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The Tuberculosis Behavioral and Social Science Research Forum Proceedings

Section III. Results of Breakout Groups Sessions

Identification of Tuberculosis Behavioral and Social Science Research Gaps and Needs

Summary of Breakout Sessions at the Forum

There were four small breakout groups consisting of approximately 12 participants that met once each day during the Forum. The objectives for the breakout sessions of the Forum were to 1) identify areas that have been sufficiently researched, 2) to identify and prioritize research needs and gaps, 3) to articulate research questions for each gap area, and 4) to delineate research methods/approaches to fill the identified research needs. The breakout sessions included brainstorming and small group discussions. At the end of the small breakout sessions, all four groups reconvened to the larger group to report out and share the highlights from their discussions.

Forum participants used the National Institutes of Health (NIH) definition of behavioral and social science research as the basis for group discussion. (Refer to the Background Section on p. 2 for a complete definition).

To guide the discussions, the four groups were formed around two major themes or domains: “external” vs. “internal” influences. Though the framework is artificial, the purpose of these groupings was to initiate thinking from the perspective of factors influencing behaviors, such as health-seeking, initiating and adhering to treatment, and providing diagnostic, care, and treatment services with respect to provider behaviors, rather than focus on the behaviors themselves. This framework was intended to facilitate discussion about and development of research concepts that focus on interventions that directly address the influential factors, and narrow the already broad focus to either “external” or “internal” influences to the extent possible. Overlap was expected and inevitable, due to the multiple dimensions of influences on behaviors and the complex way that these influences interact with one another. Examples of these types of influences were provided during the breakout sessions and are noted below.

  1. “External” influences on health and health behaviors may include factors in the physical or ‘external’ environment, organizational structures, policies, regulations, guidelines, poverty, racism, economic inequality, disparities in care, availability and access issues, legislation (e.g., immigration, public health laws).
  2. “Internal” influences on health behaviors may include individual and cultural beliefs, etiologies or explanations of causality, knowledge, attitudes, and perceptions.

Influences such as stigma, social norms and customs could and did fall under both domains, depending on whether the discussion was on how these influences are internalized OR how they are expressed in society.

The breakout sessions, each headed by a trained facilitator, were very interactive, consisting of independent brainstorming activities in which participants wrote down their ideas on notecards and flip charts and subsequently shared information with the breakout group for discussion. Each breakout session was followed by a sharing of that group’s ideas with the larger group of Forum participants for questions and discussion.

For the purpose of organizing the Forum Proceedings, the notes and flip charts were reviewed and synthesized using the five broad levels based on the Socio-Ecological Framework. The five broad levels identified are listed below:

  • Intrapersonal
  • Interpersonal
  • Health Systems and Organizations
  • Community
  • Public Policy

Organization of the Breakout Sessions Findings

The Socio-Ecological Framework was used to organize the information generated by the participants during the Forum breakout sessions because of its multi-layered structural components. According to Sallis and Owen (1997), the Socio-Ecological Framework focuses on multiple levels of influence and proposes that health and behavior are caused by multiple factors. It assumes that organisms cannot exist or act in isolation; instead they work as an interdependent network of relationships influenced by internal and external forces. More specifically, behaviors are influenced by intrapersonal (i.e., individual), social and cultural, and physical environment factors. These multiple factors and interaction among them are relevant for understanding and changing health behaviors of individuals, communities, and organizations as a whole.

Using this framework, the most relevant levels of the model were identified and modified for the purposes of the Forum breakout sessions (Refer to Figure 1: The Socio-Ecological Framework). The levels that were used to systematically organize the information derived from the Forum breakout sessions are listed below.

Intrapersonal: This level focuses on influences (e.g., knowledge, attitudes, and perceptions; patient satisfaction; and social stigma) that affect the individual behavior of patients, such as health seeking behaviors and adherence to treatment. This level also addresses individual-level issues that may affect providers’ behaviors, such as adherence to guidelines and recommendations.

Interpersonal: This dyadic level focuses on the relationship between two individuals or units regarded as a pair. Examples of this level include the patient-provider relationship and its impact on both the patient and provider as well as influences of a family member, significant other, or peer on a patient.

Health Systems and Organizations: This larger social system focuses on how individuals, small groups, and communities can be affected by structural, economic, and other organizational forces. Examples include the provision, accessibility, and use of health care services, and collaboration between provider communities and other systems.

Community: This level focuses on influences that affect behavior on a small-group level (e.g., family and social networks) in addition to larger groups, such as those in community settings. Examples include the influences of family and social networks on individuals; the relationship between local health services and individuals and communities; social norms; and social stigma.

Pubic Policy: This level focuses on the implications of public policy on the behaviors of individuals, groups, communities, and organizations, with special emphasis on issues relating to government commitment, funding, health insurance, and immigration policies.

Major research topics and subtopics were grouped to the extent possible under the five broad levels delineated in the Socio-Ecological Framework. More detailed information on specific topics identified by Forum participants are presented in the sections titled Outline of Major TB Behavioral and Social Science Research Topics and Subtopics Identified at the Forum on pgs. 28-30, and Descriptions of TB Behavioral and Social Science Research Topics and Subtopics Identified at the Forum on pgs. 31-43.

Specific research questions generated by Forum participants can be found in Appendix C: Tuberculosis Behavioral and Social Science Research Gaps and Needs: Major Topics, Subtopics, and Research Questions.

Figure 1: The Socio-Ecological Framework

Figure 1 is an illustration of the Socio-Ecological Framework which consists of five levels, including intrapersonal, interpersonal, health systems and organizations, community, and policy.


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

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