Tailoring TB services for improved treatment adherence in Ghana – A mixed-methods study

Background: Tuberculosis remains a significant health challenge in Ghana. While differentiated service delivery models have shown benefits in HIV care, their application to TB care for key populations other than persons with HIV is limited. This study aimed to assess the effect of the current untailored, facility-based TB care model on treatment adherence and explore preferences for Differentiated Service Delivery (DSD) among key populations in Ghana. Methods: A convergent parallel mixed-methods study was conducted in Ghana from October to December 2023. Participants included children, informal miners, persons with HIV, prisoners, rural poor, and smokers. Quantitative data were collected from 439 participants using REDCap-based structured questionnaires. Qualitative data were gathered through indepth and focus group interviews and analysed with Stata v.16 and Atlast.Ti respectively. Poisson generalized linear regression analysis was used to assess the association between lack of tailored services and medication adherence. Results: Qualitative findings revealed that the current untailored model presents rigid facility schedules, and a lack of nutritional support, which discourages adherence. Quantitative analysis confirmed that a lack of tailored services was significantly associated with lower treatment adherence scores in adjusted (aRR: 0.82, 95% CI: 0.68, 0.98) analyses. Prisoners had significantly lower adherence compared to persons with HIV (aRR: 0.52, 95% CI:0.28,0.88). Participants expressed strong preferences for DSD models, specifically community-based care with peer educators or community health workers (n=382, 87.0%) and mobile clinics (n=365, 83.1%). Conclusion: The current untailored, facility-based approach is associated with suboptimal treatment adherence. Key populations prefer DSD models that are community-based, augmented with mobile services, integrated with existing HIV and child health platforms, and supported by peer educators.