Non-Communicable Disease and Depressive Symptoms Among Participants of the Kharituwe Case Finding Trial

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Yeboah, Neil Martinson, Colleen Hanrahan, David W. Dowdy, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8329023/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract BACKGROUND South Africa has a high burden of non-communicable diseases (NCDs). Routine screening remains low, care-seeking is often delayed, and many individuals remain undiagnosed. Contact investigation for tuberculosis (TB) represents an opportunity to screen for NCDs as well, but the prevalence of NCDs among index participants (IPs) diagnosed with tuberculosis and their household contacts (HHCs) is not well known. METHODS We conducted a secondary data analysis within the Kharituwe TB case-finding trial. We calculated the prevalence of self-reported diabetes mellitus (DM), cardiovascular disease, Chronic Obstructive Pulmonary Disease (COPD)/Asthma, and depressive symptoms. Among adults, we used mixed-effects logistic regression models to evaluate associations with participant characteristics. RESULTS Kharituwe TB enrolled 10,579 participants: 4,417 IPs and 6,162 HHCs. Overall, 10.2% (n = 450) IPs reported an NCD. Self-reported prevalence among IPs and HHCs, respectively, was 7.0% and 7.2% for cardiovascular disease, 2.5% and 1.3% for DM, 0.8% and 0.7% for asthma/COPD, and 18.4% and 4.8% for depressive symptoms. Odds of self-reported DM [adjusted OR: 2.03 (95% CI: 1.41, 2.90)] and depressive symptoms [adjusted OR: 2.31(95% CI: 1.95–2.74)] were twice as high in IPs as in HHCs. There was notable geographical variation in the prevalence of self-reported depressive symptoms and cardiovascular disease. CONCLUSION There was a modest prevalence of depressive symptoms among people diagnosed with TB. The relatively low prevalence of self-reported NCDs may indicate underdiagnosis. Integrating NCD screening into community-based interventions like active case finding for TB may offer a high-yield opportunity to facilitate early NCD diagnosis. TRIAL REGISTRATION The Kharituwe TB contact tracing study was registered on ClinicalTrials.gov (Identifier NCT04520113) on August 20th, 2020. Tuberculosis non-communicable disease multimorbidity HIV BACKGROUND South Africa has one of the highest tuberculosis (TB) incidence rates globally (427 per 100,000 in 2023) ( 1 ). The non-communicable disease (NCD) burden is also rising, accounting for ~ 50% of all deaths in 2019 ( 2 ). In a 2021 study in KwaZulu-Natal province, the estimated prevalences of high blood glucose and high blood pressure were 8.5% and 23%, respectively ( 3 ). Hypertension rates doubled between 1998 and 2016 according to the 2016 South Africa Demographic and Health Survey (SADHS) ( 4 ). Multimorbidity, which refers to the coexistence of two or more chronic conditions in an individual, is of growing concern due to the added layer of complexity it brings to patient care ( 5 )( 6 ). In a South African study utilizing data from a nationally representative sample of individuals aged 15 years and older, the prevalence of NCD multimorbidity was estimated at 5.9% ( 7 ). Another study in the Limpopo and Free State Provinces reported a TB multimorbidity prevalence of 86% (TB plus any WHO key 5 TB co-morbidities: diabetes mellitus (DM), Human Immunodeficiency Virus (HIV), alcohol use, smoking, and undernutrition) ( 6 ). The majority of individuals in South Africa with NCDs remain undiagnosed ( 8 ) or are diagnosed late due to delays in seeking care ( 9 ). NCD screening during case finding for TB in a joint Mexico-U.S.A-South African study was found to be effective, with up to 44% of patients with DM being newly diagnosed ( 10 ). Another study in Soweto, South Africa, which integrated screening for NCDs and HIV care, revealed that 70–90% of participants with prevalent hypertension, hyperglycemia, and hypercholesterolemia were newly diagnosed ( 11 ). Further evidence of under-reporting and underdiagnosis was shown by the results of the 2016 SADHS, where self-reported hypertension prevalence was 22.9%, while the objectively measured estimate was 44% and 46% for men and women, respectively ( 4 ). It is thus crucial to invest in strategies that encourage testing and referral to care, and opportunities such as TB active case finding (ACF) may be an ideal vehicle to do so – as resources are already being dedicated to screening for TB, and the incremental cost of screening for NCDs may be low. We therefore evaluated the prevalence of self-reported NCDs (DM, cardiovascular disease, chronic obstructive pulmonary disease (COPD)/Asthma) and depressive symptoms among TB-diagnosed index participants (IPs) and their household contacts (HHCs) enrolled in the Kharituwe TB case-finding trial in South Africa. METHODS Study Setting The Kharituwe Trial was conducted in two districts of the predominantly rural Limpopo province (Waterberg and Vhembe) and the urban township of Soshanguve, Gauteng province, between September 2020 and August 2023 ( 12 ). This trial compared two novel strategies: conducting investigations among HHCs during holiday periods in Limpopo and evenings in Soshanguve versus standard contact tracing during business hours. Data for the current sub-study All consenting TB-diagnosed IPs and their HHCs completed a questionnaire on socio-economic factors, healthcare-seeking behaviors, health history, and self-reported diagnoses of DM, cardiovascular disease (including high blood pressure, heart disease, and stroke), COPD, asthma. silicosis or other destructive lung diseases, and cancers. All participants completed the two-item Patient Health Questionnaire-2 (PHQ-2) depression screener, with a score of three or above representing a positive screen for depressive symptoms ( 13 ). We defined heavy alcohol use as consuming three or more standard drinks per day, and binge drinking as consuming six or more standard drinks on one occasion for both males and females. Statistical Analysis For each participant, the presence of each condition was treated as a binary outcome (yes versus no), and we present summaries of these by socio-demographic factors, lifestyle factors (alcohol use and smoking), and self-reported HIV status. For alcohol use, we further present prevalence among those who reported heavy alcohol use or binge drinking. We assessed NCD multimorbidity, which is a self-report of two or more NCDs (DM, cardiovascular disease, and or COPD/ Asthma), and TB multimorbidity, which is a self-report of any NCD among IPs diagnosed with TB. We conducted a sub-analysis among participants aged ≥ 18 years to compare the reported prevalence of NCDs and depressive symptoms between adult IPs and HHCs. For this analysis, we used mixed-effects logistic regressions, with a random effect for clinic, which we consider a proxy for geographical catchment area. These models were adjusted for study arm, age, sex, education level, employment status, HIV status, current cigarette use, heavy alcohol use, and study site. We used the random effects estimates from these models to describe the geographical variation in the self-reported prevalence of these conditions. All statistical analyses were conducted using StataNow/ BE 18.5. Informed consent was obtained from all study participants. Ethical approval for the clinical trial was obtained from the Human Research Ethics Committees of the University of the Witwatersrand, Johannesburg, South Africa, and the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Research Committees of the Limpopo and Gauteng Departments of Health granted approval for study staff to use their facilities to identify participants. The study was funded by the National Institute of Allergy and Infectious Diseases, USA (Grant Number: R01AI147681) and is registered on ClinicalTrials.gov (Identifier: NCT04520113). BASN and EDY were supported by the infrastructure and resources provided by the Johns Hopkins University Center for AIDS Research, an NIH-funded program (1P30AI094189), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIA, NIGMS, NIDDK, NIMHD. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. RESULTS There were 10,579 participants in Kharituwe TB: 4,417 TB-diagnosed IPs and 6,162 HHCs; 40% (n = 4,259) in urban Soshanguve, and 60% (n = 6,320) in rural Limpopo. For IPs and HHCs, respectively, the median ages were 41 (IQR: 31–52) and 23 (IQR: 10–44) years; 60% and 37% were males (Table 1 ). Cardiovascular disease was the most prevalent NCD (7.0% of IPs and 7.2% of HHCs), followed by DM (2.5% of IPs and 1.3% of HHCs). The prevalence of self-reported obstructive lung diseases (COPD and asthma), silicosis or other destructive lung diseases, lung cancer, and non-skin cancers was less than 1% each for both groups. The prevalence of self-reported symptoms of depression was 18.4% for IPs and 4.8% for HHCs. A total of 450 TB-diagnosed IPs self-reported one or more NCDs, representing a TB-multimorbidity burden of 10.2%. About 1% of IPs and HHCs self-reported having two or more NCDs (DM, cardiovascular disease, and/or COPD/ Asthma). Age All NCD prevalences increased with age, with cardiovascular diseases (including high blood pressure, heart disease, and stroke) reported by 38.5% of HHCs 60 years and older and 19.3% of IPs aged 50 years or older. (Table 3 a, 3 b). Sex : Self-reported disease prevalence for male and female IPs, respectively, was 0.9% and 0.7% for COPD/ asthma; 3.3% and 1.8% for DM, and 5.9% and 8.7% for cardiovascular disease; 18.3% and 18.6% for depressive symptoms. Among HHCs, females had a high prevalence of depressive symptoms and all NCDs assessed: depressive symptoms 5.2%; COPD/ Asthma 0.7%; DM 1.6%; cardiovascular disease 9.4%; (Table 3 a, 3 b). Lifestyle Factors About 20% of IPs and 10% of HHCs reported both heavy alcohol use and binge drinking. About 27% of IPs and 6% of HHCs reported having ever smoked cigarettes. Males accounted for over half of heavy alcohol users and about 90% of cigarette users. Nearly 50–70% of cigarette users report smoking an average of six or more cigarettes per day. Of the IPs who had ever smoked cigarettes, 1.3% self-reported a diagnosis of COPD/ asthma. Location In Limpopo, 10.2%, 2.6%, 4.5%, and 1.2% of IPs reported depressive symptoms, DM, cardiovascular disease, and COPD/ asthma, respectively. In Soshanguve, these prevalences were 25.2%, 2.2%, 9.0%, and 0.4%, respectively. Among HHCs in Limpopo, the prevalence of depressive symptoms, DM, cardiovascular disease, and asthma/ COPD was 2.3%, 0.8%, 4.7%, and 0.7%. Among Soshanguve HHCs, these were 10.7%, 2.4%, 13%, and 0.6% respectively (Table 2 ). Logistic Regressions In adjusted logistic regression models, IPs were twice as likely to report DM (adjusted OR: 2.03, 95% CI: 1.41 to 2.90) and depressive symptoms (adjusted OR: 2.31, 95% CI: 1.95 to 2.74) compared to HHCs (Table 4 ). Figure 1 a shows the plot of clinic random effects for the depressive symptoms outcome in the two study sites for adult participants aged ≥ 18 years, detailing the degree to which each clinic’s average log odds of depressive symptoms deviates from the overall average. We observed geographical variability, with clinics in the more rural Limpopo district of Vhembe showing notably lower average log odds of depressive symptoms compared to the overall average. Figure 1 b suggests that several Limpopo sites have a relatively low prevalence of cardiovascular disease, which is in line with national trends ( 4 ). There was no notable geographical variability for the other conditions. DISCUSSION Among the Kharituwe trial participants, 18.4% of IPs and 4.8% of HHCs screened positive for depressive symptoms. Cardiovascular disease, comprising high blood pressure, heart disease, and stroke, was self-reported by 7% of IPs and HHCs, and DM was self-reported by 2.5% and 1.3% for IPs and HHCs, respectively. IPs were twice as likely to report depressive symptoms compared to HHCs, suggesting a disproportionate burden of depression among TB-diagnosed individuals. The World Health Organization (WHO) estimates that 40–70% of TB-diagnosed individuals experience mental health conditions ( 14 ). Depression is associated with poor TB treatment adherence, higher relapse rates, and higher mortality ( 15 ), and is often underrecognized and undertreated in low-resource settings where mental health infrastructure is limited ( 15 ). Depressive symptom screening during TB ACF may offer an opportunity to facilitate the diagnosis of depression and other mental health conditions. This intervention may be most impactful if avenues are created where symptom-screen-positive individuals are linked to care for comprehensive evaluation and management. This would require coordination between TB clinics and mental health providers. In our study, cardiovascular disease, comprising hypertension, heart disease, and stroke, was self-reported by 7% of IPs and HHCs, which aligns with self-reports in other studies ( 16 ). Similarly, self-reported DM prevalence (2.5% and 1.3% for IPs and HHCs, respectively) was in line with self-reports in other studies ( 17 ). In the 2016 SADHS, however, the prevalence of hypertension, using blood pressure measurement, was found to be about two times the prevalence of self-reported hypertension ( 3 ), highlighting a likely problem of underdiagnosis. There is potential benefit in integrating NCD testing with TB ACF efforts, which would reduce underdiagnosis - a crucial step toward achieving Sustainable Development Goal (SDG) target 3.4 ( 18 ). Given the comparatively low prevalence of DM in South Africa ( 4 )( 3 ), screening for DM during TB ACF may be more efficiently rolled out using risk stratification, targeting older adults with risk factors such as obesity and cardiovascular disease. All persons diagnosed with TB during ACF, regardless of other comorbidities, should be screened for DM in keeping with existing recommendations ( 19 )( 20 ). From our study, TB-diagnosed individuals were twice as likely to self-report a diagnosis of DM in comparison to household contacts. This may reflect the increased risk of TB among people with DM ( 21 ), coupled with increased healthcare engagement that characterizes a TB diagnosis, facilitating increased NCD diagnosis and disease awareness in comparison to persons without TB. A similar pattern was observed among persons living with HIV ( 22 ). In this study, TB-multimorbidity was found to be 10%, while a similar percentage of IPs and HHCs were found to have at least one NCD. Multimorbidity poses significant challenges due to increased treatment complexities, cost, and poorer health outcomes ( 6 ). During TB care, persons diagnosed with TB should be screened for NCDs due to an increased risk for DM, mental health conditions, and other conditions ( 19 ). Heavy alcohol use, binge drinking, and cigarette smoking are also risk factors of concern as they increase the risk of developing active TB and other diseases such as hypertension, cardiovascular disease, COPD, cancer, and mental health conditions ( 21 )( 23 )( 24 ). The literature on cost-effectiveness of integrated NCD screening during active case finding for TB or during HIV services shows mixed results ( 25 )( 19 )( 11 ), with some studies arguing that this integrated approach utilizes task-shifting models, reduces inefficiencies, improves care delivery, and reduces cost ( 19 )( 26 ). Others suggest that cost-effectiveness is achieved by focusing on high-risk groups, such as adults aged 40 and above ( 25 ). LIMITATIONS All NCD diagnoses were based on self-report, which is known to underestimate true prevalence ( 8 ). Secondly, the validated two-item PHQ-2 depression screener( 13 ), which was used as an indicator for depression prevalence, does not represent a formal diagnosis of depression; rather, this screening tool identifies individuals for whom additional evaluation is warranted. Additionally, cardiovascular disease was examined as a composite condition comprising high blood pressure, heart disease, and stroke, which may have led to the underestimation of the burden of NCD multimorbidity and also precluded an independent analysis of hypertension. CONCLUSION We observed a modest burden of depressive symptoms among people diagnosed with TB and a relatively low prevalence of NCDs among people diagnosed with TB and their household contacts in two sites in South Africa. TB active case finding or other types of interventions that decentralize disease screening may be a high-yield opportunity to facilitate early diagnosis of NCDs. List of abbreviations ACF: Active case finding CI: Confidence interval COPD: Chronic Obstructive Pulmonary Disease DM: Diabetes Mellitus HHC: Household contact HIV: Human Immunodeficiency Virus IP: Index participant NCD: Non-communicable disease OR: Odds ratio PHQ-2: Patient Health Questionnaire-2 SADHS: South Africa Demographic and Health Survey SDG: Sustainable Development Goals TB: Tuberculosis WHO: World Health Organization Declarations Ethics approval and consent to participate: All procedures were carried out in accordance with relevant ethical guidelines and regulations, including the principles of the Declaration of Helsinki. Informed consent was obtained from all participants, and no identifiable personal information was collected or reported. Ethical approval for the clinical trial was obtained from the Human Research Ethics Committees of the University of the Witwatersrand, Johannesburg, South Africa, and the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (IRB00011124). Consent for publication: Not applicable Competing interests: The authors declare that they have no competing interests. Funding: The study was funded by the National Institute of Allergy and Infectious Diseases, USA (Grant Number: R01AI147681). B.A.S.N and E.D.Y were supported by the infrastructure and resources provided by the Johns Hopkins University Center for AIDS Research, an NIH-funded program (1P30AI094189), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIA, NIGMS, NIDDK, NIMHD. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Author Contribution B.A.S.N conceptualized the study. E.D.Y wrote the original draft of the manuscript, analyzed and interpreted the data. N.M, C.H, D.W.D, and B.A.S.N reviewed and edited the manuscript. Acknowledgement We acknowledge the participants in this trial. Data Availability The datasets analyzed during this study may be made available upon reasonable request and approval from the corresponding author. References Department of Health SA, National. TB Recovery Plan 4.0 [Internet]. 2025. Available from: https://www.health.gov.za/wp-content/uploads/2025/05/TB-Recovery-Plan-4_final_250526-1.pdf South Africa. pdf [Internet]. [cited 2025 June 18]. Available from: https://www.afro.who.int/sites/default/files/2023-08/South%20Africa.pdf Wong EB, Olivier S, Gunda R, Koole O, Surujdeen A, Gareta D et al. Convergence of infectious and non-communicable disease epidemics in rural South Africa: a cross-sectional, population-based multimorbidity study. 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Foo CD, Shrestha P, Wang L, Du Q, García-Basteiro AL, Abdullah AS, et al. Integrating tuberculosis and noncommunicable diseases care in low- and middle-income countries (LMICs): A systematic review. PLoS Med. 2022;19(1):e1003899. Tables Table 1 Baseline Characteristics of Trial Participants (N = 10579) Baseline Characteristics Index Participants with Tuberculosis (N = 4417) Household Contacts (N = 6162) Soshanguve (N = 2416) Limpopo (N = 2001) Soshanguve (N = 1843) Limpopo (N = 4319) Median age (IQR) , years 42 (32–53) 41 (31–52) 34 (21–55) 18 (6–38) n (%) n (%) n (%) n (%) Sex , Male 1520 (62.9%) 1131 (56.5%) 648 (35.2%) 1650 (38.2%) Educational level Less than high school 1124 (46.5%) 1170 (58.5%) 853 (46.3%) 3007 (69.2%) Employment Status Student/ unemployed/ Retired 1897 (78.6%) 1618 (80.9%) 1561 (84.7%) 3966 (91.9%) HIV status Positive 1185 (49.1%) 1190 (59.5%) 237 (12.9%) 284 (6.6%) Negative 889 (36.8%) 665 (33.2%) 1007 (54.3%) 1617 (37.4%) Heavy alcohol use 395 (16.4%) 573 (28.6%) 204 (11.1%) 483 (11.2%) Binge drinking (≥ 6 standard drinks on one occasion) 508 (21.0%) 548 (27.3%) 251 (13.6%) 451 (10.4%) Ever used cigarettes 598 (24.8%) 581 (29.0%) 152 (8.3%) 212 (4.9%) Average number of cigarettes/ days 0–5 151 (25.1%) 231(39.8%) 67 (43.5%) 115 (54.2%) 6–10 363 (60.4%) 193 (33.5%) 83 (53.9%) 64 (30.2%) > 10 87 (14.5%) 155 (26.7%) 4 (2.6%) 33 (15.6%) IQR = Inter-quartile range NCD = Non-Communicable Disease DM = Diabetes Mellitus COPD = Chronic Obstructive Pulmonary Disease HIV = Human Immunodeficiency Virus CVD = cardiovascular disease, which includes high blood pressure, heart disease, and stroke. Table 2 Non-Communicable Disease and Depressive Symptom Prevalence by Study Site COPD = Chronic Obstructive Pulmonary Disease Index Participants with Tuberculosis (N = 4417) Household Contacts (N = 6162) Soshanguve (N = 2416) Limpopo (N = 2001) Soshanguve (N = 1843) Limpopo (N = 4319) Diabetes Mellitus 53 (2.2%) 53 (2.6%) 44 (2.4%) 34 (0.8%) Cardiovascular Disease 218 (9.0%) 91 (4.5%) 239 (13.0%) 203 (4.7%) Asthma/ COPD 10 (0.4%) 25 (1.2%) 11 (0.6%) 31 (0.7%) Depressive Symptoms 608 (25.2%) 204 (10.2%) 197 ( 10.7%) 101 (2.3%) Table 3 a: Prevalence of NCDs and depressive symptoms among index participants diagnosed with tuberculosis in South Africa (N = 4417) Demographics Obstructive lung disease (Asthma/ COPD) n (%) Diabetes Mellitus n (%) Cardiovascular Disease * n (%) Depressive Symptoms ** (PHQ 2 ≥ 3) n (%) Overall Prevalence 35 (0.8%) 106 (2.5%) 309 (7.0%) 812 (18.4%) Age, years < 30 N = 930 2 (0.2%) 3 (0.3%) 3(0.3%) 119 (12.8%) 30–39 N = 1063 3 (0.3%) 4 (0.4%) 11 (1.0%) 230 (21.7%) 40–49 N = 1055 7 (0.7%) 29 (2.8%) 38 (3.6%) 226 (21.4%) ≥ 50 N = 1329 23 (1.7%) 70 (5.3%) 257 (19.3%) 231 (17.8%) Sex Male N = 2651 23 (0.9%) 48 (3.3%) 156 (5.9%) 484 (18.3%) Female N = 1766 12 (0.7%) 58 (1.8%) 153 (8.7%) 328 (18.6%) Self-reported HIV Status Positive N = 2375 9 (0.4%) 32 (1.4%) 75 (3.2%) 469 (19.8%) Negative N = 1554 20 (1.3%) 63 (4.1%) 182 (11.7%) 239 (15.4%) Unknown/not willing to say N = 488 6 (1.2%) 11 (2.3%) 52 (10.7%) 104 (21.3%) Heavy alcohol use (≥ 3 standard drinks per day) Yes, N = 968 7 (0.7%) 9 (0.9%) 37 (3.8%) 168 (17.4%) No, N = 3449 28 (0.8%) 97 (2.8%) 272 (7.9%) 644 (18.7%) Binge drinking (≥ 6 standard drinks on one occasion) Yes, N = 1056 11 (1.0%) 8 (0.8%) 40 (3.8%) 173 (16.4%) No, N = 3361 24 (0.7%) 98 (2.9%) 269 (8.0%) 639 (19.0%) Ever Smoking Yes, N = 1179 15 (1.3%) 11 (0.9%) 49 (4.2%) 184 (15.6%) No, N = 3237 20 (0.6%) 95 (2.9%) 260 (8.0%) 628 (19.4%) Table 3 b: Prevalence of NCDs and depressive symptoms among household contacts of people diagnosed with tuberculosis in South Africa (N = 6162) Demographics Obstructive lung disease (Asthma/ COPD) n (%) Diabetes Mellitus n (%) Cardiovascular Disease * n (%) Depressive Symptoms ** (PHQ 2 ≥ 3) n (%) Overall Prevalence 42 (0.7%) 78 (1.3%) 442 (7.2%) 298 (4.8%) Age, years < 20 N = 2695 15 (0.6%) 1 (0.0%) 2 (0.1%) 27 (1.0%) 20–39 N = 1685 6 (0.4%) 1 (0.1%) 13 (0.8%) 117 (6.9%) 40–59 N = 950 11 (1.2%) 19 (2.0%) 107 (11.3%) 91 (9.6%) ≥ 60 N = 832 10 (1.2%) 58 (6.9%) 320 (38.5%) 63 (7.6%) Sex Male N = 2298 13 (0.6%) 17 (0.7%) 79 (3.4%) 98 (4.3%) Female N= 3864 29 (0.7%) 62 (1.6%) 363 (9.4%) 200 (5.2%) Self-reported HIV Status Positive N = 521 - 4 (0.8%) 29 (5.6%) 49 (9.4%) Negative, N = 2618 23 (0.9%) 43 (1.6%) 240 (9.2%) 192 (7.3%) Unknown/ not willing to say, N = 3023 19 (0.6%) 31(1.0%) 173 (5.7%) 57 (1.9%) Heavy drinking (≥ 3 drinks per day) Yes, N = 689 3 (0.4%) 4 (0.6%) 26 (3.8%) 45 (6.6%) No, N = 5486 39 (0.7%) 74 (1.4%) 416 (7.6%) 253(4.6%) Binge drinking (≥ 6 standard drinks on one occasion) Yes, N = 702 3 (0.4%) 5 (0.7%) 28 (4.0%) 52 (7.4%) No, N = 5460 39 (0.7%) 73 (1.3%) 414 (7.6%) 246 (4.5%) Ever Smoking Yes, N = 366 0 (0.0%) 7 (1.9%) 19 (5.2%) 33 (9.1%) No, N = 5809 42 (0.7%) 71 (1.2%) 423 (7.3%) 265 (4.6%) * Cardiovascular disease includes high blood pressure, heart disease, and stroke. ** Depressive symptoms were measured on a PHQ-2 depression screener, where scores 0 to 2 represent negative screening, and scores 3 to 6 represent positive screening Table 4 Mixed-Effects Logistic Regression of NCD and Depressive Symptoms by Participant Type Diabetes Mellitus Cardiovascular Disease COPD/ Asthma Depressive Symptoms OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Index Participants 2.03 (1.41–2.90) 0.88 (0.72–1.09) 1.71 (0.93–3.14) 2.31 (1.95–2.74) Household Contacts 1 (Reference) 1 (Reference) 1 (Reference) 1 (Reference) OR = Odd’s Ratios 95% CI = 95% confidence interval Models were adjusted for study arm, age, sex, education level, employment status, HIV status, current cigarette use, heavy alcohol use, and study site Additional Declarations No competing interests reported. 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12:22:00","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":234257,"visible":true,"origin":"","legend":"","description":"","filename":"SUPPLEMENTARYFIGURE.docx","url":"https://assets-eu.researchsquare.com/files/rs-8329023/v1/b0e7b0bc79aa62e66cab1b7c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Non-Communicable Disease and Depressive Symptoms Among Participants of the Kharituwe Case Finding Trial","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eSouth Africa has one of the highest tuberculosis (TB) incidence rates globally (427 per 100,000 in 2023) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The non-communicable disease (NCD) burden is also rising, accounting for ~\u0026thinsp;50% of all deaths in 2019 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In a 2021 study in KwaZulu-Natal province, the estimated prevalences of high blood glucose and high blood pressure were 8.5% and 23%, respectively (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Hypertension rates doubled between 1998 and 2016 according to the 2016 South Africa Demographic and Health Survey (SADHS) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Multimorbidity, which refers to the coexistence of two or more chronic conditions in an individual, is of growing concern due to the added layer of complexity it brings to patient care (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In a South African study utilizing data from a nationally representative sample of individuals aged 15 years and older, the prevalence of NCD multimorbidity was estimated at 5.9% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Another study in the Limpopo and Free State Provinces reported a TB multimorbidity prevalence of 86% (TB plus any WHO key 5 TB co-morbidities: diabetes mellitus (DM), Human Immunodeficiency Virus (HIV), alcohol use, smoking, and undernutrition) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe majority of individuals in South Africa with NCDs remain undiagnosed (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) or are diagnosed late due to delays in seeking care (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). NCD screening during case finding for TB in a joint Mexico-U.S.A-South African study was found to be effective, with up to 44% of patients with DM being newly diagnosed (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Another study in Soweto, South Africa, which integrated screening for NCDs and HIV care, revealed that 70\u0026ndash;90% of participants with prevalent hypertension, hyperglycemia, and hypercholesterolemia were newly diagnosed (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Further evidence of under-reporting and underdiagnosis was shown by the results of the 2016 SADHS, where self-reported hypertension prevalence was 22.9%, while the objectively measured estimate was 44% and 46% for men and women, respectively (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt is thus crucial to invest in strategies that encourage testing and referral to care, and opportunities such as TB active case finding (ACF) may be an ideal vehicle to do so \u0026ndash; as resources are already being dedicated to screening for TB, and the incremental cost of screening for NCDs may be low. We therefore evaluated the prevalence of self-reported NCDs (DM, cardiovascular disease, chronic obstructive pulmonary disease (COPD)/Asthma) and depressive symptoms among TB-diagnosed index participants (IPs) and their household contacts (HHCs) enrolled in the Kharituwe TB case-finding trial in South Africa.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Setting\u003c/h2\u003e \u003cp\u003eThe Kharituwe Trial was conducted in two districts of the predominantly rural Limpopo province (Waterberg and Vhembe) and the urban township of Soshanguve, Gauteng province, between September 2020 and August 2023 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This trial compared two novel strategies: conducting investigations among HHCs during holiday periods in Limpopo and evenings in Soshanguve versus standard contact tracing during business hours.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData for the current sub-study\u003c/h3\u003e\n\u003cp\u003eAll consenting TB-diagnosed IPs and their HHCs completed a questionnaire on socio-economic factors, healthcare-seeking behaviors, health history, and self-reported diagnoses of DM, cardiovascular disease (including high blood pressure, heart disease, and stroke), COPD, asthma. silicosis or other destructive lung diseases, and cancers. All participants completed the two-item Patient Health Questionnaire-2 (PHQ-2) depression screener, with a score of three or above representing a positive screen for depressive symptoms (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). We defined heavy alcohol use as consuming three or more standard drinks per day, and binge drinking as consuming six or more standard drinks on one occasion for both males and females.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eFor each participant, the presence of each condition was treated as a binary outcome (yes versus no), and we present summaries of these by socio-demographic factors, lifestyle factors (alcohol use and smoking), and self-reported HIV status. For alcohol use, we further present prevalence among those who reported heavy alcohol use or binge drinking.\u003c/p\u003e \u003cp\u003eWe assessed NCD multimorbidity, which is a self-report of two or more NCDs (DM, cardiovascular disease, and or COPD/ Asthma), and TB multimorbidity, which is a self-report of any NCD among IPs diagnosed with TB. We conducted a sub-analysis among participants aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years to compare the reported prevalence of NCDs and depressive symptoms between adult IPs and HHCs. For this analysis, we used mixed-effects logistic regressions, with a random effect for clinic, which we consider a proxy for geographical catchment area. These models were adjusted for study arm, age, sex, education level, employment status, HIV status, current cigarette use, heavy alcohol use, and study site. We used the random effects estimates from these models to describe the geographical variation in the self-reported prevalence of these conditions.\u003c/p\u003e \u003cp\u003eAll statistical analyses were conducted using StataNow/ BE 18.5.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003ewas obtained from all study participants. Ethical approval for the clinical trial was obtained from the Human Research Ethics Committees of the University of the Witwatersrand, Johannesburg, South Africa, and the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Research Committees of the Limpopo and Gauteng Departments of Health granted approval for study staff to use their facilities to identify participants.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe study was funded by the National Institute of Allergy and Infectious Diseases, USA (Grant Number: R01AI147681) and is registered on ClinicalTrials.gov (Identifier: NCT04520113). BASN and EDY were supported by the infrastructure and resources provided by the Johns Hopkins University Center for AIDS Research, an NIH-funded program (1P30AI094189), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIA, NIGMS, NIDDK, NIMHD. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThere were 10,579 participants in Kharituwe TB: 4,417 TB-diagnosed IPs and 6,162 HHCs; 40% (n\u0026thinsp;=\u0026thinsp;4,259) in urban Soshanguve, and 60% (n\u0026thinsp;=\u0026thinsp;6,320) in rural Limpopo. For IPs and HHCs, respectively, the median ages were 41 (IQR: 31\u0026ndash;52) and 23 (IQR: 10\u0026ndash;44) years; 60% and 37% were males (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCardiovascular disease was the most prevalent NCD (7.0% of IPs and 7.2% of HHCs), followed by DM (2.5% of IPs and 1.3% of HHCs). The prevalence of self-reported obstructive lung diseases (COPD and asthma), silicosis or other destructive lung diseases, lung cancer, and non-skin cancers was less than 1% each for both groups. The prevalence of self-reported symptoms of depression was 18.4% for IPs and 4.8% for HHCs. A total of 450 TB-diagnosed IPs self-reported one or more NCDs, representing a TB-multimorbidity burden of 10.2%. About 1% of IPs and HHCs self-reported having two or more NCDs (DM, cardiovascular disease, and/or COPD/ Asthma).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAge\u003c/strong\u003e \u003cp\u003eAll NCD prevalences increased with age, with cardiovascular diseases (including high blood pressure, heart disease, and stroke) reported by 38.5% of HHCs 60 years and older and 19.3% of IPs aged 50 years or older. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea, \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSex\u003c/b\u003e: Self-reported disease prevalence for male and female IPs, respectively, was 0.9% and 0.7% for COPD/ asthma; 3.3% and 1.8% for DM, and 5.9% and 8.7% for cardiovascular disease; 18.3% and 18.6% for depressive symptoms. Among HHCs, females had a high prevalence of depressive symptoms and all NCDs assessed: depressive symptoms 5.2%; COPD/ Asthma 0.7%; DM 1.6%; cardiovascular disease 9.4%; (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea, \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLifestyle Factors\u003c/strong\u003e \u003cp\u003eAbout 20% of IPs and 10% of HHCs reported both heavy alcohol use and binge drinking. About 27% of IPs and 6% of HHCs reported having ever smoked cigarettes. Males accounted for over half of heavy alcohol users and about 90% of cigarette users. Nearly 50\u0026ndash;70% of cigarette users report smoking an average of six or more cigarettes per day. Of the IPs who had ever smoked cigarettes, 1.3% self-reported a diagnosis of COPD/ asthma.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLocation\u003c/strong\u003e \u003cp\u003eIn Limpopo, 10.2%, 2.6%, 4.5%, and 1.2% of IPs reported depressive symptoms, DM, cardiovascular disease, and COPD/ asthma, respectively. In Soshanguve, these prevalences were 25.2%, 2.2%, 9.0%, and 0.4%, respectively. Among HHCs in Limpopo, the prevalence of depressive symptoms, DM, cardiovascular disease, and asthma/ COPD was 2.3%, 0.8%, 4.7%, and 0.7%. Among Soshanguve HHCs, these were 10.7%, 2.4%, 13%, and 0.6% respectively (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLogistic Regressions\u003c/strong\u003e \u003cp\u003eIn adjusted logistic regression models,\u003c/p\u003e \u003c/p\u003e \u003cp\u003eIPs were twice as likely to report DM (adjusted OR: 2.03, 95% CI: 1.41 to 2.90) and depressive symptoms (adjusted OR: 2.31, 95% CI: 1.95 to 2.74) compared to HHCs (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea shows the plot of clinic random effects for the depressive symptoms outcome in the two study sites for adult participants aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years, detailing the degree to which each clinic\u0026rsquo;s average log odds of depressive symptoms deviates from the overall average. We observed geographical variability, with clinics in the more rural Limpopo district of Vhembe showing notably lower average log odds of depressive symptoms compared to the overall average. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb suggests that several Limpopo sites have a relatively low prevalence of cardiovascular disease, which is in line with national trends (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). There was no notable geographical variability for the other conditions.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAmong the Kharituwe trial participants, 18.4% of IPs and 4.8% of HHCs screened positive for depressive symptoms. Cardiovascular disease, comprising high blood pressure, heart disease, and stroke, was self-reported by 7% of IPs and HHCs, and DM was self-reported by 2.5% and 1.3% for IPs and HHCs, respectively. IPs were twice as likely to report depressive symptoms compared to HHCs, suggesting a disproportionate burden of depression among TB-diagnosed individuals. The World Health Organization (WHO) estimates that 40\u0026ndash;70% of TB-diagnosed individuals experience mental health conditions (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Depression is associated with poor TB treatment adherence, higher relapse rates, and higher mortality (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), and is often underrecognized and undertreated in low-resource settings where mental health infrastructure is limited (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDepressive symptom screening during TB ACF may offer an opportunity to facilitate the diagnosis of depression and other mental health conditions. This intervention may be most impactful if avenues are created where symptom-screen-positive individuals are linked to care for comprehensive evaluation and management. This would require coordination between TB clinics and mental health providers.\u003c/p\u003e \u003cp\u003eIn our study, cardiovascular disease, comprising hypertension, heart disease, and stroke, was self-reported by 7% of IPs and HHCs, which aligns with self-reports in other studies (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Similarly, self-reported DM prevalence (2.5% and 1.3% for IPs and HHCs, respectively) was in line with self-reports in other studies (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In the 2016 SADHS, however, the prevalence of hypertension, using blood pressure measurement, was found to be about two times the prevalence of self-reported hypertension (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), highlighting a likely problem of underdiagnosis. There is potential benefit in integrating NCD testing with TB ACF efforts, which would reduce underdiagnosis - a crucial step toward achieving Sustainable Development Goal (SDG) target 3.4 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the comparatively low prevalence of DM in South Africa (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), screening for DM during TB ACF may be more efficiently rolled out using risk stratification, targeting older adults with risk factors such as obesity and cardiovascular disease. All persons diagnosed with TB during ACF, regardless of other comorbidities, should be screened for DM in keeping with existing recommendations (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrom our study, TB-diagnosed individuals were twice as likely to self-report a diagnosis of DM in comparison to household contacts. This may reflect the increased risk of TB among people with DM (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), coupled with increased healthcare engagement that characterizes a TB diagnosis, facilitating increased NCD diagnosis and disease awareness in comparison to persons without TB. A similar pattern was observed among persons living with HIV (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, TB-multimorbidity was found to be 10%, while a similar percentage of IPs and HHCs were found to have at least one NCD. Multimorbidity poses significant challenges due to increased treatment complexities, cost, and poorer health outcomes (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). During TB care, persons diagnosed with TB should be screened for NCDs due to an increased risk for DM, mental health conditions, and other conditions (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHeavy alcohol use, binge drinking, and cigarette smoking are also risk factors of concern as they increase the risk of developing active TB and other diseases such as hypertension, cardiovascular disease, COPD, cancer, and mental health conditions (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe literature on cost-effectiveness of integrated NCD screening during active case finding for TB or during HIV services shows mixed results (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), with some studies arguing that this integrated approach utilizes task-shifting models, reduces inefficiencies, improves care delivery, and reduces cost (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Others suggest that cost-effectiveness is achieved by focusing on high-risk groups, such as adults aged 40 and above (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLIMITATIONS\u003c/h2\u003e \u003cp\u003eAll NCD diagnoses were based on self-report, which is known to underestimate true prevalence (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Secondly, the validated two-item PHQ-2 depression screener(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), which was used as an indicator for depression prevalence, does not represent a formal diagnosis of depression; rather, this screening tool identifies individuals for whom additional evaluation is warranted. Additionally, cardiovascular disease was examined as a composite condition comprising high blood pressure, heart disease, and stroke, which may have led to the underestimation of the burden of NCD multimorbidity and also precluded an independent analysis of hypertension.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWe observed a modest burden of depressive symptoms among people diagnosed with TB and a relatively low prevalence of NCDs among people diagnosed with TB and their household contacts in two sites in South Africa. TB active case finding or other types of interventions that decentralize disease screening may be a high-yield opportunity to facilitate early diagnosis of NCDs.\u003c/p\u003e"},{"header":"List of abbreviations","content":"\u003cp\u003eACF: Active case finding\u003c/p\u003e\n\u003cp\u003eCI: Confidence interval\u003c/p\u003e\n\u003cp\u003eCOPD: Chronic Obstructive Pulmonary Disease\u003c/p\u003e\n\u003cp\u003eDM: Diabetes Mellitus\u003c/p\u003e\n\u003cp\u003eHHC: Household contact\u003c/p\u003e\n\u003cp\u003eHIV: Human Immunodeficiency Virus\u003c/p\u003e\n\u003cp\u003eIP: Index participant\u003c/p\u003e\n\u003cp\u003eNCD: Non-communicable disease\u003c/p\u003e\n\u003cp\u003eOR: Odds ratio\u003c/p\u003e\n\u003cp\u003ePHQ-2: Patient Health Questionnaire-2\u003c/p\u003e\n\u003cp\u003eSADHS: South Africa Demographic and Health Survey\u003c/p\u003e\n\u003cp\u003eSDG: Sustainable Development Goals\u003c/p\u003e\n\u003cp\u003eTB: Tuberculosis\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e All procedures were carried out in accordance with relevant ethical guidelines and regulations, including the principles of the Declaration of Helsinki. Informed consent was obtained from all participants, and no identifiable personal information was collected or reported. Ethical approval for the clinical trial was obtained from the Human Research Ethics Committees of the University of the Witwatersrand, Johannesburg, South Africa, and the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA (IRB00011124).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThe study was funded by the National Institute of Allergy and Infectious Diseases, USA (Grant Number: R01AI147681). B.A.S.N and E.D.Y were supported by the infrastructure and resources provided by the Johns Hopkins University Center for AIDS Research, an NIH-funded program (1P30AI094189), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIA, NIGMS, NIDDK, NIMHD. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eB.A.S.N conceptualized the study. E.D.Y wrote the original draft of the manuscript, analyzed and interpreted the data. N.M, C.H, D.W.D, and B.A.S.N reviewed and edited the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe acknowledge the participants in this trial.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets analyzed during this study may be made available upon reasonable request and approval from the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDepartment of Health SA, National. TB Recovery Plan 4.0 [Internet]. 2025. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/tobacco/about/index.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/tobacco/about/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCDC, Alcohol U. 2025 [cited 2025 Aug 19]. Alcohol Use and Your Health. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/alcohol/about-alcohol-use/index.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/alcohol/about-alcohol-use/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHamada Y, Mukora R, Pelusa R, Ntshiqa T, Shedrawy J, Velen K, et al. Costs and cost-effectiveness of integrated screening for non-communicable diseases in TB contacts. IJTLD Open. 2025;2(3):160\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFoo CD, Shrestha P, Wang L, Du Q, Garc\u0026iacute;a-Basteiro AL, Abdullah AS, et al. Integrating tuberculosis and noncommunicable diseases care in low- and middle-income countries (LMICs): A systematic review. PLoS Med. 2022;19(1):e1003899.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":" \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Characteristics of Trial Participants (N\u0026thinsp;=\u0026thinsp;10579)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eIndex Participants with Tuberculosis\u0026nbsp;(N\u0026thinsp;=\u0026thinsp;4417)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eHousehold Contacts\u0026nbsp;(N\u0026thinsp;=\u0026thinsp;6162)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSoshanguve (N\u0026thinsp;=\u0026thinsp;2416)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimpopo\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;2001)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSoshanguve\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;1843)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLimpopo\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;4319)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian age (IQR)\u003c/b\u003e, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (32\u0026ndash;53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (31\u0026ndash;52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (21\u0026ndash;55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (6\u0026ndash;38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e, Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1520 (62.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1131 (56.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e648 (35.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1650 (38.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1124 (46.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1170 (58.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e853 (46.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3007 (69.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent/ unemployed/ Retired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1897 (78.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1618 (80.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1561 (84.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3966 (91.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHIV status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1185 (49.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1190 (59.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e237 (12.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e284 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e889 (36.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e665 (33.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1007 (54.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1617 (37.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeavy alcohol use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e395 (16.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e573 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e204 (11.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e483 (11.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBinge drinking (\u0026ge;\u0026thinsp;6 standard drinks on one occasion)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e508 (21.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e548 (27.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e251 (13.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e451 (10.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEver used cigarettes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e598 (24.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e581 (29.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e152 (8.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e212 (4.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAverage number of cigarettes/ days\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e151 (25.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e231(39.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67 (43.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e115 (54.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e363 (60.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e193 (33.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83 (53.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64 (30.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (14.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e155 (26.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eIQR\u0026thinsp;=\u0026thinsp;Inter-quartile range\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNCD\u0026thinsp;=\u0026thinsp;Non-Communicable Disease DM\u0026thinsp;=\u0026thinsp;Diabetes Mellitus COPD\u0026thinsp;=\u0026thinsp;Chronic Obstructive Pulmonary Disease HIV\u0026thinsp;=\u0026thinsp;Human Immunodeficiency Virus CVD\u0026thinsp;=\u0026thinsp;cardiovascular disease, which includes high blood pressure, heart disease, and stroke.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eNon-Communicable Disease and Depressive Symptom Prevalence by Study Site\u003c/span\u003e COPD\u0026thinsp;=\u0026thinsp;Chronic Obstructive Pulmonary Disease\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eIndex Participants with Tuberculosis (N\u0026thinsp;=\u0026thinsp;4417)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eHousehold Contacts (N\u0026thinsp;=\u0026thinsp;6162)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSoshanguve (N\u0026thinsp;=\u0026thinsp;2416)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimpopo (N\u0026thinsp;=\u0026thinsp;2001)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSoshanguve\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;1843)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLimpopo\u003c/p\u003e \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;4319)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53 (2.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular Disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e218 (9.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e91 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e239 (13.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e203 (4.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsthma/ COPD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e31 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepressive Symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e608 (25.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e204 (10.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e197 ( 10.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e101 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ea: Prevalence of NCDs and depressive symptoms among index participants diagnosed with tuberculosis in South Africa (N\u0026thinsp;=\u0026thinsp;4417)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstructive lung disease (Asthma/ COPD)\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCardiovascular Disease\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDepressive Symptoms\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(PHQ 2\u0026thinsp;\u0026ge;\u0026thinsp;3)\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e106 (2.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e309 (7.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e812 (18.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;30\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;930\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3(0.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e119 (12.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e230 (21.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (2.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e226 (21.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;50\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e257 (19.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e231 (17.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2651\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e156 (5.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e484 (18.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1766\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (1.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e153 (8.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e328 (18.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-reported HIV Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2375\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75 (3.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e469 (19.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1554\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e182 (11.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e239 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown/not willing to say\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;488\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52 (10.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e104 (21.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeavy alcohol use (\u0026ge;\u0026thinsp;3 standard drinks per day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, N\u0026thinsp;=\u0026thinsp;968\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e168 (17.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, N\u0026thinsp;=\u0026thinsp;3449\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97 (2.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e272 (7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e644 (18.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBinge drinking (\u0026ge;\u0026thinsp;6 standard drinks on one occasion)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, N\u0026thinsp;=\u0026thinsp;1056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e173 (16.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, N\u0026thinsp;=\u0026thinsp;3361\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e98 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e269 (8.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e639 (19.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEver Smoking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, N\u0026thinsp;=\u0026thinsp;1179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e184 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, N\u0026thinsp;=\u0026thinsp;3237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95 (2.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e260 (8.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e628 (19.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb: Prevalence of NCDs and depressive symptoms among household contacts of people diagnosed with tuberculosis in South Africa (N\u0026thinsp;=\u0026thinsp;6162)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObstructive lung disease (Asthma/ COPD)\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003cp\u003eMellitus\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCardiovascular Disease\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDepressive Symptoms\u003csup\u003e**\u003c/sup\u003e (PHQ 2\u0026thinsp;\u0026ge;\u0026thinsp;3)\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Prevalence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e442 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e298 (4.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2695\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (0.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (1.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026ndash;39\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;1685\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e117 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;59\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;950\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e107 (11.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91 (9.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;60\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;832\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58 (6.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e320 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e63 (7.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e98 (4.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eN= 3864\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e363 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e200 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSelf-reported HIV Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;521\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (0.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative,\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;2618\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (1.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e240 (9.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e192 (7.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown/ not willing to say, N\u0026thinsp;=\u0026thinsp;3023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31(1.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e173 (5.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeavy drinking (\u0026ge;\u0026thinsp;3 drinks per day)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, N\u0026thinsp;=\u0026thinsp;689\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (0.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45 (6.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, N\u0026thinsp;=\u0026thinsp;5486\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (1.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e416 (7.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e253(4.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBinge drinking (\u0026ge;\u0026thinsp;6 standard drinks on one occasion)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, N\u0026thinsp;=\u0026thinsp;702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (0.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28 (4.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e52 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, N\u0026thinsp;=\u0026thinsp;5460\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73 (1.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e414 (7.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e246 (4.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEver Smoking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes, N\u0026thinsp;=\u0026thinsp;366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (5.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33 (9.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo, N\u0026thinsp;=\u0026thinsp;5809\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (0.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (1.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e423 (7.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e265 (4.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e*\u003c/sup\u003eCardiovascular disease includes high blood pressure, heart disease, and stroke.\u003c/p\u003e \u003cp\u003e \u003csup\u003e**\u003c/sup\u003e Depressive symptoms were measured on a PHQ-2 depression screener, where scores 0 to 2 represent negative screening, and scores 3 to 6 represent positive screening\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMixed-Effects Logistic Regression of NCD and Depressive Symptoms by Participant Type\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCardiovascular Disease\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCOPD/ Asthma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDepressive Symptoms\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndex Participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.03 (1.41\u0026ndash;2.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.88 (0.72\u0026ndash;1.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.71 (0.93\u0026ndash;3.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.31 (1.95\u0026ndash;2.74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousehold Contacts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (Reference)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (Reference)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eOR\u0026thinsp;=\u0026thinsp;Odd\u0026rsquo;s Ratios 95% CI\u0026thinsp;=\u0026thinsp;95% confidence interval\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eModels were adjusted for study arm, age, sex, education level, employment status, HIV status, current cigarette use, heavy alcohol use, and study site\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"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":"Tuberculosis, non-communicable disease, multimorbidity, HIV","lastPublishedDoi":"10.21203/rs.3.rs-8329023/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8329023/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e \u003cp\u003eSouth Africa has a high burden of non-communicable diseases (NCDs). Routine screening remains low, care-seeking is often delayed, and many individuals remain undiagnosed. Contact investigation for tuberculosis (TB) represents an opportunity to screen for NCDs as well, but the prevalence of NCDs among index participants (IPs) diagnosed with tuberculosis and their household contacts (HHCs) is not well known.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003eWe conducted a secondary data analysis within the Kharituwe TB case-finding trial. We calculated the prevalence of self-reported diabetes mellitus (DM), cardiovascular disease, Chronic Obstructive Pulmonary Disease (COPD)/Asthma, and depressive symptoms. Among adults, we used mixed-effects logistic regression models to evaluate associations with participant characteristics.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eKharituwe TB enrolled 10,579 participants: 4,417 IPs and 6,162 HHCs. Overall, 10.2% (n\u0026thinsp;=\u0026thinsp;450) IPs reported an NCD. Self-reported prevalence among IPs and HHCs, respectively, was 7.0% and 7.2% for cardiovascular disease, 2.5% and 1.3% for DM, 0.8% and 0.7% for asthma/COPD, and 18.4% and 4.8% for depressive symptoms. Odds of self-reported DM [adjusted OR: 2.03 (95% CI: 1.41, 2.90)] and depressive symptoms [adjusted OR: 2.31(95% CI: 1.95\u0026ndash;2.74)] were twice as high in IPs as in HHCs. There was notable geographical variation in the prevalence of self-reported depressive symptoms and cardiovascular disease.\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e \u003cp\u003eThere was a modest prevalence of depressive symptoms among people diagnosed with TB. The relatively low prevalence of self-reported NCDs may indicate underdiagnosis. Integrating NCD screening into community-based interventions like active case finding for TB may offer a high-yield opportunity to facilitate early NCD diagnosis.\u003c/p\u003e\u003ch2\u003eTRIAL REGISTRATION\u003c/h2\u003e \u003cp\u003eThe Kharituwe TB contact tracing study was registered on ClinicalTrials.gov (Identifier NCT04520113) on August 20th, 2020.\u003c/p\u003e","manuscriptTitle":"Non-Communicable Disease and Depressive Symptoms Among Participants of the Kharituwe Case Finding Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 12:21:51","doi":"10.21203/rs.3.rs-8329023/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-01-21T18:27:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274710936426245716745090838978006512384","date":"2026-01-14T09:41:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-13T14:49:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317475754560176817519973548976508491923","date":"2026-01-13T07:07:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-08T06:03:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-05T11:57:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-18T16:22:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-18T16:05:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-12-18T14:55:43+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":"68834bbf-0332-4204-b3cc-9798ccaee2d6","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T12:21:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-12 12:21:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8329023","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8329023","identity":"rs-8329023","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}