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Journal of Community Health Nursing

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Barriers to and Interventions for

Improved Tuberculosis Detection
and Treatment among Homeless and
Immigrant Populations: A Literature
Review
a
Mariya Tankimovich
a
University of Texas Health Science Center at Houston , Houston ,
Texas
Published online: 09 May 2013.

To cite this article: Mariya Tankimovich (2013) Barriers to and Interventions for Improved Tuberculosis
Detection and Treatment among Homeless and Immigrant Populations: A Literature Review, Journal of
Community Health Nursing, 30:2, 83-95, DOI: 10.1080/07370016.2013.778723

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 Journal of Community Health Nursing, 30: 83–95, 2013
Copyright © Taylor & Francis Group, LLC
ISSN: 0737-0016 print / 1532-7655 online
DOI: 10.1080/07370016.2013.778723

Barriers to and Interventions for Improved Tuberculosis

Detection and Treatment among Homeless and Immigrant
Populations: A Literature Review

Mariya Tankimovich
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University of Texas Health Science Center at Houston, Houston, Texas

Tuberculosis (TB) cases worldwide have declined over the last 10 years, but strong barriers to detec-
tion and treatment of TB still exist, especially among 2 special subgroups of low-income populations,
immigrants and the homeless, where the incidence of TB can be up to 20 times higher than the gen-
eral population even in affluent countries.
A systematic review of literature was performed, aimed at identifying the main (1) barriers to
and (2) effective interventions for the improved detection and treatment of TB in homeless and
immigrant populations. Data were collected from 22 studies out of 80 potentially relevant citations
worldwide published between 1998 and 2012. Key findings show that hard-to-reach groups like immi-
grants and the homeless seem willing to obtain care if they believe it is important, but any new
detection/treatment efforts must go beyond current bio-medical models to bio-psychosocial models
of the target populations’ cultural values. Preliminary results also suggest that the best interventions
for the homeless and immigrant populations will be a combination of, at least, monetary incentive
and improved accessibility of care.

The spread of tuberculosis (TB) manifests above-normal prevalence in low-income populations,

even in industrialized nations (Carvalho, Migliori, & Cirillo, 2010; de Vries & van Hest 2005).
Because low-income populations are socioeconomically unstable, members of the population
who have the disease are often faced with the dilemma of seeking treatment at the risk, for
example, of losing their jobs (Noyes & Popay, 2007; Van Rensburg et al., 2003); others in
low-economic populations commonly lack adequate health literacy and may cease treatment
prematurely (i.e., when TB symptoms disappear; Chamanga, 2010).
Particularly problematic are the barriers to detection and treatment of TB among two special
subgroups of low-income populations: immigrants and the homeless. In the United States, over
half of all cases of TB occur in those born abroad (58%), an increase of 28% since 1993 and
10 times higher than in US-born subjects. Moreover, because of inadequate detection methods and

Address correspondence to Mariya Tankimovich, MSN, APRN, FNP-C, UTHSCH School of Nursing, Department of
Family Health, 6901 Butner Ave., Room 771, Houston, TX 77030, E-mail: m.tankov@sbcglobal.net
 84 TANKIMOVICH

the nature of the disease, half of the foreign-born cases are not detected until 5 years after arrival,
because only a small percentage have active pulmonary disease detectable via chest x-ray at the
time of immigration. Chest x-ray detects only an active respiratory disease, and it detects neither
nonrespiratory TB nor latent TB infection (LTBI), which are the most prevalent presentations in
immigrants (Moore-Gillon, Davies, & Ormerod, 2010).
The distinction between symptomatic active TB disease and asymptomatic LTBI is crucial as
an estimated one-third of the world’s population has LTBI. Roughly, one-tenth of this approxi-
mately 2 billion people will develop an active disease in their lifetime. LTBI may turn into TB
disease. A person with LTBI has a 90% chance of living his or her life without developing TB
disease, but a 10% chance of developing TB disease during his or her life. The greatest chance of
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LTBI turning into TB disease is in the 2 years after becoming infected (World Health Organization
[WHO], 2012).

THE HOMELESS AND TB

For the homeless, TB has been seen as a serious health threat since the early 20th century.
The connections between stable housing and good health are well-established (Kirkpatrick &
Byrne, 2009), and international literature shows that homeless adults have mortality rates three
to four times higher than housed individuals (Nordentoft & Wandall-Holm 2003; Ohsaka, Sakai,
Kuroda, & Matoba, 2003). Although efforts by agencies such as the Center for Disease Control
and Prevention (CDC) have helped create an unprecedented decline in TB cases over the last
10 years (Lashley, 2006), the threat of TB can be up to 20 times higher in the homeless than
in the general population (Figueroa-Munoz & Ramon-Prado, 2008). It is estimated that between
18% and 51% of the homeless have LTBIs, and that such high rates among the homeless are
attributable not only to their low-income status but to risk factors like alcohol and drug abuse,
HIV infection, greater chance of environmental exposure to TB (Lashley, 2006), and the lack of
safe places to rest and recuperate from the disease (Zlotnik & Zerger, 2008). Moreover, accord-
ing to Khan et al., (2011), as the number of foreign-born homeless people increases, the risk of
TB strains resistant to drugs increases, and inadequate detection and treatment levels in high-
income countries (51% and 70% vs. WHO targets of 70% and 85%) are largely attributable to
multidrug resistant strains of TB, many of which are prevalent in Eastern Europe (Carvalho et al.,
2010).
For immigrant and/or homeless populations, cultural and socio-political barriers exist in addi-
tion to socioeconomic-related barriers. Immigrants without legal status often will not seek out
and/or follow up with medical care, and they will also avoid giving useful contact information
in case health care professionals wish to follow up themselves. The homeless also tend to lack
contact information, and living on the streets exposes them to violence, contagious disease, and
the stigma of being perceived as possibly dangerous people on the fringes of normal society
(Chamanga, 2010).
The main objective of this literature review was to discover answers to the following questions:
What are the main barriers to the detection and treatment of TB in immigrant and homeless pop-
ulations in the United States? What interventions work to break down these barriers to detection
and treatment?
 TB BARRIERS AND INTERVENTIONS: A LITERATURE REVIEW 85

METHODS

Theoretical Framework

Pender’s Health Promotion Model (HPM) is a middle-range nursing theory applicable to

understanding certain of the barriers identified that hamper the successful detection and treat-
ment of TB in two low-income population subgroups: immigrants and the homeless. The HPM is
a model aimed at motivating people to engage in behaviors that enhance their health by analyz-
ing biological, psychological, and social processes influencing their behavior in, and specifically
their behaviors related to, their personal health and its maintenance (Pender, 1996).
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The major concepts of the model and their relations are (a) individual characteristics and expe-
riences: individual personality traits, as well as the nature of an individual’s personal experiences,
will affect how they value or disvalue ideas, goals, actions, and procedures—and thus commit-
ments to health-promoting behaviors; (b) behavior-specific cognitions and affect: perceptions of
benefits or barriers to actions, perceptions of one’s ability to carry out actions, perceptions of
others’ values about actions or perceptions of the situations in which the action must occur will
affect the likelihood of behaviors leading to health enhancement being committed to or the extent
to which they will be carried out; and (c) behavioral outcomes: commitments to a plan of action,
immediate competing demands and preferences, influences of behaviors competing with such
plans, and health-promoting behavior, are model-specific measures for determining successful
health- enhancement strategies (Pender, 1996).

Application of Pender’s HPM Model

This review aimed to analyze, understand, and suggest ways to overcome barriers that hamper
adequate detection and treatment of TB among two “hard to reach” populations (Chamanga,
2010, p. 29), defined for these purposes as immigrants and the homeless. Overall, the liter-
ature review proposes to apply select concepts from the HPM Model as a guide to explore
more systematically how these groups are hard to reach and what that suggests about the pos-
sible design for interventions to increase desirable detection and treatment outcomes for TB.
Researchers are aware that other theoretical models might be better adapted to analysis of
some of the barriers involved in TB detection and control (e.g., problems with the diagnostic
accuracy of TB tests or analyses of political or social structures like immigration policy and
illegal alien laws), but the HPM seemed well-adapted to barriers relating to issues of personal
motivation.
For example, in relation to the immigrant population, the HPM concepts of “prior related
personal experiences” and “interpersonal influences” (Pender, 1966) are particularly important
as analytic tools. Immigrants might be accustomed to different levels of availability or different
health-care procedures because of their previous experiences. Also, an immigrant patient might
be subject to kinds of family/peer pressures or attitudes toward illness different from those
common in their host country. For the homeless, the HPM concepts of “situational influences”
(e.g., limited options) or “immediate competing demands” (over which the population may
have little control) are fruitful investigative tools which may help explain why the homeless
are particularly difficult to contact; how their possible exposure to alcohol, drug abuse, and
 86 TANKIMOVICH

HIV might stymie their willingness to pursue desirable health-related behaviors; and how those
same situational influences affect the kinds of interventions that can be designed to increase the
frequency of health-enhancing behaviors.

Expected Relationships among the Variables

The majority of researchers reviewed in this article hypothesized that a more detailed understand-
ing of the motives of immigrant and homeless populations may open the door to the design of apt
interventions intended to break down barriers to TB detection and control (especially Chamanga,
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2010; Chemtob et al., 2003; Gelberg et al., 2007; Gele et al., 2010). Some focused on cultural
values and beliefs as key motivators, citing ideas such as “personal sociocultural influences”
and “interpersonal influences” (Chamanga, 2010, p. 29). Others, notably Tulsky et al. (1999,
p. 531), maintained the importance of values or “motivational determinant” specific to popu-
lation environments. For example, for the homeless, the idea of competing demands (Pender,
1996) is operative insofar as the need to obtain shelter often competes with executing desir-
able TB treatment/adherence behaviors (Tulsky et al., 2004). In one study it was hypothesized
that case management interventions in homeless situations would help reveal population motives
and inform ways to better educate target populations (Nyamathi et al., 2006). Overall, better
knowledge about TB population motives is assumed as key to more effective TB population edu-
cation, and that education can, in turn, better motivate more desirable health behaviors among TB
populations.

Search Strategy

Databases searched for this review were MEDLINE, CINAHL, WHOSIS, and CDC.GOV. The
main topics searched were tuberculosis detection & treatment, barriers to TB detection and treat-
ment, barriers prevalent among homeless and immigrants,” and types of interventions to increase
instances of TB detection and treatment. The review was aimed at the behaviors/values of the
homeless and immigrant populations with TB, primarily in the United States. Nonetheless, the lit-
erature search included articles with an international scope based on the assumption that different
behaviors/values held by immigrant populations could be identified, as could any cross-cultural
universals that might exist. Keyword combinations used were TB + homeless, TB + immigrants,
TB + homeless + barriers, TB + immigrants + barriers, TB + detection + prevention +
treatment + barriers, and TB + barriers + interventions.”

Selection Criteria

Included articles were research studies published between 1998 and 2012, in English, which
employed either quantitative and/or qualitative methods (a) to examine TB detection/treatment
barriers in homeless and immigrant populations, and/or, (b) to test or evaluate interventions to
barriers to TB detection/treatment among the immigrant and homeless populations. Included arti-
cles displayed: clear and concise abstracts, clearly stated research questions, clearly defined key
 TB BARRIERS AND INTERVENTIONS: A LITERATURE REVIEW 87

Studies retrieved using all search

terms from screened databases
N = 80

Studies excluded; reviews, case

studies or non-related area of
interest
n = 40
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Abstracts retrieved for more

detailed evaluation
n = 34

Studies excluded after reading

full text:
• don’t meet inclusion criteria
regarding variables & /or
populations studied
n = 18

Studies included in this review

that meet inclusion and quality
criteria
n = 22

FIGURE 1 Flow Diagram of Literature Searches.

terms, appropriate methods of statistical analysis, and clear discussions of investigative results
and their implications. Excluded studies failed to meet one or more of the aforementioned criteria
(See Figure 1).

Data Abstraction and Synthesis

Data extraction forms were designed and the following datasets collected for each: purpose (bar-
rier or intervention), type (qualitative or quantitative), location, number/type of subjects, study
design, outcomes/methods of measurement, findings on differences, and overall study quality.
 88 TANKIMOVICH

RESULTS

Characteristics of the Studies

Of the 22 articles included, 17 were quantitative and 5 were qualitative. Twelve studies focused
on barriers to TB detection/treatment, and the remaining 10 studies either directly tested or
evaluated intervention strategies to improve TB detection/treatment. The barrier studies focused
on the homeless and/or immigrant populations themselves and how their personal and cultural
attitudes and behaviors, their knowledge about health care and TB in particular, and their habits
and living conditions contributed to TB risk. Five barrier studies were qualitative, relying on
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personal interviews with a sample of homeless and/or immigrant populations (Chamanga, 2010;
Chemtob, Levanthal, & Weiler-Ravell, 2003; Gelberg, Andersen, & Leake, 2000; Gelberg et al.,
1997; Gele, Sagbakken, Abebbe, & Bjune, 2010). The remaining seven barrier studies were quan-
titative (Carvalho et al., 2010; Haddad, Wilson, Ijaz, Marks, & Moore, 2005; Khan et al., 2011;
McAdam, Bucher, Brickner, Vincent, & Lascher, 2009; McElroy et al., 2003; Mohtashemi &
Kawamura, 2010; Tulsky, White, Young, Meakin, & Moss, 1999) and used different methodolog-
ical approaches. Four of the quantitative barrier studies were cross-sectional analyses (Carvalho
et al., 2010; Gelberg et al., 1997; Mohtashemi & Kawamura, 2010; Tulsky et al, 1999). The study
by Mohtashemi and Kawamura (2010) applied wavelet coherence and phase analyses to reach a
compelling finding that TB rates and the spread of TB in homeless populations, where TB and
HIV frequently overlap, hinge upon the interdependence of these two diseases within the target
population. The remaining three quantitative barrier studies (Haddad et al., 2005; Khan et al.,
2011; McAdam et al., 2009) were retrospective cohort studies.
The 10 intervention studies, all quantitative, tested different ways, or evaluated previously
tested strategies, to improve TB detection and treatment completion among hard to reach groups.
Five of the studies focused on the consequences of making TB detection and treatment more
accessible to the target populations (deVries & van Hest, 2005; Kong et al., 2002; Lowenthal
et al., 2011; Marks et al., 2000; Varkey et al., 2010). Two of these were technology-based inter-
ventions (deVries & van Hest, 2005; Kong et al., 2002) using advanced screening technologies
for detection. Kong et al. (2002) used DNA fingerprinting; deVries and van Hest (2005) used
digital X-ray and molecular technologies for detection. Three of the studies tested the efficacy of
monetary (e.g., cash or cash value) incentives given directly to TB patients to evaluate their effect
on increasing detection and treatment of TB and treatment adherence (Bock, Sales, Rogers, &
DeVoe, 2001; Davidson et al., 2000; Tulsky et al., 2004). Three intervention studies tested a com-
bination of motivational and accessibility strategies (Carvalho et al., 2010; Marco et al., 1998;
Nyamathi, Chritiani, Nahid, Gregerson, & Leake, 2006).

Location. TB among the homeless population and immigrants is a worldwide health care
problem, especially in large cities. Studies in the last 10–15 years have reported that TB is a prob-
lem for homeless and immigrant populations in Spain (Marco et al., 1998), Israel (Chemtob et al.,
2003), England (Chamanga, 2010), The Netherlands (deVries & van Hest, 2005), and Ethiopia
(Gele et al., 2010). However, nearly half of the studies (n = 9) reported TB among the homeless
and immigrant population in the United States, especially in larger cities (San Francisco, Los
Angeles, New York, Denver, Raleigh), confirming that research most often occurred in commu-
nity settings (i.e., homeless shelters, soup kitchens, etc.), often in skid-row areas in urban centers.
 TB BARRIERS AND INTERVENTIONS: A LITERATURE REVIEW 89

One study (Gelberg et al., 2000) included a population on the street in Los Angeles that was not
using community resources. Two studies used data sets representing populations from the United
States at large (Davidson et al., 2000; Marks et al., 2000).

Subjects. The number of subjects in the quantitative studies ranged from 186,000 in a cross-
sectional study (Haddad et al., 2005) to nine in a study (McElroy et al., 2003), which required
that subjects be frequenters of a specific homeless shelter. Two quantitative studies gave no count
(Kong et al., 2002; Chemtob et al., 2003). Excluding the high and low counts for quantitative
studies, the mean was approximately 20,000 subjects.
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Qualitative studies ranged from 19 subjects (Gele et al., 2010: a pastoral/nomadic population
in Ethiopia) to 363 subjects (Gelberg et al., 2000); two were indeterminate, and the mean =
214. One qualitative analysis did not specify the number of subjects (Chamanga, 2010). Only
two studies specified an age range for subjects (Nyamathi et al., 2006: ages 18–55; Marks et al.,
2000: age 15+); no indication of age range was otherwise included in the remaining studies.
Subject characteristics included homelessness or immigrant status and those currently diag-
nosed with TB, LTBI, or in a high-risk profile for TB acquisition or those who might be in contact
with other at-risk people. Most studies (n = 17) did not explicitly define the term homeless, but
culled their sample from subjects living on the streets or from probability samples or other data
sources (e.g., the CDC). Nyamathi et al. (2006, p. 776) specified that homeless meant “slept in
one of the study shelters the previous night.” Gelberg et al. (2000) required that a homeless person
had spent at least one night in a 2-week period in an impermanent shelter or a place not designed
for shelter. Marco et al. (1998) studied a sample of prison inmates who had no other permanent
residence. One study (McElroy et al., 2003) required that TB infected subjects have a history of
residence at the same homeless shelter.
Bock et al. (2001) and Marks et al. (2000) only used subjects who were on a treatment regimen
(unspecified) and had missed directly observed therapy (DOT) doses. Bock et al. required that
subjects miss at least 25% of DOT doses in a 4-week period; Marks et al. defined a treatment
interruption as missing more than 2 weeks of DOT. Mohtashemi and Kawamura (2010), who
investigated risk factors in a TB and HIV environment, included 387 homeless subjects who were
both TB+ and HIV+. Gele et al. (2010), in his qualitative study, required only that subjects be TB
infected and knowledgeable about TB, their living environments, and local (pastoral) community
attitudes.

Designs and outcomes. An overarching assumption of the researchers in the chosen arti-
cles (especially Chamanga, 2010; Chemtob et al., 2003; Gelberg et al., 2007; Gele et al., 2010)
was that cultural and subcultural factors, such as attitudes toward illness in general or TB specif-
ically, or attitudes toward health care, would vary and might also reveal barriers to detection and
treatment of TB.
All but two of the 10 intervention studies (Bock et al., 2001; Kong et al., 2002) employed
randomized clinical trials assessing the efficacy of either personal incentives, improved treatment
access and/or improved treatment effectiveness to bring about desired outcomes (Davidson et al.,
2000; de Vries & van Hest, 2005; Lowenthal et al., 2011; Marco et al., 1998; Marks et al., 2000;
Nyamathi et al., 2006; Tulsky et al., 2004; Varkey et al., 2010). Incentives were mainly cash
or cash-value in nature, but sometimes incentive took the form of social aid (e.g., a subsidized,
monitored methadone regimen) in the case of inmates with TB and/or HIV (Bock et al., 2001;
 90 TANKIMOVICH

Davidson et al., 2000; Marco et al., 1998; Nyamathi et al., 2006; Tulsky et al., 2004). Another
common study purpose was to evaluate the effectiveness of already existing programs of detection
or care, individually or comparatively (e.g., a nurse case management intervention [NCMI] vs.
care without NCMI) to assess attainment of desired outcomes (Nyamathi et al., 2006). One study
tested mobile digital X-ray units, a novel technology, to facilitate outreach strategies to TB control
among hard to reach groups (de Vries & van Hest, 2005).
Dependent variables in the ten intervention studies were distributed as follows: six studies
measured improvements in treatment adherence and/or completion (Bock et al., 2001; Davidson
et al., 2000; Lowenthal et al., 2011; Marco et al., 1998; Nyamathi et al., 2006; Tulsky et al., 2004;
Varkey et al., 2010); four measured reduced spread of TB occurrence (Marks et al., 2000; Kong
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et al., 2002; de Vries, van Hest, & Richardus, 2007); one also measured increased knowledge of
TB and its effects on treatment completion (Nyamathi et al., 2006).
Of the 12 barrier studies, eight were cross-sectional analyses (Carvalho et al., 2010; Chemtob
et al., 2003; Gelberg et al., 2000; Gelberg et al., 1997; Gele et al., 2010; Khan et al., 2011;
Mohtashemi & Kawamura, 2010; Tulsky et al., 1999), three were retrospective cohort studies
(Haddad et al., 2005; McAdam et al., 2009; McElroy et al., 2003), and one was a study of the val-
ues of “hard to reach groups” using the bio-psychosocial model as the analytic tool (Chamanga,
2010, p. 29). Five of the barrier studies measured increased knowledge about TB and its effects
on the greater willingness to obtain available health care; improved control over the spread of TB;
and, shortened follow-up time to treatment after disease detection (Chamanga, 2010; Chemtob
et al., 2003; Gele et al., 2010; Gelberg et al., 2000; Tulsky et al., 1999). Three barrier studies
focused on the role of improved TB patient knowledge in relation to completion and adherence
outcomes, each using pre- and postintervention questionnaires (Gelberg et al., 1997; Nyamathi
et al, 2006; Tulsky et al., 1999).

Discussion

Hard-to-reach groups, like the homeless and immigrant populations, will continue to pose sig-
nificant problems for the detection and treatment of TB (Chamanga, 2010; Chemtob et al.,
2003). Although there is a general trend toward a reduction of the transmission of TB among
the homeless (McAdam et al., 2009), relevant studies show that formidable barriers, working
in a complex dynamic (Gelberg et al., 1997; Nyamathi et al. 2006), will continue to make
the detection/treatment of TB among homeless and immigrant populations especially difficult.
An overarching barrier is the inadequate health literacy among these populations (Tulsky et al.,
2004), but other barriers are equally operative in this complex dynamic. The homeless (and immi-
grants to a significant extent, as well), even if willing to seek detection/treatment, often do not
have conveniently accessible or affordable facilities for detection and treatment (Gelberg et al.,
1997; Nyamathi et al. 2006). Consequently, opportunities for detection are often threatened and
treatment regimens are either stymied before they get started or are prematurely interrupted.
Cultural, value-laden barriers may exacerbate the problem (Chamanga, 2010). Immigrants are
sometimes health literate, but their native health knowledge may conflict with the health knowl-
edge of the culture into which they have emigrated, such as negative attitudes toward TB and
attendant behaviors. Also, many knowledgeable immigrants may not seek treatment for fear of
revealing their (illegal) immigration status. The difficulty in tracing contacts of infected homeless
 TB BARRIERS AND INTERVENTIONS: A LITERATURE REVIEW 91

and some immigrants thwarts measures to curb the spread of the disease (Chemtob et al., 2003;
de Vries & van Hest, 2005; Kong et al., 2002; Marks et al., 2000). Mohtashemi and Kawamura
(2010) reported that in San Francisco, the problem of tracing contacts for TB was compounded
by the interdependence between TB and HIV in the homeless population.
There is, however, a general trend toward a reduction of the transmission of TB among the
homeless (Khan et al., 2011; McAdam et al., 2009). Moreover, the TB burden might be further
reduced—and is perhaps best reduced—if coordinated collaborative programs were employed
(Kong et al., 2002; Marco et al., 1998; Varkey, 2010). Monetary incentives such as cash and cash
value tokens/items, especially when increased over time, are very useful interventions on their
own for TB homeless populations (Davidson et al., 2000). They bring about desired outcomes
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and are cost-effective in the process—informally estimated to be less than the cost of treatment
for one case of TB (Bock et al., 2001). Incentive programs were even more effective if incentives
were meted out at locations conveniently accessible to the target population (Gele et al., 2010;
Tulsky et al., 2004; Tulsky et al., 1999) and in conjunction with nurse case management programs
that have an educational component (Nyamathi et al., 2006). Finally, Chamanga (2010) judged
that any coordinated detection/treatment efforts must go beyond current bio-medical models that
guide TB detection and treatment to involve a complementary bio-psychosocial model, especially
for hard-to-reach groups such as the homeless and immigrants.
There were two recurrent findings: Although egalitarian and efficient TB control is still diffi-
cult to guarantee (Chemtob et al., 2003), hard-to-reach groups like the homeless and immigrant
populations seem willing to obtain care if they believe it is important—and that is a function
of education (Gelberg et al., 2000), increased knowledge in conjunction with case management
(Nyamathi et al., 2006), and a better understanding of cultural attitudes and beliefs that create
barriers to detection/treatment of TB (Chamanga, 2010; Gelberg et al., 1997; Gele et al., 2010).

Summary of Significant Findings

Barriers. Barriers to TB detection and treatment among homeless and immigrant popula-
tions consist in a “complex dynamic” of:

• Inadequate convenient accessibility of health care facilities and technology to target popu-
lations: TB clinics need to be in strategic places relative to target populations (Gele et al.,
2010), and Gelberg et al. (2000) noted that homeless are willing to obtain health care if it is
conveniently available;
• Inadequate education about TB among target populations: Hard-to-reach groups like the
homeless and immigrant populations seem willing to obtain care if they believe it is
important—and such belief is a function of education (Gelberg et al., 2000);
• Native health knowledge conflicts that often thwart desirable detection and treatment behav-
iors: Improved TB control among immigrants tied to assessment and response to cultural
needs (Chemtob et al., 2003);
• Contact difficulties due to itinerant lifestyles, foreign attitudes toward TB, and concerns
about immigrants’ legal status (Chemtob et al., 2003; de Vries & van Hest, 2005; Kong
et al., 2002; Marks et al., 2000); and
• Co-morbidity: for example, HIV (Mohtashemi & Kawamura, 2010).
 92 TANKIMOVICH

Effective interventions. To combat the complex dynamic of barriers to TB detection and

treatment among the homeless and immigrant populations, research from this review points to
the importance of what I call a 4Cs approach to intervention design:

• Cash (or cash-in-kind) incentives are very effective at bringing about desired health care
behaviors among the target populations and are cost effective

◦ Incentives are always positive interventions and become stronger when values are increased over
time and disbursement methods are varied (Davidson et al., 2000; Tulsky et al., 2004)
◦ Target populations more likely to complete therapy within 32 weeks (Bock et al., 2001)
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• Conveniently accessible and affordable health care facilities and technology: Target popu-
lations are, in fact, willing to seek out detection and treatment when it is easier to do so
(Gelberg et al., 2000; Gele et al., 2010)
• Cultural knowledge: Intervention designs must go beyond bio-medical models to bio-
psychosocial models that employ knowledge about the values of the target populations
(Chamanga, 2010)
• Coordination: The best interventions will likely coordinate cash incentives, health care con-
venience, and cultural knowledge: There is a current lack of coordinated efforts between
governments, academic institutions, private institutions, and communities (Carvalho et al.,
2010)

Implications for Nursing Practice

The implications for nursing practice involve new areas of knowledge and redesigned coordina-
tion skills for planning programs to better detect and treat TB. Nurses will need more detailed
and dependable knowledge of TB populations and their cultural and subcultural values as they
relate to personal health, health care, and TB. More specifically, nurses would need to:

• Assess knowledge levels of TB-infected patients about TB detection and treatment;

• Be aware of the immigrant status of some TB patients;
• Understand how TB carriers might be stigmatized within cultural groups;
• Design ways to find and treat those who may be reluctant to seek treatment on their own
(e.g., undocumented aliens); and
• Be prepared to instruct homeless and immigrant populations about TB prevention and
treatment, and provide them convenient resources and attractive incentives to follow
through.

Nurses will have to become skilled at aiding in the design and implementation of coordi-
nated programs of TB detection and treatment involving new technology, incentive methods, and
improved health care accessibility. One key finding in this review suggested that increased ease
of treatment access plus improved detection and treatment techniques, when in combination,
significantly helped reduce the burden of TB in homeless populations.
 TB BARRIERS AND INTERVENTIONS: A LITERATURE REVIEW 93

Implications for Research

The studies reviewed imply that:

• Research into TB detection/adherence and spread must go beyond a strictly biomedical-

model and should include bio-psychosocial attitudes, beliefs, and values for its populations
(Chamanga, 2010);
• Future studies should use a 4Cs approach to intervention that should investigate the effec-
tiveness of different coordinated arrangements of cash, cultural values, and convenience to
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see which are most effective;

• A more consistent definition of homeless should undergird future studies;
• Further research into the overlap of HIV+ and TB+ populations would be valuable for cre-
ating plans for corralling the spread of TB in homeless populations, especially (Mohtashemi
& Kawamura, 2010);
• Further studies of skid row, urban, and suburban homeless with TB would aid in the
improved assessment of the generalizability of findings for each population, and across
these populations; and
• Researchers should investigate how to make the best technology for detecting LTBI more
accessible to target populations.

CONCLUSION

The specter of TB is still daunting, but there are reasons to be optimistic that further efforts to
control the spread of TB among homeless and immigrant populations will enjoy success both
nationally and internationally. It seems most likely that interventions involving new technology
and improved methods for finding TB contacts (e.g., detection/spread) will be most successful.
In addition, coordinated research designs using cash incentives, increased access to convenient
health care, and increased knowledge about TB and the cultural attitudes toward it (e.g., treatment
and the willingness to be treated) will enhance the chances of success even more.
Whatever new challenges the 4Cs approach poses in the continuing fight against TB, nurses
seem central to coordination efforts. It seems reasonable to think that community health nurses
would be leading contributors to bringing about more convenient detection and treatment meth-
ods for the homeless and immigrant populations in their communities. Next, nurses will always
be central to health education efforts, and this review has shown that even hard-to-reach, high-
risk populations such as immigrants and the homeless have proven to be more likely to seek out
TB detection and treatment, as well as finish TB treatment, when better educated about the dis-
ease (Gelberg et al., 2000). Finally, several studies in this review have underscored the emerging
importance of cultural values and the role they play in TB detection and TB treatment behaviors
among immigrant and homeless populations. According to indications in several of the studies
under review, the best coordination efforts will have to be guided by an understanding of these
underlying values. It seems very likely that community health nurses are in the best possible posi-
tion to go beyond bio-medical models to bio-psychosocial models of TB patient care (Chamanga,
2010). They might well be the vanguard of the restrategized fight against TB.
 94 TANKIMOVICH

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