“Geographical, social, and political contexts of tuberculosis control and intervention, as reported by mid-level health managers in Uganda: ‘The activity around town’.”

Johnson-Peretz J, Chamie G, Kakande E, et al. (2023). Social Science & Medicine  (SSM).

“Now the challenge is getting the TB contacts because it also depends on the location of both the district and where the patient is coming from. The districts near the lakes, most people there are immigrants, so you find that the primary person is coming from the landing site and tracing the contact becomes very difficult.” (District Health Officer, Intervention Arm)

Synopsis: Though often overlooked in the literature, all study trials take place within a geographic and social context that can have profound effects on both intervention and control activities. We examine what participants from both the control and intervention groups of a TB-prevention rollout trial had to say about the social, political, and healthcare administration contexts in which the intervention was implemented, including the natural and built environments, national and subnational politics, human geography, and societal change. By ‘human geography’ and ‘social geography,’ we mean the relationships people and communities have with and across natural, built, and social environments.
Key Findings: The multiple challenges managers faced fell along political, administrative, and social axes.
* Politically, the individual relationships mid-level health managers have with local political and media leaders serve either to facilitate or hinder public health efforts to inform the public and provide much-needed services in an effective and targeted manner.
* At the administrative level, much work is dependent on implementation partner engagement and funding, which creates an expectation on the part of providers that they will be given money when directed to widen their scope of standard-of-care practices. At other times, greater coordination between national-level logistics and local needs is required.
* Social challenges included local settings which promote the spread of TB, such as crowded housing conditions and drinking venues, as well as regionally distinct employment opportunities often entailing both long- and short-distance mobility around regional hubs and international border crossings in often rural-to-urban directions. 
* Misinformation about what TB is and how it can be effectively addressed added to these challenges.
Recommendations: The geography of districts, social contexts and mobility of the patient populations concerned, political and implementing partner variability, and local clinical gaps interact together to create the health ecosystem. These contextual factors should be acknowledged and included in strategic healthcare capacity-building efforts at the mid-management level for sustainable TB and infectious-disease prevention planning in the region.