{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,23]],"date-time":"2026-04-23T06:37:32Z","timestamp":1776926252754,"version":"3.51.2"},"reference-count":36,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,4,23]],"date-time":"2026-04-23T00:00:00Z","timestamp":1776902400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Tuberc."],"abstract":"<jats:p>Health facility readiness assessment is a foundational element in designing and implementing integrated tuberculosis (TB) and comorbidity interventions, particularly in low- and middle-income countries (LMICs) like Pakistan. The integration of TB care with management of comorbid conditions like diabetes mellitus, depression, and tobacco use is complicated and challenged by diverse, multifaceted barriers at the health system, organizational, and individual levels. Evidence-based frameworks, such as Consolidated Framework for Implementation Research (CFIR), Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, and related tools, help researchers to systematically evaluate service system capacity for service delivery, determine operational gaps and shortcomings, and understand socio-cultural and infrastructural constraints. This ensures that subsequent interventions are not only scientifically grounded but also tailored and well-suited to local capacities, thereby enhancing the sustainability and overall effectiveness of integration. In this perspective paper, we argue that readiness assessment should be institutionalized that is, formally embedded within service delivery structure, routine policy, planning, and decision-making processes, as a strategic prerequisite for integrating tuberculosis and comorbidity care, and we highlight how implementation science frameworks can support context-sensitive planning and scale-up in Pakistan and other similar health system settings.<\/jats:p>","DOI":"10.3389\/ftubr.2026.1809118","type":"journal-article","created":{"date-parts":[[2026,4,23]],"date-time":"2026-04-23T05:38:18Z","timestamp":1776922698000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Readiness assessment as a strategy, not an afterthought: leveraging implementation science to integrate tuberculosis comorbidity care in Pakistan's health system"],"prefix":"10.3389","volume":"4","author":[{"given":"Saima","family":"Aleem","sequence":"first","affiliation":[{"name":"Institute of Public Health & Social Sciences, Khyber Medical University","place":["Peshawar, Pakistan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Zohaib","family":"Khan","sequence":"additional","affiliation":[{"name":"Office of Research Innovation and Commercialization, Khyber Medical University","place":["Peshawar, Pakistan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bilal Ahmad","family":"Khan","sequence":"additional","affiliation":[{"name":"Office of Research Innovation and Commercialization, Khyber Medical University","place":["Peshawar, Pakistan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"family":"Zala","sequence":"additional","affiliation":[{"name":"Institute of Public Health & Social Sciences, Khyber Medical University","place":["Peshawar, Pakistan"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Saima","family":"Afaq","sequence":"additional","affiliation":[{"name":"Department of Health Sciences, University of York","place":["York, United Kingdom"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2026,4,23]]},"reference":[{"key":"B1","year":"2025"},{"key":"B2","doi-asserted-by":"publisher","first-page":"e093747","DOI":"10.1136\/bmjopen-2024-093747","article-title":"Implementation strategies for providing optimised tuberculosis and diabetes integrated care in LMICs (POTENTIAL): protocol for a multiphase sequential and concurrent mixed-methods study","volume":"14","author":"Afaq","year":"2024","journal-title":"BMJ Open"},{"key":"B3","doi-asserted-by":"publisher","first-page":"e13985","DOI":"10.1111\/hex.13985","article-title":"Depression care integration in tuberculosis services: a feasibility assessment in Pakistan","volume":"27","author":"Afaq","year":"2024","journal-title":"Health Expect"},{"key":"B4","doi-asserted-by":"publisher","first-page":"71","DOI":"10.1186\/s12913-019-3909-4","article-title":"Using behaviour change theory to train health workers on tobacco cessation support for tuberculosis patients: a mixed-methods study in Bangladesh, Nepal and Pakistan","volume":"19","author":"Warsi","year":"2019","journal-title":"BMC Health Serv Res"},{"key":"B5","doi-asserted-by":"publisher","first-page":"147","DOI":"10.5588\/pha.20.0030","article-title":"Strengthening the response to drug-resistant TB in Pakistan: a practice theory-informed approach","volume":"10","author":"Abbas","year":"2020","journal-title":"Public Health Action"},{"key":"B6","doi-asserted-by":"publisher","first-page":"104009","DOI":"10.1016\/j.amsu.2022.104009","article-title":"MDR-TB in Pakistan: challenges, efforts, and recommendations","volume":"79","author":"Khan","year":"2022","journal-title":"Ann Med Surg (Lond)"},{"key":"B7","doi-asserted-by":"publisher","first-page":"e0004607","DOI":"10.1371\/journal.pgph.0004607","article-title":"TB And diabetes in eswatini: addressing suboptimal treatment outcomes through integrated services","volume":"5","author":"Hirsch-Moverman","year":"2025","journal-title":"PLOS Glob Public Health"},{"key":"B8","doi-asserted-by":"publisher","first-page":"667","DOI":"10.7326\/0003-4819-158-9-201305070-00006","article-title":"Action to stop smoking in suspected tuberculosis (ASSIST) in Pakistan","volume":"158","author":"Siddiqi","year":"2013","journal-title":"Ann Intern Med"},{"key":"B9","doi-asserted-by":"publisher","first-page":"24","DOI":"10.18332\/tid\/133054","article-title":"Measuring fidelity to delivery of a new smoking cessation intervention integrated into routine tuberculosis care in Pakistan and Bangladesh: contextual differences and opportunities","volume":"19","author":"Boeckmann","year":"2021","journal-title":"Tob Induc Dis"},{"key":"B10","doi-asserted-by":"publisher","first-page":"e0207148","DOI":"10.1371\/journal.pone.0207148","article-title":"Risk of adverse treatment outcomes among new pulmonary TB patients co-infected with diabetes in Pakistan: a prospective cohort study","volume":"13","author":"Mukhtar","year":"2018","journal-title":"PLoS One"},{"key":"B11","doi-asserted-by":"publisher","first-page":"14","DOI":"10.5588\/pha.17.0098","article-title":"Did diabetes mellitus affect treatment outcome in drug-resistant tuberculosis patients in Pakistan from 2010 to 2014?","volume":"8","author":"Latif","year":"2018","journal-title":"Public Health Action"},{"key":"B12","doi-asserted-by":"publisher","first-page":"147","DOI":"10.1186\/s12913-019-3975-7","article-title":"Operationalization of bi-directional screening for tuberculosis and diabetes in private sector healthcare clinics in karachi, Pakistan","volume":"19","author":"Basir","year":"2019","journal-title":"BMC Health Serv Res"},{"key":"B13","doi-asserted-by":"publisher","first-page":"23992026211011310","DOI":"10.1177\/23992026211011314","article-title":"Impact of integrating mental health services within existing tuberculosis treatment facilities","volume":"5","author":"Pasha","year":"2021","journal-title":"Med Access Point Care"},{"key":"B14","doi-asserted-by":"publisher","first-page":"e083483","DOI":"10.1136\/bmjopen-2023-083483","article-title":"Cognitive therapy for depression in tuberculosis treatment: protocol for multicentre pragmatic parallel arm randomised control trial with an internal pilot","volume":"14","author":"Fonseka","year":"2024","journal-title":"BMJ Open"},{"key":"B15","doi-asserted-by":"publisher","first-page":"43","DOI":"10.1186\/s12961-022-00842-1","article-title":"Scaling up tobacco cessation within TB programmes: findings from a multi-country, mixed-methods implementation study","volume":"20","author":"Elsey","year":"2022","journal-title":"Health Res Policy Syst"},{"key":"B16","doi-asserted-by":"publisher","first-page":"136","DOI":"10.5588\/ijtldopen.23.0587","article-title":"2022 TB programme review in Pakistan: strengthening governance, with better patient diagnosis and treatment","volume":"1","author":"van den Boom","year":"2024","journal-title":"IJTLD Open"},{"key":"B17","doi-asserted-by":"publisher","first-page":"818","DOI":"10.1186\/s12913-023-09783-z","article-title":"Barriers and facilitators to integrating depression care in tuberculosis services in south Asia: a multi-country qualitative study","volume":"23","author":"Todowede","year":"2023","journal-title":"BMC Health Serv Res"},{"key":"B18","year":""},{"key":"B19","doi-asserted-by":"publisher","first-page":"e20","DOI":"10.1371\/journal.pmed.0040020","article-title":"Tobacco smoke, indoor air pollution and tuberculosis: a systematic review and meta-analysis","volume":"4","author":"Lin","year":"2007","journal-title":"PLoS Med"},{"key":"B20","doi-asserted-by":"publisher","first-page":"749","DOI":"10.1111\/tmi.14140","article-title":"Effect of glycemic control on tuberculosis treatment outcomes among patients with tuberculosis and diabetes mellitus: a systematic review and meta-analysis","volume":"30","author":"Zahid","year":"2025","journal-title":"Trop Med Int Health"},{"key":"B21","doi-asserted-by":"publisher","first-page":"e0227472","DOI":"10.1371\/journal.pone.0227472","article-title":"Association between tuberculosis and depression on negative outcomes of tuberculosis treatment: a systematic review and meta-analysis","volume":"15","author":"Ruiz-Grosso","year":"2020","journal-title":"PLoS One"},{"key":"B22","doi-asserted-by":"publisher","first-page":"e0239333","DOI":"10.1371\/journal.pone.0239333","article-title":"Effect of smoking on tuberculosis treatment outcomes: a systematic review and meta-analysis","volume":"15","author":"Burusie","year":"2020","journal-title":"PLoS One"},{"key":"B23","doi-asserted-by":"publisher","first-page":"47","DOI":"10.26719\/2010.16.Supp.47","article-title":"Tuberculosis control in Pakistan: reviewing a decade of success and challenges","volume":"16","author":"Metzger","year":"2010","journal-title":"East Mediterr Health J"},{"key":"B24","doi-asserted-by":"publisher","first-page":"703631","DOI":"10.3389\/fpubh.2021.703631","article-title":"Public-Private mix models of tuberculosis care in Pakistan: a high-burden country perspective","volume":"9","author":"Ullah","year":"2021","journal-title":"Front Public Health"},{"key":"B25","doi-asserted-by":"publisher","first-page":"75","DOI":"10.1186\/s13012-022-01245-0","article-title":"The updated consolidated framework for implementation research based on user feedback","volume":"17","author":"Damschroder","year":"2022","journal-title":"Implement Sci"},{"key":"B26","doi-asserted-by":"publisher","first-page":"128","DOI":"10.1186\/s12982-026-01444-w","article-title":"Implementation determinants of integrated diabetes care in the Pakistan tuberculosis control program: a pragmatic mixed method study protocol","volume":"23","author":"Aleem","year":"2026","journal-title":"Discov Public Health"},{"key":"B27","doi-asserted-by":"publisher","first-page":"50","DOI":"10.1186\/1748-5908-4-50","article-title":"Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science","volume":"4","author":"Damschroder","year":"2009","journal-title":"Implement Sci"},{"key":"B28","doi-asserted-by":"publisher","first-page":"52","DOI":"10.1186\/s40249-024-01222-3","article-title":"Implementation factors of tuberculosis control program in primary healthcare settings in China: a mixed-methods using the consolidated framework for implementation research framework","volume":"13","author":"Zhou","year":"2024","journal-title":"Infect Dis Poverty"},{"key":"B29","doi-asserted-by":"publisher","first-page":"64","DOI":"10.3389\/fpubh.2019.00064","article-title":"RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review","volume":"7","author":"Glasgow","year":"2019","journal-title":"Front Public Health"},{"key":"B30","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s13012-018-0842-6","article-title":"Systematic review of the exploration, preparation, implementation, sustainment (EPIS) framework","volume":"14","author":"Moullin","year":"2019","journal-title":"Implement Sci"},{"key":"B31","doi-asserted-by":"publisher","first-page":"1178632921999652","DOI":"10.1177\/1178632921999652","article-title":"The role of implementation science in advancing resource generation for health interventions in low-and middle-income countries","volume":"14","author":"Ojo","year":"2021","journal-title":"Health Serv Insights"},{"key":"B32","doi-asserted-by":"publisher","first-page":"04230","DOI":"10.7189\/jogh.15.04230","article-title":"Exploring potential barriers and facilitators to integrate tuberculosis, diabetes mellitus, and tobacco-control programmes in India","volume":"15","author":"Mutalikdesai","year":"2025","journal-title":"J Glob Health."},{"key":"B33","doi-asserted-by":"publisher","first-page":"2609","DOI":"10.2147\/RMHP.S432943","article-title":"Integration challenges and opportunity of implementing non-communicable disease screening intervention with tuberculosis patient care: a mixed implementation study","volume":"16","author":"Nunemo","year":"2023","journal-title":"Risk Manag Healthc Policy"},{"key":"B34","doi-asserted-by":"publisher","first-page":"898","DOI":"10.1186\/s12913-022-08295-6","article-title":"Factors influencing the implementation of TB screening among PLHIV in selected HIV clinics in Ghana: a qualitative study","volume":"22","author":"Narh-Bana","year":"2022","journal-title":"BMC Health Serv Res"},{"key":"B35","doi-asserted-by":"publisher","first-page":"e1003899","DOI":"10.1371\/journal.pmed.1003899","article-title":"Integrating tuberculosis and noncommunicable diseases care in low-and middle-income countries (LMICs): a systematic review","volume":"19","author":"Foo","year":"2022","journal-title":"PLoS Med"},{"key":"B36","doi-asserted-by":"publisher","first-page":"1","DOI":"10.32593\/jstmu\/Vol7.Iss1.308","article-title":"Sociocultural dimensions of research on public health roles for community pharmacists in tuberculosis disease control in a developing country","volume":"7","author":"Ullah","year":"2024","journal-title":"J Shifa Tameer-e-Millat Univ"}],"container-title":["Frontiers in Tuberculosis"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/ftubr.2026.1809118\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,23]],"date-time":"2026-04-23T05:38:19Z","timestamp":1776922699000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/ftubr.2026.1809118\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,23]]},"references-count":36,"alternative-id":["10.3389\/ftubr.2026.1809118"],"URL":"https:\/\/doi.org\/10.3389\/ftubr.2026.1809118","relation":{},"ISSN":["2813-7868"],"issn-type":[{"value":"2813-7868","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,23]]},"article-number":"1809118"}}