5a","order_by":1,"name":"Mrs. Pam Hung","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"Mrs.","firstName":"Pam","middleName":"","lastName":"Hung","suffix":""},{"id":391051153,"identity":"798d695d-e18c-4679-a25a-c85f688d08f9","order_by":2,"name":"Dr. Maxi Miciak","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"Dr.","firstName":"Maxi","middleName":"","lastName":"Miciak","suffix":""},{"id":391051154,"identity":"e0671f6c-b2ab-486e-858d-ba5acf32b929","order_by":3,"name":"Dr. Angela Lau","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"Dr.","firstName":"Angela","middleName":"","lastName":"Lau","suffix":""},{"id":391051155,"identity":"b3485618-e83c-4470-b421-1ebe8f43eb99","order_by":4,"name":"Dr. Courtney Heffernan","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"Dr.","firstName":"Courtney","middleName":"","lastName":"Heffernan","suffix":""},{"id":391051156,"identity":"97135338-a6c5-4e90-85d8-5558c8379e1b","order_by":5,"name":"Dr. Giovanni Ferrara","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"Dr.","firstName":"Giovanni","middleName":"","lastName":"Ferrara","suffix":""},{"id":391051157,"identity":"78b96381-0fe7-44c5-8b3f-fea0d0b69c55","order_by":6,"name":"Dr. Rachel Lim","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"Dr.","firstName":"Rachel","middleName":"","lastName":"Lim","suffix":""},{"id":391051158,"identity":"58077ec4-513d-4140-b206-84cc453a2157","order_by":7,"name":"Dr. Kadija Perreault","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"Dr.","firstName":"Kadija","middleName":"","lastName":"Perreault","suffix":""},{"id":391051159,"identity":"dc69c6d8-eaf2-42ee-b92c-8ae833b25060","order_by":8,"name":"Dr. Jason Weatherald","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"Dr.","firstName":"Jason","middleName":"","lastName":"Weatherald","suffix":""},{"id":391051160,"identity":"2e90bd30-c9bc-4bf9-bcc8-ae8bcbc2e724","order_by":9,"name":"Dr. Paul E. Ronksley","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"Dr.","firstName":"Paul","middleName":"E.","lastName":"Ronksley","suffix":""},{"id":391051161,"identity":"111420c9-dd8a-478d-929a-65b1f83f65df","order_by":10,"name":"Dr. Michael K. Stickland","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"Dr.","firstName":"Michael","middleName":"K.","lastName":"Stickland","suffix":""},{"id":391051162,"identity":"a30f30c7-ff77-4beb-b677-3ccdcbd2529c","order_by":11,"name":"Dr. Douglas P. Gross","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"Dr.","firstName":"Douglas","middleName":"P.","lastName":"Gross","suffix":""},{"id":391051163,"identity":"3c6f2e79-0ab9-4afe-b7e1-050c10e4dc25","order_by":12,"name":"Dr. Grace Y. Lam","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"Dr.","firstName":"Grace","middleName":"Y.","lastName":"Lam","suffix":""}],"badges":[],"createdAt":"2024-12-16 19:55:37","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5656441/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5656441/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71803950,"identity":"6cab7ae3-e22a-4c9b-89e4-4870d7e9a12c","added_by":"auto","created_at":"2024-12-18 17:12:10","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":393499,"visible":true,"origin":"","legend":"\u003cp\u003eThe bi-directional arrow reflects a time axis. Before the start of the COVID-19 pandemic, TB care was delivered mostly in-person (telehealth care available for all rural and reserve communities across the province). After the start of the pandemic, the COVID-19 virus complicated the TB diagnostic process and created competition for healthcare resources. However, the pandemic also introduced streamlined virtual care which helped TB patients access care. Both before and during the pandemic, front-line provider inexperience and unfamiliarity with TB resulted in some diagnostic delays. In-person care has been valued for its ability to foster communication and connection since before the pandemic and that did not change during the pandemic. The intersection of the COVID-19 and TB pandemics highlighted learnings that may impact future TB care: inequitable access to resources and increased understanding and utility of public health practices\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5656441/v1/fb0884f79131b3b12ff7c8c6.jpg"},{"id":71804389,"identity":"0e936d2c-5832-457f-a8ce-34e8031ec603","added_by":"auto","created_at":"2024-12-18 17:20:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":984521,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5656441/v1/21336b2f-6c4a-4d6a-b6d1-579e5795210c.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003ePatient and provider perceptions of the impact of COVID-19 on tuberculosis healthcare access and delivery: A qualitative study of the complexities of a pandemic within a pandemic\u003c/p\u003e","fulltext":[{"header":"Contributions to knowledge","content":"\u003cp\u003eWhat does this study add to existing knowledge?\u003c/p\u003e\n\u003cp\u003eDue to the nature of the disease, TB had to remain a public health priority regardless of shifting healthcare priorities to respond to COVID-19. To our knowledge, we conducted the first qualitative study investigating the perceptions of patients with TB and their healthcare providers on access to care and service delivery during the COVID-19 pandemic in a Canadian context. We believe that this study has built scholarship to inform health system leadership about how the COVID-19 pandemic impacted care of other public health threats like TB, helping to prepare more effectively and equitably for future challenges.\u003c/p\u003e\n\u003cp\u003eWhat are the key implications for public health interventions, practice or policy?\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe continued use of virtual DOT should be prioritized to ensure patients with TB are met where they are therefore reducing the burden of treatment while improving adherence.\u003c/li\u003e\n \u003cli\u003eThis study highlights the opportunity for multilingual TB providers to be part of TB clinics across Canada to ensure ease of communication and facilitate trusting relationships with patients.\u003c/li\u003e\n \u003cli\u003eGiven that the TB population in Canada is inequitably impacted by the social determinants of health, this study highlights the need for TB clinics to receive increased social work staffing resources to more effectively manage social needs in this population.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eTuberculosis (TB) is a preventable and curable condition (Long et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) that affects around ten million people every year globally (World Health Organization, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The majority of TB cases are found in low- and middle- income countries (World Health Organization, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) but the condition exists as a global pandemic due to migration. In high income nations with a low overall rate, TB is distributed disproportionately among sub-populations experiencing social inequities. In Canada, the incidence of active TB (per 100,000) was 4.8 in 2021 with people born outside of Canada accounting for the majority of all cases (76.7%), and Indigenous peoples experiencing the highest overall rate of disease (16.6/100,000 population) (Public Health Agency of Canada, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In Alberta, Canada, the incidence was higher in 2021 than the national rate at 5.4 per 100,000 population with over 90% of the total annual TB diagnoses occurring among people born outside of Canada (Public Health Agency of Canada, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTB is a slow-moving pandemic (Long et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This is in stark contrast to the fast-moving viral COVID-19 pandemic caused by SARS-CoV-2 (Long et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). As these two pandemics converged, diversion of resources from TB to COVID-19 has had tremendous consequences for TB patients and the global population as a whole. Previous research demonstrated a reduction in TB incidence rates during the COVID-19 pandemic but a greater mortality due to missed and delayed diagnoses (Duarte et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Hashem et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Pai et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Lower incidence rates may have resulted from mandated lockdowns, \u0026ldquo;stay at home\u0026rdquo; messaging, fear of visiting healthcare facilities, and increased stigma due to symptom commonalities between COVID-19 and pulmonary TB (Sahu et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDue to the nature of the disease, TB had to remain a public health priority regardless of shifting healthcare priorities to respond to COVID-19. However, little research has analyzed how shifting priorities during COVID-19 impacted service delivery and created unintended barriers to accessing TB-related healthcare. Further, to our knowledge, perceptions of patients with TB and their healthcare providers on access to care and service delivery during the pandemic have not been explored in a Canadian context. As such, the objective of this study was to explore patient and provider perspectives of the impact of the COVID-19 pandemic on TB healthcare access and service delivery with consideration given to how patient health may have been affected.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis study was conducted in Alberta, Canada. Ethics approval was obtained from the University of Alberta\u0026rsquo;s Health Research Ethics Board (Pro00118367) and the University of Calgary\u0026rsquo;s Conjoint Health Research Ethics Board (pSite-22-0025). All participants provided informed verbal consent. Verbal consent was documented on a written consent form completed by the researcher and sent to the participant following the interview for their records.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Researchers\u0026rsquo; Positionality\u003c/h2\u003e \u003cp\u003eThe interdisciplinary research team was comprised of clinicians and researchers with diverse levels of experience and various professional backgrounds. Some team members provided pulmonary care during the pandemic whereas others acted as diverse research and clinical experts outside of pulmonary care (Thorne, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). The various perspectives included during data analysis offered wide-ranging and important insights into data interpretation and clinical relevance (Thorne, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Methodological Approach\u003c/h2\u003e \u003cp\u003eWe used Interpretive Description (ID), a qualitative approach with the end-goal of generating clinically meaningful findings that inform practice (Hunt, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Thompson Burdine et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Thorne, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Findings are co-constructed by combining researchers\u0026rsquo; knowledge of the discipline and their inductive interpretations of participants\u0026rsquo; experiences within the context (Hunt, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Thorne, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Conceptual Framework\u003c/h2\u003e \u003cp\u003eWe used Levesque et al\u0026rsquo;s \u0026lsquo;\u003cem\u003eConceptual framework of access to health care\u0026rsquo;\u003c/em\u003e to help conceptualize how patients\u0026rsquo; abilities to perceive, seek, reach, pay, and engage in healthcare services interacted with aspects of the health system (Cu et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Levesque et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). We used the framework to inform development of our semi-structured interview guides.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Context and Study Population\u003c/h2\u003e \u003cp\u003eAlberta TB care is delivered out of three public health clinics: a central \u0026ldquo;virtual\u0026rdquo; clinic that serves all patients from rural and reserve communities, and two urban clinics, one in each of Calgary and Edmonton (Long et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Individuals accessing TB clinics in Alberta are mostly born outside of Canada who have either immigrated, or are visiting; Indigenous peoples; or those from other marginalized groups such as those experiencing homelessness. This population is unique as they are disproportionately impacted by social determinants of health, or \u0026ldquo;conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes\u0026rdquo; (Healthy People 2030). The TB program also provides occupational screening for healthcare workers, volunteers, people in corrections facilities, and patients from other disciplines such as nephrology, organ transplant, or rheumatology. Those that have recently immigrated or are visiting Canada may not have current health insurance, speak English, or be familiar with the Canadian health system. These social determinants make affordability of testing and treatments, communication with healthcare providers, and health literacy more challenging. These populations also may not be employed or be employed in positions with limited time off making it challenging to attend appointments. This is an important consideration given that the gold standard of TB care in Alberta is direct observed therapy (DOT) where a healthcare provider directly observes a patient taking their medication on weekdays to adherance thus reduce potential for transmission.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Recruitment\u003c/h2\u003e \u003cp\u003eRecruitment occurred between December 1, 2022 and April 30, 2023. We aimed to recruit 6\u0026ndash;10 patient participants and 6\u0026ndash;10 provider participants with equal representation from both urban clinics. All participants met the inclusion criteria of: (1) living in Alberta, (2) age\u0026thinsp;\u0026ge;\u0026thinsp;18 years, (3) willing to participate in research, and (4) able to provide informed consent. We attempted to gain insight from providers with various professional designations.\u003c/p\u003e \u003cp\u003ePurposive sampling was used to diversify the sample based on age, gender, and geographical location (rural or urban). A diverse sample of patients who met the inclusion criteria were identified and approached by healthcare providers involved in their care who introduced the study and confirmed consent to share contact information with the research team. The study coordinator (KB) followed up with each eligible and interested patient to provide further information, gain informed consent, and schedule an interview.\u003c/p\u003e \u003cp\u003eAll providers working in the included clinics were sent an email by a colleague who is also a member of the research team. The email introduced the study and provided contact information for the study coordinator. Providers interested in participating contacted the study coordinator who provided additional information about the study, gained informed consent, and scheduled an interview.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Data Generation\u003c/h2\u003e \u003cp\u003eOne-on-one semi-structured interviews were completed by videoconference or phone by one interviewer (KB). Separate interview guides (see Appendix 1) were developed for TB patients and providers and focused on factors from the Levesque et al\u0026rsquo;s conceptual framework (Levesque et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Probing questions explored topics in greater depth and detail, as needed. Data generation and analysis occurred concurrently, providing opportunity for iterative refinements to the interview guides (Thorne, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e At the end of the interviews, participants were asked open-ended questions to facilitate self-report of gender, cultural or ethnic background, and the first three digits of their postal code (patients) or years of professional experience (providers). These questions were intentionally open-ended to ensure participants used terminology meaningful to them. Interviews were recorded, transcribed verbatim, reviewed for accuracy, and imported into NVivo for analysis (QSR International Pty Ltd, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Data Analysis\u003c/h2\u003e \u003cp\u003eThe analysis was guided by Braun and Clarke\u0026rsquo;s reflexive thematic analysis (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Braun \u0026amp; Clarke, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020a\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2020b\u003c/span\u003e; Braun \u0026amp; Clarke, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The primary study analyst (KB) began by familiarizing herself with the data during transcript cleaning and by re-reading all transcripts. Initial analytic thoughts and codes were developed inductively for each transcript. Codes were considered in relation to one another and expanded or collapsed based on patterns of meaning.\u003c/p\u003e \u003cp\u003eA relational approach to analysis was used to generate dialogue between KB, PH and MM to advance the analysis and reflexively co-construct findings that were clinically relevant (Thorne, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). PH was involved at the raw data level by reading each transcript and meeting with KB to discuss important ideas and clinically relevant information as well as to develop iterations of potential themes and subthemes. Themes and subthemes were then named, defined, and exemplary quotes retrieved from the transcripts and shared with MM, who had not read the transcripts. MM provided critical methodological and clinical perspectives on internal coherence within themes and subthemes and external coherence between themes to ensure they were distinct from one another. Further discussion and critique between KB, PH, and MM occurred until the final themes and subthemes had been generated and defined.\u003c/p\u003e \u003cp\u003eTo further enhance credibility of the analysis, KB contacted each participant to elicit feedback on the resonance of proposed themes and subthemes (Tracy, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Two provider participants and two patient participants provided feedback. Proposed themes and subthemes were written in a narrative format that combined images and exemplary quotes. Any questions or concerns were noted and reflected upon. Subsequent changes were made as necessary. Analysis continued while the final report was drafted and included integration of participant feedback.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.8 Rigour\u003c/h2\u003e \u003cp\u003eTo enhance trustworthiness, strategies to ensure epistemological integrity, representative credibility, analytic logic, and interpretive authority were utilized (Thorne, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). We ensured epistemological integrity of the study by choosing ID as our method to address our objective since ID acknowledges the importance of both patient and provider perspectives to understand experiences in the clinical context (Hunt, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Thompson Burdine et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Thorne, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Representative credibility was enhanced by interviewing both patients and providers to ensure the co-construction of knowledge. Analytic logic was enhanced through thick description to prioritize verbatim participant accounts. Interpretive authority was enhanced through constant reflection during analysis about potential biases or experiences that could impact interpretation.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participant Characteristics\u003c/h2\u003e \u003cp\u003eWe completed 15 interviews: 6 with patients and 9 with providers. Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (patient) and 2 (provider) outline participant characteristics. Most patient participants (66.7%) self-identified as male. Most provider participants (88.9%) self-identified as female. All patient participants lived in an urban centre and had a mean (standard deviation) age of 53.0 (23.6) years. Providers had been working in the TB space for a range of 3 to 40 years with a median (interquartile range) of 10.0 (4.0\u0026ndash;14.0) years. On average, interviews with providers tended to last slightly longer (39.8\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;2.8 minutes) than with patients (33.5\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;3.5 minutes).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient participant characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) or Mean (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGender\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age (years) (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.0 (23.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eRural/Urban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (100.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEthnicity\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCambodian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrinidadian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (16.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEast Indian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFilipino\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003ea\u003c/sup\u003e All participants were asked their gender as an open-ended question in conversation with the interviewer. All responded using sex-based categories of male/female. We are reporting terms that participants used.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003eb\u003c/sup\u003e All participants were asked to identify their cultural or ethnic background in an open-ended question in conversation with the interviewer. We are reporting terms that the participants used.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[INSERT Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e AND Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e HERE]\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProvider participant characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%), Median (IQR), or Mean (standard deviation (SD))\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGender\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (88.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean age (years) (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.9 (9.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian years of experience (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.0 (4.0\u0026ndash;14.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eEthnicity\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (44.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaucasian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (44.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM\u0026eacute;tis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003ea\u003c/sup\u003e All participants were asked their gender as an open-ended question in conversation with the interviewer. All responded using sex-based categories of male/female. We are reporting terms that participants used.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003eb\u003c/sup\u003e All participants were asked to identify their cultural or ethnic background in an open-ended question in conversation with the interviewer. We are reporting terms that the participants used.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Impact of the pandemic on healthcare access, service delivery, and health of individuals with TB\u003c/h2\u003e \u003cp\u003eThree key themes were generated: (a) Diagnostic hurdles created delay; (b) Hybrid services promote health equity; and (c) Navigating the complexities of a pandemic within a pandemic. The relationship between the themes and subthemes is depicted in Fig.\u0026nbsp;1.\u003c/p\u003e \u003cp\u003e[INSERT FIGURE 1 HERE]\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure\u0026nbsp;1\u003c/b\u003e The bi-directional arrow reflects a time axis. Before the start of the COVID-19 pandemic, TB care was delivered mostly in-person (telehealth care available for all rural and reserve communities across the province). After the start of the pandemic, the COVID-19 virus complicated the TB diagnostic process and created competition for healthcare resources. However, the pandemic also introduced streamlined virtual care which helped TB patients access care. Both before and during the pandemic, front-line provider inexperience and unfamiliarity with TB resulted in some diagnostic delays. In-person care has been valued for its ability to foster communication and connection since before the pandemic and that did not change during the pandemic. The intersection of the COVID-19 and TB pandemics highlighted learnings that may impact future TB care: inequitable access to resources and increased understanding and utility of public health practices\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Diagnostic hurdles created delay\u003c/h2\u003e \u003cp\u003eThe first theme highlights challenges that were present prior to the COVID-19 pandemic related to diagnosing active TB and the additional challenges that COVID-19 created. These diagnostic challenges subsequently caused delays in patients receiving TB treatment, which is associated with increased morbidity and mortality.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eFront-line provider inexperience and unfamiliarity with active TB.\u003c/span\u003e Given the relatively low rates of TB in Canada, participants perceived that family and emergency department physicians were often unfamiliar and lacked experience to diagnose TB in a prompt manner both before and during the COVID-19 pandemic.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;because [TB is] relatively rare in Canada compared to other places, it\u0026rsquo;s often a delayed diagnosis because it\u0026rsquo;s doesn\u0026rsquo;t come to the forefront of differentials when a patient presents with cough and constitutional symptoms \u0026hellip; the symptoms of TB are pretty non-specific\u0026rdquo;\u003c/em\u003e (provider 1, female)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;the only things that I\u0026rsquo;d \u0026hellip; recommend is about the family doctor \u0026hellip; [to not] forget to notice \u0026hellip; TB symptom[s]. Because I know that some \u0026hellip; don\u0026rsquo;t really notice this kind of symptom that regularly because they just don\u0026rsquo;t think it\u0026rsquo;s TB, right?\u0026rdquo;\u003c/em\u003e (patient 1, male)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis issue was further complicated by the fact that TB can have extrapulmonary manifestations making diagnosis even more challenging and sometimes delayed, subsequently delaying treatment:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;my ankle on the right side was swelling and \u0026hellip; I went to my family doctor and [after] going through a couple of rounds of x-rays we didn\u0026rsquo;t figure out what it [wa]s \u0026hellip; and they sent me in for \u0026hellip; immediate surgery \u0026hellip; after I think almost like a month they realized that it\u0026rsquo;s \u0026hellip; TB.\u0026rdquo;\u003c/em\u003e (patient 3, male)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eCOVID-19 complicated the diagnostic process.\u003c/span\u003e The challenges with diagnosing TB were further complicated by the presence of COVID-19. Given the similarities in symptomology between pulmonary TB and COVID-19, some patients were assumed to have COVID-19 before being properly diagnosed with TB, delaying the start of treatment: \u003cem\u003e\u0026ldquo;Repeatedly [providers thought COVID before TB] and they just aren\u0026rsquo;t getting better. \u0026hellip; so it could be a while before that diagnosis was caught\u0026rdquo;\u003c/em\u003e (provider 5, female). Patients also perceived that the pandemic had an impact on their diagnostic process: \u003cem\u003e\u0026ldquo;Yeah, \u0026hellip; I think the pandemic did impact [my diagnosis] \u0026hellip; because \u0026hellip; every time you\u0026rsquo;re coughing, people will think you might have COVID \u0026hellip; And some clinics don\u0026rsquo;t even want you to be in their clinic\u0026rdquo;\u003c/em\u003e (patient 1, male).\u003c/p\u003e \u003cp\u003eLimited access to healthcare facilities due to public health restrictions and individuals\u0026rsquo; nervousness to seek care also created delays for patients. Some TB screening programs (i.e., immigration screens, screening for those who live in crowded conditions such as nursing homes) were also paused or delayed in response to the pandemic, resulting in some patients\u0026rsquo; diagnoses occurring later than they would have been before the pandemic. However, there was also less immigration during the pandemic significantly decreasing the number of individuals who needed to be screened for TB which allowed for prioritization of other areas of the TB program (i.e., active cases and close contacts).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2 Hybrid services promote health equity\u003c/h2\u003e \u003cp\u003eThe second theme highlights how a combination of virtual and in-person service delivery helped individuals with TB access required healthcare services regardless of social factors.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eVirtual care improved accessibility by meeting patients where they are.\u003c/span\u003e While there was virtual coordination of care for patients with TB living in rural Alberta for over 20 years prior to the pandemic, DOT treatment was still delivered in-person on weekdays at a clinic or a pharmacy. The pandemic introduced virtual DOT which was more convenient and flexible for patients and meant they did not have to take time off work or pay to travel to the clinic every weekday to complete their treatment:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We used \u0026hellip; Zoom \u0026hellip; [for] my medication \u0026hellip; [and] I loved that, because I d[id]n\u0026rsquo;t have to travel to the clinic \u0026hellip; [for] the nurse to see \u0026hellip; if I\u0026rsquo;m taking my medication, so \u0026hellip; I \u0026hellip; save my gas and my time.\u0026rdquo;\u003c/em\u003e (patient 5, male)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, virtual DOT did not reduce the burden on patients\u0026rsquo; support people (who often assisted with language translation during appointments) as they still needed to take time off work to attend the patient\u0026rsquo;s appointment. Virtual DOT, which was delivered in a synchronous format, also increased the workload for providers in the TB clinic because the service became their responsibility. The public health centres or pharmacies did not provide virtual DOT services:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; in the past \u0026hellip; most of the patients would go to a public health centre for their DOT. So once we started doing virtual, that work came back to our clinic \u0026hellip; so that affected \u0026hellip; staffing that we needed to have.\u0026rdquo;\u003c/em\u003e (provider 7, female)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eIn-person care fosters communication and connection.\u003c/span\u003e While virtual DOT appointments were favoured by patients because of their convenience, they still appreciated having some in-person connection with the TB clinic as they viewed it to be easier to ask questions and connect with their provider: \u003cem\u003e\u0026ldquo;I think it was really helpful that I had to go in. It makes it more comfortable and it gives you more time to \u0026hellip; know the doctor and ask better questions\u0026rdquo;\u003c/em\u003e (patient 3, male). Providers also recognized the value of in-person appointments as they perceived that it allowed for better assessment of patients: \u003cem\u003e\u0026ldquo;We stopped seeing patients in-person for quite a while \u0026hellip; Not being able to examine patients \u0026hellip; I think severely affected their care\u0026rdquo;\u003c/em\u003e (provider 9, female). In-person appointments were also perceived by providers to help build trust and relationships with patients: \u003cem\u003e\u0026ldquo;If you can actually see the person to communicate with them, it\u0026rsquo;s easier to foster that relationship [compared to] just a telephone call\u0026rdquo;\u003c/em\u003e (provider 5, female). Trust and relationship building are essential aspects of TB care as it is sometimes challenging to convince patients that they need to take their medications for the entire treatment period since their symptoms typically resolve prior to the end of treatment.\u003c/p\u003e \u003cp\u003eIn-person appointments also made communication easier with individuals whose first language was not English, which is a significant amount of the population who typically presents with TB in Canada. However, given pandemic restrictions, patients\u0026rsquo; access to their support person was challenged during in-person appointments often causing uncertainty, nervousness, and unclear communication:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; limiting the support person was a negative for sure. \u0026hellip; [having] a supportive person there, \u0026hellip; someone who just spoke their language \u0026hellip; from their community, it was very beneficial and supported them at \u0026hellip; clearly communicating, understanding. \u0026hellip; because when they\u0026rsquo;re stressed and not speaking the language \u0026hellip; we just noticed there were definitely gaps in information-sharing and understanding.\u0026rdquo;\u003c/em\u003e (provider 8, female)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.2.3 Navigating the complexities of a pandemic within a pandemic\u003c/h2\u003e \u003cp\u003eThe final theme highlights healthcare system-level changes that did or could impact TB care provision that providers perceived resulted from navigating the TB pandemic within the context of the broader, global COVID-19 pandemic.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eCompetition for finite healthcare resources.\u003c/span\u003e The additional stress that COVID-19 put on the healthcare system resulted in there being competition to access air exchanging rooms in hospitals, lab spaces for regular monitoring, and availability of some healthcare providers. Air exchanging rooms are fundamentally important to properly isolate individuals with TB in hospital. However, such rooms became important for managing the spread of COVID-19, which created competition for the limited resource:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;certain patients are usually admitted [to hospital] at the beginning of their treatment, and so there might be an issue around getting a bed \u0026hellip; [because] we usually need a bed in a specially ventilated room \u0026hellip; [which] were at a premium during COVID.\u0026rdquo;\u003c/em\u003e (provider 6, male)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilarly, access to labs for bloodwork is critical to monitor patients during treatment. Patient participants did not express any challenges accessing labs for monitoring appointments. In comparison, provider participants perceived challenges with access to labs for patients:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;patients who are on active therapy require \u0026hellip; bloodwork done throughout \u0026hellip; active and latent treatment \u0026hellip; [and] access to a lab was an issue for everyone \u0026hellip; So I think that there was an access component that limited our ability to monitor like we usually would.\u0026rdquo;\u003c/em\u003e (provider 9, female)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDue to their specialized skillset and the fact that they were managing a public health priority themselves, TB nurses were prioritized to stay in their positions and were not redeployed to help manage COVID-19 patients. However, there was pressure on doctors who work in the TB space (both TB pulmonologists and infectious disease doctors) to cover COVID-19 wards given their experience with managing an infectious pulmonary condition:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;there\u0026rsquo;s only about a dozen physicians in the province who specialise in the management of TB, and those physicians were also \u0026hellip; in high demand during COVID. So, there was pressure on their time to make themselves available to COVID wards \u0026hellip; The real work of the program is done by a public health nursing network, which is very strong and was \u0026hellip; intact during COVID \u0026hellip; because TB is another public health issue. And so \u0026hellip; we\u0026rsquo;d be \u0026hellip; robbing Peter to pay Paul if you stripped it of its capacity.\u0026rdquo;\u003c/em\u003e (provider 6, male)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe additional stress on the healthcare system also sometimes led to care delays or early hospital discharge which was perceived to negatively impact the health of individuals with TB: \u003cem\u003e\u0026ldquo;\u0026hellip; we did notice that people were being sent home very ill\u0026hellip; We had people who were \u0026hellip; really sick at home \u0026hellip; because they were sent home \u0026hellip; before they\u0026rsquo;re actually ready\u0026rdquo;\u003c/em\u003e (provider 8, female).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eIlluminated inequitable access to resources.\u003c/span\u003e Healthcare providers working in the TB space have always recognized that isolation supports (i.e., paid time off work, isolation facilities) would benefit individuals with TB. However, none of these supports have ever been available. When the COVID-19 pandemic started, isolation resources became available to support those who tested positive for COVID-19. Some providers were frustrated by this inequitable access to isolation resources and felt that supports were put into place rapidly because the entire population was affected, rather than just a small subset:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think \u0026hellip; the whole way that we treated COVID so differently than we treat TB, the resources that we provided for people to isolate, the free testing and all of that, \u0026hellip;, it\u0026rsquo;s a little bit discouraging in the TB world that \u0026hellip; when in need, those things are available if we have the political will. But for some reason, we don\u0026rsquo;t have those same resources available for TB.\u0026rdquo;\u003c/em\u003e (provider 3, female)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eInequitable access to resources was further complicated by limited access to social work support, which is fundamentally important to facilitate system navigation and access. However, social work supports were perceived to be lacking even prior to the pandemic: \u003cem\u003e\u0026ldquo;I certainly think that we need more resources for our patients \u0026hellip; We haven\u0026rsquo;t always had a social worker. And I think \u0026hellip; a lot of our patients need a lot of support\u0026rdquo;\u003c/em\u003e (provider 3, female). The limited access to social work supports in a population with \u003cem\u003e\u0026ldquo;a social disease with a medical aspect\u0026rdquo;\u003c/em\u003e (provider 6, male) seemed to be further complicated during COVID-19 with the part-time position in Edmonton not being filled during a portion of the pandemic. A provider from the Calgary clinic also discussed wishing there was more social work support in general but recognized how funding was the limiting factor. This lack of social work support makes limited resources even harder to access by the often socially vulnerable population of individuals with TB.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eIncreased understanding and utility of public health measures.\u003c/span\u003e Since TB is a public health concern and pandemic itself, TB providers were already intimately familiar with the importance of public health measures like hand hygiene, social distancing, isolation/quarantine, masking, and contact tracing. However, it was perceived that individuals with TB did not necessarily follow this public health advice completely because perhaps they did not understand it, did not want to be stigmatized and draw attention to themselves, or did not have the resources to follow such public health measures. The COVID-19 pandemic made these public health measures commonplace for the global population which providers felt helped to normalize the behaviour:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; previously when we would place patients on home isolation \u0026hellip; or talked about contact tracing, that was a real foreign concept to most people \u0026hellip; But \u0026hellip; I think [COVID-19] kind of normalized that behavior\u0026rdquo;\u003c/em\u003e (provider 9, female)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eProviders also recognized how there were fewer contacts involved for contact tracing in active TB cases due to the public health measures. This helped to somewhat reduce the pressures on the TB clinic that were present due to some staff being redeployed to work in COVID-19 care.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eWe explored patient and provider perspectives of the COVID-19 pandemic on TB healthcare access and service delivery. Diagnosing TB was challenging prior to the pandemic and was complicated with the onset of the COVID-19. However, the pandemic also introduced streamlined virtual care for patients which was convenient and improved access but cannot supplant in-person care. The intersection of the COVID-19 and TB pandemics created competition for limited resources but also highlighted learnings that may positively impact future TB care.\u003c/p\u003e \u003cp\u003eIt has been established that there were pre-pandemic challenges with diagnosing TB. In a systematic review (n\u0026thinsp;=\u0026thinsp;58) conducted before COVID-19, poorly trained personnel and practitioners with low awareness of TB were noted as contributing to the diagnostic delay (Storla et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). The current study also found that diagnoses seemed to be delayed further with the onset of the COVID-19 pandemic. In a cross-sectional multiple methods study (n\u0026thinsp;=\u0026thinsp;672 survey participants, 28 interview participants), the authors found some TB patients were improperly quarantined in health facilities with presumed COVID-19 due to their pulmonary TB symptoms (Bbuye et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe rapid shift to virtual service delivery made DOT more accessible, convenient, and flexible for patients in the current study. Similar to our findings, a systematic review (n\u0026thinsp;=\u0026thinsp;22) found that patients preferred virtual DOT due to convenience as well as the reduction of time- and cost- related barriers (Chen et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). A survey study (n\u0026thinsp;=\u0026thinsp;842) outlined how virtual DOT is a more person-centered model of care compared to the traditional in-person DOT model as it is more accessible and helps reduce stigma faced by individuals with TB (Zimmer et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). However, our provider participants found that providing virtual services was more resource intensive. Chi Chen and colleagues (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) found four articles in their systematic review (n\u0026thinsp;=\u0026thinsp;22) highlighting how virtual DOT required less staffing time compared to in-person DOT. However, these four articles describe TB care in locations other than Canada where perhaps DOT was already entirely the responsibility of the clinic prior to the pandemic which may explain the differences in perceptions.\u003c/p\u003e \u003cp\u003eWhile virtual DOT was valued for its convenience, our participants did not think that it could completely supplant in-person visits. In a rapid review (n\u0026thinsp;=\u0026thinsp;20), Chapman and Veras-Est\u0026eacute;vaz recognized that in-person, comprehensive physical assessments cannot be completely removed from TB care (Chapman \u0026amp; Veras-Est\u0026eacute;vaz, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Our participants felt that in-person visits promoted clear communication as well as connections between patients and providers that contributed to trust, an essential component of TB care. In a qualitative study (n\u0026thinsp;=\u0026thinsp;59), healthcare workers discussed how a trusting relationship between themselves and their patients allowed patients to be more open which helped improve treatment adherence and satisfaction with care (Franke et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In our study, trust was especially important for individuals who required language translation services, highlighting how there could be an important role for multilingual doctors in TB care moving forward to help facilitate trusting relationships with patients.\u003c/p\u003e \u003cp\u003eGiven the swift and substantial financial and governmental response to the COVID-19 pandemic, it is not surprising that the role of \u0026lsquo;political will\u0026rsquo; has been discussed in the literature in terms of the differences in responses to the COVID-19 and TB pandemics. Provider participants from the current study described frustration with all the resources that became available to support individuals with COVID-19 to isolate, recover, and manage financially. Other authors have similarly described how the global COVID-19 response has shown that if governments have the will to mobilize necessary resources to combat a pandemic, they can do so promptly and therefore should do so to meet TB elimination goals (Bedingfield et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Chapman \u0026amp; Veras-Est\u0026eacute;vaz, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Duarte et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Trajman et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Zimmer et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Also discussed by provider participants in the current study, the supports that were made available for COVID-19 patients would go a long way to mitigate some of the inequities experienced by TB patients while also curbing the spread of TB (Bedingfield et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Chapman \u0026amp; Veras-Est\u0026eacute;vaz, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Zimmer et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic also created opportunities for future TB care. Participants in the current study discussed how the normalization of masking and greater understanding of isolation and contact tracing can and will positively impact TB care in the future. Trajman \u003cem\u003eet al\u003c/em\u003e. reported that the COVID-19 pandemic has improved awareness and behaviours around respiratory infection prevention and etiquette. The authors also noted that the COVID-19 pandemic has normalized masking and that this normalization should be capitalized on in response to the TB pandemic (Trajman et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Similarly, Zimmer and colleagues noted that the COVID-19 pandemic normalized the idea of contact tracing which may help address stigma and hesitation around this concept when used in TB care in the future (Zimmer et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Limitations\u003c/h2\u003e \u003cp\u003eSome limitations may impact the transferability of our results. First, we interviewed more healthcare providers than patients which may skew the results to their perspective. Recruiting individuals with TB was challenging as patients are not routinely followed by the clinic following treatment conclusion and social challenges may impede them from participating in research. However, given that providers and patients discussed similar ideas, we do not believe this had a severe impact on our results. Second, we were not able to recruit rural participants and only interviewed individuals who could speak English. This may have impacted the variety of voices and perspectives we heard given that this is a highly ethnically diverse population and that rural TB patients likely have unique needs. Future research engaging rural perspectives and people whose primary or preferred language is not English should be conducted to ensure that these voices are heard when making decisions about health services.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eWe studied the impact of the COVID-19 pandemic on TB healthcare access and delivery by integrating patient and provider perspectives to lay the groundwork to identify implementable strategies for post-pandemic health system improvements. We identified that the COVID-19 pandemic exacerbated challenges in TB diagnosis and management from both patient and provider perspectives and the implementation of virtual care was convenient for patients. Our findings can inform health system leadership about how the COVID-19 pandemic impacted care of other public health threats like TB, helping to prepare more effectively and equitably for future challenges.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBbuye, M., Muyanja, S. Z., Sekitoleko, I., Padalkar, R., Robertson, N., Helwig, M., Hopkinson, D., Siddharthan, T., \u0026amp; Jackson, P. (2024). 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A Program-Wide Evaluation in Alberta, Canada. \u003cem\u003ePLoS One\u003c/em\u003e,\u003cem\u003e\u0026nbsp;10\u003c/em\u003e(12), e0144784. https://doi.org/10.1371/journal.pone.0144784\u003c/li\u003e\n \u003cli\u003eLong, R., King, M., Doroshenko, A., \u0026amp; Heffernan, C. (2020). Tuberculosis and COVID-19 in Canada. \u003cem\u003eEClinicalMedicine\u003c/em\u003e,\u003cem\u003e\u0026nbsp;27\u003c/em\u003e, 100584. https://doi.org/10.1016/j.eclinm.2020.100584\u003c/li\u003e\n \u003cli\u003ePai, M., Kasaeva, T., \u0026amp; Swaminathan, S. (2022). Covid-19\u0026rsquo;s Devastating Effect on Tuberculosis Care \u0026mdash; A Path to Recovery. \u003cem\u003eN Engl J Med\u003c/em\u003e,\u003cem\u003e\u0026nbsp;386\u003c/em\u003e(16), 1490-1493. https://doi.org/10.1056/NEJMp2119571\u003c/li\u003e\n \u003cli\u003ePublic Health Agency of Canada. (2024). \u003cem\u003eTuberculosis in Canada: 2012-2021 Expanded Report\u003c/em\u003e. Government of Canada.\u003c/li\u003e\n \u003cli\u003eQSR International Pty Ltd. (2020). \u003cem\u003eNVivo (released in March 2020)\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eSahu, S., Wandwalo, E., \u0026amp; Arinaminpathy, N. (2022). Exploring the Impact of the COVID-19 Pandemic on Tuberculosis Care and Prevention. \u003cem\u003eJ Pediatric Infect Dis Soc\u003c/em\u003e,\u003cem\u003e\u0026nbsp;11\u003c/em\u003e(Supplement_3), S67-S71. https://doi.org/10.1093/jpids/piac102\u003c/li\u003e\n \u003cli\u003eStorla, D. G., Yimer, S., \u0026amp; Bjune, G. A. (2008). A systematic review of delay in the diagnosis and treatment of tuberculosis. \u003cem\u003eBMC Public Health\u003c/em\u003e,\u003cem\u003e\u0026nbsp;8\u003c/em\u003e, 15. https://doi.org/10.1186/1471-2458-8-15\u003c/li\u003e\n \u003cli\u003eThompson Burdine, J., Thorne, S., \u0026amp; Sandhu, G. (2021). 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The COVID-19 and TB syndemic: the way forward. \u003cem\u003eInt J Tuberc Lung Dis\u003c/em\u003e,\u003cem\u003e\u0026nbsp;26\u003c/em\u003e(8), 710-719. https://doi.org/10.5588/ijtld.22.0006\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2024). \u003cem\u003eTuberculosis\u003c/em\u003e. https://www.who.int/health-topics/tuberculosis#tab=tab_1\u003c/li\u003e\n \u003cli\u003eZimmer, A. J., Heitkamp, P., Malar, J., Dantas, C., O\u0026apos;Brien, K., Pandita, A., \u0026amp; Waite, R. C. (2021). Facility-based directly observed therapy (DOT) for tuberculosis during COVID-19: A community perspective. \u003cem\u003eJ Clin Tuberc Other Mycobact Dis\u003c/em\u003e,\u003cem\u003e\u0026nbsp;24\u003c/em\u003e, 100248. https://doi.org/10.1016/j.jctube.2021.100248\u003c/li\u003e\n \u003cli\u003eZimmer, A. J., Klinton, J. S., Oga-Omenka, C., Heitkamp, P., Nawina Nyirenda, C., Furin, J., \u0026amp; Pai, M. (2022). Tuberculosis in times of COVID-19. \u003cem\u003eJ Epidemiol Community Health\u003c/em\u003e,\u003cem\u003e\u0026nbsp;76\u003c/em\u003e(3), 310-316. https://doi.org/10.1136/jech-2021-217529\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Alberta","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"tuberculosis, access, healthcare quality, interpretive description","lastPublishedDoi":"10.21203/rs.3.rs-5656441/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5656441/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eWe aimed to explore patient and provider perspectives of the impact of the COVID-19 pandemic on tuberculosis healthcare access and service delivery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe used Interpretive Description, a qualitative approach with the end-goal of informing decisions and actions in clinical practice. Levesque \u003cem\u003eet al.’s “\u003c/em\u003eConceptual framework of access to health care” informed the development of our interview guides. Interviews were conducted virtually and confidentially transcribed verbatim. Data generation and analysis occurred concurrently. Analysis was informed by Braun and Clarke’s six phases of reflexive thematic analysis. Strategies to enhance rigour and trustworthiness of the findings were utilized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eWe completed 15 interviews: 6 with patients and 9 with providers. Three key themes were generated: (a) Diagnostic hurdles created delay; (b) Hybrid services promote health equity; and (c) Navigating the complexities of a pandemic within a pandemic. Diagnosing tuberculosis was challenging even prior to the pandemic since some providers lacked experience and familiarity with the condition. The diagnostic process was further complicated with the onset of the COVID-19 pandemic. However, COVID-19 also introduced streamlined virtual care for patients which was convenient and improved access but was not viewed as being equivalent to in-person care. The intersection of the COVID-19 and tuberculosis pandemics created competition for limited resources while highlighting learnings that may positively impact future tuberculosis care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eOur findings can inform health system leadership about how the COVID-19 pandemic impacted care of other public health threats like tuberculosis, helping to prepare more effectively and equitably for future challenges.\u003c/p\u003e","manuscriptTitle":"Patient and provider perceptions of the impact of COVID-19 on tuberculosis healthcare access and delivery: A qualitative study of the complexities of a pandemic within a pandemic","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-18 17:04:06","doi":"10.21203/rs.3.rs-5656441/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d22b3ee9-ad3c-445c-b086-d15febff8996","owner":[],"postedDate":"December 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-18T17:04:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-18 17:04:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5656441","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5656441","identity":"rs-5656441","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}