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Appendix C: TB Behavioral and Social Science Research Gaps and Needs: Major Research Topics, Subtopics, and Research Questions

Major Research Topics, Subtopics, and Research Questions

VI. Public Policy

Public policy influences focus on the implications that public policies have on the behaviors of individuals, groups, communities, and organizations, with special emphasis on issues relating to government commitment, funding, health insurance, and immigration policies.

A. Government commitment and funding

Governmental entities, from federal to local, play a critical role in TB-related services. From federal-level research funding to service delivery at local health departments, TB control is affected greatly by policy decisions. Given these arrangements, the development of a better understanding of the policy process and greater engagement of decision-makers by those working in TB control may lead to improvement in TB services.

Forum participants identified as important the need to focus on identifying appropriate decision makers, potential advocates, and strategies to influence TB-related policies. They also specifically addressed funding issues such as the identification of effective ways to advocate for TB funding as well as possible models for allocation of funds within the TB framework.

  • Who are the TB local, state, and national policy-makers? What are their interests? How can TB be made a policy agenda item?
  • How can state programs be influenced to advocate for TB? Where are the decisions being made?
  • Who are the best advocates for TB control? (i.e., What is the role of state programs in advocacy?)
  • What are the best ways to advocate for TB funding?
  • What are some ways to conduct a demonstration in which TB funding is allocated similarly to Ryan White Care Act dollars? What are some ways to test an HIV model (e.g., Ryan White Care Act) within the TB framework?
  • Which cultural interventions can be practically integrated into TB programs with limited resources?

B. Health insurance

As of 2002, data from the U.S. Census Bureau indicated that 43.6 million people were uninsured in the United States.3 The lack of health insurance among people in the U.S. creates a serious impediment for those who seek or wish to seek health care for LTBI or TB disease, especially as it relates to TB testing and treatment. It is unknown to what extent a lack of appropriate insurance coverage or fear of treatment costs hinder care-seeking, but it is suspected that this economic deterrent has clear negative implications.

Forum participants identified the need to determine the effect of health insurance or lack of appropriate coverage for TB services on health behaviors and health outcomes, including access to TB diagnosis and treatment. Further research is needed to determine the impact this has on TB patients and their families, in addition to finding alternative funding solutions to increasing health care costs and expenses.

  • What is the effect of health insurance (or lack thereof) in regards to early interventions for the treatment of TB?
  • How can the poor get health access (e.g., insurance)?

C. Immigration policies

With over half of TB cases in the United States occurring among individuals born outside of the country, the link between immigration and TB services has become increasingly important in recent years. Efforts to coordinate public health efforts with immigration activities pose an evolving challenge as changes occur to immigration policy and enforcement agencies. Understanding the impact of these specific changes as well as developing a broader body of knowledge of immigrant issues in general, will likely lead to improved TB services and better health outcomes.

Forum participants identified as important the need to focus on the effect of immigration policies, specifically regarding recent changes to policies, on TB services. Additional discussion focused on the need to develop strategies for collaboration with immigration authorities to increase access to immigrant communities.

  • What is the effect of new immigration policies on TB case identification, follow-up, treatment, and adherence? What about their effect on TB control among Latino immigrants?
  • What types of research are needed to maximize the screening of new and recent arrivals? Issues to address include access to the population and collaboration with Immigration and Customs Enforcement.
  • How can undocumented persons be helped to overcome their fear of government agencies and institutions?

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