People at the Centre: Lessons from the LIGHT TB Research Programme

In this episode of LSTM in Conversation, host Dr Kerry Millington, Senior Research & Policy Associate at LSTM and working as a Research Uptake Manager on the LIGHT research programme, speaks with Dr Jasper Nidoi and Dr Chukwuebuka Ugwu, early career researchers at the Liverpool School of Tropical Medicine, about their work on the LIGHT Research Programme, a UK AID–funded initiative tackling gender and social barriers to tuberculosis (TB) care in Africa. 

From Uganda to Nigeria, Jasper and Ebuka share insights from their doctoral studies on developing gender-responsive and community-led approaches to TB diagnosis and treatment, highlighting why men are often “missing” from TB services and how co-designed, people-centred interventions are changing that. 

Later in the episode, LSTM alumnus Dr Mohammed Yassin, Senior Advisor on Tuberculosis at The Global Fund, joins the discussion to reflect on the importance of mentoring early career researchers, building equitable partnerships, and translating evidence into policy to accelerate progress towards ending TB. 

Transcript

Speaker 1: 0:06

Hi everyone, and welcome to the Liverpool School of Tropical Medicine in Conversation podcast series, where we explore cutting edge research, global health challenges and inspiring stories from experts working to improve health worldwide. I'm Dr Kerry Millington, a senior research and policy associate here at the Liverpool School. And today, we are joined by two early career researchers who will share their experiences working on a global health research programme called LIGHT funded by UKAID LIGHT aims to improve access to care for people with tuberculosis, especially in urban settings, by understanding and addressing gender and social barriers to health. Later in the episode, we'll also hear from another guest and LSTM alumnus who will reflect on how the programme connects with global efforts to end tuberculosis. I've had the privilege of working with all three of our guests today. But first, let me introduce Jasper and Ebuka Dr Jasper a Ugandan trained medical doctor and health economist with over five years experience in trials and health systems research. Today, she will share insights from her access to tuberculosis care Periurban, Uganda, known as the is a Nigerian trained medical with practical experience in TB Covid nineteen response. Today, he will share his insights from on the development and TB interventions in Nigerian Dustin Study. So welcome, Jasper and Ebuka. Let's start with a bit about you. Can you each tell us a bit about background and what led you to be involved with the LIGHT Program? Jasper, over to you first.

Speaker 2: 2:08

Thank you, Kerry, for that very And I think it's the salient features that are just missing in there. And, um, part of my training in introduced me to equity and, you health and how this really And um, before I enjoyed the LIGHT Project has involved in studies that looked at the impact of social determinants of health and tuberculosis health outcomes. And when LIGHT came along, um, in this area. And LIGHT focuses on one social And in Uganda we see that TB is The burden of TB is higher among Estimates put it as high as one and also men are missed out by So LIGHT came at a time when I was looking to further my studies, gain more expertise in social determinants of health, and it presented a unique opportunity to gain expertise in this area.

Speaker 1: 3:13

Thanks, Jasper. I'm looking forward to exploring Ebuka. Introduce yourself.

Speaker 3: 3:18

Thank you Kerry, and thanks, After I became a medical doctor, five years before I sort of Part of the reason was that I felt the need to intervene for my, you know, patients, the people I was seeing in HIV and TB clinics. You know, at a bit of a higher And whilst in public health, I happen to have worked for the W.H.O. in Nigeria, said TB Surveillance officer. This is when Nigeria was Pushing finding the people at risk of TB observed within these outreaches outreaches seemed to have been In other words, if you come to attendees will be women. Depending on how you've planned But but most of the TB we with TB at the end would come came around to the outreaches, This was around twenty nineteen, submitted an abstract to the have held in Seville. I titled it Where are the Men? And I described what I was So I was already sort of where are the men? How do we reach them? Because also we had seen some of the evidence from our prevalence of in Nigeria, how that men not only dominated the TB body, but also had lengthier delays in reaching care with with onward transmission implications within the household. So when light came along, I for me personally, because it then wrestle with a question I'd depth and give me protected time of go deeper into this issue. So I really, even though I to Seville, I'd be looking Having read The Alchemist, but the virtual version of The Union provided the opportunity to share findings, which then snowballed into my applying for light and becoming part of the wonderful research and A network with built in the past three to four years.

Speaker 1: 5:52

Thanks, Rebecca, and I hope you And the face giving is a really lovely intro of the timing, how that was for the light program to offer the opportunities to to do some research in the area you'd identified on where the men. Can you tell us a little bit research you did, the key importantly, what change this and the destined studies.

Speaker 2: 6:19

So for.

Speaker 1: 6:20

The Ignite study, we.

Speaker 2: 6:21

Focused on public health care As a Booker has mentioned, men are missing in communities and it's affirming public health care facilities. We see more women and we see So we held formative discussions with TB survivors, healthcare workers, policymakers and researchers to try to co-create solutions that would bridge this gap. And we came up with three key First, we noticed that our is not appealing and no friendly public healthcare facilities. So we developed a male friendly services package that incorporated screening for TB with HIV, diabetes and hypertension. And we hope this would be a pull factor to draw men into healthcare facilities. Secondly, about sixty percent is female, and part of our sometimes men would prefer to So we introduced male corners, in which a male champion who was a TB survivor would interact with men, provide health education counseling, share his TB journey, and try to encourage more men to access TB care services. We also extended the working hours from about four pm to six thirty PM, because part of the part of our work found that masculinity tendencies and the role that men have in society to provide really leads them to prioritize work over health care seeking. So extended working hours up to Secondly, we rolled out a stamp that was developed by the National TB and Leprosy Program that really wasn't in use to improve screening at all service delivery points. We hoped that this stamp would more in a routine fashion. Um, and also, the healthcare workers would be able to track patients who have been screened or not. So that stamp was just a symptoms of TB. And these would go on the patient's record, enabling subsequent workers who say this patient may have been screened for TB. And what was the outcome of that Lastly, we introduced educational material and that was distributed both in the facility and in the communities to increase awareness about TB and also increase self-referrals to the healthcare facility for TB screening. So we implemented this December twenty twenty three, in And what we observed was a fifty one percent increase in TB notifications overall. But this increase in men compared to women. And men had fifty percent higher So what we saw from the intervention was that the intervention was able focusing on men was able to increase notifications among men significantly without negatively impacting notifications among women. And this is very important that we get when we talk about improve care for all? And if we improve care for all, that men have. So the fact that we were able to intervention without negatively builds the case for having TB care in Uganda.

Speaker 1: 9:59

Thanks, Jasper. And and it's really phenomenal notifications among men. But also good to hear that, you know, there weren't any negative effects on women being notified for TB disease, but highlights the need for tailored strategies. Ebuka tell us a little bit about your research on the Destine study.

Speaker 3: 10:22

It's really complimentary, the I think the way LIGHT was really So whilst the ignite worked in public hospitals, the Destine study in Nigeria worked through within communities. If you think of the cascade of know it starts in the end in the communities, but So I think the two studies complement each other in that sense. I mean, the study we did three things we explored, we co-created, and then we evaluated. I, as the researcher, led the The co-creation was a Whilst the community led the evaluation during the exploration, we found a few important things. You know, we sought to know what the issues were with men and care as far as Nigeria was concerned. And we we did a variety of We conducted a scoping review to other parts of the world. And the summary is precious responsive team interventions. There were a few shining I think I'm happy to report that Muhammad, who is on this call, you know, was one of the shining lights from many, many years ago. And it was so good that he had But there were just precious few literature in TB. But we also asked men in our local areas what their issues were with reaching care, and it did come out clearly that TB information did not reach men as we had hoped it would reach them. Um, is it that we were channeling information through channels that men didn't really trust? Um, or the language of transmission was an issue, or men lacked examples that were men, as a Jasper had mentioned earlier. And then stigma was also an Men complained of, Um, and there in some of the quotes. We we had a man, for example, he hears on radio, he considers And this is, you know, stemming nineteen pandemic where there around the the air space. And men had misinterpreted and misunderstood a lot of that information. So this affected tuberculosis, Um, all the things we've found challenges of informal work. And because the survival pressure is very high in periurban settings, many of the men we found were engaged in informal work. And the, the unprotected labour, um, you know, high levels of underemployment and just the pressure to keep providing for the family was high and became a barrier to seeking care for something considered just a cough, you know, considered not very important. So armed with these findings sat down together with This included TB program healthcare workers, TB advocates, and groups of men in We sat down and asked ourselves, what will become for our context, a gender responsive care that can help to overcome these barriers we already identified. And, you know, we went through an in-person participatory southeast, where we then agreed It was this intervention that a local TB action group called the AirTag. AirTag is a community group. Um, you know, there's sort of an understanding that men have a poor health seeking, um, behavior. And this was one of the things So. So the L tag was led by men. It was a group of, like, twelve And of that twelve, seven were community and the other eight So it was very much men led and they were to conduct the activities we agreed on in their community. So this was entirely community led, and they implemented targeted awareness creation and anti-stigma messaging within the communities. They went from public address, to sort of small group meeting engagement meetings where Them ask questions. Can I truly marry from a family they will bust that myth? And we we utilized we leveraged systems and can help drivers. This is the popular tricycle in Tricycles originally from India. I think so. So we engage the drivers, we We engage religious leaders in you know, local authority In other words, you could say We hijacked it in a sense, but this time to spread the good communication. And we found that at the end of knowledge dramatically improved compared to the control area. But secondly, and in my opinion, stigma really, really declined And to think that these activities were entirely community led, and part of the key things they did was to translate all the TB information into their local languages, change the kind of pictures we put on the posters, you know, have repeated engagements leveraging social spaces where men gather, you know, as well as religious meetings and chief policies in marjah, you know, these are normalized places where people meet in that context. Um, we also found that the acceptable and also feasible. Um, I think these were really context of, you know, global alternatives that can be community systems, not just for system at large.

Speaker 1: 17:27

He both described beautifully person at the center of care. And I wonder if I just wanted to a little bit further. You mentioned the Delphi method. What is that?

Speaker 3: 17:44

The Delphi is one of the that is used commonly in health kinds of research. It's been used to set curriculums, it's used to agree on guidelines. And before sort of the advent of and other guideline drafting Delphi a lot. We implemented it by sending participants where they provided know, sections of text on each We ask them looking at this list of interventions we found in our scoping review, to what extent do you think there can be gender responsive? And the responders responded with large sections of texts and we analyzed them using framework thematic analysis. Afterwards, we reduced that long list of seventeen interventions to nine following the responses from the first round, and we then recycled a second round of questionnaires to the participants. And they provided further but refined comments and sort of put the interventions in packages, you know, considering how synergistic they could be with each other. And this was then what we took So we had two rounds of Delphi anonymized, individualized written questionnaires to stakeholders and then one round of in-person participatory workshop. Right.

Speaker 1: 19:22

So gender and equity are really central to the tuberculosis response. And I think more broadly to as And I'm sure Mohammad will touch now turn away from your research Has early career researchers. What have been the biggest opportunities and challenges for you during the The LIGHT programme? It's one of.

Speaker 2: 19:47

The biggest challenges is, um, approaches, particularly those Um, I think the, the global trend and this is not a bit men against women, but I think, um, against that, you know, women emancipation campaigns, you know, trying to achieve equity in areas of education, control, autonomy, control over household income and all of these other areas. Women, um, are are historically But when we look at certain areas, you know, like TB, for example, um, men are being left behind. So one of my greatest challenges was, um, putting forward or selling the idea of introducing gender specific approaches for men. Even if it's known that men have There was pushback and there should introduce, we should And when we look at some of the um, let's say long waiting times This is gendered. Even if both men and women face the long healthcare waiting, that long waiting times, the healthcare facilities will find that, um, in a setting like Uganda, um, a woman is able to benefit more from the healthcare services. So even if she waits for a longer time, she'll benefit from antenatal services, immunization services, and in the end, their satisfaction levels might be higher. But when we look at the men, facility, get treatment real And this might also apply to So one of the challenges in doing this work once was, you know, trying to to to emphasize the need for gender specific approaches and, uh, how this can really help men bridge the gap and access to care services more. Fortunately, at that time, we started this study, stop TB, um, while doing community rights and gender assessment, community rights and gender assessments in countries. And this included Uganda and in Uganda is about to participate in the first gender and populations assessment. And this document provided to to on which life was able to try to um, engage various policy gender specific approaches. Right now, we are developing the twenty twenty five. All the way up to twenty thirty. And the progress that LIGHT has uh, in the community rights and We are seeing gender specific We are seeing, um, the introduction of, of of male action groups, um, you know, trying to formalize them within that, the national strategic plan structure. Right now, Uganda has, um, a cast campaign which stands for community Awareness, Sensitisation and Testing and Treatment Strategy, in which we go door to door to in within communities to try to, um, screen people for TB if collect sputum samples, take them to health facilities, if you're diagnosed with TB initiative and treatment, if you qualify for TB preventative therapy. And within this we also see, um, strategies coming out that would try to focus on areas where men can be found because in the health facilities they are lacking. But when the communities can we So the progress that has been made from from where we began, um, where there was a little bit of resistance or lack of awareness for the need for gender sensitive strategies to right now gender featuring in the national strategic plan and gender trying to introduce areas in which we can focus on men is a huge achievement of of the light programme.

Speaker 1: 23:42

I think that certainly has to And thanks so much for placing And it's it's great to see that I wonder if we focus a little throughout your PhD and you

Speaker 2: 23:59

So as we mentioned earlier, my focus has been on my research interest is in applying health economics. And um, you know, this health So through this work, um, it's I've been able to have first patient related data, um, systems and analyzing this, um, such interventions can be. And this is a unique opportunity because as I've mentioned earlier, ignite has several components. So hosting a very complex intervention with multiple components, um, healthcare workers community arms, uh, involving several people within the healthcare workforce has really been a huge learning experience. Um, and this has really fostered development of skills in this area. And also just broadly thinking about stakeholder engagement, because through this program, I've been able to engage more closely with various stakeholders working at the national TB and leprosy uh program. So that has been key. Um, and also mentorship. Mentorship has been a very strong area within the Lake consortium. We were paired with, um, we had and also are paired with interactions with them and, you we that I have received, um, This has really been a very

Speaker 1: 25:33

Thanks, Jasper. And I'm looking mentorship aspect that you Tell us about your reflections

Speaker 3: 25:43

I think I promise you've not but, um, a lot of similarities which is the conceptual the experienced when I first started have been a conflation, um, of mean, in the public health literature, as if gender is a It's interesting because there's the Ministry of Women Affairs in Nigeria. Um, I had to engage them as part research, and I was surprised ministry, ninety percent of the I was like, come on, let's be At least other countries have But they were also worried why I And even within the TB space, a TB space were in a sense, of gender in TB and the program. Some of our data collection were just simply gender blind. And to that end, I think one of made is that sort of conceptual The antibody is now properly illuminated, is now part of the discourse. And I think it's very important because men and women are very much related. A lot of the things happening in men's life is because of the women in their lives and and vice versa. Some of the challenges women their lives and because we healthcare workers in a very Nigeria, the most of the the officers and decision making It was the women, the women, health care workers on the front line. You know that directly interface discovered the needs of men. They are the ones that are They are the one that put in place informal adaptations that was not funded nor guided to ensure that they retain men in care because they found the additional challenges men faced with adherence and care retention. So I think, you know, we really comprehensively from COVID-19. I take an example from Covid and maybe from mining work in during Covid vaccination. The National Primary Health Care Development Agency in Nigeria, they are quite active on Twitter. And if you check their Twitter handle, their handle on X rather, um, they shared data on vaccination numbers of Covid nineteen vaccines. And I found that in the northern part of the country, women were very few compared to men in the numbers vaccinated. Whilst in the southern part of the country, the men just wouldn't take up the Covid nineteen vaccine. In other words, women dominated the numbers and I think it's always important that when we think of gender equity, we think of it broadly, you know, across the entire health system, our services, how they have been shaped historically and at present and how they are being received. Mining, again, is a profession masculine word, and it is maybe But there are certain parts of my country, Nigeria, where female miners make up up to eighty to ninety percent of the mining population. And when I say mining, I mean They throw dynamite into holes They they quarry, they carry And the only thing they don't do But there are a lot of them. And they belong to mining associations, which are led by men. And these women. Um, we don't quite know that their gendered needs are being catered for adequately, even beyond TB. If you think of the entire pulmonary ecosystem, lung health, you know, chronic lung diseases, you know, how are their their needs being addressed in a gender responsive manner? So I think a gender equitable health as a whole. And this is how I reflect on my obtained here are transferable healthcare, um, beyond the way Another advantage I've mentioned, is the networks I've around the world, both the group members, you know, but contribute to global discourse. I now belong to the Gender union where through which actually lead the conversations And we found the opportunity to position during the UN high country's position, you know, speeches for for important watching how the document I think for me, it was a really Other than that, we also have some pieces of evidence that is out there, you know, that people can look at and sort of draw inspiration. Like in Uganda, gender equity Nigeria's TB strategic plan. It's now its own objective, and projected in that document. And I think in the future we can pivot on that document to push more. Scaling of the interventions we have piloted within the LIGHT Consortium.

Speaker 1: 32:04

Let's bring Doctor Mohamed He is an LSTM alumnus and senior advisor on TB at the Global Fund. With his extensive experience in health system strengthening, and Consortium External Advisory mentioned earlier, he plays a to help accelerate progress Mohamed, you've heard from Jasper and Ibuka and their growing confidence in the discourse and discussion and leadership in the tuberculosis and, more broadly, the global health response. Why do you think it's important to nurture and support early career researchers in their journeys?

Speaker 4: 32:51

I believe that supporting and nurturing early career researcher is critical because they can, um, bring new ideas, innovations, energy to tackle infectious disease, including old and new, like TB, and contribute to advancing our understanding of global health dynamics. Especially now this has been evolving and getting even more complex. So early career researchers are innovations and improvements in national level as well. And the they are the ones who um, access related issues and interventions and for infectious broader global health. Um the process of that nurturing established researchers and colleagues, I would actually knowledge happens and the skills make our world better for for So it's very important to And we see that they have

Speaker 1: 34:25

I think that's really great to Mohammed, about that transition or translation of knowledge from research to changing policy and strategies, thinking going forwards. And and I like the way you bring energy, uh, to an ideas. So is that right? Do you have energy? Jasper Nabuco?

Speaker 3: 34:46

I think I have some left a

Speaker 1: 34:50

That's good to hear. Do you have any advice, somebody who's starting out on

Speaker 4: 34:57

Yeah, there are more address TB now than ever before. That's not just specific to TB, to other global health related issues. And I believe that contributing especially those who are who are by by infectious disease access, is really rewarding. I advise early career researchers to keep asking questions why, what and how as well. Not just to ask questions, but also to contribute to addressing those questions on our part that that include, you know, how we can address some of the bottlenecks and then keep being passionate about what you do and, you know, keep innovating and exploring new ways of implementation, new tools that could help to generating evidence and sharing those evidence broadly so that this could contribute to overall improving access and quality as well. And we are talking about people who may be disproportionately affected, but they may have also gaps in accessing service available. So yes, it's very important that, uh, the maintain and strengthen their networks as well, and collaboration, including with their mentors, classroom mates and colleagues and others that would help them in their in their future career as well. I mean, I see that even with my network, maintaining the network

Speaker 1: 36:54

Thanks for that valuable advice. And just turning back to the the LIGHT research from a global perspective. Mohammed, what do you see as over the past six years?

Speaker 4: 37:06

I had the opportunity to be part and I think the main the LIGHT promoted partnership to capacity building and career researchers like Jasper stars in the country as well. So that that collaboration it LSTM senior researchers, is So that what Tyler says transitioning are already happening. So the LIGHT really facilitated And I consider this as one of But overall, the LIGHT the research which we have heard from Jasper and the book on addressing gender related barriers, including some of the cost effective elements and also understanding the gender related dynamics and the misunderstanding, including of how we, uh, understand the TB and gender dynamics and including implementation of some of the solutions which are not necessarily be based on evidence. So the LIGHT already quality research findings, And I believe this informed level but at global level as implementation as well. And I would consider this a

Speaker 1: 38:51

Thanks, Mohammed. I'm wondering if we can focus You're now working as a senior advisor on TB at the Global Fund. Could you share a little about what has shaped your career?

Speaker 4: 39:08

I started my career as a as a physician working in a rural health center in Ethiopia, where infectious diseases including tuberculosis, malaria and others were the major hurdles causing mortalities and many people dying of these infectious disease. And I have seen, you know, how service, including for TB, which pilot dot Center in Ethiopia for millions of people. I know how people really treatment of TB, including all And as TB is a disease of poverty among even poor people and all the stigma and access related challenges. So that really shaped my my And I decided to really contribute towards more broader public health than diagnosing and treating individual patients and and addressing some of the bottlenecks that are contributing to our this our understanding of the overall epidemiology of this infectious disease and and designing and implementing more problem oriented research and implementation projects, which contribute to improving the coverage and quality, as well as addressing some of the the bottlenecks which disproportionately affect people with TB, including the poor people who may not afford to access. That really shaped my career. And I had the opportunity also level TB, HIV and communicable expanded the service massively Joining LSTM, studying and working at LSTM as well further enriched my skills, experience and expertise. A great opportunity to meet my with others in the countries on collaborative projects including Nepal and Brazil, which my skills and understanding, but towards conducting research towards addressing gaps. And I had the opportunity also between LSTM and universities in All this contributes towards to people who are struggling to Um, then I had the opportunity to join a global fund fifteen years ago. That's a critical milestone for source of funding for TB, HIV, health system strengthening. Um, joining Global Fund means actually broader opportunity to contribute to towards these, uh, this movement and be part of it and work together with the national TB programs in many countries. Technical experts at the global, Researchers and organizations addressing different aspects of TB, including private sector and communities. I had the opportunity also to work with not only TB, HIV, but on antimicrobial resistance and Covid response and all my experience as a as a physician researcher, global health professionals helped me to when we had interactions and discussion, when I support programs and global fund teams so that whatever advice I provide are actually based on evidence, as I always keep, uh, updating myself, the things are moving quickly and advancing and all those helped me and are advising relevant teams on a strategic investment of resource and cost effective approach and accelerating uptake of new tools, innovation and maximising impact. Always promote innovations and with early career researchers well at different levels. And my engagement with LIGHT is part of that interest and passion. And I enjoy what I'm doing. But I believe that I'm decided to contribute to that is service without incurring any accelerating towards ending which are curable, treatable and health in general.

Speaker 1: 44:40

It's been really inspiring to of you, of those who now work at for increasing access to reach everyone, and that has And and it's been lovely that we collaborations going on through hope Ebuka and Jasper, you'll you as your careers develop. To close, I'd love to go round all three of you and just ask you to give one or two key points that you'd like our listeners to take away from this podcast today. Mohammed, over to you first.

Speaker 4: 45:24

Yeah. Um, thank you very much. I think this is, um, it's a I see how they less they might general contributing towards informing policy at all level. But that generating evidence is also, um, based on that partnership and as you mentioned, co-creating of some of these solutions and early engagement of relevant stakeholders, including national TB programs. And um, and we have or already facilitating the uptake of any of the recommendations and findings and the buy in happening early. And I, I really like the way the whole projects are being designed. It's more problem and solution and cooperative Creative, the meantime, fostering each other, but also, um, problems, including our understanding of all the TB and related to equity. And overall, the the contribution to this generating evidence would help to to moving more to people centered approach, more cost effective implementation. And I'm happy to hear that we well, not just TB, but broader We shouldn't miss the And I like that the way we are talking about cost effectiveness, because we know that, uh, probably there may not be enough resources to implement everything everywhere. And while it's good to see that that's overall we understand are not also overlooking or well, where access related issue But overall about informing our evidence and and and and the same air when it comes to TB infectious disease, we all responsibility and are thinner, um, accelerating ending TB.

Speaker 2: 48:18

My closing reflections are really, um, I come from a medical background, so it's really going beyond just biomedical approaches and really critically thinking about the social determinants of health, because these are the drivers of inequality, both in that TB, TB burden, TB treatment outcome, you know, across the entire spectrum, even exposure and and risks of developing, um, infections. So gender has been a very into this area. And I hope to build further You know, that really focuses on of health and how this can be other infectious diseases.

Speaker 3: 49:01

Um, I think I've learned that when we build trust, um, invest resources and time to build trust with communities, we then repeat when we need their cooperation. For example, maybe during a pandemic or in leading a health intervention. And I found that a community led acceptable than the one we leave And then putting people right at that storm did better than us. So overall, I think it's just an started the journey towards not reached our destination yet. So we keep pushing the and hoping to attract more to lead the care and improve

Speaker 1: 49:57

Thank you all for joining us today and sharing your reflections and valuable insights. Don't forget to follow the LSTM you are listening out there. And so you don't miss an And if you enjoyed the episode today, please do share with your colleagues. The more people who hear these can make together. Thanks again for listening and