Review of food insecurity and delayed TB treatment initiation in Botswana

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medRxiv Published April 16, 2026 Medically reviewed April 25, 2026 Study authors: Sakyi, E.; Molebatsi, K.; Modongo, C.; Shin, S. S. DOI ↗ By Dr. Amelia Tan, PhD · Internal Medicine & Chronic Disease

Key Takeaway

Consider that food insecurity may indirectly affect TB treatment timing via depression and anxiety, but direct associations are not evident.

This is an observational review synthesizing findings from a study of 180 people newly diagnosed with tuberculosis in Gaborone, Botswana. The review's scope was to examine the association between food insecurity and delayed TB treatment initiation, with depression and anxiety as potential mediators.

The authors report that the overall association between food insecurity and delayed treatment was not significant (OR = 1.04, 95% CI 0.98-1.11, p = 0.20). Among the 180 participants, 45 (25%) experienced delayed TB treatment initiation. However, a mediation analysis showed 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). Median food insecurity scores were slightly higher in the delayed group (2 vs. 1, p = 0.11), while depression (9 vs. 6, p = 0.001) and anxiety (37 vs. 34, p = 0.05) scores were significantly higher.

The authors note that further studies are needed to confirm these pathways and acknowledge limitations in the evidence. The review highlights the importance of considering both socioeconomic and psychological factors in addressing delayed TB treatment, but the certainty of total and direct effects through depression and anxiety is insufficient. Practice relevance is restrained, emphasizing consideration of these factors without implying causation.

Study Details

Sample sizen = 180

EvidenceLevel 5

PublishedApr 2026

View Original Abstract ↓

BackgroundDelayed tuberculosis (TB) treatment remains a major challenge to TB control and is associated with increased mortality, drug resistance, and onward transmission. Food insecurity may contribute to delayed TB treatment through economic, physical, and psychosocial pathways. Depression and anxiety are also associated with delayed TB treatment and may mediate the relationship between food insecurity and delayed TB treatment. This study examined the association between food insecurity and delayed TB treatment initiation and assessed the mediation roles of depression and anxiety for this relationship among people newly diagnosed with TB. MethodsWe 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. Delayed TB treatment was defined as > 2 months since first TB symptoms. Logistic regression was used to examine the association between food insecurity and delayed TB treatment. Causal mediation analysis was conducted to assess the mediating roles of depression and anxiety. ResultsAmong the 180 participants, 45 (25%) experienced delayed TB treatment initiation. Participants with delayed TB treatment had slightly higher median scores for food insecurity (2 vs. 1, p = 0.11), depression (9 vs. 6, p = 0.001), and anxiety (37 vs. 34, p = 0.05). There was insufficient evidence of an overall association between food insecurity and delayed TB treatment initiation (OR = 1.04, 95% CI 0.98-1.11, p = 0.20). Mediation analysis found insufficient evidence of total and direct effects through depression and anxiety. However, there was evidence of 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). ConclusionMediation analysis revealed associations between food insecurity and delayed TB treatment initiation mediated by depression and anxiety which were not evident in total effects analysis. These findings highlight the importance of considering both socioeconomic and psychological factors in addressing delayed TB treatment. Further studies are needed to confirm these pathways.