Hunger, Mental Health, and Delayed TB Care in Botswana

Delayed tuberculosis (TB) treatment is a major barrier to controlling the disease. It raises the chances of death, leads to drug resistance, and increases the risk that infected people will pass TB on to others. Researchers led by Emmanuel Kojo Sakyi set out to understand one possible pathway that might slow people’s access to care: food insecurity. Food insecurity can affect people’s ability to seek care in several ways—through economic hardship, reduced physical strength, and increased stress or poor mental health. Depression and anxiety have been linked to delays in seeking TB care and could help explain how food insecurity translates into postponed treatment. To investigate, the team studied people newly diagnosed with TB in Gaborone, Botswana. They enrolled 180 participants and measured levels of food insecurity, depression, and anxiety to see whether these factors were associated with starting TB treatment late, and whether depression or anxiety could be mediators in that relationship.

The study used established tools to measure the main factors. Food insecurity was assessed with the Household Food Insecurity Access Scale, depression with the PHQ-9, and anxiety with the Zung Self-Rating Anxiety Scale. Delayed TB treatment was defined as more than 2 months since the first TB symptoms. The team analyzed associations using logistic regression and conducted causal mediation analysis to test whether depression or anxiety explained any link between food insecurity and delayed treatment. Of the 180 participants, 45 (25%) experienced delayed TB treatment initiation. Those with delays had slightly higher median scores for food insecurity (2 vs. 1, p = 0.11), higher depression scores (9 vs. 6, p = 0.001), and higher anxiety scores (37 vs. 34, p = 0.05). Logistic regression found insufficient evidence of an overall association between food insecurity and delayed treatment (OR = 1.04, 95% CI 0.98–1.11, p = 0.20). Mediation analysis showed insufficient evidence for total and direct effects through depression and anxiety, but did find a significant indirect effect through depression (OR = 1.04, 95% CI 1.01–1.08, p < 0.001) and a borderline indirect effect through anxiety (OR = 1.02, 95% CI 1.00–1.04, p = 0.05).

The findings suggest that even when a direct link between hunger and delayed TB care is not clear, mental health can be an important pathway connecting them. In other words, food insecurity may contribute to depression and anxiety, and these psychological conditions in turn may help explain why some people wait longer than two months to start TB treatment. This matters for TB control efforts because it points to the value of addressing both socioeconomic needs and mental health when aiming to reduce treatment delays. The authors note that the mediation signals were visible in the causal analysis even though the total effect was not strong, highlighting that complex relationships can hide behind simple comparisons. The study concludes that programs tackling delayed TB treatment should consider combining support for food needs with attention to depression and anxiety, and that further research is needed to confirm these pathways and inform effective interventions.