The Tuberculosis Behavioral and Social Science Research Forum
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.
- “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).
- “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:
- Health Systems and Organizations
- 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
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
Figure 1: The Socio-Ecological