Self-reported adherence and associated factors to isoniazid preventive therapy for latent tuberculosis among people living with HIV/AIDS at health centers in Gondar town, North West Ethiopia

Integrating narrative and bibliometric approaches to examine factors and impacts of tuberculosis treatment non-compliance

BACKGROUND

Tuberculosis (TB) treatment non-compliance remains a significant global public health issue, undermining disease control efforts and leading to adverse clinical and epidemiological outcomes. While considerable research has explored this issue, gaps remain in understanding the multifactorial influences on non-compliance, particularly its key factors and impacts, as well as the interconnections that exacerbate these challenges. This study integrates narrative and bibliometric approaches to critically synthesize and visualize factors contributing to TB treatment non-compliance and its impacts. By addressing research gaps, this study aims to provide a comprehensive framework for understanding the multifactorial challenges and proposing evidence-informed strategies to address clinical and epidemiological issues.

METHODS

A systematic search of Scopus, EBSCO (Medline), ScienceDirect, and PubMed databases identified empirical studies published up to December 2024. Thematic synthesis categorized factors into overarching themes, while bibliometric analysis using VOSviewer software visualized factors and their interconnections.

RESULTS

The review identified key factors such as poor tuberculosis knowledge, stigma, side effects, and economic constraints, interacting with demographic, psychological, and systemic barriers. Network visualization highlighted the interconnections among these factors, illustrating how they compound to exacerbate non-compliance. Clinical and epidemiological impacts include MDR/XDR-TB, prolonged treatment, and community transmission.

CONCLUSIONS

TB treatment non-compliance arises from a complex interplay of individual, socio-economic, and healthcare-related factors. This review emphasizes the importance of integrated narrative and bibliometric approaches to develop context-specific strategies for improving adherence, reducing the global TB burden, and guiding future research and policy.

Adherence to treatment in pulmonary tuberculosis: Rodgers' evolutionary concept analysis

Background

Adherence to treatment is essential for the management of pulmonary tuberculosis. Nurses and healthcare professionals play a significant role in promoting adherence behavior among this population. Nevertheless, defining adherence to treatment within this particular population remains complex.

Objective

This study aimed to explore and clarify the concept of adherence to treatment among individuals with pulmonary tuberculosis.

Methods

Rodgers' evolutionary concept analysis was employed in this study. A literature search was conducted in the PubMed and Scopus databases to identify relevant studies published between July 2013 and July 2023.

Results

The attributes of adherence to treatment in pulmonary tuberculosis consist of multiple components: biological, individual, social, health service, and policy-making processes. Antecedents include various patient-related factors as well as factors associated with clinical conditions and patient-health professional engagement. Three consequences of the concept have emerged: enhanced treatment efficacy, increased commitment to tuberculosis treatment adherence, and improved health service quality.

Conclusion

This study provides a comprehensive operational definition of adherence to tuberculosis treatment, including its attributes, antecedents, and consequences. This framework will assist nurses in evaluating adherence more effectively. However, further research into the experiences of individuals adhering to tuberculosis treatment is needed to confirm and enhance these strategies.

Completion of tuberculosis preventive therapy and associated factors among clients on antiretroviral therapy at Debre Berhan town health facilities, North Shoa Zone, Ethiopia

BACKGROUND

Tuberculosis preventive therapy is vital in caring for HIV-positive individuals, as it prevents the progression from latent tuberculosis infection to tuberculosis disease. The aim of the study is to assess the completion of tuberculosis preventive therapy and associated factors among clients receiving antiretroviral therapy in Debre Berhan town, Ethiopia, in 2022.

METHOD

Institutional based cross sectional study was conducted. Random sampling methods were used to select both study participants and health facilities. Both bivariate and multivariate logistic regression analyses were performed. P-values less than 0.05 were statistically significant.

RESULT

The study found that, 83% of participants were completed tuberculosis preventive therapy. Completed tuberculosis preventive therapy was associated with no adverse drug events, taking first-line ART, and good ART adherence.

CONCLUSION

According to the Ethiopian ART guidelines, the study found a low completion rate of tuberculosis preventive therapy among HIV-positive clients on antiretroviral therapy. Factors like no adverse drug events, first-line antiretroviral regimen, and good adherence were significantly associated with completing tuberculosis preventive therapy.

Biomarker-confirmed suboptimal adherence to isoniazid preventive therapy among children with HIV in western Kenya

OBJECTIVES

The aim of this study was to assess the level and correlates of biomarker-confirmed adherence to isoniazid (INH) preventive therapy (IPT) among children with HIV (CLHIV).

DESIGN

This prospective cohort study assessed adherence among CLHIV on IPT in public sector HIV clinics from 2019 through 2020.

METHODS

Adherence was assessed by pill counts or caregiver or self-reports, and urine biomarkers (in-house dipstick and Isoscreen). Both urine biomarker tests detect INH metabolites within 48 h of ingestion. Consistent adherence was defined as having positive results on either biomarker at all visits. Correlates of biomarker-confirmed nonadherence at each visit were evaluated using generalized estimating equations. The in-house dipstick was validated using Isoscreen as the reference.

RESULTS

Among 97 CLHIV on IPT with adherence assessments, median age was 10 years (IQR 7-13). All were on ART at IPT initiation (median duration 46 months [IQR 4-89]); 81% were virally suppressed (<1000 copies/ml). At all visits, 59% ( n  = 57) of CLHIV reported taking at least 80% of their doses, while 39% ( n  = 38) had biomarker-confirmed adherence. Viral nonsuppression (adjusted risk ratio [aRR] = 1.65; 95% confidence interval [95% CI] 1.09-2.49) and the sixth month of IPT use (aRR = 2.49; 95% CI 1.34-4.65) were independent correlates of biomarker-confirmed nonadherence at each visit. Sensitivity and specificity of the in-house dipstick were 98.1% ( 94.7 - 99.6%) and 94.7% ( 88.1 - 98.3%) , respectively, versus Isoscreen.

CONCLUSION

Biomarker-confirmed adherence to IPT was sub-optimal and was associated with viral nonsuppression and duration of IPT. Urine dipstick testing may be useful in assessing adherence to IPT in clinical care.

Unhealthy Alcohol Use Is Associated With Suboptimal Adherence to Isoniazid Preventive Therapy in Persons With HIV in Southwestern Uganda

BACKGROUND

Unhealthy alcohol use is associated with increased progression to tuberculosis (TB) disease, but its effect on adherence to isoniazid (INH) preventive therapy is not known.

METHODS

This was a prospective study of persons with HIV with latent TB in southwestern Uganda reporting any current (previous 3 months) alcohol use or no alcohol consumption in the previous year (2:1 ratio). All received INH. We defined suboptimal adherence as <90% of days with at least 1 Medication Event Monitoring System cap opening, over the previous 90 days. Alcohol use was categorized as follows: none: no self-report and phosphatidylethanol (PEth) <8 ng/mL; moderate: Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) 1-2 (women) or 1-3 (men) and/or PEth 8 ≥ 50 ng/mL; and unhealthy: AUDIT-C ≥3 (women) or ≥4 (men) and/or PEth ≥50 ng/mL. We used generalized estimating equation logistic regression analyses to assess the association between the level of alcohol use and suboptimal INH adherence.

RESULTS

Three hundred two persons were enrolled; 279 were on INH for 3 or more months. The prevalence of suboptimal INH adherence was 31.3% at 3 months and 43.9% at 6 months. The odds of suboptimal INH adherence were higher for unhealthy (adjusted odds ratio, 2.78; 95% confidence interval: 1.62 to 4.76) and moderate (adjusted odds ratio, 1.59; 95% confidence interval: 0.94 to 2.71) compared with no alcohol consumption.

CONCLUSIONS

Suboptimal adherence to INH at 3 and 6 months was high among prospective study of persons with HIV and associated with unhealthy alcohol use. Adherence support and alcohol reduction strategies are needed for this group at high risk for active TB.

Prioritising attributes for tuberculosis preventive treatment regimens: a modelling analysis

BACKGROUND

Recent years have seen important improvements in available preventive treatment regimens for tuberculosis (TB), and research is ongoing to develop these further. To assist with the formulation of target product profiles for future regimens, we examined which regimen properties would be most influential in the epidemiological impact of preventive treatment.

METHODS

Following expert consultation, we identified 5 regimen properties relevant to the incidence-reducing impact of a future preventive treatment regimen: regimen duration, efficacy, ease-of-adherence (treatment completion rates in programmatic conditions), forgiveness to non-completion and the barrier to developing rifampicin resistance during treatment. For each regimen property, we elicited expert input for minimally acceptable and optimal (ideal-but-feasible) performance scenarios for future regimens. Using mathematical modelling, we then examined how each regimen property would influence the TB incidence reduction arising from full uptake of future regimens according to current WHO guidelines, in four countries: South Africa, Kenya, India and Brazil.

RESULTS

Of all regimen properties, efficacy is the single most important predictor of epidemiological impact, while ease-of-adherence plays an important secondary role. These results are qualitatively consistent across country settings; sensitivity analyses show that these results are also qualitatively robust to a range of model assumptions, including the mechanism of action of future preventive regimens.

CONCLUSIONS

As preventive treatment regimens against TB continue to improve, understanding the key drivers of epidemiological impact can assist in guiding further development. By meeting these key targets, future preventive treatment regimens could play a critical role in global efforts to end TB.

High burden of adverse drug reactions to Isoniazid Preventive Therapy in people living with HIV at three tertiary hospitals in Uganda: associated factors

BACKGROUND

HIV is one of the most important risk factors for TB-related morbidity and mortality. Isoniazid preventive therapy (IPT) is recommended to prevent latent TB reactivation in HIV patients. However, due to multiple therapies and comorbidities these patients are predisposed to adverse drug reactions (ADRs) which lead to increased morbidity and mortality. The aim of this study was to determine the prevalence and associated factors of suspected IPT-linked ADRs in HIV-positive patients using IPT.

METHODS

A cross-sectional study was conducted between February and March 2020 at three regional referral hospitals (RRHs) in central Uganda. We sampled 660 HIV-positive patients aged 10 years and older who received IPT between July and December 2019 inclusive. Patients were interviewed using a pre-tested structured questionnaire and their treatment records were reviewed. A modified poisson regression model with clustered robust standard errors was used to identify factors associated with suspected IPT-linked ADRs.

RESULTS

The prevalence of the suspected ADRs was 51 % (334/660; 95% CI: 18% - 83%). Patients' self-reported 7-fold more suspected ADRs than were documented by the Health Care Workers (HCWs). Musculoskeletal symptoms were the most frequently experienced reaction (14%) followed by dizziness (13%) and peripheral neuropathy (11%). Serious suspected ADRs were experienced by 12 % of the study participants; the most common were hepatotoxicity (26%), dizziness (23%) and neuropathy (17%). Female sex (aPR: 0.92, 95% CI = 0.88-0.95), study site (aPR: 1.09, 95% CI = 1.09-1.18), level of education (aPR: 0.94, 95% CI = 0.94-0.99) and history of TB (aPR: 0.93, 95% CI = 0.87-0.99), good IPT adherence (aPR: 1.16, 95% CI = 1.05-1.29) and use of protease inhibitor (PI)-based ART (aPR: 1.01, 95% CI = 1.00-1.02) were significantly associated with suspected IPT-linked ADRs.

CONCLUSION

The prevalence of suspected IPT-linked ADRs is high and hepatotoxicity is the most commonly reported serious suspected ADR. Patients self-reported more suspected ADRs than were documented by HCWs. Patient engagement could improve ADR detection and potentially strengthen the pharmacovigilance system. High ADR-risk patients ought to be monitored regularly to enable early detection and management.

Impact of Isoniazid Preventive Therapy on Tuberculosis incidence among people living with HIV: A secondary data analysis using Inverse Probability Weighting of individuals attending HIV care and treatment clinics in Tanzania

BACKGROUND

Information on how well Isoniazid Preventive Therapy (IPT) works on reducing TB incidence among people living with HIV (PLHIV) in routine settings using robust statistical methods to establish causality in observational studies is scarce.

OBJECTIVES

To evaluate the effectiveness of IPT in routine clinical settings by comparing TB incidence between IPT and non-IPT groups.

METHODS

We used data from PLHIV enrolled in 315 HIV care and treatment clinic from January 2012 to December 2016. We used Inverse Probability of Treatment Weighting to adjust for the probability of receiving IPT; balancing the baseline covariates between IPT and non-IPT groups. The effectiveness of IPT on TB incidence was estimated using Cox regression using the weighted sample.

RESULTS

Of 171,743 PLHIV enrolled in the clinics over the five years, 10,326 (6.01%) were excluded leaving 161,417 available for the analysis. Of the 24,800 who received IPT, 1.00% developed TB disease whereas of the 136,617 who never received IPT 6,085 (4.98%) developed TB disease. In 278,545.90 person-years of follow up, a total 7,052 new TB cases were diagnosed. Using the weighted sample, the overall TB incidence was 11.57 (95% CI: 11.09-12.07) per 1,000 person-years. The TB incidence among PLHIV who received IPT was 10.49 (95% CI: 9.11-12.15) per 1,000 person-years and 12.00 (95% CI: 11.69-12.33) per 1,000 person-years in those who never received IPT. After adjusting for other covariates there was 52% lower risk of developing TB disease among those who received IPT compared to those who never received IPT: aHR = 0.48 (95% CI: 0.40-0.58, P<0.001).

CONCLUSION

IPT reduced TB incidence by 52% in PLHIV attending routine CTC in Tanzania. IPTW adjusted the groups for imbalances in the covariates associated with receiving IPT to achieve comparable groups of IPT and non-IPT. This study has added evidence on the effectiveness of IPT in routine clinical settings and on the use of IPTW to determine impact of interventions in observational studies.

Coverage of isoniazid preventive therapy among people living with HIV; A retrospective cohort study in Tanzania (2012-2016)

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There was low IPT initiation among those who were eligible.

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Female sex, ART, obesity and WHO clinical stage II, enrolment in Njombe region and being in public hospitals were associated with increased IPT initiation.

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Strategies are needed to work on barriers and to sustain enabling factors to improve IPT initiation.

Background

Isoniazid Preventive Therapy (IPT) is a proven public health tool to reduce Tuberculosis (TB) among people living with HIV. However, its implementation in most countries is suboptimal. This retrospective study was conducted to determine the coverage and factors associated with IPT initiation to inform program scale up and improve quality of service in Tanzania and elsewhere.

Methods

Retrospective cohort study design involving HIV clinics in Dar es Salaam, Iringa and Njombe regions from January 2012 to December 2016.

Results

A total of 171,743 PLHIV were in the cohort from 2012 to 2016. Of these, 166,709 were involved in the analysis. Of those analyzed, 23,970 (14.38%) were ever initiated on IPT. Female sex (aOR = 1.72, 95% CI: 1.13, P < 0.001), obesity (aOR = 1.29, 95% CI:1.20−1.39, P < 0.001), WHO clinical stage II (aOR = 1.48, 95% CI: 1.42−1.55, P < 0.001), enrolment in hospitals (aOR = 1.98, 95% CI: 1.89−2.06, P < 0.001), enrolment in Njombe region (aOR = 1.25: 95% CI: 1.18−1.33, P < 0.001) and enrolment in public health facilities (aOR = 1.93: 95% CI: 1.82−2.04, P < 0.001) were associated with increased IPT uptake. Being on ART (aOR = 0.67, 95% CI: 0.65−0.70, P < 0.001) and severe nutritional status (aOR = 0.72, 95% CI: 0.60−0.88, P < 0.001) were associated with decreased IPT initiation.

Conclusions

Our study documented low IPT initiation in the study area as well as documented factors which enable IPT initiation and those which impair IPT initiation. Strategies are needed to work on barriers and sustain enabling factors to improve IPT coverage.

Factors Influencing Patient Adherence to Tuberculosis Treatment in Ethiopia: A Literature Review

Background: Tuberculosis (TB) is a major global public health problem and one of the leading causes of death among infectious diseases. Although TB can be cured with first-line antibiotics treatment of 6 months regimen, non-adherence to the treatment remains the main challenge for TB prevention and control. Interventions to promote adherence need to address multiple underlying factors linked to non-adherence, which requires a synthesis of studies to understand these factors in the local context. Our review accordingly examines these factors for TB treatment in Ethiopia. Methods: Articles were searched from PubMed and ScienceDirect databases, as well as manual searches through Google and Google Scholar search engines. Both quantitative and qualitative studies that showed factors associated with or reasons for non-adherence, default or loss to follow up from TB treatment were included. A total of 276 articles were screened, and 29 articles were ultimately included in the review. Findings: The extracted factors were synthesized thematically into seven dimensions of patient-centred, social, economic, health system, therapy, lifestyle, and geographic access factors. More than 20 distinct factors were identified under these headings. Some of these factors may also apply quite widely in other settings, with greater or lesser influence, but some are particularly applicable to the Ethiopian setting. Conclusion: Helping patients to achieve full adherence to TB medication is a complex problem as it is influenced by interplay between many factors. Healthcare managers, providers, and researchers need to consider and address multiple underlying factors when designing adherence interventions. This work provides a reference set of such factors for Ethiopian interventions.

Determinants of isoniazid preventive therapy completion among people living with HIV attending care and treatment clinics from 2013 to 2017 in Dar es Salaam Region, Tanzania. A cross-sectional analytical study

BACKGROUND

Tuberculosis (TB) disease is a common opportunistic infection among people living with HIV (PLHIV). WHO recommends at least 6 months of isoniazid Preventive Therapy (IPT) to reduce the risk of active TB. It is important to monitor the six-month IPT completion since a suboptimal dose may not protect PLHIV from TB infection. This study determined the six-month IPT completion and factors associated with six-month IPT completion among PLHIV aged 15 years or more in Dar es Salaam region, Tanzania.

METHODS

Secondary analysis of routine data from PLHIV attending 58 care and treatment clinics in Dar es Salaam region was used. PLHIV, aged 15 years and above, who screened negative for TB symptoms and initiated IPT from January, 2013 to June, 2017 were recruited. Modified Poisson regression with robust standard errors was used to estimate prevalence ratios (PR) and 95% confidence interval (CI) for factors associated with IPT completion. Multilevel analysis was used to account for health facility random effects in order to estimate adjusted PR (APR) for factors associated with IPT six-month completion.

RESULTS

A total of 29,382 PLHIV were initiated IPT, with 21,808 (74%) female. Overall 17,092 (58%) six-month IPT completion, increasing from 42% (773/1857) in year 2013 to 76% (2929/3856) in 2017. Multilevel multivariable model accounting for health facilities as clusters, showed PLHIV who were not on ART had 46% lower IPT completion compared to those were on ART (APR: 0.54: 95%CI: 0.45-0.64). There was 37% lower IPT completion among PLHIV who transferred from another clinic (APR: 0.63: 95% CI (0.54-0.74) compared to those who did not transfer. PLHIV aged 25-34 years had a 6% lower prevalence of IPT completion as compared to those aged 15 to 24 years (APR:0.94 95%CI:0.89-0.98).

CONCLUSION

The IPT completion rate in PLHIV increased over time, but there was lower IPT completion in PLHIV who transferred from other clinics, who were aged 25 to 34 years and those not on ART. Interventions to support IPT in these groups are urgently needed.

To start or to complete? - Challenges in implementing tuberculosis preventive therapy among people living with HIV: a mixed-methods study from Karnataka, India

Background: Isoniazid preventive therapy (IPT) has been shown to reduce the risk of tuberculosis (TB) among people living with HIV (PLHIV). In 2017, India began a nationwide roll-out of IPT, but there is a lack of evidence on the implementation and the challenges.Objectives: Among PLHIV newly initiated on antiretroviral therapy (ART) from January 2017 to June 2018, to: (i) assess the proportion who started and completed IPT and (ii) explore reasons for non-initiation and non-completion from health-care providers' and patients' perspectives.Methods: An explanatory mixed-methods study was conducted in two selected districts of Karnataka, South India. A quantitative phase (cohort analysis of routinely collected program data) was followed by a qualitative phase involving thematic analysis of in-depth interviews with providers (n = 22) and patients (n = 8).Results: Of the 4020 included PLHIV, 3780 (94%) were eligible for IPT, of whom, 1496 (40%, 95% CI: 38%-41%) were initiated on IPT. Among those initiated, 423 (28.3%) were still on IPT at the time of analysis. Among 1073 patients with declared IPT outcomes 870 (81%, 95% CI: 79%-83%) had completed the six-month course of IPT. The main reason for IPT non-initiation and non-completion was frequent drug stock-outs. This required health-care providers to restrict IPT initiation in selected patient subgroups and earmark six-monthly courses for each patient to ensure that, once started, treatment was not interrupted. The other reasons for non-completion were adverse drug effects and loss to follow-up.Conclusion: The combined picture of 'low IPT initiation and high completion' seen in our study mirrors findings from other countries. Drug stock-out was the key challenge, which obliged health-care providers to prioritize 'IPT completion' over 'IPT initiation'. There is an urgent need to improve the procurement and supply chain management of isoniazid.

Role of Treatment Adherence, Doctor-Patient Trust, and Communication in Predicting Treatment Effects Among Tuberculosis Patients: Difference Between Urban and Rural Areas

PURPOSE

China is the second highest tuberculosis (TB) burden in the world, and TB patients in the rural areas are about twice as many as urban patients. The purpose of present study was to explore the roles of medication adherence, doctor-patient trust and communication on treatment effects, and its inequality between urban and rural areas.

METHODS

There were 564 eligible TB patients, from four tuberculosis hospitals in China, participating in this cross-sectional study. They filled out questionnaires regarding socio-demographic characteristics, medication adherence, treatment effect, doctor-patient trust, and communication. The structural equation model (SEM) was applied to explore the hypotheses in this study. All statistical analysis was done by SPSS 25.0 and Mplus 7.0 statistical software.

RESULTS

This study included 267 (47.34%) urban and 297 (52.66%) rural eligible TB patients. The data fitted the research model well, and the urban TB patients reported better treatment effect than the rural ones (P=0.027). Overall, treatment adherence positively predicted treatment effect (Est.=0.353, P<0.001); doctor-patient communication positively influenced treatment adherence (Est.=0.214, P=0.002); and treatment adherence positively mediated the role of communication on treatment effect (Est.=0.076), 95% CI (0.026, 0.152). While in the grouping model, the urban patients' treatment effect was only influenced by adherence (Est.=0.286, P=0.003); for the rural patients, treatment adherence (Est.=0.464, P<0.001) and doctor-patient trust (Est.=0.382, P=0.019) directly predicted treatment effects, and treatment adherence positively mediated the role of doctor-patient communication on treatment effect (Est.=0.175, P=0.006).

CONCLUSION

The treatment effect of TB patients, from urban and rural China, was influenced by a different mechanism, among which rural TB patients need not only improve the treatment adherence but also establish good doctor-patient trust and communication to improve treatment effects. These findings provided a theoretical guide on treatment and control for rural TB patients.

Initiation and completion rates of isoniazid preventive therapy among people living with HIV in Far-Western Region of Nepal: a retrospective cohort study

OBJECTIVES

Isoniazid preventive therapy (IPT), for people living with HIV (PLHIV) is the proven and recommended intervention to avert tuberculosis (TB). In 2015, Nepal implemented 6 months of IPT for all PLHIV registered for HIV care in antiretroviral therapy (ART) centres. After programmatic implementation, there has been no systematic assessment of IPT initiation and completion rates among PLHIV. We aimed to assess IPT initiation and completion rates in the Far-Western Region (FWR) of Nepal.

DESIGN

We conducted a retrospective cohort study using secondary data extracted from registers maintained at ART centres.

SETTING

All 11 ART centres in the FWR of Nepal.

PARTICIPANTS

All PLHIV registered for care between January 2016 and December 2017 in 11 ART centres.

PRIMARY OUTCOME MEASURES

IPT initiation and completion rates were summarised as percentages with 95% CI. Independent association between patient characteristics and non-initiation of IPT was assessed using cluster-adjusted generalised linear model (log binomial regression) and adjusted relative risk (RR) with 95% CI was calculated.

RESULT

Of the 492 PLHIV included, 477 (97.0%) did not have active TB at registration. Among 477 without active TB, 141 (29.8%, 95% CI 25.7% to 34.1%) had been initiated on IPT and 85 (17.8%) were initiated within 3 months of registration. Of 141 initiated on IPT, 133 (94.3%, 95% CI 89.1% to 97.5%) had completed 6 months of IPT. Being more than 60 years of age (RR-1.3, 95% CI 1.1 to 1.7), migrant worker (RR-1.3, 95% CI 1.1 to 1.4) and not being initiated on ART (RR-1.4, 95% CI 1.1 to 1.8) were significantly associated with IPT initiation.

CONCLUSIONS

In FWR of Nepal, three out of 10 eligible PLHIV had received IPT. Among those who have received IPT, the completion rate was good. The HIV care programme needs to explore the potential reasons for this low coverage and take context specific corrective action to fix this gap.