Barriers to tuberculosis control in five high-burden provinces of Afghanistan: A Cross-Sectional Study

Abstract

ABSTRACT

Background: Tuberculosis (TB) remains a common health problem in Afghanistan despite continued implementation of the WHO End TB Strategy. This study identifies specific barriers that currentlyuu limit the TB Control Program in Afghanistan and provides evidence to inform priority actions for timely anti-tuberculosis care.

Methods: A multi-center quantitative cross-sectional survey was conducted from November to December 2025 among 200 adult TB patients and 25 healthcare providers in five purposively selected high-burden provinces (Khost, Nangarhar, Nimroz, Zabul, and Helmand). A study-specific semi-structured questionnaire was administered. Data were analyzed using Epi Info version 7.2 and RStudio version 4.4.2 with descriptive statistics, Pearson’s chi-square test, and Fisher’s exact test. Eligible participants were adults (≥18 years) with confirmed TB; patient and physician response rates were 91.7% and 92.6%, respectively.

Results: Social stigma was the most frequent patient-reported barrier (176/200, 88%), followed by low TB literacy, weak economic status, delayed access to diagnosis and treatment, and paid medical examinations (each 144/200, 72%). Among providers, difficulty securing sustainable funding for non-governmental organizations (NGOs) was the leading barrier (19/25, 76%), followed by unstable internet connectivity affecting laboratory results (18/25, 72%). Other major provider barriers included insufficient use of chest X-ray, inadequate child-appropriate diagnostics, limited laboratory monitoring for adverse effects, and treatment-initiation delays. No statistically significant provincial differences were found for the five main patient barriers (all p > 0.05); for example, social stigma showed the weakest association with province (χ² = 0.66, p = 0.956).

Conclusion: Persistent patient- and health-system barriers impede TB control in these high-burden provinces. Priority actions include reducing stigma, strengthening laboratory services, ensuring free TB care, and securing sustainable support for community TB programs to advance the WHO End TB Strategy, underscoring the need for coordinated investment in laboratory infrastructure and community-based support systems.

Keywords: Afghanistan; healthcare barriers; quantitative cross-sectional survey; stigma; tuberculosis.