Frontline healthcare worker barriers impacting tuberculosis service demand and access in high burden settings: a scoping review

Abstract

Background: Extensive literature exists on health-seeking behaviour and barriers related to the uptake of tuberculosis (TB)-related services in high TB burden settings. However, prior reviews have focused on patient- and health facility/systems-level barriers to TB-related care. In this scoping review, we aimed to synthesise frontline healthcare worker (FLHCW)-related barriers that limit individuals' demand for, access to, and retention in TB services. Methods: We searched PubMed for studies describing FLHCW-related barriers that impact demand for and/or access to TB services (preventive treatment, active case finding, diagnosis and treatment initiation, treatment completion, and post-TB care). We included studies that were published between 2010 and 2025 in English, and that reported on original research findings from the World Health Organization lists of high TB burden countries. Two reviewers independently conducted title and abstract screening, and full-text review. We narratively summarised barriers by theme and applied the Capability, Opportunity, Motivation-Behavior (COM-B) framework to facilitate interpretation. Results: We screened a total of 5,306 records, and included 189 studies, most of which were from India, South Africa, and Ethiopia. Among the included studies, most reported barriers were for doctors (n = 101, 53%) and nurses (n = 82, 43%). Studies identified FLHCW-related barriers at every step of the care cascade except for post-TB care. Knowledge and skill gaps leading to missed opportunities to engage or retain individuals in care were the most frequent barriers identified (n = 128 studies). Other major themes included provider-patient communication, discrimination and stigma from FLHCWs, and motivation to provide quality TB clinical care. Mapping barriers onto COM-B identified actionable targets for strategies to improve TB care. Conclusions: FLHCW-related barriers to TB care are pervasive and multifaceted, affecting the care cascade from prevention to diagnosis to treatment initiation and completion. Addressing these barriers will require multi-component implementation strategies that are context-specific and designed to empower FLHCWs as drivers of care.