Behavioral barriers in tuberculosis control: A literature review Silvio Waisbord The CHANGE Project/Academy for Educational Development I ntroduction Tuberculosis (TB) continues to cause a large burden of disease in the world, killing an approximately 2 million people a year. It is estimated that 95 % of all TB cases and 98% percent of all TB death occur in the South. Fueled by poverty, poor public health systems, and increasing HIV/AIDS prevalence, TB continues to be a persistent challenge for global health and development. TB control programs currently emphasize the Direct Observed Therapy Short-Course (DOTS) strategy, promoted by the World Health Organization and the International UNION Against Tuberculosis and Lung Disease. The current goals are to achieve 85% treatment success and 70% case detection. Among others, TB global control currently confronts two challenges to meet those goals: diagnosis delay and non-completion of treatment. The TB control community has recognized and addressed system components in which behavior is a key issue. Both diagnosis delay and non-completion of treatment are two central behavioral challenges. Patients are expected to seek care and complete treatment. Health care providers are expected to perform successfully a number of actions, including offering sputum smear examination to patients, conducting tests adequately, and monitoring medicine intake. Success in TB detection and treatment requires specific behaviors from patients and health care providers within contexts that facilitate those practices. It is important to recognize that components of the DOTS strategy are, in fact, responses to behavioral challenges in TB control. Direct observation and supervision of patients is assumed to be more effective than self-administration to ensure that patients successfully complete the recommended six-to-nine month chemotherapy. Weekly distribution of medicines is intended to be a more effective method than monthly distribution to induce adherence. The provision of free diagnosis and medicines aims to eliminate costs that deter patients from seeking care and completing treatment. Packaging medicines in blisters and storing them in individualized boxes aims to facilitate correct intake and adherence. Recent studies seem to support the rationale behind those decisions. For example, treatment completion rates are higher among patients with direct supervision rather than among those with no supervision. Several ongoing national and global initiatives that are part of TB control programs also aim to address behavioral challenges. Programs that offer enablers such as transportation and food subsidies for patients assume that by minimizing costs the numbers of patients seeking diagnosis and care would increase. Similarly, incentive programs also assume that modifying the behaviors of health providers is necessary to increase treatment rates, for example, through offering monetary retributions for each patient who completes treatment. Initiatives to expand the outreach of health systems through partnerships between public and private providers also 1