Exploring Potential Barriers and Facilitators to Integrate Tuberculosis, Diabetes Mellitus, and Tobacco-Control Programs in India

Background Integrating Tuberculosis (TB), Diabetes Mellitus (DM), and Tobacco-Control (TC) programs in India presents a promising strategy to address the triple burden of these diseases. However, limited information exists regarding the feasibility and influencing factors of such integration. This study investigates potential barriers and facilitators to integrate TB, DM, and TC programs in Ambegaon Block of Pune District in Maharashtra and Ballabgarh Block of Faridabad District in Haryana states of India. Methods Qualitative in-depth interviews were conducted between Nov 2022 to March 2023 among health workers, program managers, and stakeholders involved in program implementation (n=32). Interview guide was based on World Health Organization's Health System Strengthening framework. Purposive sampling and snowball sampling were used to select participants. Rapid analysis of the data was done using the WHO HSS Framework. Results There were barriers and facilitators for the integration of TB-DM-TC programs observed in India. The primary challenges for integration are at the level of service delivery which is largely attributed to inadequate implementation of all three programs and negligible involvement of private practitioners in the program implementation. Moreover, inadequate referral system, insufficient infrastructure, limited resources, a shortage of trained staff, and lack of essential drugs and equipment impeded the uptake and coverage of services. Conclusion The results highlight the critical importance of addressing barriers and facilitators of implementation program in India to build a robust structure of managing the triple burden of TB, DM and tobacco control. The proposed strategies, such as sensitizing health system staff, implementing feedback and referral systems, and developing cross-program digital platforms offer a roadmap for policymakers and healthcare system managers. A multidimensional approach is vital for overcoming barriers and facilitating integration. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This project was funded by Swedish Research Council Grant Number 2018-05194. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study received ethical approval from KEM Hospital Research Centre’s Research Ethics Committee (Reference No. KEMHRC/RVM/EC/2105) and the Institute Ethics Committee of All India Institute of Medical Sciences, New Delhi (Ref No. IEC-866/04.11.2022). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All the data underlying our findings are included within the manuscript and the coded data will be made available on request.