“It’s too hard” – the management of latent TB in under-served populations in the UK: a qualitative study

Abstract

Background UK national guidance recommends systematic screening for latent tuberculosis infection (LTBI) in under-served populations, including people experiencing homelessness and people who use drugs. This is not routinely implemented in the UK, and the reasons for this policy-practice mismatch remain underexplored. Methods Semi-structured qualitative interviews were conducted with 19 healthcare professionals from across the UK. Participants were recruited using purposive sampling and snowballing, identifying individuals with excellent knowledge of their regions practice and policy of LTBI management. The interviews were conducted online, and were audio recorded, with transcripts thematically analysed using a two-stage inductive coding process to explore perceived barriers and enablers to LTBI screening. Results Most participants had previous experience managing LTBI in under-served populations, but none were conducting systematic screening as per national guidance. We identified service provision challenges and low prioritisation of LTBI as the key explanatory themes driving this policy-practice mismatch. Lack of resource, and the complexity of clinical decision making were two key service level barriers. System and service inertia, and lack of cost effectiveness evidence led to LTBI being deprioritised. Service integration and promotion of WHO targets for TB elimination were highlighted as potential solutions. Conclusion Integrating LTBI testing and treatment with existing health services for under-served populations could improve feasibility and efficacy. Promotion of UK TB elimination goals and generation of regional evidence to support commissioning for LTBI care is vital. Without such a multi-pronged approach inertia is likely to persist and the zeitgeist will remain: “it’s too hard”.

A synthesis of qualitative evidence of barriers and facilitators in implementing guidelines for TB testing in healthcare settings

“…Eight studies were from lower-middle-income countries [ 9 , 31 , 36 , 37 , 40 , 41 , 43 , 46 ], five were from upper-middle-income countries [ 6 , 33 , 34 , 39 , 45 ], six were from high-income countries [ 7 , 8 , 32 , 38 , 47 , 48 ] and two were from low-income countries [ 35 , 42 ]. Four studies had representatives from a mix of countries with different income levels [ 5 , 29 , 30 , 44 ].…”

“…For providers of care, lack of confidence in TB tests, mistrust of the guidelines, fear of misusing tests, perceived difficulty in obtaining specimens and patients’ reaction guiding practice were barriers to implementing TB diagnostic guidelines [ 6 , 29 – 32 , 34 – 36 , 40 , 41 , 43 – 45 , 47 , 48 ]. Lack of confidence in TB test factors were perceived non-feasibility, low sensitivity of diagnostic tests and scepticism about test speed and reliability [ 6 , 29 – 32 , 34 – 36 , 40 , 41 , 43 – 45 , 47 , 48 ]. Providers deviated from guidelines/algorithms based on their perceptions of patient reactions to clinical decisions, for example, ordering X-rays against clinical policy to meet perceived expectations of the patient [ 29 ].…”

“…All barriers were reported across both LMICs and HI countries. The potential to reduce future workload promoted the implementation of guidelines in both LMICs and HI countries [ 47 ].…”

“…For providers of care, barriers to implementing TB diagnosis guidelines were poor awareness and understanding of guidelines/diagnostic algorithms, poor understanding of TB disease and challenges in sample collection, especially among children [ 6 – 8 , 31 , 34 , 36 , 37 , 39 – 41 , 43 , 44 , 47 , 48 ]. Adequate knowledge about the guidelines/diagnostic algorithms and disease promoted the implementation of TB diagnostic guidelines [ 5 , 6 , 36 , 37 , 40 , 43 , 45 , 46 , 48 ].…”

“…Poor facilities, such as insufficient tests and infrastructure and logistical and poor specimen transport issues, were crucial barriers to TB diagnostic guideline implementation in LMICs [ 6 , 35 , 39 , 41 , 42 , 45 , 46 ]. The COVID-19 pandemic disrupted the implementation of guidelines as TB screening services were paused and priority was given to the COVID-19 pandemic and was reported in a HI country [ 47 ].…”