Abstract / Summary
Abstract Background Delayed tuberculosis (TB) diagnosis remains a major challenge to TB control in low- and middle-income countries, where it contributes to prolonged infection, higher costs, and increased drug resistance. Food insecurity is an important determinant of health among people with TB and may contribute to delayed diagnosis through economic, physical, and psychosocial pathways. Depression and anxiety have also been associated with both food insecurity and delayed TB diagnosis, suggesting that they may mediate this relationship. This study examined the association between food insecurity and delayed TB diagnosis and assessed the mediating roles of depression and anxiety for this relationship among people newly diagnosed with TB in Botswana. Methods We recruited 180 participants newly diagnosed with TB in Gaborone, Botswana. Food insecurity, depression, and anxiety were measured using the Household Food Insecurity Access Scale, PHQ-9, and Zung Self-Rating Anxiety Scale, respectively. Logistic regression was used to examine the association between food insecurity and delayed TB diagnosis. Mediation analysis using a counterfactual framework was conducted to assess the mediating roles of depression and anxiety. Results Among the 180 participants, 45 (25%) experienced delayed TB diagnosis. Participants with delayed TB diagnosis had higher mean scores for food insecurity (4.16 vs. 2.99, p = 0.11), depression (10.1 vs. 6.92, p = 0.001), and anxiety (37.1 vs. 33.9, p = 0.05). In the standard regression model, every one-unit increase in food insecurity was associated with 4% higher odds of delayed TB diagnosis (OR = 1.04, 95% CI: 0.98–1.11, p = 0.22). Our mediation analysis found positive natural indirect effects through depression (OR = 1.05, 95% CI: 1.02–1.10, p = 0.01) and anxiety (OR = 1.04, 95% CI: 1.01–1.08, p < 0.001). Conclusion Mediation analysis revealed that depression and anxiety may represent pathways linking food insecurity to delayed TB diagnosis. These findings highlight the importance of considering both socioeconomic and psychological factors in addressing delayed TB diagnosis. Further studies are needed to confirm these pathways.