Pathways and barriers to tuberculosis care for refugees in Taraba State, Nigeria.

Introduction: Refugee and displaced populations experience high tuberculosis (TB) burdens and face substantial barriers to accessing diagnosis and treatment. Taraba State in north-eastern Nigeria hosts approximately 80,000 refugees, primarily from Cameroon, many living in remote areas with limited TB services. Evidence on how refugees access TB care in this setting remains limited. This study examined the pathways refugees follow from symptom onset to TB diagnosis and identified barriers to accessing and sustaining care. Methods: A mixed-methods study was conducted between May 2022 and December 2023 in Sardauna, Gashaka, and Kurmi Local Government Areas of Taraba State. Qualitative data included semi-structured interviews with 41 people receiving TB treatment, eight family members, eight community and religious leaders, and eight facilitated discussions with healthcare workers and people affected by TB. Quantitative data were collected through a 15-item Likert-scale questionnaire administered to 130 people receiving TB treatment. Qualitative data were thematically analyzed, while quantitative data were analyzed descriptively. Results: Refugees described prolonged and complex pathways to TB diagnosis. Symptoms were often initially attributed to common illnesses, leading most participants to first seek care from patent medicine vendors or traditional providers. Misdiagnoses across sectors contributed to substantial delays, with a median time to diagnosis of 7 months and longer delays among women. Participants reported high out-of-pocket expenditures before diagnosis. Our sample focused on people who received a TB diagnosis. The tenacity, resources, and resilience for diagnosis they described suggest that many others likely went undiagnosed. Major barriers to accessing and sustaining care included food insecurity, transport and healthcare costs, anticipated stigma, language barriers, long distances to facilities, poor facility conditions, and negative experiences with healthcare providers. Discussion: Refugees in Taraba State navigate long, costly, and often arduous journeys before receiving a TB diagnosis, frequently consulting multiple providers and exhausting scarce resources in the process. Multiple, gendered barriers to care make continued care access an ongoing challenge. These findings underscore both the persistence of people seeking care and the systemic barriers that shape access to TB services. Without addressing these structural constraints, earlier diagnosis and equitable TB care for displaced populations will remain difficult to achieve.