Addressing tuberculosis through complex community-based socioeconomic interventions in low- and middle-income countries: A systematic realist review

Introduction

Tuberculosis continues to be the leading cause of death from an infectious disease, with an estimated 10.0 million people developing the disease in 2018 (World Health Organization, 2019). The global burden of tuberculosis disproportionately affects populations experiencing poverty in low- and middle-income countries (LMICs), where most tuberculosis cases in 2018 were geographically distributed in South-East Asia (44%), Africa (24%), and the Western Pacific (18%) (World Health Organization, 2019).

Since the promotion of DOTS (directly observed treatment, shortcourse) in the 1990s as the primary approach to address the tuberculosis epidemic in low-resource settings, global strategies have evolved with increasing attention focused on addressing the social determinants of tuberculosis (Lönnroth et al., 2009, 2014; Rasanathan et al., 2011; Raviglione & Pio, 2002; Satyanarayana et al., 2020).

The relationship between the multidimensional aspects of poverty and tuberculosis has been well-established in the literature. More specifically, low educational attainment, financial limit-
ations, and a lack of livelihood opportunities that contribute to food insecurity, transportation restrictions, and poor mental health have been shown to influence tuberculosis risk and cure rates (see Appendix A). Recognising the connection between the social determinants of health and tuberculosis, interventions have started to address poverty and tuberculosis concurrently. Previous systematic reviews have shown the effectiveness of social protection and poverty alleviation efforts in improving tuberculosis treatment outcomes (de Andrade et al., 2018; Richterman et al., 2018; van Hoorn et al., 2016).