Developing Tuberculosis Prevention Strategies via Interdisciplinary Systems-Thinking: Latent Tuberculosis Infection Risk Recognition and Care

Abstract

Background: Tuberculosis (TB) remains a threat to public health, both globally and within the US. An estimated 80% of active TB cases in the US are from reactivation of latent TB infection (LTBI). Reactivation is preventable with proactive, targeted LTBI screening and treatment but public health agencies lack the capacity to mitigate this threat. Recent guidelines recommend that LTBI-related services be rendered by private sector healthcare providers. In order to identify systemic barriers to appropriate LTBI-related care in the private sector and brainstorm new strategies to facilitate this care, UNTHSC hosted an LTBI Systems Thinking Symposium. Aims: 1) To identify barriers and facilitating factors that influence patient and provider recognition of LTBI risk and subsequent care-seeking or care-recommending behavior, as articulated by symposium participants. 2) To determine whether the factors identified by attendees varied by attendee profession. Methods: Thirty healthcare and public health professionals were divided into 6 interdisciplinary groups. Participants identified barriers to care and opportunities to facilitate care by discussing each step in the LTBI care continuum. We used Grounded Theory approach to code participants’ distinct ideas. Each open code was systematically categorized into axial codes by two independent coders. A third coder calculated inter-coder reliability; the two coders agreed 80% of the time. Coders collaborated on the remaining 20% to create a final list of axial codes, which were further categorized into selective themes. Results: Barriers (78%) to targeted LTBI screening and treatment were mentioned more frequently than strategies to facilitate care (22%). The top three barriers were lack of awareness among patients, lack of ideal testing tools, and lack of health insurance among high-risk persons. Facilitators included increasing patient awareness, health insurance that covers LTBI services, community outreach, and population-level health communication. Variations in perceived barriers and facilitating factors based on the industries our participants represented were observed. Conclusion: Both patient and health systems-related factors present barriers to the initial identification of LTBI in the private sector healthcare setting, but there are opportunities to overcome these barriers. The facilitating factors identified by symposium participants can serve as beacons for prevention strategies and future health policies.