Introduction
Childhood tuberculosis (TB) is a major global health problem. There are
an estimated 1.1 million children living with TB1 and
250,000 deaths caused by TB annually2. Tuberculosis
ranks among the top ten global causes of death for children, including
children under five years3. The prevalence of TB is
especially high among children and adults from low- and middle-income
countries such as South Africa4; 5. South Africa has
one of the highest country burdens of TB globally with over 300,000
people falling ill with TB in 2018, of which 9% were
children1.
Conceptual hierarchical frameworks are useful to characterize etiology
of chronic health conditions such as TB. Previous studies have utilized
frameworks that organize determinants of chronic disease into proximal,
medial and distal levels of the ecosystem6; 7.
Consideration of these ecosystem dimensions of health can guide efforts
to reduce disease burden for priority populations in the TB epidemic
such as children. Attention towards the ecological aspects of TB health
for children is vital for several reasons. Diagnosis and appropriate
treatment of TB among children are dependent on having an effective,
healthy caregiver. Individuals and families affected by TB are often
faced with challenging economic environments. These adverse economic
environments can contribute to psychological distress, reduce access to
protective resources and increase individual vulnerability to poor TB
outcomes8; 9. Such environments can predispose
children to malnutrition, which can increase the risk of childhood
TB10-12. More directly, caregiver health including
psychological distress and substance abuse has been linked to TB
non-adherence among adults; these caregiver factors may also affect TB
outcomes among children. Therefore, the overarching child ecosystem may
affect childhood TB incidence and outcomes.The child ecosystem,
including caregiver health and the broader social and economic
environment are vital factors to address.
The aim of this study was to investigate factors associated with PTB in
children and explore health markers that characterize the ecosystem of
childcare to better understand the links between the childhood ecosystem
and PTB.