Figure 1
Domains and Constructs of Consolidated Framework for Implementation Research [20].
Figure 2
PRISMA flow diagram for selection of articles for systematic review of implementation determinants of integrated TB diabetes care in SAARC countries.
Table 1
Study characteristics of included studies.
| AUTHORS AND YEAR | TITLE | COUNTRY | JOURNAL | STUDY SETTING | SAMPLE SIZE | STUDY POPULATION CHARACTERISTICS/INCLUSION CRITERIA | AIMS & OBJECTIVES | STUDY DESIGN |
|---|---|---|---|---|---|---|---|---|
| Basir et al; 2019 [29] | Operationalization of bi-directional screening for TB and diabetes in private sector healthcare clinics in Karachi, Pakistan | Pakistan | BMC Health Services Research | Private clinics | 450,385 individuals tested (18,109 with presumptive DM and 90,137 with probable TB). | Clinic attendees screened for TB and/or DM; bacteriologically confirmed TB referred for DM testing; pre-DM/DM referred for CXR and Xpert | Feasibility of bi-directional TB–DM screening in private sector using a social business approach | Cross-sectional |
| Swain et al; 2021[4] | Factors Affecting Diabetes Management among TB-Diabetes Comorbid Patients in Udupi District | India | Indian Journal of Community Medicine | Public healthcare facilities under the Revised National TB Control Program (RNTCP) | Quantitative Study: 154 patients Qualitative Study: 10 Medical Officers | All TB-DM comorbid patients registered in NIKSHAY (2018–2019); purposive sample of MOs for IDIs | Identify factors and barriers influencing diabetes management among TB-DM patients | Mixed-method cross-sectional with convergent parallel design. |
| Joshi et al; 2022 [30] | Integrated Management of Diabetes and TB in Rural India – Results from a Pilot Study | India | Frontiers in Public Health, | 10 Primary Health Centers (PHCs) with co-located DOTS centers. | 120 patients (57 intervention, 63 control) | Adults (≥18) with recent TB diagnosis (≤4 months) | Field-test a multidisciplinary, digitally supported TB–DM integration model (SMARThealth); assess feasibility and effect | Cluster RCT with mixed-methods evaluation |
| Satyanarayana 2013 [8] | Screening of patients with TB for diabetes mellitus in India | India | Tropical Medicine & International Health | 8 tertiary hospitals; >60 PHIs across 8 TB units | 8269 TB patients screened for diabetes | Newly registered/confirmed TB patients | Assess feasibility and outcomes of DM screening within routine TB care | Prospective observational implementation study |
| Koya et al; 2022 [31] | TB and Diabetes in India: Stakeholder Perspectives on Health System Challenges and Opportunities for Integrated Care | India | Journal of Epidemiology and Global Health | Program staff and providers across two states | 33 participants (program officials, partners, MO, private clinician; two FGDs with HCWs)) | Stakeholders from TB–DM programs (public/private) | Explore system-level challenges and opportunities for TB–DM integration | Qualitative |
| Anand et al; 2018 [32] | Integrating screening for non-communicable diseases and their risk factors in routine TB care in Delhi, India: A mixed-methods study | India | PLoS One | DOTS centers at two medical institutions, Delhi. | 410 TB patients and HCP interviews | TB patients ≥ 20 years on treatment; participating HCPs | Evaluate feasibility/acceptability of 2-stage integrated NCD (incl. DM) screening in TB care | Mixed-methods |
| Majumdar et al; 2019 [33] | TB-diabetes screening: how well are we doing? A mixed-methods study from North India | India | Public Health Action | Public healthcare facilities, Sonipat, India | 652 TB patients | All TB cases (Nov 2016–Apr 2017) and DM patients at NCD clinics | Estimate TB diabetes patients’ proportions screened both ways; identify facilitators/barriers and solutions | Mixed methods |
| Rafi et al; 2024 [34] | An approach to integrated management of diabetes in TB patients: Availability and readiness of the health facilities of Bangladesh | Bangladesh | PLoS One | National facility survey, | 1596 health facilities | Facilities providing TB diagnosis/treatment (OPD and inpatient) | Assess availability and readiness of TB care centres for DM management | cross-sectional survey (health-facility readiness) |
| Rajapakshe et al; 2015 [35] | Screening patients with TB for diabetes mellitus in Ampara, Sri Lanka | Sri-Lanka | Public Health Action | chest clinic in the Ampara, Sri Lanka | 112 TB patients | Registered TB patients; DM defined by FBG thresholds; new DM/IFG enrolled to care | Determine prevalence and feasibility of DM screening among TB patients | cross-sectional pilot study |
| Kunjathur et al; 2025 [36] | Diabetes among tuberculosis patients in Bengaluru is alarming: Time to tackle it efficiently | India | Indian Journal of Tuberculosis | 32 TB units; 147 DMCs; Bengaluru | 17,052 presumptive TB cases; staff interviews across 8 TB units | Presumptive TB cases screened; qualitative interviews with NTEP staff | Examine TB–DM association; feasibility and operational barriers/facilitators for screening | Cross-sectional with qualitative component |
Table 2
Inner Setting Barriers to TB-DM Integrated Care.
| BARRIER | WHAT IT LOOKS LIKE IN SAARC SETTINGS | WHY IT MATTERS (MECHANISM) | KEY STUDIES |
|---|---|---|---|
| Structural characteristics | Rural infrastructure gaps; few trained NCD staff; high ANM caseloads; fragmented TB–NCD pathways | Low feasibility; weak continuity; need for task-sharing and clearer pathways | (30) |
| Workforce & workload | Understaffing; limited training; added screening duties overload DOTS; limited male cadres | Slower screening: counselling/follow-up crowded out; reduced engagement with male patients | (33, 32, 30, 4) |
| Networks & communications | Weak RNTCP–NPCDCS coordination; unclear referral channels | Missed transitions to DM care after TB treatment ends; fragmentation | (4) |
| Readiness for implementation | Lack of staff and guidelines, diagnostics and equipment gaps; scarce supplies at the primary level | Constraints sustained bidirectional screening and DM management | (34, 33) |
| Resource limitations | Unavailable tests and diagnostics; equipment shortages; supply gaps; out-of-pocket expenses for patients | Delays and drop-off, cost, and distance suppress diagnostic completion | (36, 8, 32, 29) |
| Reporting & monitoring | Paper records; non-standard Diabetes reporting in TB services; unclear post-TB diabetes protocols | Inconsistent documentation, tracking, and follow-up | (8, 32, 4) |
Table 3
TB-DM integrated care barriers mapped to CFIR domains.
| AUTHORS AND YEAR | BARRIERS CHARACTERISTICS | CFIR CONSTRUCT | ||||
|---|---|---|---|---|---|---|
| INNOVATION | OUTER SETTING | INNER SETTING | INDIVIDUAL | IMPLEMENTATION PROCESS | ||
| Basir et al; 2019 [29] | Operational constraints | Systemic and financial constraints | Cost barriers | Operational constraints | Asymptomatic patients | Detection gap |
| Swain et al; 2021 [4] | Patient and health care provider related barriers | Lack of follow up protocol for diabetes after end of TB treatment | Limited support | Understaffed facilities | Alcoholic patients | Protocol confusion |
| Joshi et al; 2022 [30] | Workload | Not mentioned | Poor coordination | High workload | Limited training | Not mentioned |
| Satyanarayana 2013 [8] | Workload pressure | Difficulty in collation of a total denominator for the study | Weak referral | Equipment shortage | Limited awareness | Workload pressure |
| Koya et al; 2022 [31] | Perception barriers | Not mentioned | Public-private gap | Ownership issues | Training needs | Case detection barriers |
| Anand et al; 2018 [32] | Workload concerns | Not mentioned | Not mentioned | Inadequate supplies | Inadequate skills | Not mentioned |
| Majumdar et al; 2019 [33] | Patient awareness | Non-availability | Staff shortage | Resource constraints | Awareness deficit | Knowledge gaps |
| Rafi et al; 2024 [34] | Knowledge gaps | Diagnostic tools | Policy gaps | Fragmented structure | Staff knowledge gaps | Poor coordination |
| Rajapakshe et al; 2015 [35] | Inadequate addressed TB co-morbidities esp diabetes | Limited diagnostics | Cost effectiveness | Follow-up issues | Stress inducted hyperglycaemia | Operational challenges |
| Kunjathur et al; 2025 [36] | Operational challenges | Appropriate diagnostic facilities | Lack of x rays leading to referrals | Lack of availability of tests that were needed to be done for the patients | Patients not complaint to FBS appointments and timings Lack of awareness among patients for screening | Operational challenges |
Table 4
Implementation Facilitators for TB-DM Integrated Care.Implementation Facilitators for TB-DM Integrated Care.
| AUTHORS AND YEAR | FACILITATORS CHARACTERISTICS | CFIR CONSTRUCT | ||||
|---|---|---|---|---|---|---|
| INNOVATION | OUTER SETTING | INNER SETTING | INDIVIDUAL | IMPLEMENTATION PROCESS | ||
| Basir et al; 2019 [29] | Private sector involvement | Preventative intervention | Cost-free services | Operationalizing CMW role with private service providers | Encourage screening | Selection bias |
| Swain et al; 2021 [4] | Single-point care | Re-screening effectiveness | Not mentioned | Care continuity | Not mentioned | Structured counselling |
| Joshi et al; 2022 [30] | Existing trust | Digital support | Policy alignment | Embedded care | Trust relationship | Supportive supervision |
| Satyanarayana 2013 [8] | Policy support | Minimize inconvenience | Strong policy | Existing infrastructure | Positive response | Not mentioned |
| Koya et al; 2022 [31] | Healthcare infrastructure | Existing frameworks | Effective communication | Strong infrastructure | Not mentioned | Not mentioned |
| Anand et al; 2018 [32] | Simple tools | Simple tools | Not mentioned | Short wait times | Simple tools | Short wait times |
| Majumdar et al; 2019 [33] | Positive attitude | Decentralized testing | Positive attitude | Decentralized facilities | Positive attitude | Training providers |
| Rafi et al; 2024 [34] | Policy support | Existing clinics | Policy support | Resource leverage | Community workers | Extended roles |
| Rajapakshe et al; 2015 [35] | Implementation feasibility | Global alignment | National support | Integration success | High enrolment | Feasibility demonstrated |
| Kunjathur et al; 2025 [36] | Existing strong human resource and teams | Screening was easy to conduct | Policy support | Availability of medicines | Strong team | Feasibility demonstrated for screening |