Socio-economic drivers of Drug-Resistant Tuberculosis in Africa: A Scoping Review

Socio-economic drivers of Drug-Resistant Tuberculosis in Africa: A Scoping Review | 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 Socio-economic drivers of Drug-Resistant Tuberculosis in Africa: A Scoping Review Lesley-Ann Lynnath Cannon, Kelechi Elizabeth Oladimeji, Daniel Ter Goon This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-22668/v3 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Mar, 2021 Read the published version in BMC Public Health → Version 3 posted 9 You are reading this latest preprint version Show more versions Abstract Background: Drug-resistant TB (DR-TB) remains a public health concern due to the high morbidity and mortality rates from the disease. The DR-TB is a multifaceted illness with expensive treatment regimens, toxic medications and most often the long duration of treatment constitutes a substantial financial burden on both infected patients and the health system. Despite significant research advances in the diagnosis and treatment, there is a paucity of synthesized evidence on how socio-economic factors are associated with DR-TB. This review aims to address this gap by synthesizing available evidence and data on the common socio-economic drivers of DR-TB infection in Africa. Methods: A systematic search was conducted on PUBMED and Google Scholar databases from January 2011 to January 2020 using Joanna Briggs Institute’s scoping review approach. An updated search was conducted on 21 September 2020. The eligibility criteria only included systematic reviews and studies with quantitative research methods (cross-sectional, case-control, cohort, and randomized-control trials). Studies conducted in Africa and focusing on socio-economic factors influencing DR-TB burden in African countries were also considered. Data was extracted from all the studies that met the eligibility criteria based on the study’s objectives. Results: Out of the 154 articles that were retrieved for review, 20 abstracts of these articles met all the eligibility criteria. Of the 20 articles, 17 quantitative and 3 reviews. 2 additional articles were found eligible, following the updated search. The following themes were identified as major findings: Social and economic drivers associated with DR-TB. Substance abuse of which, stigma and discrimination were the prominent social drivers. Economic drivers included poverty, financial constraints because of job loss, loss of productive time during hospital admission and treatment costs. Conclusion: This review has highlighted which socio-economic factors contribute to DR- TB This is relevant to assist DR-TB management program and TB stakeholders in different settings to address identified socio-economic gaps and to reduce its negative impact on the programmatic management of DR TB. Therefore, redirecting strategies with more focus on socio-economic empowerment of DR-TB patients could be one of the innovative solutions to reduce the spread and eliminate DR-TB in Africa. Infectious Diseases Health Economics & Outcomes Research Health Policy Drug-resistant TB socio-economic drivers Africa Figures Figure 1 Figure 2 Background Tuberculosis (TB) is a global public health concern and one of the leading causes of morbidity and mortality worldwide [ 1-3 ]. Drug-resistant TB (DR-TB) has evolved due to a high TB defaulter rate, leading to complications with TB diagnosis and case management especially in low- and middle-income countries [ 4-6 ]. As described in the World Health Organization (WHO) global TB report for 2019, roughly 500 000 persons (range 417 000- 556 000) developed or acquired rifampicin-resistant TB (RR-TB) and of these, 78% had multidrug-resistant TB (MDR-TB). Of all newly reported TB cases globally, a projected 3.4% had RR-/ MDR-TB while among previously treated patients, 18% had RR-/MDR-TB [ 7 ]. Further, there is an increase in DR-TB case notification worldwide as indicated in the total number of 186 772 cases of MDR/RR-TB detected and notified in 2018 when compared to the 160 684 notified DR TB cases in 2017. Similarly, increased number of DR-TB cases (156 071 in 2018 compared to 139 114 in 2017) commenced treatment Even with this increased number placed on treatment, treatment success globally remains low, at 56% [ 7 ]. The precise burden of DR-TB in the African countries is poorly described; with only 51% of countries having done official reviews [ 8 ]. Thus, DR-TB is commonly missed in Africa and this looms prospects to attain the year 2035 targets of the End TB strategy [ 9 ]. This can lead to difficulty in estimating the accurate degree of the problem in the African Region. Available data reveals that between 36 000 and 44 000 MDR-TB cases were reported in the AFRO Region in 2016 and of these, 15% of new MDR-TB patients were found to have RR [ 3 ]. Empirical evidence indicates that DR-TB is a multifaceted illness with expensive treatment regimens, toxic medications and long duration of treatment creating a substantial financial burden on the health system [ 10 , 11 ]. Consequently, socio-economic status, job loss, overpopulation, poor hygiene, immunocompromising illnesses and malnourishment have been identified as risk factors that influence this disease burden hence it is commonly referred to as the disease of the poor [ 12 ]. Other facilitators of the disease burden influencing the disease management and outcomes include treatment inaccessibility and distance to the healthcare facility, transport expenses and costs experienced during hospitalization [ 9 , 13-15 ]. Though significant research developments have been made in the diagnosis and treatment aspects of DR-TB [ 16 ], research focused on socio-economic factors associated with DR-TB are limited. Scoping review research question Drug resistant TB is a huge public health problem as discussed, hence this review set out to answer these questions: What are the social factors that contribute to the burden of DR- TB and treatment outcomes in Africa? What are the economic factors influencing the burden of DR-TB and treatment outcomes in Africa? Scoping review objective The objective of this review was to synthesize published articles to identify socio-economic drivers contributing to the burden of DR- TB in Africa. Methods This scoping review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for scoping review [ 17 ] and framework by Joanna Briggs Institute (JBI) [ 18 ]. This review was not registered in the Prospective Register of Systematic Reviews (PROSPERO) since it is a scoping review and not a systematic review. However, there is the prospect of change in trend where registration for scoping review becomes mandatory in databases like PROSPERO, Open Science Framework and Figshare [18]. This scoping review was therefore registered in the Open Science Framework ( https://osf.io/m23pk ). Search strategy PubMed and Google Scholar databases were searched to retrieve articles published between the year 2011 and 2020. Accordingly, only studies meeting the eligibility criteria discussed below was included in the review. The initial search was done on 7 January 2020 and an updated search on 21 September 2020. The following search terms and keywords were used; socio-economic factors, drug-resistance TB, multidrug-resistant tuberculosis, extremely/extensively drug-resistant TB, Africa, social factors, economic factors, contributing factors, and risk factors. During the data sources search process, sorting by year of publication was first applied and next, we only considered the first 10 pages of the search results due to multiple similarities (duplicates) and unrelated articles (not about TB/ not SES). Eligibility criteria Inclusion criteria Since this is a scoping review, we used the PCC (Population / Concept / Context) framework recommended by JBI [ 18 ] to identify eligible studies as discussed below. Population (P) – Drug Resistant TB patients Concept (C) – quantitative studies investigating the influence of socio- economic factors/ drivers/ status on treatment outcomes such as adherence/ cure and treatment completed rates/ Death rates/ Reinfections. Context (C) – we carried out our search process between 1 January 2011 to 7 January 2020. Only cohort, case-control, cross-section studies and systematic reviews evaluating socio-economic factors influencing adult DR-TB patients from African countries were included for further screening and synthesis. An updated search was carried out on 21 September 2020. Exclusion criteria Publication not peer-reviewed Studies on drug sensitive TB and general TB were excluded Other reviews (editorial, commentaries), book chapters, editorials, letters, and conference abstracts. Publication of any other language than English. Qualitative studies Studies including children under 12 years and participants in prison. Selection Process We adopted a selection process described by the Joanna Briggs Institute online manual. Two reviewers independently searched for articles using the eligibility criteria. Articles retrieved were exported into MS Excel sheet by both reviewers and assessed for duplication and eligibility. There were no discrepancies in articles selected and screened for inclusion in this review. Data extraction and analysis Two review authors (LLC/ KEO) independently screened titles and abstracts of the articles for eligibility using the earlier discussed criteria. Full text screening was then further carried out on identified eligible studies from title and abstract screening. Both the reviewers selected the studies based on full text review. Data was thereafter extracted based on the aim of this study and thematically analyzed. The data extracted is presented in table 1 and addendum 3 and includes author(s)/, year of publication, country of origin (where the study was published or conducted), methodology, study population, objectives, findings, implications and main SE factors. Themes that emerged will be discussed in the findings and discussion section. Results Search Outcome The search process yielded 388 articles on PubMed and 57560 on Google Scholar on the 7 th January 2020 (Addendum 1). After screening of the titles of these records- 154 articles were selected. From the 154 articles retrieved, 91 were from Google Scholar and 63 from PubMed. 42 of these were found to be duplications and removed. The 112 remaining articles were screened for appropriateness. Seventeen articles were removed based on qualitative study design. The 95 remaining articles (19 reviews and 76 quantitative studies), full papers were reviewed and further assessed for eligibility. For articles where the full text was not available, we used the Sci Hub website to retrieve the full text. Of the 95 articles whose full texts were screened, only 20 were found eligible and further assessed. Thus, a total number of 75 articles were further excluded as can be seen in Addendum 2. Out of the excluded articles, 59 were quantitative articles and involved 4 children<5years; 23 not Africa; 18 general/ Drug-Sensitive TB (DS-TB); 11 other factors- clinical; 1 isoniazid-resistant (INH) resistance; 2 XDR with unrelated content and 16 reviews excluded: 5 general- DS-TB; 4 other factors-clinical; 3 not applicable; 1 epidemiological study; 3 not systematic reviews.An updated database search was conducted on the 21 st of September 2020 to identify the latest research on the topic. The search yielded 26 new articles in PubMed and 2639 in Google Scholar (Addendum 1). These articles were screened for eligibility as presented in Figure 1. Only 2 of the articles were identified as eligible. Figure 1 below presents a schema for the search process and the outcome of the article selection process. Study setting of reviewed articles Among the 20 eligible articles selected for review, eight studies (7) were conducted in Ethiopia, five (5) in South Africa and then respectively one (1) in each of the following countries: Cameroon, Nigeria, Ghana, and Angola. The three systematic reviews and one (1) cross- sectional study featured more than one nation all including Sub Sahara African countries. The 2 eligible articles in the updated search were done in Ethiopia (cross- sectional) and Sub Sahara African countries (systematic review). This is illustrated in Figure 2. Summary of the studies reviewed Tables 1 presents the characteristics of the study population. Addendum 3 shows a summary of all 22 eligible articles, with specific focus on the main objectives and socio- economic factors that influence DR-TB. Of these selected studies, sixteen (17) were quantitative and three (3) were systematic reviews. Of the 17 quantitative articles, 5 were case controls, 4 cohort studies, 8 cross-sectional. These studies broadly focused on socio-economic risk factors, social issues, and financial issues. Eleven (11) of the articles reviewed focused on only social aspects, four (4) only on financial/ economic issues and five (5) articles covered both social and economic aspects. Of the selected articles, with the updated search one (1) was a cross- sectional study focusing on social aspects and a systematic review covering both social and economic aspects. Table 1: Characteristics of the study population Characteristics N % Citation Mean age 33, 7 - [ 19 - 32 ] , [ 34 ] , [3 5 ] , [36] , [41- 42] Sex Male 276751 66,9 [ 19 - 38] ] , [41] Female 137025 33,1 [ 19 - 38] , [41] Type of DR TB RR/ MDR 2173 0,5 [ 19 - 37] PRE- XDR 104 0, 03 [ 19 - 37] XDR 330 0,08 [ 19 - 37] Mono drug resistance (other than RIF) 136 0,03 [ 19 - 37] Poli drug resistance) 18 0,004 [ 19 - 37] STB/ controls 2473 0,5 [ 19 - 37] DRTB type not indicated (no breakdown) 408542 98,7 [38] , [41- 42] Duration of study – Average duration of studies 32 months - [ 19 - 38] , [41- 42] Treatment outcomes Favourable (Cured/ Treatment completed) 89410 21,60 [29] , [31] , [34] , [42] Unfavourable (Died/ Defaulted/ LTFU/ Failed/ relapse) 66063 15, 96 [29] , [31] , [34] . [42] Transferred out 8 0,002 [31] Treatment outcome not evaluated in study 258295 62,42 [30] , [32-33] , [35- 38] [41] Emerged themes from studies reviewed Social issues influencing MDR-TB Thirteen studies identified in the initial search and both the studies in the updated search looked at the social issues influencing MDR-TB. This included apprehensions on stigma and prejudice, the impact of ethanol on the management of MDR-TB, low educational level, overcrowding, lack of treatment support and problems related to MDR-TB/HIV coinfection. 1.1 Substance use and abuse: Five articles on treatment outcomes among the eligible studies found that alcohol consumption influenced MDR-TB. Alcohol consumption was found to be a predictor of MDR-TB poor treatment outcomes [ 21 ], while substance use was observed to cause poor adherence to treatment [38]. Hence, substance use and abuse were identified as risk factors for MDR-TB acquisition or development and conversely, alcohol consumption was associated with treatment default and failure rate among new DR-TB cases 28]. 1.2 Poverty: The highest rates of DS-TB and DR-TB were discovered in the disadvantaged settings of the community such as the rural areas, overcrowded households and congested areas [ 19 , 23 , 33 ]. Biru et al. (2020) found that residing in a one-roomed house is an independent factor related to DR-TB [41] . Low-income people and persons with little educational exposure had an increased risk of infection [ 36 , 38 ]. Poverty may result in poor nutrition, which may be related, with alterations in the immune system, causing an increased vulnerability. Poverty, on the other hand, results in congestion, poor ventilation and unhygienic environments, increasing the risk of TB transmission [38]. 1.3 Stigma and Discrimination: Thomas et al . (2016) highlight stigma and discrimination as the drivers for the infection and transmission of MDR-TB [38]. Stigma and discrimination in MDR-TB burdened setting was shown to also affect a patient’s health-seeking behavior and access to healthcare negatively. Stigma and discrimination included rejection from family, friends or health workers, financial uncertainty and feelings of anxiety and depression []. It was found that MDR-TB patients would willingly isolate themselves for fear of infecting other members of the family. This can often resulted in isolation, cancellation of engagements, failed relationships and separation within the family [38]. Economic Factors influencing MDR-TB MDR-TB has a vast financial effect on patients due to the complex nature and long duration and of treatment regimens. Socio-economic barriers affecting patient care included treatment distance, inaccessibility, transport costs and costs experienced during hospitalization [35]. Oga-Omenka et al. (2020) identified the inability to pay care-related costs as a barrier for diagnosis and treatment of DR-TB [42] . There was also associated job losses and production time loss during the initial intensive phase of treatment [ 24 , 25 ]. Thomas et al. (2016) found that patients who had not returned to work after one year of being on medication were their family’s breadwinners which had to cease working for a substantial amount of time [38]. Decrease in income due to absenteeism from work and the treatment-related loss of income and extra costs was generally catastrophic [ 24 ]. Quality of Evidence The Mixed Method Quality Appraisal Tool (MMAT) Version 2018 [41] was utilized to assess the quality of all the included quantitative studies (17) while, The Critical Appraisal Skills Programme (CASP) [42] tool was used to assess the systematic reviews. . Two reviewers (LLC/ KEO) assessed the quality of the articles. The following categories were assessed: the appropriateness of the aim of the study, adequacy and methodology, study design, participant recruitment, data collection, data analysis, and findings presented. The quality score ranges from ≤ 50% as low quality, 51–75% an average quality, and 76–100% high quality. All the 17 included quantitative studies had high quality percentage of 76– 100%. None of the included studies for quality assessment scored low quality. The case control study retrieved through the update search, also scored high quality The CASP has 3 domains which has 10 questions. 2 of the reviews were found high quality and one average. The review generated from the updated search scored high quality with an overall of 70%. Quality assessment of evidence is attached as additional files (Addendum 4.1 and 4.2). The studies were considered to have minimal risk of bias. Discussion This review specifically focused on the African region as this area has a high rate of DR- TB with limited resources to combat the disease burden. Thus, it is of utmost importance to identify these factors to stimulate the development of interventions to improve DR-TB treatment outcomes and decrease the incidence rate of DR- TB. The social factors identified in the reviewed articles include apprehensions around stigma and prejudice, the impact of alcohol on the management of DR-TB, low educational level, overcrowding, and lack of treatment support. The social causes of TB are attributed to the mode of spread of TB, as well as the risk factors for acquiring the disease. This review highlights the social factors influencing DR-TB specifically emphasizing overcrowding as a major contributing factor. Eradicating extreme poverty and providing social protection could significantly reduce DR-TB. Patients with DR-TB would willingly isolate themselves for fear of infecting other members of the family, due to discrimination and stigma. This can often lead to separation, cancellation of engagements, failure of relationships and separation within the family [ 38 ]. In places like Africa where TB and HIV are still regarded as a “ killer disease”, TB clients could suffer detrimental effects of being isolated, negatively affecting their treatment adherence status, thus, creating a risk for increased morbidity and mortality. Substance use is frequently observed among patients with poor adherence and has an impact on MDR-TB management. Substance abuse is also associated with high poverty and unemployment levels. In the population with an increased drug and alcohol utilization, it is empirical to study the impact of this increased substance abuse on MDR-TB and to identify intervention strategies to curb the problem. The review also identified economic factors influencing DR-TB. Numerous factors were identified to cause financial constraints- job loss, loss of productive time, absenteeism, and regular reviews all due to the long duration of care and admission time. Breadwinners who are admitted cause significant emotional distress in families- these are also reasons for defaulting and absconding, to avoid admission- to be able to provide for the family. There are also treatment-related costs- getting to review date has associated transport cost. Serious effort needs to be made to address and develop strategies to decrease the financial burden. There is, however, limited evidence to notify policymakers and TB control officers on how socioeconomic interferences should be used to improve MDR-TB control and reduce MDR-TB-related health disparities. There needs to be an immense scale-up of collaborative efforts toward the implementation of integrated model care, considering the health systems, socio-economic factors as well as medical factors. Limitations Although a thorough literature search was conducted, only a small number of eligible articles were available. This limited number of articles could be because only two databases were used to retrieve information. The authors used these databases because they were robust open-access databases that required no institutional payments before they could be searched for eligible articles. Lastly, this scoping review focused on socio-economic factors that influence DR-TB in African regions. However, these factors could differ in other continents. Conclusion In conclusion, this review has highlighted socio-economic factors that contribute to DR-TB. Furthermore, it is crucial to understand these socio-economic factors driving DR-TB in a context-specific setting, to come up with evidence-based intervention strategies that would curb the burden of DR-TB. To achieve the End TB strategy targets, it is imperative to harness both medical and socio-economic efforts to fight against DR-TB disease. DR-TB elimination would require a holistic, comprehensive approach, utilization of available strategies, and associated medical, socio and economic challenges. The management of DR-TB require concerted efforts that address the socio-economic factors as well. To strengthen the findings from this review and the body of evidence, larger-scale randomized control trials to test socio-economic interventions should be undertaken. Abbreviations DS-TB - Drug-Sensitive TB DR-TB - Drug-Resistance TB LFT - Lost from Treatment MDR-TB – Multi-Drug Resistance TB XDR-TB- Extensively Drug Resistance TB Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Availability of data and materials All data generated and analyzed for the review are available upon request from the authors. Competing interests The authors declare that they have no competing interests Funding No funds were received to conduct this review Authors’ contributions LLC and KEO conceptualized and performed the scoping review, LLC wrote the manuscript using synthesized data, KEO provided guidance to LLC, KEO and DTG revised the manuscript. All three authors approved the final version of the manuscript Acknowledgements The authors wish to acknowledge the staff and leadership of the public health department, University of Fort Hare. References Cramm, J.M., Finkenflügel, H.J.M., Møller, V., and Nieboer, A.P., TB treatment initiation and adherence in a South African community influenced more by perceptions than by knowledge of tuberculosis. BMC public health, 2010. 10 (1): p. 72. 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Lukoye, D., Ssengooba, W., Musisi, K., Kasule, G.W., Cobelens, F.G.J., Joloba, M., et al., Variation and risk factors of drug resistant tuberculosis in sub-Saharan Africa: a systematic review and meta-analysis. BMC public health, 2015. 15 (1): p. 291. Thomas, B.E., Shanmugam, P., Malaisamy, M., Ovung, S., Suresh, C., Subbaraman, R., et al., Psycho-socio-economic issues challenging multidrug resistant tuberculosis patients: a systematic review. PloS one, 2016. 11 (1). Hong, Q.N., Pluye, P., Fàbregues, S., Bartlett, G., Boardman, F., Cargo, M., et al., Mixed methods appraisal tool (MMAT), version 2018. Registration of copyright, 2018. 1148552 . Critical Appraisals Skills Programme. CASP Checklist: 10 questions to help you make sense of a Systematic Review . 2018 21 September 2020 Available from: https://casp-uk.net/wp-content/uploads/2018/03/CASP-Systematic-Review-Checklist-2018_fillable-form.pdf Biru, D. and Woldesemayat, E.M., Determinants of Drug-Resistant Tuberculosis in Southern Ethiopia: A Case–Control Study. Infection and Drug Resistance, 2020. 13 : p. 1823. Oga-Omenka, C., Tseja-Akinrin, A., Sen, P., Mac-Seing, M., Agbaje, A., Menzies, D., et al., Factors influencing diagnosis and treatment initiation for multidrug-resistant/rifampicin-resistant tuberculosis in six sub-Saharan African countries: a mixed-methods systematic review. BMJ global health, 2020. 5 (7): p. e002280. Supplementary Files PRISMAFilledChecklistSESDRTBmanuscript11042020.pdf Addendum1SearchStrategy.docx Addendum 1: Search Strategy Addendum2Excludedstudieswithreasons.docx Addendum 2: Excluded studies with reasons Addendum3Summaryofarticles.docx Addendum 3: Summary of the main socio-economic and other factors associated with DR-TB in Africa Addendum4.1MMATQualityAssessmentChecklist.xlsx Addendum 4.1: MMAT Quality Assessment Checklist Addendum4.2CASPQualtityAssessmentTool.docx Addendum 4.2: CASP Quality Assessment Checklists Cite Share Download PDF Status: Published Journal Publication published 11 Mar, 2021 Read the published version in BMC Public Health → Version 3 posted Editorial decision: Minor revision 04 Jan, 2021 Review # 2 received at journal 11 Dec, 2020 Reviewer # 2 agreed at journal 02 Dec, 2020 Review # 1 received at journal 01 Nov, 2020 Reviewers invited by journal 22 Oct, 2020 Reviewer # 1 agreed at journal 22 Oct, 2020 Editor assigned by journal 12 Oct, 2020 Submission checks completed at journal 11 Oct, 2020 Editor invited by journal 11 Oct, 2020 You are reading this latest preprint version Show more versions 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. 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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-22668","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":3640315,"identity":"b3526c3b-e946-480b-bc99-4a5a89ed8eae","order_by":0,"name":"Lesley-Ann Lynnath Cannon","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYBACPgYGxgNw3geICDNeLWxADNfCOIOBQYKNJC3MPERpYW9/cOBjm528uXTzscc2FYfr2NibDxsw1NhE49TCc8bg4My2ZMOdc46lG+ecOSzBxnMsOYHhWFpuAy4tEjkMh3nbDjBuuJFjJp3bBtQikWN8gLHhMG4t8s8fHP7bdsAerMWSKC0SDAaHGdsOJIK1MEK1JODVwpNjcLDnXHLyhhtpaZI9Z9Il24B+MUjA4xd+9uMPH/wos7PdcCP5mMSPCmt+fmCISXyoscGpBQwY2dBFEvApB4M/BFWMglEwCkbBSAYAMCVW0gmYgx0AAAAASUVORK5CYII=","orcid":"","institution":"University of Fort Hare","correspondingAuthor":true,"prefix":"","firstName":"Lesley-Ann","middleName":"Lynnath","lastName":"Cannon","suffix":""},{"id":3640316,"identity":"2da2af76-e5d0-4b66-90de-14a65cf25096","order_by":1,"name":"Kelechi Elizabeth Oladimeji","email":"","orcid":"","institution":"University of Fort Hare","correspondingAuthor":false,"prefix":"","firstName":"Kelechi","middleName":"Elizabeth","lastName":"Oladimeji","suffix":""},{"id":3640317,"identity":"39e74331-0055-4f73-97de-f0d3aaf21ae5","order_by":2,"name":"Daniel Ter Goon","email":"","orcid":"","institution":"University of Fort Hare","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"Ter","lastName":"Goon","suffix":""}],"badges":[],"createdAt":"2020-04-12 11:13:35","currentVersionCode":3,"declarations":"","doi":"10.21203/rs.3.rs-22668/v3","doiUrl":"https://doi.org/10.21203/rs.3.rs-22668/v3","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-021-10267-0","type":"published","date":"2021-03-11T15:00:28+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":3225786,"identity":"5c2e2aa4-c051-4162-b0c3-642f1c845512","added_by":"auto","created_at":"2020-10-27 17:00:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":57640,"visible":true,"origin":"","legend":"PRISMA flow diagram illustrating the search process which eligible articles was identified for data synthesis","description":"","filename":"Figure1PRISMAflowdiagram.png","url":"https://assets-eu.researchsquare.com/files/rs-22668/v3/11e3e3ffc12c00d061f4f6e5.png"},{"id":3225789,"identity":"f0bf5570-51f8-4537-b25b-9c2d2bb1b6a1","added_by":"auto","created_at":"2020-10-27 17:00:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":44085,"visible":true,"origin":"","legend":"Study location and designs of all studies reviewed","description":"","filename":"Figure2Studylocationanddesignsofallstudiesreviewed.png","url":"https://assets-eu.researchsquare.com/files/rs-22668/v3/4fd72ed1d9fc0ef6541d4742.png"},{"id":13606055,"identity":"e57234b2-ad9d-44db-939a-9cd5284a6d13","added_by":"auto","created_at":"2021-09-17 06:06:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":690397,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-22668/v3/b2d4b46b-0c74-467c-9e08-7585ad6dfea4.pdf"},{"id":3225787,"identity":"6a343e93-b617-4124-91cc-31dd40d8faf8","added_by":"auto","created_at":"2020-10-27 17:00:14","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2215050,"visible":true,"origin":"","legend":"","description":"","filename":"PRISMAFilledChecklistSESDRTBmanuscript11042020.pdf","url":"https://assets-eu.researchsquare.com/files/rs-22668/v3/37cb80f66f8145784292e2b4.pdf"},{"id":3225788,"identity":"19dbf495-5dd8-40a8-875a-5fa8952cf491","added_by":"auto","created_at":"2020-10-27 17:00:14","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":19433,"visible":true,"origin":"","legend":"Addendum 1: Search Strategy","description":"","filename":"Addendum1SearchStrategy.docx","url":"https://assets-eu.researchsquare.com/files/rs-22668/v3/51e0687e96aa9310bad3576f.docx"},{"id":3225790,"identity":"70880dc2-1f1c-4124-a801-784de7b14c9b","added_by":"auto","created_at":"2020-10-27 17:00:14","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":24500,"visible":true,"origin":"","legend":"Addendum 2: Excluded studies with reasons","description":"","filename":"Addendum2Excludedstudieswithreasons.docx","url":"https://assets-eu.researchsquare.com/files/rs-22668/v3/7e4045f818c1328bfb167c0b.docx"},{"id":3225791,"identity":"850b4868-62f7-4ad4-9e83-e29633ee1474","added_by":"auto","created_at":"2020-10-27 17:00:14","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":42643,"visible":true,"origin":"","legend":"Addendum 3: Summary of the main socio-economic and other factors associated with DR-TB in Africa","description":"","filename":"Addendum3Summaryofarticles.docx","url":"https://assets-eu.researchsquare.com/files/rs-22668/v3/fbaf97095f0735c84aa12897.docx"},{"id":3225792,"identity":"1e4407c9-67b9-48fd-90cb-435412348f40","added_by":"auto","created_at":"2020-10-27 17:00:15","extension":"xlsx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":68584,"visible":true,"origin":"","legend":"Addendum 4.1: MMAT Quality Assessment Checklist","description":"","filename":"Addendum4.1MMATQualityAssessmentChecklist.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-22668/v3/ed08c6346ec4f2a8ad36dfd4.xlsx"},{"id":3225793,"identity":"cf9a873d-1024-4f40-bcdd-99248992047a","added_by":"auto","created_at":"2020-10-27 17:00:15","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":16471,"visible":true,"origin":"","legend":"Addendum 4.2: CASP Quality Assessment Checklists","description":"","filename":"Addendum4.2CASPQualtityAssessmentTool.docx","url":"https://assets-eu.researchsquare.com/files/rs-22668/v3/ee5e76991e354fb14c3f2262.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003eSocio-economic drivers of Drug-Resistant Tuberculosis in Africa: A Scoping Review\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eTuberculosis (TB) is a global public health concern and one of the leading causes of morbidity and mortality worldwide [\u003ca style=\"color: #000000;\" href=\"#_ENREF_1\"\u003e1-3\u003c/a\u003e]. Drug-resistant TB (DR-TB) has evolved due to a high TB defaulter rate, leading to complications with TB diagnosis and case management especially in low- and middle-income countries [\u003ca style=\"color: #000000;\" href=\"#_ENREF_4\"\u003e4-6\u003c/a\u003e]. As described in the World Health Organization (WHO) global TB report for 2019, roughly 500 000 persons (range 417 000- 556 000) developed or acquired rifampicin-resistant TB (RR-TB) and of these, 78% had multidrug-resistant TB (MDR-TB). Of all newly reported TB cases globally, a projected 3.4% had RR-/ MDR-TB while among previously treated patients, 18% had RR-/MDR-TB [\u003ca style=\"color: #000000;\" href=\"#_ENREF_7\"\u003e7\u003c/a\u003e]. Further, there is an increase in DR-TB case notification worldwide as indicated in the total number of 186 772 cases of MDR/RR-TB detected and notified in 2018 when compared to the 160 684 notified DR TB cases in 2017. Similarly, increased number of DR-TB cases (156 071 in 2018 compared to 139 114 in 2017) commenced treatment Even with this increased number placed on treatment, treatment success globally remains low, at 56% [\u003ca style=\"color: #000000;\" href=\"#_ENREF_7\"\u003e7\u003c/a\u003e].\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eThe precise burden of DR-TB in the African countries is poorly described; with only 51% of countries having done official reviews [\u003ca style=\"color: #000000;\" href=\"#_ENREF_8\"\u003e8\u003c/a\u003e]. Thus, DR-TB is commonly missed in Africa and this looms prospects to attain the year 2035 targets of the End TB strategy [\u003ca style=\"color: #000000;\" href=\"#_ENREF_9\"\u003e9\u003c/a\u003e]. This can lead to difficulty in estimating the accurate degree of the problem in the African Region. Available data reveals that between 36 000 and 44 000 MDR-TB cases were reported in the AFRO Region in 2016 and of these, 15% of new MDR-TB patients were found to have RR [\u003ca style=\"color: #000000;\" href=\"#_ENREF_3\"\u003e3\u003c/a\u003e]. Empirical evidence indicates that DR-TB is a multifaceted illness with expensive treatment regimens, toxic medications and long duration of treatment creating a substantial financial burden on the health system [\u003ca style=\"color: #000000;\" href=\"#_ENREF_10\"\u003e10\u003c/a\u003e, \u003ca style=\"color: #000000;\" href=\"#_ENREF_11\"\u003e11\u003c/a\u003e]. Consequently, socio-economic status, job loss, overpopulation, poor hygiene, immunocompromising illnesses and malnourishment have been identified as risk factors that influence this disease burden hence it is commonly referred to as the disease of the poor [\u003ca style=\"color: #000000;\" href=\"#_ENREF_12\"\u003e12\u003c/a\u003e]. Other facilitators of the disease burden influencing the disease management and outcomes include treatment inaccessibility and distance to the healthcare facility, transport expenses and costs experienced during hospitalization [\u003ca style=\"color: #000000;\" href=\"#_ENREF_9\"\u003e9\u003c/a\u003e, \u003ca style=\"color: #000000;\" href=\"#_ENREF_13\"\u003e13-15\u003c/a\u003e]. Though significant research developments have been made in the diagnosis and treatment aspects of DR-TB [\u003ca style=\"color: #000000;\" href=\"#_ENREF_16\"\u003e16\u003c/a\u003e], research focused on socio-economic factors associated with DR-TB are limited.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eScoping review research question\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eDrug resistant TB is a huge public health problem as discussed, hence this review set out to answer these questions:\u003c/span\u003e\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eWhat are the social factors that contribute to the burden of DR- TB and treatment outcomes in Africa?\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eWhat are the economic factors influencing the burden of DR-TB and treatment outcomes in Africa?\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eScoping review objective\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eThe objective of this review was to synthesize published articles to identify socio-economic drivers contributing to the burden of DR- TB in Africa.\u003c/span\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eThis scoping review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for scoping review [\u003ca style=\"color: #000000;\" href=\"#_ENREF_17\"\u003e17\u003c/a\u003e] and framework by Joanna Briggs Institute (JBI) [\u003ca style=\"color: #000000;\" href=\"#_ENREF_18\"\u003e18\u003c/a\u003e]. This review was not registered in the Prospective Register of Systematic Reviews (PROSPERO) since it is a scoping review and not a systematic review. However, there is the prospect of change in trend where registration for scoping review becomes mandatory in databases like PROSPERO, Open Science Framework and Figshare [18]. This scoping review \u0026nbsp;was therefore registered in the Open Science Framework (\u003ca style=\"color: #000000;\" href=\"https://osf.io/m23pk\"\u003ehttps://osf.io/m23pk\u003c/a\u003e).\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eSearch strategy \u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003ePubMed and Google Scholar databases were searched to retrieve articles published between the year 2011 and 2020. Accordingly, only studies meeting the eligibility criteria discussed below was included in the review. The initial search was done on 7 January 2020 and an updated search on 21 September 2020. The following search terms and keywords were used; socio-economic factors, drug-resistance TB, multidrug-resistant tuberculosis, extremely/extensively drug-resistant TB, Africa, social factors, economic factors, contributing factors, and risk factors. During the data sources search process, sorting\u0026nbsp; by year of publication was first applied and next, we only considered the first 10 pages of the search results due to multiple similarities (duplicates) and unrelated articles (not about TB/ not SES).\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eEligibility criteria \u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cu\u003eInclusion criteria\u003c/u\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eSince this is a scoping review, we used the PCC (Population / Concept / Context)\u0026nbsp; framework recommended by JBI [\u003ca style=\"color: #000000;\" href=\"#_ENREF_18\"\u003e18\u003c/a\u003e] to identify eligible studies as discussed below.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003ePopulation (P)\u003c/strong\u003e \u0026ndash; Drug Resistant TB patients\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eConcept (C)\u003c/strong\u003e \u0026ndash; quantitative studies investigating the influence of socio- economic factors/ drivers/ status on treatment outcomes such as adherence/ cure and treatment completed rates/ Death rates/ Reinfections.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eContext (C)\u003c/strong\u003e \u0026ndash; we carried out our search process between 1 January 2011 to 7 January 2020. Only cohort, case-control, cross-section studies and systematic reviews evaluating socio-economic factors influencing adult DR-TB patients from African countries were included for further screening and synthesis. An updated search was carried out on 21 September 2020.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cu\u003eExclusion criteria\u003c/u\u003e\u003c/span\u003e\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003ePublication not peer-reviewed\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eStudies on drug sensitive TB and general TB were excluded\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eOther reviews (editorial, commentaries), book chapters, editorials, letters, and conference abstracts.\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003ePublication of any other language than English.\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eQualitative studies\u003c/span\u003e\u003c/li\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003eStudies including children under 12 years and participants in prison.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eSelection Process\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eWe adopted a selection process described by the Joanna Briggs Institute online manual. Two reviewers independently searched for articles using the eligibility criteria. Articles retrieved were exported into MS Excel sheet by both reviewers and assessed for duplication and eligibility. There were no discrepancies in articles selected and screened for inclusion in this review.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eData extraction and analysis\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eTwo review authors (LLC/ KEO) independently screened titles and abstracts of the articles for eligibility using the earlier discussed criteria. Full text screening was then further carried out on identified eligible studies from title and abstract screening. Both the reviewers selected the studies based on full text review. Data was thereafter extracted based on the aim of this study and thematically analyzed. The data extracted is presented in table 1 and addendum 3 and includes author(s)/, year of publication, country of origin (where the study was published or conducted), methodology, study population, objectives, findings, implications and main SE factors. Themes that emerged will be discussed in the findings and discussion section.\u003c/span\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eSearch Outcome\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eThe search process yielded 388 articles on PubMed and 57560 on Google Scholar on the 7\u003csup\u003eth\u003c/sup\u003e January 2020 (Addendum 1). After screening of the titles of these records- 154 articles were selected. From the 154 articles retrieved, 91 were from Google Scholar and 63 from PubMed. 42 of these were found to be duplications and removed. The 112 remaining articles were screened for appropriateness. Seventeen articles were removed based on qualitative study design. The 95 remaining articles (19 reviews and 76 quantitative studies), full papers were reviewed and further assessed for eligibility. For articles where the full text was not available, we used the Sci Hub website to retrieve the full text. Of the 95 articles whose full texts were screened, only 20 were found eligible and further assessed. Thus, a total number of 75 articles were further excluded as can be seen in Addendum 2. Out of the excluded articles, 59 were quantitative articles and involved \u0026nbsp;4 children\u0026lt;5years; 23 not Africa; 18 general/ Drug-Sensitive TB (DS-TB); 11 other factors- clinical; 1 isoniazid-resistant (INH) resistance; 2 XDR with unrelated content and 16 reviews excluded: 5 general- DS-TB; 4 other factors-clinical; 3 not applicable; 1 epidemiological study; 3 not systematic reviews.An updated database search was conducted on the 21\u003csup\u003est\u003c/sup\u003e of September 2020 to identify the latest research on the topic. The search yielded 26 new articles in PubMed and 2639 in Google Scholar (Addendum 1). These articles were screened for eligibility as presented in Figure 1. Only 2 of the articles were identified as eligible. Figure 1 below presents a schema for the search process and the outcome of the article selection process.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eStudy setting of reviewed articles\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eAmong the 20 eligible articles selected for review, eight studies (7) were conducted in Ethiopia, five (5) in South Africa and then respectively one (1) in each of the following countries: Cameroon, Nigeria, Ghana, and Angola. The three systematic reviews and one (1) cross- sectional study featured more than one nation all including Sub Sahara African countries. The 2 eligible articles in the updated search were done in Ethiopia (cross- sectional) and Sub Sahara African countries (systematic review). This is illustrated in Figure 2.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eSummary of the studies reviewed\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eTables 1 presents the characteristics of the study population. Addendum 3 shows a summary of all 22 eligible articles, with specific focus on the main objectives and socio- economic factors that influence DR-TB. Of these selected studies, sixteen (17) were quantitative and three (3) were systematic reviews. Of the 17 quantitative articles, 5 were case controls, 4 cohort studies, 8 cross-sectional. These studies broadly focused on socio-economic risk factors, social issues, and financial issues. Eleven (11) of the articles reviewed focused on only social aspects, four (4) only on financial/ economic issues and five (5) articles covered both social and economic aspects. Of the selected articles, with the updated search one (1) was a cross- sectional study focusing on social aspects and a systematic review covering both social and economic aspects.\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eTable 1: Characteristics of the study population\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"669\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;N\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eCitation\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eMean age\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e33, 7\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003ca style=\"color: #000000;\" href=\"#_ENREF_19\"\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/a\u003e\u003cstrong\u003e- \u003c/strong\u003e\u003ca style=\"color: #000000;\" href=\"#_ENREF_32\"\u003e\u003cstrong\u003e32\u003c/strong\u003e\u003c/a\u003e\u003cstrong\u003e]\u003c/strong\u003e\u003cstrong\u003e, \u003c/strong\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003ca style=\"color: #000000;\" href=\"#_ENREF_34\"\u003e\u003cstrong\u003e34\u003c/strong\u003e\u003c/a\u003e\u003cstrong\u003e]\u003c/strong\u003e\u003cstrong\u003e, \u003c/strong\u003e\u003cstrong\u003e[3\u003c/strong\u003e\u003ca style=\"color: #000000;\" href=\"#_ENREF_34\"\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/a\u003e\u003cstrong\u003e]\u003c/strong\u003e\u003cstrong\u003e, \u003c/strong\u003e\u003cstrong\u003e[36]\u003c/strong\u003e\u003cstrong\u003e, \u003c/strong\u003e\u003cstrong\u003e[41- 42]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\u003cspan style=\"color: #000000;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eMale\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e276751 \u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e66,9\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003ca style=\"color: #000000;\" href=\"#_ENREF_19\"\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/a\u003e- \u003cstrong\u003e38]\u003c/strong\u003e\u003cstrong\u003e]\u003c/strong\u003e\u003cstrong\u003e, \u003c/strong\u003e\u003cstrong\u003e[41]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eFemale\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e137025\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e33,1\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003ca style=\"color: #000000;\" href=\"#_ENREF_19\"\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/a\u003e-\u003cstrong\u003e 38]\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e \u003cstrong\u003e[41]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eType of DR TB\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u0026nbsp;RR/ MDR\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e2173\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e0,5\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003ca style=\"color: #000000;\" href=\"#_ENREF_19\"\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/a\u003e-\u003cstrong\u003e 37]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u0026nbsp;PRE- XDR\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e104\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e0, 03\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003ca style=\"color: #000000;\" href=\"#_ENREF_19\"\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/a\u003e-\u003cstrong\u003e 37]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u0026nbsp;XDR\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e330\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e0,08\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003ca style=\"color: #000000;\" href=\"#_ENREF_19\"\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/a\u003e-\u003cstrong\u003e 37]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eMono drug resistance (other than RIF)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e136 \u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e0,03\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003ca style=\"color: #000000;\" href=\"#_ENREF_19\"\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/a\u003e-\u003cstrong\u003e 37]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003ePoli drug resistance)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e18\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e0,004\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003ca style=\"color: #000000;\" href=\"#_ENREF_19\"\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/a\u003e-\u003cstrong\u003e 37]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eSTB/ controls\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e2473\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e0,5\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003ca style=\"color: #000000;\" href=\"#_ENREF_19\"\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/a\u003e-\u003cstrong\u003e 37]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eDRTB type not indicated (no breakdown)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e408542\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e98,7\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[38]\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e \u003cstrong\u003e[41- 42]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eDuration of study \u0026ndash; Average duration of studies\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e32 months\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[\u003c/strong\u003e\u003ca style=\"color: #000000;\" href=\"#_ENREF_19\"\u003e\u003cstrong\u003e19\u003c/strong\u003e\u003c/a\u003e-\u003cstrong\u003e 38]\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e \u003cstrong\u003e[41- 42]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eTreatment outcomes\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eFavourable (Cured/ Treatment completed)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e89410\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e21,60\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[29]\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e \u003cstrong\u003e[31]\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e \u003cstrong\u003e[34]\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e \u003cstrong\u003e[42]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eUnfavourable (Died/ Defaulted/ LTFU/ Failed/ relapse)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e66063\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e15, 96\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[29]\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e \u003cstrong\u003e[31]\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e \u003cstrong\u003e[34]\u003c/strong\u003e\u003cstrong\u003e. \u003c/strong\u003e\u003cstrong\u003e[42]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eTransferred out\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e0,002\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[31]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"347\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eTreatment outcome not evaluated in study\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"112\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e258295\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e62,42\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"140\"\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e[30]\u003c/strong\u003e\u003cstrong\u003e, \u003c/strong\u003e\u003cstrong\u003e[32-33]\u003c/strong\u003e\u003cstrong\u003e, \u003c/strong\u003e\u003cstrong\u003e[35- 38]\u003c/strong\u003e \u003cstrong\u003e[41]\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e\u003cu\u003eEmerged themes from studies reviewed\u003c/u\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eSocial issues influencing MDR-TB\u003c/strong\u003e\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eThirteen studies identified in the initial search and both the studies in the updated search looked at the social issues influencing MDR-TB. This included apprehensions on stigma and prejudice, the impact of ethanol on the management of MDR-TB, low educational level, overcrowding, lack of treatment support and problems related to MDR-TB/HIV coinfection.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e1.1 Substance use and abuse: \u003c/strong\u003eFive articles on treatment outcomes among the eligible studies found that alcohol consumption influenced MDR-TB. Alcohol consumption was found to be a predictor of MDR-TB poor treatment outcomes [\u003ca style=\"color: #000000;\" href=\"#_ENREF_21\"\u003e21\u003c/a\u003e], while substance use was observed to cause poor adherence to treatment [38]. Hence, substance use and abuse were identified as risk factors for MDR-TB acquisition or development and conversely, alcohol consumption was associated with treatment default and failure rate among new DR-TB cases 28].\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e1.2 Poverty: \u003c/strong\u003eThe highest rates of\u0026nbsp; DS-TB and DR-TB were discovered in the disadvantaged settings of the community such as the rural areas, overcrowded households and congested areas [\u003ca style=\"color: #000000;\" href=\"#_ENREF_19\"\u003e19\u003c/a\u003e, \u003ca style=\"color: #000000;\" href=\"#_ENREF_23\"\u003e23\u003c/a\u003e, \u003ca style=\"color: #000000;\" href=\"#_ENREF_33\"\u003e33\u003c/a\u003e]. Biru et al. (2020) found that residing in a one-roomed house is an independent factor related to DR-TB [41] . Low-income people and persons with little educational exposure had an increased risk of infection [\u003ca style=\"color: #000000;\" href=\"#_ENREF_36\"\u003e36\u003c/a\u003e, \u003ca style=\"color: #000000;\" href=\"#_ENREF_38\"\u003e38\u003c/a\u003e]. Poverty may result in poor nutrition, which may be related, with alterations in the immune system, causing an increased vulnerability. Poverty, on the other hand, results in congestion, poor ventilation and unhygienic environments, increasing the risk of TB transmission [38].\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003e1.3 Stigma and Discrimination: \u003c/strong\u003eThomas et al\u003cem\u003e. \u003c/em\u003e(2016) highlight stigma and discrimination as the drivers for the infection and transmission of MDR-TB [38]. Stigma and discrimination in MDR-TB burdened setting was shown to also affect a patient\u0026rsquo;s health-seeking behavior and access to healthcare negatively. Stigma and discrimination included rejection from family, friends or health workers, financial uncertainty and feelings of anxiety and depression []. It was found that MDR-TB patients would willingly isolate themselves for fear of infecting other members of the family. This can often resulted in isolation, cancellation of engagements, failed relationships and separation within the family [38].\u003c/span\u003e\u003c/p\u003e\n\u003col start=\"2\"\u003e\n\u003cli\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eEconomic Factors influencing MDR-TB\u003c/strong\u003e\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eMDR-TB has a vast financial effect on patients due to the complex nature and long duration and of treatment regimens. Socio-economic barriers affecting patient care included treatment distance, inaccessibility, transport costs and costs experienced during hospitalization [35]. Oga-Omenka et al. (2020) identified the inability to pay care-related costs as a barrier for diagnosis and treatment of DR-TB [42] . There was also associated job losses and production time loss during the initial intensive phase of treatment \u0026nbsp;[\u003ca style=\"color: #000000;\" href=\"#_ENREF_24\"\u003e24\u003c/a\u003e, \u003ca style=\"color: #000000;\" href=\"#_ENREF_25\"\u003e25\u003c/a\u003e]. Thomas et al. (2016) found that patients who had not returned to work after one year of being on medication were their family\u0026rsquo;s breadwinners which had to cease working for a substantial amount of time [38]. Decrease in income due to absenteeism from work and the treatment-related loss of income and extra costs was generally catastrophic [\u003ca style=\"color: #000000;\" href=\"#_ENREF_32\"\u003e24\u003c/a\u003e].\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eQuality of Evidence\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eThe Mixed Method Quality Appraisal Tool (MMAT) Version 2018 [41] was utilized to assess the quality of all the included quantitative studies (17) while, The Critical Appraisal Skills Programme (CASP) [42] tool was used to assess the systematic reviews. . Two reviewers (LLC/ KEO) assessed the quality of the articles. The following categories were assessed: the appropriateness of the aim of the study, adequacy and methodology, study design, participant recruitment, data collection, data analysis, and findings presented. The quality score ranges from \u0026le; 50% as low quality, 51\u0026ndash;75% an average quality, and 76\u0026ndash;100% high quality. All the 17 included quantitative studies had high quality percentage of 76\u0026ndash; 100%. None of the included studies for quality assessment scored low quality. The case control study retrieved through the update search, also scored high quality The CASP has 3 domains which has 10 questions. 2 of the reviews were found high quality and one average. The review generated from the updated search scored high quality with an overall of 70%. Quality assessment of evidence is attached as additional files (Addendum 4.1\u0026nbsp;and 4.2). The studies were considered to have minimal risk of bias.\u003c/span\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eThis review specifically focused on the African region as this area has a high rate of DR- TB with limited resources to combat the disease burden. Thus, it is of utmost importance to identify these factors to stimulate the development of interventions to improve DR-TB treatment outcomes and decrease the incidence rate of DR- TB.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eThe social factors identified in the reviewed articles include apprehensions around stigma and prejudice, the impact of alcohol on the management of DR-TB, low educational level, overcrowding, and lack of treatment support. The social causes of TB are attributed to the mode of spread of TB, as well as the risk factors for acquiring the disease. This review highlights the social factors influencing DR-TB specifically emphasizing overcrowding as a major contributing factor. Eradicating extreme poverty and providing social protection could significantly reduce DR-TB. \u0026nbsp;Patients with DR-TB would willingly isolate themselves for fear of infecting other members of the family, due to discrimination and stigma. This can often lead to separation, cancellation of engagements, failure of relationships and separation within the family [\u003ca style=\"color: #000000;\" href=\"#_ENREF_22\"\u003e38\u003c/a\u003e]. In places like Africa where TB and HIV are still regarded as a \u0026ldquo;\u003cem\u003ekiller disease\u0026rdquo;,\u003c/em\u003e TB clients could suffer detrimental effects of being isolated, negatively affecting their treatment adherence status, thus, \u0026nbsp;creating a risk for increased morbidity and mortality. Substance use is frequently observed among patients with poor adherence and has an impact on MDR-TB management. Substance abuse is also associated with high poverty and unemployment levels. In the population with an increased drug and alcohol utilization, it is empirical to study the impact of this increased substance abuse on MDR-TB and to identify intervention strategies to curb the problem.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eThe review also identified economic factors influencing DR-TB. Numerous factors were identified to cause financial constraints- job loss, loss of productive time, absenteeism, and regular reviews all due to the long duration of care and admission time. Breadwinners who are admitted cause significant emotional distress in families- these are also reasons for defaulting and absconding, to avoid admission- to be able to provide for the family. There are also treatment-related costs- getting to review date has associated transport cost. Serious effort needs to be made to address and develop strategies to decrease the financial burden.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eThere is, however, limited evidence to notify policymakers and TB control officers on how socioeconomic interferences should be used to improve MDR-TB control and reduce MDR-TB-related health disparities. There needs to be an immense scale-up of collaborative efforts toward the implementation of integrated model care, considering the health systems, socio-economic factors as well as medical factors.\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: #000000;\"\u003eAlthough a thorough literature search was conducted, only a small number of eligible articles were available. This limited number of articles could be because only two databases were used to retrieve information. The authors used these databases because they were robust open-access databases that required no institutional payments before they could be searched for eligible articles. Lastly, this scoping review focused on socio-economic factors that influence DR-TB in African regions. However, these factors could differ in other continents.\u003c/span\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this review has highlighted socio-economic factors that contribute to DR-TB. Furthermore, it is crucial to understand these socio-economic factors driving DR-TB in a context-specific setting, to come up with evidence-based intervention strategies that would curb the burden of DR-TB. To achieve the End TB strategy targets, it is imperative to harness both medical and socio-economic efforts to fight against DR-TB disease. DR-TB elimination would require a holistic, comprehensive approach, utilization of available strategies, and associated medical, socio and economic challenges. The management of DR-TB require concerted efforts that address the socio-economic factors as well. To strengthen the findings from this review and the body of evidence, larger-scale randomized control trials to test socio-economic interventions should be undertaken.\u003c/p\u003e"},{"header":"Abbreviations ","content":"\u003cp\u003eDS-TB - Drug-Sensitive TB\u003c/p\u003e\n\u003cp\u003eDR-TB - Drug-Resistance TB\u003c/p\u003e\n\u003cp\u003eLFT - Lost from Treatment\u003c/p\u003e\n\u003cp\u003eMDR-TB \u0026ndash; Multi-Drug Resistance TB\u003c/p\u003e\n\u003cp\u003eXDR-TB- Extensively Drug Resistance TB\u003c/p\u003e"},{"header":"Declarations ","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated and analyzed for the review are available upon request from the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funds were received to conduct this review\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLLC and KEO conceptualized and performed the scoping review, LLC wrote the manuscript using synthesized data, KEO provided guidance to LLC, KEO and DTG revised the manuscript.\u0026nbsp; All three authors approved the final version of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to acknowledge the staff and leadership of the public health department, University of Fort Hare.\u003c/p\u003e"},{"header":"References ","content":"\u003col\u003e\n\u003cli\u003eCramm, J.M., Finkenfl\u0026uuml;gel, H.J.M., M\u0026oslash;ller, V., and Nieboer, A.P., \u003cem\u003eTB treatment initiation and adherence in a South African community influenced more by perceptions than by knowledge of tuberculosis.\u003c/em\u003e BMC public health, 2010. \u003cstrong\u003e10\u003c/strong\u003e(1): p. 72.\u003c/li\u003e\n\u003cli\u003eMcnally, T.W., De Wildt, G., Meza, G., and Wiskin, C.M.D., \u003cem\u003eImproving outcomes for multi-drug-resistant tuberculosis in the Peruvian Amazon\u0026ndash;a qualitative study exploring the experiences and perceptions of patients and healthcare professionals.\u003c/em\u003e BMC health services research, 2019. \u003cstrong\u003e19\u003c/strong\u003e(1): p. 594.\u003c/li\u003e\n\u003cli\u003eWorld Health Organisation, \u003cem\u003eGlobal tuberculosis report 2018.\u003c/em\u003e France: World Health Organization, 2018.\u003c/li\u003e\n\u003cli\u003eMigliori, G.B., Richardson, M.D.A., Sotgiu, G., and Lange, C., \u003cem\u003eMultidrug-resistant and extensively drug-resistant tuberculosis in the West. 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Indonesia and Kazakhstan.\u003c/em\u003e BMC infectious diseases, 2016. \u003cstrong\u003e16\u003c/strong\u003e(1): p. 470.\u003c/li\u003e\n\u003cli\u003eRamma, L., Cox, H., Wilkinson, L., Foster, N., Cunnama, L., Vassall, A., et al., \u003cem\u003ePatients' costs associated with seeking and accessing treatment for drug-resistant tuberculosis in South Africa.\u003c/em\u003e The international journal of tuberculosis and lung disease, 2015. \u003cstrong\u003e19\u003c/strong\u003e(12): p. 1513-1519.\u003c/li\u003e\n\u003cli\u003eDu Toit, E., Squire, S.B., Dunbar, R., Machekano, R., Madan, J., Beyers, N., et al., \u003cem\u003eComparing multidrug-resistant tuberculosis patient costs under molecular diagnostic algorithms in South Africa.\u003c/em\u003e The International Journal of Tuberculosis and Lung Disease, 2015. \u003cstrong\u003e19\u003c/strong\u003e(8): p. 960-968.\u003c/li\u003e\n\u003cli\u003eXavier, P.B. and Peixoto, B., \u003cem\u003eEmotional distress in Angolan patients with several types of tuberculosis.\u003c/em\u003e African health sciences, 2015. \u003cstrong\u003e15\u003c/strong\u003e(2): p. 378-384.\u003c/li\u003e\n\u003cli\u003eMulu, W., Mekkonnen, D., Yimer, M., Admassu, A., and Abera, B., \u003cem\u003eRisk factors for multidrug resistant tuberculosis patients in Amhara National Regional State.\u003c/em\u003e African health sciences, 2015. \u003cstrong\u003e15\u003c/strong\u003e(2): p. 368-377.\u003c/li\u003e\n\u003cli\u003eKendall, E.A., Theron, D., Franke, M.F., Van Helden, P., Victor, T.C., Murray, M.B., et al., \u003cem\u003eAlcohol, hospital discharge, and socioeconomic risk factors for default from multidrug resistant tuberculosis treatment in rural South Africa: a retrospective cohort study.\u003c/em\u003e PLoS One, 2013. \u003cstrong\u003e8\u003c/strong\u003e(12).\u003c/li\u003e\n\u003cli\u003eMeriki, H.D., Tufon, K.A., Atanga, P.N., Ane-Anyangwe, I.N., Anong, D.N., Cho-Ngwa, F., et al., \u003cem\u003eDrug resistance profiles of Mycobacterium tuberculosis complex and factors associated with drug resistance in the Northwest and Southwest Regions of Cameroon.\u003c/em\u003e PloS one, 2013. \u003cstrong\u003e8\u003c/strong\u003e(10).\u003c/li\u003e\n\u003cli\u003eMolie, T., Teklemariam, Z., Klinkenberg, E., Dessie, Y., Kumsa, A., Mohammed, H., et al., \u003cem\u003eIntensive phase treatment outcome and associated factors among patients treated for multi drug resistant tuberculosis in Ethiopia: a retrospective cohort study.\u003c/em\u003e BMC infectious diseases, 2019. \u003cstrong\u003e19\u003c/strong\u003e(1): p. 818.\u003c/li\u003e\n\u003cli\u003eOladimeji, O., Ushie, B.A., Udoh, E.E., Oladimeji, K.E., Ige, O.M., Obasanya, O., et al., \u003cem\u003ePsychosocial wellbeing of patients with multidrug resistant tuberculosis voluntarily confined to long-term hospitalisation in Nigeria.\u003c/em\u003e BMJ global health, 2016. \u003cstrong\u003e1\u003c/strong\u003e(3): p. e000006.\u003c/li\u003e\n\u003cli\u003eAlene, K.A., Viney, K., Mcbryde, E.S., and Clements, A.C.A., \u003cem\u003eSpatial patterns of multidrug resistant tuberculosis and relationships to socio-economic, demographic and household factors in northwest Ethiopia.\u003c/em\u003e PloS one, 2017. \u003cstrong\u003e12\u003c/strong\u003e(2).\u003c/li\u003e\n\u003cli\u003eMoyo, S., Cox, H.S., Hughes, J., Daniels, J., Synman, L., De Azevedo, V., et al., \u003cem\u003eLoss from treatment for drug resistant tuberculosis: risk factors and patient outcomes in a community-based program in Khayelitsha, South Africa.\u003c/em\u003e PloS one, 2015. \u003cstrong\u003e10\u003c/strong\u003e(3).\u003c/li\u003e\n\u003cli\u003ePedrazzoli, D., Siroka, A., Boccia, D., Bonsu, F., Nartey, K., Houben, R., et al., \u003cem\u003eHow affordable is TB care? Findings from a nationwide TB patient cost survey in Ghana.\u003c/em\u003e Tropical Medicine \u0026amp; International Health, 2018. \u003cstrong\u003e23\u003c/strong\u003e(8): p. 870-878.\u003c/li\u003e\n\u003cli\u003eDi Gennaro, F., Pizzol, D., Cebola, B., Stubbs, B., Monno, L., Saracino, A., et al., \u003cem\u003eSocial determinants of therapy failure and multi drug resistance among people with tuberculosis: A review.\u003c/em\u003e Tuberculosis, 2017. \u003cstrong\u003e103\u003c/strong\u003e: p. 44-51.\u003c/li\u003e\n\u003cli\u003eLukoye, D., Ssengooba, W., Musisi, K., Kasule, G.W., Cobelens, F.G.J., Joloba, M., et al., \u003cem\u003eVariation and risk factors of drug resistant tuberculosis in sub-Saharan Africa: a systematic review and meta-analysis.\u003c/em\u003e BMC public health, 2015. \u003cstrong\u003e15\u003c/strong\u003e(1): p. 291.\u003c/li\u003e\n\u003cli\u003eThomas, B.E., Shanmugam, P., Malaisamy, M., Ovung, S., Suresh, C., Subbaraman, R., et al., \u003cem\u003ePsycho-socio-economic issues challenging multidrug resistant tuberculosis patients: a systematic review.\u003c/em\u003e PloS one, 2016. \u003cstrong\u003e11\u003c/strong\u003e(1).\u003c/li\u003e\n\u003cli\u003eHong, Q.N., Pluye, P., F\u0026agrave;bregues, S., Bartlett, G., Boardman, F., Cargo, M., et al., \u003cem\u003eMixed methods appraisal tool (MMAT), version 2018.\u003c/em\u003e Registration of copyright, 2018. \u003cstrong\u003e1148552\u003c/strong\u003e.\u003c/li\u003e\n\u003cli\u003eCritical Appraisals Skills Programme. \u003cem\u003eCASP Checklist: 10 questions to help you make sense of a Systematic Review\u003c/em\u003e. 2018 21 September 2020 Available from: https://casp-uk.net/wp-content/uploads/2018/03/CASP-Systematic-Review-Checklist-2018_fillable-form.pdf\u003c/li\u003e\n\u003cli\u003eBiru, D. and Woldesemayat, E.M., \u003cem\u003eDeterminants of Drug-Resistant Tuberculosis in Southern Ethiopia: A Case\u0026ndash;Control Study.\u003c/em\u003e Infection and Drug Resistance, 2020. \u003cstrong\u003e13\u003c/strong\u003e: p. 1823.\u003c/li\u003e\n\u003cli\u003eOga-Omenka, C., Tseja-Akinrin, A., Sen, P., Mac-Seing, M., Agbaje, A., Menzies, D., et al., \u003cem\u003eFactors influencing diagnosis and treatment initiation for multidrug-resistant/rifampicin-resistant tuberculosis in six sub-Saharan African countries: a mixed-methods systematic review.\u003c/em\u003e BMJ global health, 2020. \u003cstrong\u003e5\u003c/strong\u003e(7): p. e002280.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Drug-resistant TB, socio-economic drivers, Africa","lastPublishedDoi":"10.21203/rs.3.rs-22668/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-22668/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eDrug-resistant TB (DR-TB) remains a public health concern due to the high morbidity and mortality rates from the disease. The DR-TB is a multifaceted illness with expensive treatment regimens, toxic medications and most often the long duration of treatment constitutes a substantial financial burden on both infected patients and the health system. Despite significant research advances in the diagnosis and treatment, there is a paucity of synthesized evidence on how socio-economic factors are associated with DR-TB. This review aims to address this gap by synthesizing available evidence and data on the common socio-economic drivers of DR-TB infection in Africa.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA systematic search was conducted on PUBMED and Google Scholar databases from January 2011 to January 2020 using Joanna Briggs Institute’s scoping review approach. An updated search was conducted on 21 September 2020. The eligibility criteria only included systematic reviews and studies with quantitative research methods (cross-sectional, case-control, cohort, and randomized-control trials). Studies conducted in Africa and focusing on socio-economic factors influencing DR-TB burden in African countries were also considered. Data was extracted from all the studies that met the eligibility criteria based on the study’s objectives.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOut of the 154 articles that were retrieved for review, 20 abstracts of these articles met all the eligibility criteria. Of the 20 articles, 17 quantitative and 3 reviews. 2 additional articles were found eligible, following the updated search. The following themes were identified as major findings: Social and economic drivers associated with DR-TB. Substance abuse of which, stigma and discrimination were the prominent social drivers. Economic drivers included poverty, financial constraints because of job loss, loss of productive time during hospital admission and treatment costs.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThis review has highlighted which socio-economic factors contribute to DR- TB This is relevant to assist DR-TB management program and TB stakeholders in different settings to address identified socio-economic gaps and to reduce its negative impact on the programmatic management of DR TB. Therefore, redirecting strategies with more focus on socio-economic empowerment of DR-TB patients could be one of the innovative solutions to reduce the spread and eliminate DR-TB in Africa.\u003c/p\u003e","manuscriptTitle":"Socio-economic drivers of Drug-Resistant Tuberculosis in Africa: A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2020-10-27 17:00:12","doi":"10.21203/rs.3.rs-22668/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2021-01-05T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-12-12T00:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\n\"PEER REVIEWER ASSESSMENTS:\n\nOBJECTIVE - Full research articles: is there a clear objective that addresses one or several testable research questions? (Brief or other article types: is there a clear objective?)\nYes - there is a clear objective\n\nDESIGN - Is the current approach (including controls and analysis protocols) appropriate for the objective?\nYes - the approach is appropriate\n\nEXECUTION - Are the experiments and analyses performed with sufficient technical rigor to allow confidence in the results?\nYes - experiments and analyses were performed appropriately\n\nSTATISTICS - Is the use of statistics in the manuscript appropriate?\nN/A - there are no statistics in this study\n\nINTERPRETATION - Is the current interpretation/discussion of the results reasonable and not overstated?\nYes - the author's interpretation is reasonable\n\nOVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently for you to now recommend the work as a technically sound contribution? If not, can further revisions be made to make the work technically sound?\nYes - current version is technically sound\n\nPEER REVIEWER COMMENTS:\n\nGENERAL COMMENTS: * What is your overall impression of the study?\nThis fairly well-written manuscript titled: \"Socio-economic drivers of Drug-Resistant Tuberculosis in Africa: A Scoping Review\" describes a scoping review of the Socio-economic drivers of Drug-Resistant Tuberculosis in Africa; and this study adds to the literature in this poorly-studied area of research.\n\n* What the authors' have done well?\nThe Introduction, Methods, Results and Discussion sections are detailed and well-written. There are no major weaknesses in the study\n\n* In what ways does it not meet best practice?\nI have severally read the manuscript. I found no major weaknesses in the study and the authors have satisfactorily addressed all issues raised during the previous review.\n\nREQUESTED REVISIONS:\nSPECIFIC COMMENTS\n\n(1) Abstract\nThis is well-written, succinct and clear\n\n(2) Introduction\nThe Introduction section is well-written. The authors provided sufficient background information, placed the study in a broad context and highlighted why it is important. The authors provided adequate information on the Socio-economic drivers of Drug-Resistant Tuberculosis in Africa. Some key and important references were cited. The authors reviewed the literature very well and did identify some strengths, limitations and controversy that justified the study. In addition, the word count is compatible with journals in the health sciences and the authors have satisfactorily addressed all issues raised during the previous review\n\n(3) Methods\nThis is well-written, succinct and clear. The Methods Section was well-written and detailed. The authors were able to provide adequate description of the subjects, adequate description of the data sources and classifications, sufficient information were provided as well as variables retrieved. In addition, the Methods are repeatable and can be reproduced. The statistical analysis was well-described and the authors have satisfactorily addressed all issues raised during the previous review\n\n\n(4) Results\nThis is fairly well-written and follows the suggestions given during the previous review. All the Figures and Tables are complete, self-explanatory and cited in the text.\n\n\n(5) Discussion\nThe key Results of the study were well-discussed. However, with respect to the current state of knowledge on the Socio-economic drivers of Drug-Resistant Tuberculosis in Africa, the Discussion is well-written as most important studies in this area were reviewed and cited.\nThe authors extensively discussed the study findings which led to an interesting and accurate Conclusion. A good number of old and important studies were cited to discuss the findings and they were properly referenced. All the major findings were extensively discussed as well as important limitations of the analysis.\n\n(6) References\nThe number of references cited are adequate and the authors used a consistent format in writing their references.\nADDITIONAL REQUESTS/SUGGESTIONS:\nNone\"* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **This reviewer has been recruited by a partner organization, Research Square. Reviewers with declared or apparent competing interests are not utilized for these reviews. This reviewer has agreed to publication of their comments online under a Creative Commons Attribution License attributed to Research Square and was paid a small honorarium for completing the review within a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer recommendation.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-12-03T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-11-02T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nPEER REVIEWER ASSESSMENTS:\n\nOBJECTIVE - Full research articles: is there a clear objective that addresses one or several testable research questions? (Brief or other article types: is there a clear objective?)\nYes - there is a clear objective\n\nDESIGN - Is the current approach (including controls and analysis protocols) appropriate for the objective?\nYes - the approach is appropriate\n\nEXECUTION - Are the experiments and analyses performed with sufficient technical rigor to allow confidence in the results?\nYes - experiments and analyses were performed appropriately\n\nSTATISTICS - Is the use of statistics in the manuscript appropriate?\nYes - appropriate statistical analyses have been used in the study\n\nINTERPRETATION - Is the current interpretation/discussion of the results reasonable and not overstated?\nYes - the author's interpretation is reasonable\n\nOVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently for you to now recommend the work as a technically sound contribution? If not, can further revisions be made to make the work technically sound?\nYes - current version is technically sound\n\nPEER REVIEWER COMMENTS:\n\nGENERAL COMMENTS: * Have the authors responded adequately to each of the questions or concerns you raised in your comments?\nThe authors have responded adequately to each of the questions or concerns raised during the previous review. In particular, they have addressed all the issues raised in the Introduction, Methods, Results and Discussion. Also, they have clarified confusing areas related to the number of databases searched as well as addressed a few grammatical errors observed.\n\n* Have they also made changes to reflect their responses in the manuscript itself?\nThe authors have made necessary changes in the manuscript to reflect their response in different sections of the manuscript.\n\n* What is your overall impression of the revised manuscript?\n\nMy overall impression of the study is the manuscript is well written, and findings are succinct, coherent and well-presented. The authors have done well in using a scoping review to examine the Socio-economic drivers of Drug-Resistant Tuberculosis in Africa. I have no objection to the further consideration of this manuscript for publication\nADDITIONAL REQUESTS/SUGGESTIONS:\nThe authors should format their references in accordance with the journal guidelines. Presently, it seems distorted.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **This reviewer has been recruited by a partner organization, Research Square. Reviewers with declared or apparent competing interests are not utilized for these reviews. This reviewer has agreed to publication of their comments online under a Creative Commons Attribution License attributed to Research Square and was paid a small honorarium for completing the review within a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer recommendation.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewersInvited","content":"","date":"2020-10-22T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-10-22T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-10-12T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-10-11T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-10-11T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-10-19 13:24:45","doi":"10.21203/rs.3.rs-22668/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-10-07T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-10-05T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-10-04T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-10-04T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-04-20 23:04:40","doi":"10.21203/rs.3.rs-22668/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-07-20T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-07-13T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nPEER REVIEWER ASSESSMENTS:\n\nOBJECTIVE - Full research articles: is there a clear objective that addresses a testable research question(s) (brief or other article types: is there a clear objective)?\nNo - there are minor issues\n\nDESIGN - Is the current approach (including controls and analysis protocols) appropriate for the objective?\nNo - there are minor issues\n\nEXECUTION - Are the experiments and analyses performed with technical rigor to allow confidence in the results?\nNo - there are minor issues\n\nSTATISTICS - Is the use of statistics in the manuscript appropriate?\nN/A - there are no statistics in this study\n\nINTERPRETATION - Is the current interpretation/discussion of the results reasonable and not overstated?\nNo - there are minor issues\n\nOVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically sound? If not, can revisions be made to make the work technically sound?\nProbably - with minor revisions\n\nPEER REVIEWER COMMENTS:\n\nGENERAL COMMENTS:\n* What is your overall impression of the study?\nThis fairly well-written manuscript titled: \"Socio-economic drivers of Drug-Resistant Tuberculosis in Africa: A Scoping Review\" describes a scoping review of the Socio-economic drivers of Drug-Resistant Tuberculosis in Africa; and this study adds to the literature in this poorly-studied area of research.\n\n* What the authors' have done well?\nThe Introduction, Methods, Results and Discussion sections are detailed and fairly well-written. There are no major weaknesses in the study\n\n* In what ways does it not meet best practice?\nI have severally read the manuscript. I found very minor revisions are needed to strengthen the manuscript\n\nREQUESTED REVISIONS:\n1) Abstract\nThis is well-written, succinct and clear\n\n(2) Introduction\nThe Introduction section is well-written. The authors provided sufficient background information, placed the study in a broad context and highlighted why it is important. The authors provided adequate information on the Socio-economic drivers of Drug-Resistant Tuberculosis in Africa. Some key and important references were cited. The authors reviewed the literature very well and did identify some strengths, limitations and controversy that justified the study. In addition, the word count is compatible with journals in the health sciences and there were no major grammatical errors that needs to be addressed here.\n\nMinor Revisions\ni) \"South Africa is one of the high MDR-TB burden countries with multiple factors reported to influence the increased incidence and poor outcomes of MDR-TB [3]. In 2018, 227 999 new and relapsed TB cases were notified in South Africa: 13 199 RR/ MDR-TB and 553 Extensively Drug\nResistance TB (XDR-TB) laboratory-confirmed cases were reported [7]\"\nComment: It is not clear why the authors reported specifically on the burden of DR-TB in South Africa. I recommend that this should be removed.\n\n(3) Methods\nThis is well-written, succinct and clear. The Methods Section was well-written and detailed. The authors were able to provide adequate description of the subjects, adequate description of the data sources and classifications, sufficient information were provided as well as variables retrieved. In addition, the Methods are repeatable and can be reproduced.\n\nMinor Revisions\ni) \"PubMed and Google Scholar databases were searched to retrieve articles published between\nthe year 2011 and 2020.\"\nComments: The number of databases searched and the search strategy is inadequate. There is a need to search at least six databases particularly databases that report African studies like AJOL and African Index Medicus.\n\nii) \"Data was thematically extracted from eligible articles and organized based on the objectives, methodology used, key findings, and implications. Themes that emerged will be discussed in the findings and discussion section\"\nComment: This described how the qualitative data obtained were analysed, however the authors did not provide adequate information on how the quantitative data obtained were analysed. How did the authors analyse data from quantitative studies?\n\n(4) Results\nThis is fairly well-written but requires some clarifications. The Results Section is fairly well-written. All the Figures and Tables are complete, self-explanatory and cited in the text.\n\nMinor revisions\ni) \"These studies broadly focused on socio-economic risk factors, social issues and financial issues\".\nComment: There is a need to clearly define how many of these studies are focused on social issues, how many focused on economic issues and how many evaluated both.\n\n\n(5) Discussion\nThe key Results of the study were well-discussed. However, with respect to the current state of knowledge on the Socio-economic drivers of Drug-Resistant Tuberculosis in Africa, the Discussion is well-written as most important studies in this area were reviewed and cited.\nThe authors extensively discussed the study findings which led to an interesting and accurate Conclusion. A good number of old and important studies were cited to discuss the findings and they were properly referenced. All the major findings were extensively discussed as well as important limitations of the analysis.\n\nMinor Revisions\n\ni) \"Series effort needs to be made to address and develop strategies to decrease the financial burden.\"\nComment: Please, clarify the sentence above.\n\n(6) References\nThe number of references cited are adequate and the authors used a consistent format in writing their references.\nADDITIONAL REQUESTS/SUGGESTIONS:\nAs stated above* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Are the methods appropriate and well described?: **No**\n* Does the work include the necessary controls?: **No**\n* Are the conclusions drawn adequately supported by the data shown?: **No**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **Not relevant to this manuscript**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **This reviewer has been recruited by a partner organization, Research Square. Reviewers with declared or apparent competing interests are not utilized for these reviews. This reviewer has agreed to publication of their comments online under a Creative Commons Attribution License attributed to Research Square and was paid a small honorarium for completing the review within a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer recommendation.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n"},{"type":"reviewerAgreed","content":"","date":"2020-06-24T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-05-19T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-05-19T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nManuscript number PUBH-D-20-01801\nTitle Socio-economic drivers of Drug-Resistant Tuberculosis in Africa: A Scoping Review\n\nOverall comments: This manuscript focused on an important topic to address this gap by synthesizing available evidence and data on the main socio-economic drivers of DR-TB infection in Africa. Overall this review address important issue but the current version required clarifications and major revision.\n\nSpecific comments\n* Whether this review is registered in Registration of systematic reviews in PROSPERO\n* What is the PICO question for this review?\n* Data extraction: Provide details of what data were extracted. What are the statistical tools used? It was mentioned in the abstract quantitate studies included; what are the data base used for search; any software sued for search and analysis?\n* Search were first sorted by relevance means what? …. only the first 10 pages were considered Is it correct?\n* How many full paper reviewed, if not available what action was taken to get full paper for review; any missing information; how the missing information is managed\n* Need to provide supplementary table on search strategy by database and number of articles retrieved\n* Provide supplementary table excluded studies with reasons\n* How the quality of the evidence assessed? \n* How risk of bias assessed; any standard check list used\n* Results: PRISMA Flow diagram: Additional records identified through other sources (n=0) not required \n* Records excluded - provide reasons\n* Full-text articles excluded, with reasons - what are the reasons\n* Studies included in qualitative synthesis - Studies included in quantitative synthesis (meta-analysis) - is it the same - how can both quantitative and qualitative 20\n* Where is the results of meta-analysis - it is not clear\n* Table 1: need to be synthesised and presented properly - split into different trebles like - study characteristics - main finding. Authors collected lot of information but not presented in proper way (Page 9 to 29) too big table.\n* Quality of Evidence- what discussed is not really a quality of evidence\n* Overall discussion to be improved. It required English language editing\n* Avoid terms like \"little evidence to notify policymakers….\" \n* Conclusion is not from the current study finding \"this review has highlighted the influence of socio-economic factors on DR- TB incidence and outcomes..\"\n\nOverall authors made good attempt to review, however the current version is not suitable for publication. I hope the comments are useful for authors to improve the article.\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **No**\n* Are the conclusions drawn adequately supported by the data shown?: **No**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n"},{"type":"reviewersInvited","content":"","date":"2020-04-29T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-04-27T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-04-16T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-04-16T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"abeb638e-1a34-4b83-8de9-a47acbc92e06","owner":[],"postedDate":"October 27th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":901466,"name":"Infectious Diseases"},{"id":901467,"name":"Health Economics \u0026 Outcomes Research"},{"id":901468,"name":"Health Policy"}],"tags":[],"updatedAt":"2021-03-14T15:00:36+00:00","versionOfRecord":{"articleIdentity":"rs-22668","link":"https://doi.org/10.1186/s12889-021-10267-0","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2021-03-11 15:00:28","publishedOnDateReadable":"March 11th, 2021"},"versionCreatedAt":"2020-10-27 17:00:12","video":"","vorDoi":"10.1186/s12889-021-10267-0","vorDoiUrl":"https://doi.org/10.1186/s12889-021-10267-0","workflowStages":[]},"version":"v3","identity":"rs-22668","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-22668","identity":"rs-22668","version":["v3"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}