Background: Men and women with undiagnosed tuberculosis (TB) in high burden countries may have differential factors influencing their healthcare seeking behaviors and access to TB services, which can result in delayed diagnoses and increase TB-related morbidity and mortality. Methods: A convergent, parallel, mixed-methods study design was used to explore and  evaluate TB care engagement among adults (³18 years) with newly diagnosed, microbiologically-confirmed TB attending three public health facilities in Lusaka, Zambia. Quantitative structured surveys characterized the TB care pathway (time to initial care-seeking, diagnosis, and treatment initiation) and collected information on factors influencing care engagement. Multinomial multivariable logistic regression was used to determine predicted probabilities of TB health-seeking behaviors and determinants of care engagement. Qualitative in-depth interviews (IDIs; n=20) were conducted and analyzed using a hybrid approach to identify barriers and facilitators to TB care engagement by gender. Results: Overall, 400 TB patients completed a structured survey, of which 275 (68.8%) and 125 (31.3%) were men and women, respectively. Men were more likely to be unmarried (39.3% and 27.2%), have a higher median daily income (50 and 30 Zambian Kwacha [ZMW]), alcohol use disorder (70.9% [AUDIT-C score >=4] and 31.2% [AUDIT-C score >=3]), and a history of smoking (63.3% and 8.8%), while women were more likely to be religious (96.8% and 70.8%) and HIV-positive (70.4% and 36.0%). After adjusting for potential confounders, the adjusted probability of delayed health-seeking >=4 weeks after symptom onset did not differ significantly by gender (44.0% and 36.2%, p=0.14). While the top reasons for delayed healthcare-seeking were largely similar by gender, men were more likely to report initially perceiving their symptoms as not being serious (94.8% and 78.7%; p=0.032), while women were more likely to report not knowing the symptoms of TB before their diagnosis (89.5% and 74.4%; p=0.007) and having a prior bad healthcare experience (26.4% and 9.9%; p=0.036). Notably, women had a higher probability of receiving TB diagnosis ³2 weeks after initial healthcare seeking (56.5% and 41.0%, p=0.007). While men and women reported similar acceptability of health-information sources, they emphasized different trusted messengers. Also, men had a higher adjusted probability of stating that no one influenced their health-related decision making (37.9% and 28.3%, p=0.001). IDIs largely corroborated the quantitative findings while offering more context and in-depth understanding of the factors that affected initial health seeking decisions, diagnoses, and treatment experiences across each step of men’s and women’s TB care pathways. To improve TB detection, men recommended TB testing sites at convenient community locations, while women endorsed an incentivized, peer-based, case-finding approach. Sensitization and TB testing strategies at bars and churches were highlighted as promising approaches to reach men and women, respectively. Conclusions: Men and women with TB differ with respect to TB risk factors, TB care engagement experiences and determinants, and broader health influences. These differences suggest that gender-tailored TB health promotion and case-finding strategies may be needed to improve TB diagnosis and care engagement in high burden settings.

The authors have declared no competing interest.

This research was supported by a grant from the National Institutes of Health, UCSF-Gladstone Center for AIDS Research, P30AI027763 (ADK). ADK is supported by the National Institute of Allergy and Infectious Diseases (K23AI157914). KAC is supported by THE by the National Institute of Allergy and Infectious Diseases (K24 AI167805). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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All participants provided written or verbal (for phone interviews) informed consent in their preferred language (Nyanja, Bemba or English). The University of Zambia Biomedical Research Ethics Committee (#010-014-19) and the institutional review board of the University of California, San Francisco (#18–26028) approved this study.

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