Intersectionality of sex and race in COVID-19 mortality and vaccination inequities in Massachusetts.

BACKGROUND: Inequities in COVID-19 incidence, morbidity, and mortality between racial and ethnic groups in the United States (U.S.) have been documented since the start of the pandemic in early 2020. Similarly, disparities by sex for COVID-19 morbidity and mortality have emerged, with men dying at a higher rate than women. Little research has been done to understand how the intersection of sex and race impacts COVID-19 inequities in Massachusetts (MA). This cross-sectional study examined how COVID-19 mortality rates (February 2020- May 2023) and vaccination rates (December 2020-February 2023) varied by sex across racial groups in MA. METHODS: Using Massachusetts Department of Public Health data of all COVID-19 mortality cases and primary series vaccinations in MA from 2020 to 2023, we calculated both age-specific and age-adjusted COVID-19 mortality rates in order to account for differences in age distributions across sex-race groups. RESULTS: Overall, men across all age-race groups consistently had a higher mortality rate compared to their female counterparts. The age-standardized mortality rate difference between White men and White women is the smallest, with the rate for White men being 1.3 times higher than White women. The age-standardized mortality rate between Hispanic men and Hispanic women varies the largest, with the rate for Hispanic men being 1.7 times higher than Hispanic women. Notably, Black women and White women have similar vaccination rates, yet the age-standardized mortality rate for Black women is 1.4 times the rate of White women. CONCLUSIONS: Our findings show that there are disparities at the intersection of sex and race for COVID-19 mortality and vaccination in MA. This highlights the importance for targeted COVID-19 interventions at the intersection of sex and race and the need for detailed COVID-19 reporting by sex within race groups.

HPV vaccine behaviors and intentions among a diverse sample of women aged 27-45 years: implications for shared clinical decision-making.

BACKGROUND: The Advisory Committee on Immunization Practices issued a shared clinical decision-making (SCDM) recommendation for HPV vaccination in persons aged 27-45. Since expanded eligibility for the vaccine was issued, little information has been available about HPV vaccine behaviors and intentions among women in this age group. METHODS: We conducted a cross-sectional online survey among women aged 27-45 years recruited through a Qualtrics™ respondent panel (N = 324) to answer the following questions (1) What is the prevalence of HPV vaccination among a diverse sample of adult women aged 27-45 years? (2) What are the characteristics of those who have or have not previously been vaccinated? and (3) What factors are associated with the intention to obtain the HPV vaccine among those who had never been vaccinated? Multivariable logistic regression analyses estimated adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs). RESULTS: Only 31.1% had at least one dose of the HPV vaccine. In multivariable analyses, those more likely to have been vaccinated were younger and were more likely to believe that the vaccine was effective. Of those unvaccinated or unsure, 54.8% indicated they were likely to get vaccinated in the future. Factors associated with future vaccine intention (compared to those not intending) included beliefs about vaccine testing, perceived likelihood of HPV infection, greater comfort in asking one's provider for vaccination, and prior negative healthcare experiences. CONCLUSIONS: Our findings suggest that many women in this age group are interested in HPV vaccination. While the recommendation is for SCDM rather than routine vaccination for all women in this age group, efforts to promote informed decision-making among mid-adult women may include educating women about the rigorous vaccine testing and approval process, their risk factors for HPV infection, and encouraging them to engage in SCDM with their medical providers. Targeted efforts to reach women who have had negative experiences with healthcare may also be needed.

Exploring Relationships Between State-Level LGBTQ Inclusivity and BRFSS Indicators of Mental Health and Risk Behaviors: A Secondary Analysis.

OBJECTIVES: Minority Stress Theory suggests that repeated exposure to enacted stigma adversely affects mental health. States have wide authority to enact policies affecting the level of inclusivity experienced by lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) residents. The purpose of this study was to explore relationships between states' level of LGBTQ inclusivity and indicators of mental health/risk behaviors among an LGBTQ sample. METHODS: The 2018 Human Rights Campaign State Equality Index (SEI) and the 2018 Behavioral Risk Factor Surveillance Survey (BRFSS) were used to examine relationships between states' levels of LGBTQ inclusivity (predictor variable) and indicators of mental health/risk behaviors (outcome variables). Relationships were explored using descriptive statistics and survey-weighted logistic regression. RESULTS: Lower state inclusivity increased odds of fair/poor general health (adjusted odds ratio [AOR]: 1.22, 95% confidence interval [CI]: 1.01-1.48), increased odds of poor mental health days (AOR: 1.34, 95% CI: 1.11-1.62), increased odds of smoking (AOR: 1.62, 95% CI: 1.27-2.07), and increased odds of heavy drinking (AOR: 1.54, 95% CI: 1.26-1.86) and binge drinking (AOR: 1.23, 95% CI: 1.01-1.49). State inclusivity did not influence odds of a depressive disorder diagnosis or driving under the influence of alcohol. CONCLUSIONS: LGBTQ persons in restrictive states had increased odds of experiencing several indicators of mental health and risk behaviors. More research is needed to determine whether state policies affect other domains of LGBTQ persons' health. Health care providers should be mindful of LGBTQ persons' mental health/risk behaviors and the state policy environment, and should seek to implement mitigating health care strategies such as the use of validated assessment.

Contested racial identity and the health of women and their infants.

Contested racial identity- self-identified race not matching socially-assigned race-may be an indication of experiences with racism. We aimed to understand the relationship between contested racial identity and women's health behaviors, health outcomes, and infant health outcomes. We used 2012-2015 Massachusetts Pregnancy Risk Assessment Monitoring System data on 5735 women linked with infants' birth certificates. We conducted regression analyses to examine associations between contested racial identity with pregnancy and infant health outcomes and further sub-analyses among women who had experienced a contested racial identity. A total of 901 (15.7%) women reported a contested racial identity. When compared to those who did not, women who had a contested racial identity had lower odds of initiating prenatal care in the first trimester (AOR: 0.76, 95% CI: 0.62, 0.95) and higher odds of smoking (AOR: 1.70, 95% CI: 1.32, 2.19). Among women who had experienced a contested racial identity, those who were socially-assigned as White had decreased odds of having a low birth weight baby (AOR: 0.52, 95% CI: 0.28, 0.99) when compared to those socially-assigned as non-White. Contested racial identity is common; it affects the behaviors that women engage in and the outcomes they experience postpartum. Further, we found that there is a potential benefit to a White social ascription. This work adds to growing evidence of the impact of racism on maternal and infant health in the United States.

Skin Tone, Discrimination, and Allostatic Load in Middle-Aged and Older Puerto Ricans.

OBJECTIVE: A growing body of research suggests that skin tone may be a health risk indicator for Hispanics. Black and darker-skinned Hispanics have worse mental and physical outcomes than White and lighter-skinned Hispanics. Discrimination exposure has been implicated as a risk factor that may explain the association between skin tone and health. However, there is scant research examining the interrelationship between skin tone, discrimination, and health, particularly among Puerto Ricans. We examine the interrelationships between two measures of skin tone, two measures of discrimination, and allostatic load (AL) among Puerto Rican adults. METHODS: Using cross-sectional data from wave 3 of the Boston Puerto Rican Health Study (n = 882), we examined the indirect association (IA) of skin tone on physiological dysregulated systems, also known as AL, through major discrimination and everyday discrimination. We tested these associations using two distinct measures of skin tone: interviewer-ascribed skin tone and spectrophotometer-measured skin tone. RESULTS: Interviewer-ascribed skin tone was indirectly associated with AL through major discrimination (IA = 0.03, 95% confidence interval = 0.004 to 0.06). However, there was no evidence of an IA of interviewer-ascribed skin tone on AL through everyday discrimination (IA = -0.01, 95% confidence interval = -0.03 to 0.01). In addition, there was no evidence that spectrophotometer-measured skin tone was indirectly associated with AL through major discrimination or everyday discrimination. CONCLUSIONS: The sociocultural significance of skin tone may affect how Puerto Ricans are perceived and treated by others, which can, in turn, have physiological health consequences. Future research is needed to replicate these findings and examine the interrelationship between skin tone, discrimination, and other health outcomes.

Disparities in influenza vaccination: Arab Americans in California.

BACKGROUND: Influenza vaccination among minoritized groups remains below federal benchmarks in the United States (US). We used data from the 2004-2016 California Health Interview Surveys (CHIS) to characterize influenza vaccination patterns among Arab Americans in California. METHODS: Influenza vaccination was self-reported by Arab American adults (N = 1163) and non-Hispanic Whites (NHW, N = 166,955). Differences in influenza vaccination prevalence and odds were compared using chi-squared tests and survey-weighted logistic regression, respectively. RESULTS: Across all years, 30.3% of Arab Americans self-reported receiving an influenza vaccine (vs. 40.5% for NHW, p < 0.05). After sequential adjustment by sociodemographic, health behavior, and acculturation variables no differences in odds of self-reported influenza vaccination were observed between Arab Americans and NHW (odds ratio: 1.02, 95% confidence interval: 0.76-1.38). Male and unemployed Arab Americans had higher odds of reporting influenza vaccination than female and employed Arab Americans. CONCLUSIONS: Future work should consider specific barriers to influenza vaccination in Arab American communities.

Understanding differences within ethnic group designation: comparing risk factors and health indicators between Iranian and Arab Americans in Northern California.

BACKGROUND: The Middle Eastern and North African (MENA) ethnic group is a diverse group composed of two primary subsets in the United States: Iranian and Arab Americans. We aimed to compare health risk factors, chronic health conditions, and mental health conditions of Iranian and Arab American adults in Northern California. METHODS: We used cross-sectional electronic health record (EHR) data from a 2016 Northern California health plan study cohort to compare adults classified as Iranian or Arab American based on ethnicity, language, or surname. We produced age-standardized prevalence estimates of obesity, smoking, hyperlipidemia, prediabetes, diabetes, hypertension, depression, and anxiety for Iranian and Arab American men and women by age group (35-44, 45-64, and 65-84) and overall (35-84). We used generalized linear models to calculate prevalence ratios (PR) to compare Iranian and Arab American adults ages 35-84 on all health indicators. RESULTS: Compared to Arab Americans, Iranian Americans had a lower prevalence of obesity (PR: 0.77, 95% confidence interval, CI: 0.73, 0.82), current smoking (PR: 0.80, 95% CI: 0.73, 0.89), and ever smoking (PR: 0.95, 95% CI: 0.91, 0.99), but a higher prevalence of hyperlipidemia (PR: 1.09, 95% CI: 1.06, 1.12), prediabetes (PR: 1.12, 95% CI: 1.09, 1.16), depression (PR; 1.41, 95% CI: 1.30, 1.52), and anxiety (PR: 1.52, 95% CI: 1.42, 1.63). Similar patterns were observed for men and women. CONCLUSION: This work supports the need to collect granular data on race and ethnicity within the MENA ethnic group to improve identification in clinical care settings and population health reporting to better address the physical and mental health needs of different MENA subgroups.

Objective and subjective poor mental health indicators among Arab Americans in Michigan: a population-based study.

Background: Arab Americans are at high risk for poor mental health outcomes and are difficult to study at a population level due to a lack of racial/ethnic identifiers for this population.Methods: Using data from the standalone 2013 Michigan Arab Behavioral Risk Factor Survey (MI ABRFS) we aimed to understand whether the burden of mental health differed between Arab Americans and non-Arab, non-Hispanic Whites. Two measures of mental health were used: a subjective (number of poor mental health days experienced in the past 30 days) and an objective (being diagnosed with depression) measure. Additionally, we aimed to understand the sociodemographic, stress, and health-related variables associated with the objective and subjective measures of psychopathologies in the Arab American population in Michigan using population-weighted logistic regression models with survey design correction.Results: Arab Americans had increased odds of adverse mental health when compared to non-Arab, non-Hispanic Whites for the subjective measure of number of poor mental health days (OR: 1.62, 95% CI: 1.08, 2.41) and decreased odds of reporting the objective measure of diagnosed depression (OR: 0.54, 95% CI: 0.30, 0.98). Having more than one poor mental health day and being diagnosed with depression among Arab Americans was associated with being female, unmarried, unemployed, and having experienced abuse as a child.Discussion: Combining mental health screenings with primary care check-ups among Arab Americans may be an important step in identifying individuals with mental health needs and extending access to care.

Undergraduate nursing students' perceptions on nursing education during the 2020 COVID-19 pandemic: A national sample.

BACKGROUND: In 2020, nursing educational programs were abruptly interrupted and largely moved online due to the COVID-19 pandemic. PURPOSE: To explore nursing students' perspectives about the effects of the pandemic on their education and intention to join the nursing workforce. METHODS: Undergraduate nursing students from 5 universities across 5 United States regions were invited to participate in an online survey to elicit both quantitative and qualitative data. FINDINGS: The final sample included quantitative data on 772 students and qualitative data on 540 students. Largely (65.1%), students reported that the pandemic strengthened their desire to become a nurse; only 11% had considered withdrawing from school. Qualitatively, students described the effect of the pandemic on their psychosocial wellbeing, adjustment to online learning, and challenges to clinical experiences. CONCLUSION: Findings highlighted the need to develop emergency education preparedness plans that address student wellbeing and novel collaborative partnerships between schools and clinical partners.

The Society for Epidemiologic Research and the Future of Diversity and Inclusion in Epidemiology.

"The mission of the Diversity and Inclusion Committee (D&I) in the Society for Epidemiologic Research is to foster the diversity of our membership and work towards the engagement of all members, from diverse backgrounds at all stages of their careers, in the Society's activities, with the intent of enhancing discovery in public health." As a foundational step in implementing our mission, the D&I Committee conducted a survey of SER membership. Here we report on the efforts we have undertaken to expand the diversity and inclusiveness of our Society and our aspirations for future efforts in support of D&I. Early on, we established the SERvisits program to conduct outreach to institutions and students that have historically been underrepresented at SER; we hope this program continues to grow in its reach and impact. We have also taken steps to increase the inclusiveness of SER activities, for example, by engaging members on issues of D&I through symposia and workshops at SER annual meetings and through social media. DeVilbiss et al. (Am J Epidemiol. 2020;189(10):998-1010) have demonstrated that there is substantial room for improvement with regards to diversity and inclusion within SER. We invite SER members to become involved and collaborate on this long-term goal.

Assessing Representation and Perceived Inclusion among Members in the Society for Epidemiologic Research.

Using web-based survey data collected June - August 2018 from the Society for Epidemiologic Research (SER) members, we characterized numerous dimensions of social identity and lived experience, and assessed relationships between these characteristics and perceptions of inclusion and society participation. We quantified associations between characteristics, feeling very welcomed, high (top 25th percentile) self-initiated participation, and any (top 10th percentile) society-initiated participation. Racial/ethnic and religious minority categories were blinded to preserve anonymity and we accounted for missing data. Most 2018 SER members (n = 1631) were white (62%) or female (66%). Females with racial/ethnic non-response were least likely, while white males were most likely to report feeling very welcomed. Members who did not report race, identified with a specific racial/ethnic minority, or were politically conservative/right-leaning were less likely than white or liberal/left-leaning members to have high self-initiated participation. Women and individuals of a specific racial/ethnic minority or minority religious affiliations were less likely to participate in events initiated by the society. These data represent a baseline for assessing trends and the impact of future initiatives aimed at improving diversity, inclusion, representation and participation within SER.

The Impact of Advertisement Messaging on Enrollment of Young Men Who Have Sex With Men for Web-Based Research: Observational Study.

BACKGROUND: Recruiting young men who have sex with men (YMSM) in community settings is difficult. The use of Web-based social networks and dating apps for recruitment can be successful approaches, although little work has been done on the impact of study advertisement content on recruitment. OBJECTIVE: The aim of this study was to evaluate the effects of advertisement message content on the recruitment of YMSM (aged 18-26 years) for a Web-based focus group study, examining perspectives and preferences for a mobile app that was designed to support sexual health among YMSM. METHODS: Between March and April 2017, a recruitment campaign to promote human papillomavirus vaccination was launched on a popular social networking and dating app for YMSM, with 3 different text-based advertisement themes (technology, cancer prevention, and sexual innuendo). The campaign recruited YMSM across 3 states (Massachusetts, New York, and Pennsylvania). We examined the click-through rates, conversion rates, and enrollment rates of each of the advertisements and examined differences in views and clicks by age, state, and time of day. RESULTS: The sexual innuendo advertisement had the highest click rates when compared with both the technology (click rate ratio [CRR] 2.06, 95% CI 1.74-2.45) and cancer prevention (CRR 1.62, 95% CI 1.38-1.90) advertisements. The sexual innuendo advertisement also had higher study enrollment rates compared with the technology (CRR 1.90, 95% CI 1.23-2.83) and cancer prevention (CRR 2.06, 95% CI 1.37-3.13) advertisements. No differences were observed in clicks or enrollment by age, state, or time of day. CONCLUSIONS: Our marketing campaign, targeting YMSM, was effective in recruiting participants for a qualitative study, using Web-based focus groups. The sexual innuendo advertisement was the most effective and cost-efficient advertisement of the 3 approaches trialed. Different populations need different targeted strategies for study recruitment. Researchers should work with key representatives to develop and test culturally relevant messaging and approaches that utilize current and popular technologies.

Relevance of the "Immigrant Health Paradox" for the Health of Arab Americans in California.

Objectives. To assess the validity of the immigrant health paradox among Arab Americans in California.Methods. We used data from the 2003 to 2017 California Health Interview Survey (n = 1425). We used survey-weighted χ2 and logistic regression analyses to compare Arabs by immigrant generation on socioeconomic indicators, health behaviors, and health outcomes.Results. Second-generation Arab Americans had higher odds of binge drinking (adjusted odds ratio [AOR] = 3.26; 95% confidence interval [CI] = 1.53, 6.94) in the past year than did first-generation Arab Americans. Third-generation Arab Americans had greater odds of receiving the influenza vaccine in the past year (AOR = 3.29; 95% CI = 1.09, 9.98) than did second-generation Arab Americans. Third-generation Arab Americans had increased odds of being overweight or obese when compared with first- (AOR = 2.59; 95% CI = 1.02, 6.58) and second-generation Arab Americans (AOR = 3.22; 95% CI = 1.25, 8.29), respectively.Conclusions. Alcohol use increased across immigrant generations, and we observed no differences in health outcomes, other than obesity. The immigrant health paradox does not appear to apply to Arab Americans in California; mechanisms that generate health in this population should be studied further.

Differences in health behaviors and health outcomes among non-Hispanic Whites and Arab Americans in a population-based survey in California.

BACKGROUND: Few population-based studies of Arab American health behaviors and outcomes exist outside of Michigan. We aimed to provide prevalence estimates of health behaviors and outcomes for Arab Americans and compare them to non-Hispanic Whites in California. METHODS: We used data from the 2003-2016 California Health Interview Surveys. We determined Arab American ethnicity using an algorithm that considered place of birth of the respondent or parent and use of Arabic language at home. Survey-weighted frequencies, chi-squared statistics, and logistic regression analyses were used to compare Arab Americans and non-Hispanic Whites on socioeconomic indicators, health behaviors and health outcomes. Multivariable models were adjusted for age, education level, and insurance status. RESULTS: Arab Americans had higher prevalence of no insurance, living below the federal poverty level, and home ownership than non-Hispanic Whites despite high levels of education and low unemployment prevalence. Arab Americans had reduced odds of alcohol consumption (OR: 0.33, 95% CI: 0.24, 0.45), binge drinking (OR: 0.28, 95% CI: 0.19, 0.40), and suicidal ideation (OR: 0.41, 0.25, 0.66) when compared to non-Hispanic Whites in multivariable models. Arab Americans had decreased odds of hypertension (OR: 0.64, 95% CI: 0.50, 0.83) and increased odds of diabetes (OR: 2.03, 95% CI: 1.23, 3.34) when compared to non-Hispanic Whites in multivariable models. CONCLUSIONS: Arab Americans in California participate in less risky health behaviors and have better health outcomes than non-Hispanic Whites, except with regards to diabetes. Future work aiming to understand the health of Arab Americans should allow for self-identification and less reliance on country of origin and language use at home for sample selection.

Interaction Patterns of Men Who Have Sex With Men on a Geosocial Networking Mobile App in Seven United States Metropolitan Areas: Observational Study.

BACKGROUND: The structure of the sexual networks and partnership characteristics of young black men who have sex with men (MSM) may be contributing to their high risk of contracting HIV in the United States. Assortative mixing, which refers to the tendency of individuals to have partners from one's own group, has been proposed as a potential explanation for disparities. OBJECTIVE: The objective of this study was to identify the age- and race-related search patterns of users of a diverse geosocial networking mobile app in seven metropolitan areas in the United States to understand the disparities in sexually transmitted infection and HIV risk in MSM communities. METHODS: Data were collected on user behavior between November 2015 and May 2016. Data pertaining to behavior on the app were collected for men who had searched for partners with at least one search parameter narrowed from defaults or used the app to send at least one private chat message and used the app at least once during the study period. Newman assortativity coefficient (R) was calculated from the study data to understand assortativity patterns of men by race. Pearson correlation coefficient was used to assess assortativity patterns by age. Heat maps were used to visualize the relationship between searcher's and candidate's characteristics by age band, race, or age band and race. RESULTS: From November 2015 through May 2016, there were 2,989,737 searches in all seven metropolitan areas among 122,417 searchers. Assortativity by age was important for looking at the profiles of candidates with correlation coefficients ranging from 0.284 (Birmingham) to 0.523 (San Francisco). Men tended to look at the profiles of candidates that matched their race in a highly assortative manner with R ranging from 0.310 (Birmingham) to 0.566 (Los Angeles). For the initiation of chats, race appeared to be slightly assortative for some groups with R ranging from 0.023 (Birmingham) to 0.305 (Los Angeles). Asian searchers were most assortative in initiating chats with Asian candidates in Boston, Los Angeles, New York, and San Francisco. In Birmingham and Tampa, searchers from all races tended to initiate chats with black candidates. CONCLUSIONS: Our results indicate that the age preferences of MSM are relatively consistent across cities, that is, younger MSM are more likely to be chatted with and have their profiles viewed compared with older MSM, but the patterns of racial mixing are more variable. Although some generalizations can be made regarding Web-based behaviors across all cities, city-specific usage patterns and trends should be analyzed to create targeted and localized interventions that may make the most difference in the lives of MSM in these areas.

Can the Heterosexual HIV Epidemic be Eliminated in South Africa Using Combination Prevention? A Modeling Analysis.

Little is known about how combining efficacious interventions for human immunodeficiency virus (HIV) prevention could lead to HIV elimination. We used an agent-based simulation model, the HIV calibrated dynamic model, to assess the potential for HIV elimination in South Africa. We examined several scenarios (from continuation of the current status quo to perfect achievement of targets) with differing combinations of male condom use, adult male circumcision, HIV testing, and early antiretroviral therapy (ART). We varied numerous parameters, including the proportion of adult males circumcised, the frequency of condom use during sex acts, acceptance of HIV testing, linkage to health care, criteria for ART initiation, ART viral suppression rates, and loss to follow-up. Maintaining current levels of combination prevention would lead to increasing HIV incidence and prevalence in South Africa, while the perfect combination scenario was projected to eliminate HIV on a 50-year time scale from 2013 to 2063. Perfecting testing and treatment, without changing condom use or circumcision rates, resulted in an 89% reduction in HIV incidence but not elimination. Universal adult male circumcision alone resulted in a 21% incidence reduction within 20 years. Substantial decreases in HIV incidence are possible from sufficient uptake of both primary prevention and ART, but with continuation of the status quo, HIV elimination in South Africa is unlikely within a 50-year time scale.

Racism as a Threat to Palestinian Health Equity.

Between October 2023 and April 2024, more than 30,000 Palestinians were killed, and countless others injured, displaced, and traumatized, in the fifth major Israeli assault on the Gaza Strip since 2006. Recent events, along with the trajectory of events over the past 75 years, demonstrate that using a public health framework could help recognize racism as a structural and social determinant of Palestinian health. Using the principles of health equity, we show how Palestinian health inequities are rooted in settler colonialism and racism, amounting to violence and oppression against Palestinian Arabs as a racialized group, regardless of religion or citizenship. Structural racism should be recognized as a driver of Palestinian health inequities.

Systems analysis and improvement approach to optimize tuberculosis (SAIA-TB) screening, treatment, and prevention in South Africa: a stepped-wedge cluster randomized trial.

BACKGROUND: The use of systems engineering tools, including the development and use of care cascades using routinely collected data, process mapping, and continuous quality improvement, is used for frontline healthcare workers to devise systems level change. South Africa experiences high rates of tuberculosis (TB) infection and disease as well as HIV co-infection. The Department of Health has made significant gains in HIV services over the last two decades, reaching their set "90-90-90" targets for HIV. However, TB services, although robust, have lagged in comparison for both disease and infection. The Systems Analysis and Improvement Approach (SAIA) is a five-step implementation science method, drawn from systems engineering, to identify, define, and implement workflow modifications using cascade analysis, process mapping, and repeated quality improvement cycles within healthcare facilities. METHODS: This stepped-wedge cluster randomized trial will evaluate the effectiveness of SAIA on TB (SAIA-TB) cascade optimization for patients with TB and high-risk contacts across 16 clinics in four local municipalities in the Sarah Baartman district, Eastern Cape, South Africa. We hypothesize that SAIA-TB implementation will lead to a 20% increase in each of: TB screening, TB preventive treatment initiation, and TB disease treatment initiation during the 18-month intervention period. Focus group discussions and key informant interviews with clinic staff will also be conducted to determine drivers of implementation variability across clinics. DISCUSSION: This study has the potential to improve TB screening, treatment initiation, and completion for both active disease and preventive measures among individuals with and without HIV in a high burden setting. SAIA-TB provides frontline health care workers with a systems-level view of their care delivery system with the aim of sustainable systems-level improvements. TRIAL REGISTRATION: Clinicaltrials.gov, NCT06314386. Registered 18 March 2024, https://clinicaltrials.gov/study/NCT06314386 . NCT06314386.