Gender disparities in multidrug-resistant tuberculosis notifications in Uganda: evidence from national surveillance data, 2014-2023

Gender disparities in multidrug-resistant tuberculosis notifications in Uganda: evidence from national surveillance data, 2014-2023 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Gender disparities in multidrug-resistant tuberculosis notifications in Uganda: evidence from national surveillance data, 2014-2023 Sarah Rachael Akello, Jimmy Patrick Alunyo, Joseph KB Matovu, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8916597/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Globally, tuberculosis and drug-resistant tuberculosis are more frequently reported among men than women. However, sex-specific patterns in multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) notifications may vary across settings and may be influenced by surveillance and health system factors. Evidence describing gender differences in MDR/RR-TB in Uganda remains limited. This study examined gender-specific patterns and temporal trends in MDR/RR-TB notifications in Uganda over a ten-year period. Methods We conducted a national ecological analysis of routinely collected MDR/RR-TB surveillance data extracted from Uganda’s District Health Information System 2 (DHIS2) for the period 2014–2023. Sex-disaggregated notification data were summarised descriptively at national and regional levels. Annual proportions were calculated, and temporal trends were assessed using longitudinal descriptive analysis to evaluate stability and variation in gender distribution over time. Results Between 2014 and 2023, a total of 324,025 MDR/RR-TB cases were notified nationally. Females accounted for 178,861 cases (55.2%), while males accounted for 145,164 cases (44.8%). Female predominance was observed consistently throughout the ten-year period, with no sustained year in which male notifications exceeded female notifications. Notifications increased over time among both sexes, but the relative distribution remained stable. Female predominance was also observed across all regions, although the magnitude of the difference varied geographically. Conclusions MDR/RR-TB notification patterns in Uganda differ from commonly reported global trends of male predominance. The consistent female predominance observed over a decade likely reflects contextual and programmatic factors influencing case detection rather than biological susceptibility alone. Strengthening gender-disaggregated surveillance and investigating potential barriers to diagnosis and care remain essential for equitable tuberculosis control. MDR-TB gender differences surveillance data tuberculosis Uganda Figures Figure 1 Figure 2 Background Tuberculosis (TB) remains a major cause of preventable morbidity and mortality worldwide, with an estimated 10.8 million new cases and 1.25 million deaths reported in 2023 [ 1 ], [ 2 ]. Although TB affects both men and women, the distribution of disease is shaped not only by biological susceptibility but also by gendered social roles, health-seeking behaviour, access to care, and structural inequities within health systems [ 3 ]. Understanding these gender dimensions is increasingly recognised as essential for achieving equitable and effective TB control. Multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) poses particular challenges in this regard. MDR/RR-TB is associated with prolonged treatment, higher toxicity, substantial financial burden, and lower treatment success compared with drug-susceptible TB [ 4 ]. Globally, MDR/RR-TB has been consistently reported to affect men more frequently than women, a pattern often attributed to higher occupational exposure, smoking and alcohol use, delayed care seeking, and poorer treatment adherence among men [ 5 ], [ 6 ]. As a result, male predominance in MDR/RR-TB has become an implicit assumption in both epidemiological reporting and programme design. However, growing evidence suggests that gender patterns in MDR/RR-TB are not universal and may vary substantially across settings, particularly in low- and middle-income countries where health system access and social norms differ [ 3 ], [ 7 ]. In some contexts, women may be more likely to interact with health services through antenatal, maternal, and child health platforms, increasing opportunities for TB screening and diagnosis. Conversely, men may delay care, disengage from services, or remain undiagnosed, leading to systematic under-ascertainment rather than true absence of disease. These dynamics raise critical questions about whether observed gender differences in MDR/RR-TB reflect underlying epidemiology or artefacts of surveillance and healthcare utilisation. In Uganda, a country classified among the 30 high-burden TB and TB/HIV countries globally, limited attention has been paid to gender-specific patterns of MDR/RR-TB. National surveillance reports routinely present aggregated MDR/RR-TB notifications without detailed gender-focused analysis, and few studies have examined whether observed sex distributions align with biological risk, social exposure, or health system factors [ 8 ], [ 9 ]. This gap is particularly important given Uganda’s reliance on rifampicin resistance detected through Xpert MTB/RIF as a proxy for MDR-TB, a diagnostic pathway that is influenced by testing coverage, care-seeking behaviour, and facility access rather than population-wide screening [ 2 ], [ 10 ]. Emerging programmatic data from Uganda suggest an unexpected pattern, with some years showing higher MDR/RR-TB notifications among women than men. Such a finding challenges prevailing assumptions about gender and drug-resistant TB and underscores the need for careful interpretation. Without systematic analysis, it remains unclear whether higher female notification reflects true differences in disease burden, differential exposure risks, or gendered pathways through the health system that influence detection and reporting. Failure to interrogate these patterns risks misdirecting resources, reinforcing inequities, and overlooking populations at greatest risk of undiagnosed disease. A gender-responsive approach to TB control requires robust, sex-disaggregated evidence that moves beyond descriptive counts to contextualised interpretation. Analysing national surveillance data through a gender lens offers an opportunity to interrogate how social, behavioural, and programmatic factors shape MDR/RR-TB notification patterns and to inform more equitable case-finding and treatment strategies. This study, therefore, aimed to examine gender differences in MDR/RR-TB notifications in Uganda between 2014 and 2023 using national surveillance data, to characterise sex-specific patterns over time and inform gender-responsive MDR/RR-TB control strategies. Methods Study design and data source We conducted a national ecological analysis of gender differences in multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) notifications in Uganda using routinely collected surveillance data. Secondary data were obtained from Uganda’s District Health Information System 2 (DHIS2), the national health information platform managed by the Ministry of Health through the National Tuberculosis and Leprosy Programme (NTLP). In line with national practice and WHO guidance, rifampicin-resistant TB detected using Xpert MTB/RIF was used as a programmatic proxy for MDR-TB, with confirmatory drug susceptibility testing performed where available. All data were aggregated, anonymised, and analysed at the population level. Study period and population The analysis covered a ten-year period from January 2014 to December 2023, capturing changes in MDR/RR-TB notification patterns before and after major diagnostic and surveillance scale-up initiatives in Uganda. The study population comprised all MDR/RR-TB cases notified nationally during the study period, disaggregated by sex as reported in DHIS2. Study variables The primary outcome was the number of MDR/RR-TB notifications, stratified by sex (female, male). Time-related dimensions included calendar year and month of notification to allow assessment of temporal consistency in gender patterns. Geographic stratification by region was used descriptively to assess heterogeneity in gender distributions across subnational contexts. No individual-level clinical or socio-demographic variables were included, as the analysis relied on aggregated surveillance data. Data management and quality assurance DHIS2 datasets were extracted in Microsoft Excel format and imported into R statistical software (version 4.3) for cleaning and analysis. Data preparation included consistency checks for sex-disaggregated reporting across years, verification of temporal completeness, and aggregation of monthly notifications into annual totals for trend assessment. Given the reliance on routine surveillance data, observed gender differences were interpreted cautiously, recognising that notification patterns may reflect health-seeking behaviour, diagnostic access, and reporting practices, in addition to underlying disease burden. Statistical analysis Descriptive gender analysis Descriptive statistics were used to summarise the distribution of MDR/RR-TB notifications by sex over the study period. Annual proportions of female and male notifications were calculated, and time-series plots were generated to visualise changes in gender distribution across years. Temporal assessment of gender patterns To assess the stability and consistency of gender differences over time, sex-specific notification trends were examined longitudinally. Visual inspection of trends was used to identify periods of convergence or divergence between female and male notifications, rather than formal hypothesis testing, in keeping with the descriptive and exploratory aims of the study. Subnational comparison Gender distributions were examined descriptively across regions to assess whether observed national patterns were consistent or varied by geographic context. Regional analyses were intended to provide contextual insight rather than causal inference. Interpretation considerations Because MDR/RR-TB notifications are influenced by diagnostic availability and care-seeking behaviour, observed gender differences were interpreted as notification patterns rather than direct measures of incidence. The ecological design precluded attribution of observed differences to biological susceptibility, behavioural risk, or access to care at the individual level. Findings were therefore framed to inform gender-responsive surveillance and programme planning, rather than to infer causal mechanisms. Results Overall gender distribution of MDR/RR-TB notifications Between 2014 and 2023, females accounted for a slightly higher proportion of multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) notifications than males at the national level (Table 1 ). Across the ten-year period, female notifications consistently exceeded male notifications, indicating a stable gender pattern rather than sporadic or year-specific variation. Table 1 Overall gender distribution of MDR/RR-TB notifications in Uganda, 2014–2023 Sex Number of MDR/RR-TB notifications Percentage (%) Female 178,861 55.2 Male 145,164 44.8 Total 324,025 100.0 Footnote : Percentages are calculated as the proportion of total MDR/RR-TB notifications reported nationally between 2014 and 2023. Temporal patterns in gender-specific MDR/RR-TB notifications Analysis of annual trends showed that MDR/RR-TB notifications increased over time among both females and males (Fig. 1 ). Despite this overall increase, the relative predominance of female notifications was maintained throughout the study period, with no sustained period in which male notifications exceeded female notifications at the national level (Fig. 1 ). The parallel rise in notifications among both sexes suggests shared temporal drivers, such as changes in diagnostic coverage and surveillance practices, rather than abrupt gender-specific shifts. Regional variation in gender distribution Gender-disaggregated analysis by region demonstrated that the female predominance in MDR/RR-TB notifications was observed across all regions, although the magnitude of the difference varied (Fig. 2 ). In some regions, female and male notifications were nearly comparable, while in others the difference was more pronounced. No region consistently demonstrated male predominance across the study period. Discussion This study aimed to examine gender differences in MDR/RR-TB notifications in Uganda using national surveillance data over a ten-year period. We found that females consistently accounted for a higher proportion of MDR/RR-TB notifications than males nationally, that this pattern was stable over time, and that it was observed across all regions, albeit with some variation in magnitude. These findings contrast with the commonly reported male predominance in tuberculosis and drug-resistant tuberculosis globally and highlight the importance of contextual interpretation of gender-disaggregated surveillance data. Globally, tuberculosis has been reported more frequently among males, a pattern attributed to higher occupational exposure, smoking and alcohol use, delayed care seeking, and poorer treatment adherence among men [ 3 ], [ 6 ]. Studies from Asia and parts of sub-Saharan Africa have similarly reported male predominance in MDR/RR-TB notifications, reinforcing the perception that drug-resistant TB disproportionately affects men [ 5 ]. In contrast, the female predominance observed in this study aligns with emerging evidence from selected African settings suggesting that gender patterns in MDR/RR-TB are not universal and may vary by health system context [ 7 ]. One plausible explanation for the observed pattern is differential health-seeking behaviour and engagement with health services. Women in many low- and middle-income countries have more frequent contact with health facilities through reproductive, maternal, and child health services, which may increase opportunities for TB screening, testing, and diagnosis. Conversely, men may delay seeking care, present later in the course of illness, or disengage from diagnostic pathways, leading to under-ascertainment of MDR/RR-TB among males. Similar interpretations have been proposed in studies where female or near-equal gender distributions were observed despite expectations of male predominance [ 3 ], [ 7 ]. The persistence of female predominance over a decade, as shown by the temporal trends, suggests that this pattern is not solely attributable to short-term programmatic changes. Rather, it may reflect structural features of the health system and surveillance processes that consistently favour detection among women. Facility-based surveillance captures individuals who successfully navigate the diagnostic pathway, and gender barriers related to employment, stigma, and opportunity costs may disproportionately limit men’s access to diagnosis and treatment. As a result, notification data may underestimate MDR/RR-TB burden among men rather than indicate true lower risk. Regional consistency in gender patterns further supports the interpretation that the observed female predominance is systemic rather than localised. However, variation in the magnitude of gender differences across regions suggests that local socio-cultural norms, service availability, and diagnostic practices may modify how gender influences MDR/RR-TB detection. Importantly, these findings do not imply biological susceptibility among women but instead highlight how gender intersects with health system access and surveillance sensitivity. In summary, these findings highlight the need to interpret gender-disaggregated MDR/RR-TB surveillance data cautiously and to avoid assuming that notification patterns directly reflect underlying epidemiology. Failure to recognise potential under-detection among men may result in missed opportunities for timely diagnosis and treatment, sustaining hidden reservoirs of drug-resistant TB transmission in the community. Strengths and limitations A key strength of this study is the use of national surveillance data spanning ten years, enabling assessment of gender patterns with sufficient temporal depth and geographic coverage. The consistent availability of sex-disaggregated data allowed evaluation of both national and regional trends, enhancing the relevance of findings for programme planning. However, the study has limitations. Surveillance data reflect diagnosed and reported cases rather than true population incidence, and the ecological design precludes inference at the individual level. The analysis could not account for gender-specific differences in care-seeking behaviour, diagnostic delays, or treatment history, which may influence notification patterns. As such, findings should be interpreted as reflecting gender differences in MDR/RR-TB detection and reporting rather than definitive differences in disease risk. Conclusion MDR/RR-TB notifications in Uganda between 2014 and 2023 demonstrated a consistent female predominance that was stable over time and observed across regions. This pattern contrasts with global expectations of male predominance in drug-resistant TB and suggests that gender differences in MDR/RR-TB notifications are shaped by contextual and programmatic factors. Gender-disaggregated analysis of surveillance data provides valuable insight into potential inequities in detection and access to care. Recommendations National TB control efforts should incorporate a gender-responsive approach to MDR/RR-TB surveillance and service delivery. Strategies to improve early diagnosis and treatment among men, including outreach tailored to male-dominated workplaces and flexible service delivery models, may help address potential under-detection. Routine analysis of sex-disaggregated data should be maintained to monitor gender disparities over time. Further research integrating surveillance data with qualitative and individual-level studies would help clarify the mechanisms underlying gender differences observed and inform more equitable MDR/RR-TB control strategies. Declarations Ethics approval and consent to participate Ethical approval was obtained from the Busitema University Higher Degrees Committee and the Mbale Regional Referral Hospital Research Ethics Committee (MRRH-2025-605). Administrative clearance was granted by the Ministry of Health, Uganda. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Funding This work was supported by the European & Developing Countries Clinical Trials Partnership (EDCTP2) programme supported by the European Union. P-OO, JPA, SRA, JO, GNS, MNB, PB, MM, BCO, WO, SN, GP, and DA are supported through the EDCTP2 programme under the IDEA Fellowship (grant number CSA2020E-3126), funded by the National Institute for Health Research (NIHR) to support global health research. The views expressed in this publication are those of the authors and do not necessarily reflect those of EDCTP, NIHR, or the UK Department of Health and Social Care. Author Contribution SRA conceived and led the study, coordinated data acquisition, performed the initial data analysis, and drafted the manuscript. JPA and AO contributed to study design, supported data analysis, and co-led interpretation of findings and manuscript development. JK-BM provided technical oversight and contributed to manuscript revision. JO, GNS, MNB, PB, MM, BCO, WO, SN, EM, and DA contributed to data acquisition and drafting of manuscript sections. DM and P-OO supervised the study, provided scientific oversight, and critically revised the manuscript. JPA, AO, and GP contributed to statistical analysis and data validation. All authors read and approved the final manuscript. Acknowledgements The authors thank the Ministry of Health, Division of Health Information, Uganda, for providing access to the DHIS2 surveillance dataset used in this study. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. References WHO, Tuberculosis (TB). 2023, [Online]. Available at: https://www.afro.who.int/health-topics/tuberculosis-tb#:~:text=In 2022%2C 2.5 million people,occur in the African Region. WHO. 1.3 Drug-resistant TB, 2024. [Online]. Available at: https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2024/tb-disease-burden/1-3-drug-resistant-tb#:~:text=Globally%2C the estimated annual number,360 000–440 000). Horton KC, MacPherson P, Houben RMGJ, White RG, en, Corbett EL. Sex Differences in Tuberculosis Burden and Notifications in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis, PLoS Med. , vol 13, no 9, bll 1–23, 2016, 10.1371/journal.pmed.1002119 Kendall EA et al. The Spectrum of Tuberculosis Disease in an Urban Ugandan Community and Its Health Facilities, Clin. Infect. Dis. , vol 72, no 12, bll E1035–E1043, 2021, 10.1093/cid/ciaa1824 Oladimeji O et al. Gender and Drug-Resistant Tuberculosis in Nigeria, Trop. Med. Infect. Dis. , vol 8, no 2, bll 1–11, 2023, 10.3390/tropicalmed8020104 Teo AKJ, Singh SR, Prem K, Hsu LY, en, Yi S. Duration and determinants of delayed tuberculosis diagnosis and treatment in high-burden countries: a mixed-methods systematic review and meta-analysis. Respir Res. 2021;22(1). 10.1186/s12931-021-01841-6 . Muttamba W et al. Using intersectional gender analysis to identify challenges in tuberculosis care at four health care facilities in Uganda, Infect. Dis. Poverty , vol 13, no 1, bll 1–10, 2024, 10.1186/s40249-023-01171-3 NTLP U. NTLP BULLETIN-National Quarterly Bulletin., 2023. Omona K en, Opiyo AM. Assessment of risk factors associated with multi-drug resistant tuberculosis (MDR-TB) in Gulu regional referral hospital, Afr. Health Sci. , vol 23, no 3, bll 343–357, 2023, 10.4314/ahs.v23i3.41 Stevens WS, Scott L, Noble L, Gous N, en, Dheda K. Impact of the GeneXpert MTB/RIF technology on tuberculosis control, Tuberc. Tuber. Bacillus Second Ed. , no 1, bll 389–410, 2017, 10.1128/9781555819569.ch18 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8916597","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":601783057,"identity":"87344063-0755-4a54-acb0-a125edd5ad6e","order_by":0,"name":"Sarah Rachael 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(2014-2023)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8916597/v1/baf9fc3fa0774fb2146e0c53.png"},{"id":104311485,"identity":"b4c210c5-ed89-48b9-8838-c2646adfdb56","added_by":"auto","created_at":"2026-03-10 10:59:31","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":36533,"visible":true,"origin":"","legend":"\u003cp\u003eGender distribution and temporal trends of MDR/RR-TB cases in Uganda\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8916597/v1/0691c80fbf0bda7538e4a9ae.png"},{"id":105378656,"identity":"095fd975-4edf-4e00-9d02-fb492b373af6","added_by":"auto","created_at":"2026-03-25 10:42:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":763326,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8916597/v1/778b00e4-1e33-4083-bd96-ceeaf7a91a2b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Gender disparities in multidrug-resistant tuberculosis notifications in Uganda: evidence from national surveillance data, 2014-2023","fulltext":[{"header":"Background","content":"\u003cp\u003eTuberculosis (TB) remains a major cause of preventable morbidity and mortality worldwide, with an estimated 10.8\u0026nbsp;million new cases and 1.25\u0026nbsp;million deaths reported in 2023 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Although TB affects both men and women, the distribution of disease is shaped not only by biological susceptibility but also by gendered social roles, health-seeking behaviour, access to care, and structural inequities within health systems [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Understanding these gender dimensions is increasingly recognised as essential for achieving equitable and effective TB control.\u003c/p\u003e \u003cp\u003eMultidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) poses particular challenges in this regard. MDR/RR-TB is associated with prolonged treatment, higher toxicity, substantial financial burden, and lower treatment success compared with drug-susceptible TB [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Globally, MDR/RR-TB has been consistently reported to affect men more frequently than women, a pattern often attributed to higher occupational exposure, smoking and alcohol use, delayed care seeking, and poorer treatment adherence among men [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. As a result, male predominance in MDR/RR-TB has become an implicit assumption in both epidemiological reporting and programme design.\u003c/p\u003e \u003cp\u003eHowever, growing evidence suggests that gender patterns in MDR/RR-TB are not universal and may vary substantially across settings, particularly in low- and middle-income countries where health system access and social norms differ [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In some contexts, women may be more likely to interact with health services through antenatal, maternal, and child health platforms, increasing opportunities for TB screening and diagnosis. Conversely, men may delay care, disengage from services, or remain undiagnosed, leading to systematic under-ascertainment rather than true absence of disease. These dynamics raise critical questions about whether observed gender differences in MDR/RR-TB reflect underlying epidemiology or artefacts of surveillance and healthcare utilisation.\u003c/p\u003e \u003cp\u003eIn Uganda, a country classified among the 30 high-burden TB and TB/HIV countries globally, limited attention has been paid to gender-specific patterns of MDR/RR-TB. National surveillance reports routinely present aggregated MDR/RR-TB notifications without detailed gender-focused analysis, and few studies have examined whether observed sex distributions align with biological risk, social exposure, or health system factors [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This gap is particularly important given Uganda\u0026rsquo;s reliance on rifampicin resistance detected through Xpert MTB/RIF as a proxy for MDR-TB, a diagnostic pathway that is influenced by testing coverage, care-seeking behaviour, and facility access rather than population-wide screening [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Emerging programmatic data from Uganda suggest an unexpected pattern, with some years showing higher MDR/RR-TB notifications among women than men. Such a finding challenges prevailing assumptions about gender and drug-resistant TB and underscores the need for careful interpretation. Without systematic analysis, it remains unclear whether higher female notification reflects true differences in disease burden, differential exposure risks, or gendered pathways through the health system that influence detection and reporting. Failure to interrogate these patterns risks misdirecting resources, reinforcing inequities, and overlooking populations at greatest risk of undiagnosed disease.\u003c/p\u003e \u003cp\u003eA gender-responsive approach to TB control requires robust, sex-disaggregated evidence that moves beyond descriptive counts to contextualised interpretation. Analysing national surveillance data through a gender lens offers an opportunity to interrogate how social, behavioural, and programmatic factors shape MDR/RR-TB notification patterns and to inform more equitable case-finding and treatment strategies.\u003c/p\u003e \u003cp\u003eThis study, therefore, aimed to examine gender differences in MDR/RR-TB notifications in Uganda between 2014 and 2023 using national surveillance data, to characterise sex-specific patterns over time and inform gender-responsive MDR/RR-TB control strategies.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and data source\u003c/h2\u003e \u003cp\u003eWe conducted a national ecological analysis of gender differences in multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) notifications in Uganda using routinely collected surveillance data. Secondary data were obtained from Uganda\u0026rsquo;s District Health Information System 2 (DHIS2), the national health information platform managed by the Ministry of Health through the National Tuberculosis and Leprosy Programme (NTLP).\u003c/p\u003e \u003cp\u003eIn line with national practice and WHO guidance, rifampicin-resistant TB detected using Xpert MTB/RIF was used as a programmatic proxy for MDR-TB, with confirmatory drug susceptibility testing performed where available. All data were aggregated, anonymised, and analysed at the population level.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy period and population\u003c/h3\u003e\n\u003cp\u003eThe analysis covered a ten-year period from January 2014 to December 2023, capturing changes in MDR/RR-TB notification patterns before and after major diagnostic and surveillance scale-up initiatives in Uganda. The study population comprised all MDR/RR-TB cases notified nationally during the study period, disaggregated by sex as reported in DHIS2.\u003c/p\u003e\n\u003ch3\u003eStudy variables\u003c/h3\u003e\n\u003cp\u003eThe primary outcome was the number of MDR/RR-TB notifications, stratified by sex (female, male). Time-related dimensions included calendar year and month of notification to allow assessment of temporal consistency in gender patterns. Geographic stratification by region was used descriptively to assess heterogeneity in gender distributions across subnational contexts.\u003c/p\u003e \u003cp\u003eNo individual-level clinical or socio-demographic variables were included, as the analysis relied on aggregated surveillance data.\u003c/p\u003e\n\u003ch3\u003eData management and quality assurance\u003c/h3\u003e\n\u003cp\u003eDHIS2 datasets were extracted in Microsoft Excel format and imported into R statistical software (version 4.3) for cleaning and analysis. Data preparation included consistency checks for sex-disaggregated reporting across years, verification of temporal completeness, and aggregation of monthly notifications into annual totals for trend assessment.\u003c/p\u003e \u003cp\u003eGiven the reliance on routine surveillance data, observed gender differences were interpreted cautiously, recognising that notification patterns may reflect health-seeking behaviour, diagnostic access, and reporting practices, in addition to underlying disease burden.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eDescriptive gender analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarise the distribution of MDR/RR-TB notifications by sex over the study period. Annual proportions of female and male notifications were calculated, and time-series plots were generated to visualise changes in gender distribution across years.\u003c/p\u003e \u003cp\u003eTemporal assessment of gender patterns\u003c/p\u003e \u003cp\u003eTo assess the stability and consistency of gender differences over time, sex-specific notification trends were examined longitudinally. Visual inspection of trends was used to identify periods of convergence or divergence between female and male notifications, rather than formal hypothesis testing, in keeping with the descriptive and exploratory aims of the study.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eSubnational comparison\u003c/h3\u003e\n\u003cp\u003eGender distributions were examined descriptively across regions to assess whether observed national patterns were consistent or varied by geographic context. Regional analyses were intended to provide contextual insight rather than causal inference.\u003c/p\u003e\n\u003ch3\u003eInterpretation considerations\u003c/h3\u003e\n\u003cp\u003eBecause MDR/RR-TB notifications are influenced by diagnostic availability and care-seeking behaviour, observed gender differences were interpreted as notification patterns rather than direct measures of incidence. The ecological design precluded attribution of observed differences to biological susceptibility, behavioural risk, or access to care at the individual level. Findings were therefore framed to inform gender-responsive surveillance and programme planning, rather than to infer causal mechanisms.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOverall gender distribution of MDR/RR-TB notifications\u003c/h2\u003e \u003cp\u003eBetween 2014 and 2023, females accounted for a slightly higher proportion of multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) notifications than males at the national level (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Across the ten-year period, female notifications consistently exceeded male notifications, indicating a stable gender pattern rather than sporadic or year-specific variation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverall gender distribution of MDR/RR-TB notifications in Uganda, 2014\u0026ndash;2023\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of MDR/RR-TB notifications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e178,861\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e145,164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e324,025\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e100.0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003eFootnote\u003c/b\u003e: \u003cem\u003ePercentages are calculated as the proportion of total MDR/RR-TB notifications reported nationally between 2014 and 2023.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTemporal patterns in gender-specific MDR/RR-TB notifications\u003c/h2\u003e \u003cp\u003eAnalysis of annual trends showed that MDR/RR-TB notifications increased over time among both females and males (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Despite this overall increase, the relative predominance of female notifications was maintained throughout the study period, with no sustained period in which male notifications exceeded female notifications at the national level (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The parallel rise in notifications among both sexes suggests shared temporal drivers, such as changes in diagnostic coverage and surveillance practices, rather than abrupt gender-specific shifts.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eRegional variation in gender distribution\u003c/h2\u003e \u003cp\u003eGender-disaggregated analysis by region demonstrated that the female predominance in MDR/RR-TB notifications was observed across all regions, although the magnitude of the difference varied (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In some regions, female and male notifications were nearly comparable, while in others the difference was more pronounced. No region consistently demonstrated male predominance across the study period.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to examine gender differences in MDR/RR-TB notifications in Uganda using national surveillance data over a ten-year period. We found that females consistently accounted for a higher proportion of MDR/RR-TB notifications than males nationally, that this pattern was stable over time, and that it was observed across all regions, albeit with some variation in magnitude. These findings contrast with the commonly reported male predominance in tuberculosis and drug-resistant tuberculosis globally and highlight the importance of contextual interpretation of gender-disaggregated surveillance data.\u003c/p\u003e \u003cp\u003eGlobally, tuberculosis has been reported more frequently among males, a pattern attributed to higher occupational exposure, smoking and alcohol use, delayed care seeking, and poorer treatment adherence among men [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Studies from Asia and parts of sub-Saharan Africa have similarly reported male predominance in MDR/RR-TB notifications, reinforcing the perception that drug-resistant TB disproportionately affects men [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In contrast, the female predominance observed in this study aligns with emerging evidence from selected African settings suggesting that gender patterns in MDR/RR-TB are not universal and may vary by health system context [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne plausible explanation for the observed pattern is differential health-seeking behaviour and engagement with health services. Women in many low- and middle-income countries have more frequent contact with health facilities through reproductive, maternal, and child health services, which may increase opportunities for TB screening, testing, and diagnosis. Conversely, men may delay seeking care, present later in the course of illness, or disengage from diagnostic pathways, leading to under-ascertainment of MDR/RR-TB among males. Similar interpretations have been proposed in studies where female or near-equal gender distributions were observed despite expectations of male predominance [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe persistence of female predominance over a decade, as shown by the temporal trends, suggests that this pattern is not solely attributable to short-term programmatic changes. Rather, it may reflect structural features of the health system and surveillance processes that consistently favour detection among women. Facility-based surveillance captures individuals who successfully navigate the diagnostic pathway, and gender barriers related to employment, stigma, and opportunity costs may disproportionately limit men\u0026rsquo;s access to diagnosis and treatment. As a result, notification data may underestimate MDR/RR-TB burden among men rather than indicate true lower risk.\u003c/p\u003e \u003cp\u003eRegional consistency in gender patterns further supports the interpretation that the observed female predominance is systemic rather than localised. However, variation in the magnitude of gender differences across regions suggests that local socio-cultural norms, service availability, and diagnostic practices may modify how gender influences MDR/RR-TB detection. Importantly, these findings do not imply biological susceptibility among women but instead highlight how gender intersects with health system access and surveillance sensitivity.\u003c/p\u003e \u003cp\u003eIn summary, these findings highlight the need to interpret gender-disaggregated MDR/RR-TB surveillance data cautiously and to avoid assuming that notification patterns directly reflect underlying epidemiology. Failure to recognise potential under-detection among men may result in missed opportunities for timely diagnosis and treatment, sustaining hidden reservoirs of drug-resistant TB transmission in the community.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eA key strength of this study is the use of national surveillance data spanning ten years, enabling assessment of gender patterns with sufficient temporal depth and geographic coverage. The consistent availability of sex-disaggregated data allowed evaluation of both national and regional trends, enhancing the relevance of findings for programme planning.\u003c/p\u003e \u003cp\u003eHowever, the study has limitations. Surveillance data reflect diagnosed and reported cases rather than true population incidence, and the ecological design precludes inference at the individual level. The analysis could not account for gender-specific differences in care-seeking behaviour, diagnostic delays, or treatment history, which may influence notification patterns. As such, findings should be interpreted as reflecting gender differences in MDR/RR-TB detection and reporting rather than definitive differences in disease risk.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eMDR/RR-TB notifications in Uganda between 2014 and 2023 demonstrated a consistent female predominance that was stable over time and observed across regions. This pattern contrasts with global expectations of male predominance in drug-resistant TB and suggests that gender differences in MDR/RR-TB notifications are shaped by contextual and programmatic factors. Gender-disaggregated analysis of surveillance data provides valuable insight into potential inequities in detection and access to care.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003eNational TB control efforts should incorporate a gender-responsive approach to MDR/RR-TB surveillance and service delivery. Strategies to improve early diagnosis and treatment among men, including outreach tailored to male-dominated workplaces and flexible service delivery models, may help address potential under-detection. Routine analysis of sex-disaggregated data should be maintained to monitor gender disparities over time. Further research integrating surveillance data with qualitative and individual-level studies would help clarify the mechanisms underlying gender differences observed and inform more equitable MDR/RR-TB control strategies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003eEthical approval was obtained from the Busitema University Higher Degrees Committee and the Mbale Regional Referral Hospital Research Ethics Committee (MRRH-2025-605). Administrative clearance was granted by the Ministry of Health, Uganda.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for publication\u003c/h2\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\u003eThis work was supported by the European \u0026amp; Developing Countries Clinical Trials Partnership (EDCTP2) programme supported by the European Union. P-OO, JPA, SRA, JO, GNS, MNB, PB, MM, BCO, WO, SN, GP, and DA are supported through the EDCTP2 programme under the IDEA Fellowship (grant number CSA2020E-3126), funded by the National Institute for Health Research (NIHR) to support global health research. The views expressed in this publication are those of the authors and do not necessarily reflect those of EDCTP, NIHR, or the UK Department of Health and Social Care.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSRA conceived and led the study, coordinated data acquisition, performed the initial data analysis, and drafted the manuscript. JPA and AO contributed to study design, supported data analysis, and co-led interpretation of findings and manuscript development. JK-BM provided technical oversight and contributed to manuscript revision. JO, GNS, MNB, PB, MM, BCO, WO, SN, EM, and DA contributed to data acquisition and drafting of manuscript sections. DM and P-OO supervised the study, provided scientific oversight, and critically revised the manuscript. JPA, AO, and GP contributed to statistical analysis and data validation. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe authors thank the Ministry of Health, Division of Health Information, Uganda, for providing access to the DHIS2 surveillance dataset used in this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO, Tuberculosis (TB). 2023, [Online]. 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Health Sci.\u003c/em\u003e, vol 23, no 3, bll 343\u0026ndash;357, 2023, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4314/ahs.v23i3.41\u003c/span\u003e\u003cspan address=\"10.4314/ahs.v23i3.41\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStevens WS, Scott L, Noble L, Gous N, en, Dheda K. Impact of the GeneXpert MTB/RIF technology on tuberculosis control, \u003cem\u003eTuberc. Tuber. Bacillus Second Ed.\u003c/em\u003e, no 1, bll 389\u0026ndash;410, 2017, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1128/9781555819569.ch18\u003c/span\u003e\u003cspan address=\"10.1128/9781555819569.ch18\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"MDR-TB, gender differences, surveillance data, tuberculosis, Uganda","lastPublishedDoi":"10.21203/rs.3.rs-8916597/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8916597/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGlobally, tuberculosis and drug-resistant tuberculosis are more frequently reported among men than women. However, sex-specific patterns in multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) notifications may vary across settings and may be influenced by surveillance and health system factors. Evidence describing gender differences in MDR/RR-TB in Uganda remains limited. This study examined gender-specific patterns and temporal trends in MDR/RR-TB notifications in Uganda over a ten-year period.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a national ecological analysis of routinely collected MDR/RR-TB surveillance data extracted from Uganda\u0026rsquo;s District Health Information System 2 (DHIS2) for the period 2014\u0026ndash;2023. Sex-disaggregated notification data were summarised descriptively at national and regional levels. Annual proportions were calculated, and temporal trends were assessed using longitudinal descriptive analysis to evaluate stability and variation in gender distribution over time.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBetween 2014 and 2023, a total of 324,025 MDR/RR-TB cases were notified nationally. Females accounted for 178,861 cases (55.2%), while males accounted for 145,164 cases (44.8%). Female predominance was observed consistently throughout the ten-year period, with no sustained year in which male notifications exceeded female notifications. Notifications increased over time among both sexes, but the relative distribution remained stable. Female predominance was also observed across all regions, although the magnitude of the difference varied geographically.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eMDR/RR-TB notification patterns in Uganda differ from commonly reported global trends of male predominance. The consistent female predominance observed over a decade likely reflects contextual and programmatic factors influencing case detection rather than biological susceptibility alone. Strengthening gender-disaggregated surveillance and investigating potential barriers to diagnosis and care remain essential for equitable tuberculosis control.\u003c/p\u003e","manuscriptTitle":"Gender disparities in multidrug-resistant tuberculosis notifications in Uganda: evidence from national surveillance data, 2014-2023","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-10 10:59:25","doi":"10.21203/rs.3.rs-8916597/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7c4b0e83-1cf4-42f0-ac53-d90955d49242","owner":[],"postedDate":"March 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T10:42:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-10 10:59:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8916597","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8916597","identity":"rs-8916597","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}