Uncovering barriers to integrated TB and diabetes care in Pakistan

Tuberculosis (TB) remains a major health threat in Pakistan, and the number of people with diabetes among those diagnosed with TB is growing. This dual burden creates a need for clinical services that treat both conditions together, but even where guidelines exist, putting integrated care into practice has lagged. To tackle this gap, a new study led by corresponding author Saima Afaq sets out to explore what helps and what blocks the roll-out of an integrated TB-diabetes care package within Pakistan’s Provincial TB Control Program. Rather than focusing on patient outcomes, the research concentrates on the systems that deliver care: the clinics, staff, managers and external partners that shape everyday practice. The team takes a pragmatic mixed-methods approach to capture a wide view of real-world conditions, looking at both inner settings (organizational factors inside health facilities) and outer settings (external policies and environment). Stakeholders to be engaged include policy-makers, healthcare providers and staff at TB sites across primary, secondary and tertiary centers in five districts across two provinces. The study has received ethical approval from the Ethics Review Committee of Khyber Medical University.

This study is a protocol for assessing implementation determinants using established research frameworks and tools. The Consolidated Framework for Implementation Research (CFIR) guides the overall approach to identify contextual factors that act as barriers or facilitators. A systematic review component will be carried out following PRISMA-2020 guidance. Quantitative data will be collected to measure organizational readiness for integrated care and analyzed in SPSS V.29; overall mean scores will be used to interpret readiness levels and highlight likely facilitators and obstacles. Qualitative data will be collected from stakeholders and analyzed in NVivo-12 using a framework analysis approach to surface themes and categories. To bring qualitative findings into a quantifiable form, the study will use a validated item rating scale built as a 5-point Likert scale ranging from -2(Barrier) to 0 (neutral) to +2(Facilitator), with scores of -1 to +1 indicating less strong barriers or facilitators. Together these methods aim to map which factors most influence the feasibility of integrating TB and diabetes services in routine program settings.

The planned work promises practical insights for program managers and policy-makers who must translate guidelines into functioning services. By systematically identifying organizational strengths and weaknesses, the study will point to where training, resources, coordination or policy adjustments are most needed to support integrated TB-diabetes care. Its mixed-methods design combines the breadth of readiness scores with the depth of stakeholder perspectives, producing both measurable indicators and rich descriptions of context. The research will be limited by its focus on service delivery actors rather than patients, so it will not capture patient experience directly; however, it will still reveal important system-level levers to improve care. Findings will be submitted for peer-reviewed publication and shared at conferences, offering evidence that provincial TB programs can use to design targeted implementation strategies and prioritize investments to better meet the combined challenges of TB and diabetes.