New strategies for an old disease: the social barriers to targeted testing and treatment of latent tuberculosis infection Open Access

Abstract

Tuberculosis (TB) is a bacterial infection that primarily affects the lungs and can be deadly if untreated. Although TB rates have significantly declined in the U.S., rates of decline have stalled. The primary driver of continued TB cases in the U.S. is due to longstanding, untreated latent tuberculosis infection (LTBI) among non-U.S.—born persons who have immigrated to the U.S. In response to these trends, the Centers for Disease Control and Prevention’s Division of Tuberculosis Elimination has updated its TB elimination strategic plan to include targeted testing and treatment of LTBI among non-U.S.—born populations, in addition to traditional monitoring and treatment of active disease. This dissertation provides an in-depth analysis of the social barriers to targeted testing and treatment of LTBI from two key perspectives: non-U.S.—born persons at-risk for LTBI and healthcare providers working in community health clinics (CHCs) who serve a large proportion of non-U.S.—born persons. Each chapter addresses one of the new TB elimination strategies: the focus on LTBI (Chapter 1), the focus on non-U.S.—born persons (Chapter 2), and the focus on shifting LTBI care to primary care settings (Chapter 3). The first chapter shows that participants disagree on how to classify LTBI, with some participants defining it as an illness state (infected with TB germs) and others defining it as a healthy state (not sick). These conflicting definitions lead to conflicting views on appropriate health behavior for someone diagnosed with LTBI. The second chapter shows that messages describing a link between country of birth and TB risk may be met with defensive responses, including challenging the logic of the link, or seeing oneself as exempt from risk messages because of TB tests taken for immigration. The third chapter shows that community health clinic staff still perceive the health department as the expert on LTBI, but see a benefit in keeping LTBI care in a patient’s medical home. Using sociological theories and frameworks, these papers identify key barriers that emerge in response to these shifting strategies while also highlighting fruitful areas for future interventions that can target these barriers.

Table of Contents

Table of Contents

INTRODUCTION .......................................................................................................................... 1

References ..................................................................................................................................... 14

Tables and Figures ........................................................................................................................ 23

CHAPTER 1: Do I have it or not? Latent tuberculosis infection and the consequences of liminal health categories............................................................................................................................ 25

References ..................................................................................................................................... 55

Tables and Figures ........................................................................................................................ 60

CHAPTER 2: Why does it matter where I am born? Defensive processing of health risk messages: The case of TB risk among immigrants ....................................................................... 67

References ..................................................................................................................................... 97

Tables and Figures ...................................................................................................................... 102

CHAPTER 3: To refer or not to refer: Primary care perceptions on shifting professional boundaries in tuberculosis prevention and care .......................................................................... 107

References ................................................................................................................................... 136

Tables and Figures ...................................................................................................................... 143

CONCLUSION ........................................................................................................................... 147

References ................................................................................................................................... 158

EXPLANATION OF ROLE IN COLLABORATIVE STUDIES .............................................. 159

Message testing project (CH. 1 and CH. 2) ................................................................................ 159

Community health clinic project (CH. 3) ................................................................................... 160

METHODOLOGICAL APPENDIX .......................................................................................... 161

Message testing moderator guide ................................................................................................ 161

List of messages tested................................................................................................................ 176

Photos of message testing facilities ............................................................................................ 179

Example fieldnotes...................................................................................................................... 182

Message testing codebook .......................................................................................................... 183

Visualization of message testing codebook modification ........................................................... 189

Example message testing structured search and analytical memo .............................................. 190

Example message testing structured searches of linguistic phrases ........................................... 192

Example message testing analytical matrix ................................................................................ 194

Medical uncertainty theoretical diagram .................................................................................... 196

Defensive processing framework ................................................................................................ 197

Defensive processing theoretical diagram .................................................................................. 198

Community health clinic staff interview guide (providers) ........................................................ 199

Visualization of interview schedule ............................................................................................ 204

Health department codebook ...................................................................................................... 205

Example health department analytical matrix............................................................................. 211

Tables and figures table of contents

INTRODUCTION. TABLES AND FIGURES

Figure 1. Reported TB Cases in the U.S. ...................................................................................... 23

Figure 2. Reported TB Cases by U.S.—born and non-U.S.—born .............................................. 24

CHAPTER 1. TABLES AND FIGURES

Figure 1. Conceptualizing health categories ................................................................................. 60

Table 1. Sample design ................................................................................................................. 61

Table 2. Group demographics ....................................................................................................... 62

Figure 2. Prior knowledge and experience with LTBI ................................................................. 63

Figure 3. Health and illness frameworks ...................................................................................... 64

Figure 4. LTBI as illness category ................................................................................................ 65

Figure 5. LTBI as healthy category .............................................................................................. 66

CHAPTER 2. TABLES AND FIGURES

Table 1. Sample design ............................................................................................................... 102

Table 2. Group demographics ..................................................................................................... 103

Figure 1. Counter-argumentation: how is country of birth relevant to TB risk? ........................ 104

Figure 2. Reason for TB testing among non-U.S.—born populations........................................ 105

Figure 3. Self-exemption: I passed the TB test before coming here ........................................... 106

CHAPTER 3. TABLES AND FIGURES

Table 1. Clinic characteristics ..................................................................................................... 143

Table 2. In-depth interview participants ..................................................................................... 144

Figure 1. Word Cloud of Last Interaction with the Health Department ..................................... 145

Table 3. Identified themes related to HD role in LTBI testing and treatment scale-up .............. 146

About this Dissertation

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School	Laney Graduate School
Department	Sociology
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Sociology, General Health Sciences, Public Health Sociology, Public and Social Welfare
Keyword	Behavioral science Public health Sociology Latent tuberculosis infection Health behaviors Tuberculosis Immigrants Risk perceptions
Committee Chair / Thesis Advisor	Irene Browne, Emory University
Committee Members	Timothy Dowd, Emory University Frank Lechner, Emory University John Parmer, CDC Monique Hennink, Emory University Tracy Ayers, CDC

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