Influences of the Homeless Shelter Environment on the Personal Experience of Tuberculosis Disease During a Large Outbreak in Atlanta, Georgia Open Access

Connors, William (2017)

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INTRODUCTION: Homeless persons represent a key high-risk population for tuberculosis (TB) among whom TB disease has outsized public health implications. Little is known about how homeless persons experience TB illness and prevention and control measures implemented in response to a TB outbreak. This qualitative study aimed to explore homeless persons' TB disease experiences in the context of a large TB outbreak involving overnight homeless shelters in Atlanta, Georgia.

METHODS: In-depth interviews were conducted with a purposive sample of homeless persons with active TB disease residing in Atlanta during the shelter outbreak. Key themes were identified through analysis of coded data. Following interviews a demographic questionnaire was completed and participants' medical records were reviewed.

RESULTS: Ten participants (9 male, 1 female, all African American and US born) with baseline high-risk profiles for TB were interviewed. Nine participants had sputum culture positive disease, five (56%) had the TB strain associated with the ongoing homeless shelter outbreak and four had distinct TB strains. Interviews contained five pervasive themes: (i) health and behavioral impact of the homeless shelter context, (ii) influence of homelessness on disease experience, (iii) role of acute health care services, (iv) experiences with shelter-based interventions implemented in response to the TB outbreak, and (v) sources of TB knowledge and health literacy. The central theme to emerge from analysis was that stressful social environments of homeless shelters shape illness experiences, healthcare-seeking behaviors, and limit the influence of shelter-based prevention and control measures implemented in response to a TB outbreak.

CONCLUSIONS: Homeless shelter related stress may have important implications for the prevention and control of TB outbreaks in this setting, hindering case finding and supporting a model of supplemental TB education and latent tuberculosis infection testing services at proximal community venues. Systematic qualitative assessments in the context of evolving public health responses may provide novel insights that can strengthen TB elimination efforts.

Table of Contents

CHAPTER 1 : Introduction

1.1 Introduction and rationale

Figure 1: Tuberculosis incidence among US- & foreign-born persons, by yr. - US, 2000-15

1.2 Problem statement

1.3 Purpose statement

1.4 Research questions

1.5 Significance statement

1.6 Definition of terms

CHAPTER 2 : Literature Review

2.1 Epidemiology of tuberculosis among the United States homeless population

Figure 2: Tuberculosis cases reported among homeless persons - US, 1993-2015

Figure 3: Point-in-time national overall homelessness rate - US, 2007-15

2.2 Qualitative research on the homeless health experience

2.2.1 Healthcare system experiences & their influence on health seeking behaviors

2.2.2 Qualitative research on the homeless health experience specific to TB

CHAPTER 3 : Manuscript

Table 1: Participant demographics and route to TB diagnosis

Table 2: Participant tuberculosis profile and diagnostics

Figure 1: Typical case representing patterns of healthcare engagement

CHAPTER 4 : Recommendations


APPENDIX 1: Interview Guide

APPENDIX 2: Post-interview Questionnaire

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