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Project Title: Primary Care Management of Latent and ActiveTuberculosis Among Immigrant Populations: A Study of Barriers and Facilitators

Project Dates: 2003 - 2007 Method: Focus group Topic: LTBI, treatment adherence Target Audience: Health care providers who serve foreign-born populations Principal Investigator(s): Jenny Pang, MD1 (jenny.pang@metrokc.gov); J. Carey Jackson2 (jackson.c@u.washington.edu); Nickolas DeLuca, PhD3 (ncd4@cdc.gov) 1. Seattle & King County Public Health Department, Seattle, Washington; 2. University of Washington, Seattle, Washington; 3. Centers for Disease Control and Prevention, Atlanta, Georgia

Instrument Title: Discussion Guide: Focus Group I: Topic Generation Total Participant time required: Total focus group time: Break: 1 hour + 10 minutes – 1 hour + 50 minutes 1 hour + 10 minutes – 1 hour + 50 minutes 0 minutes

OVERALL QUESTION TO ANSWER IN FOCUS GROUP DISCUSSIONS: The purpose of the study is to conduct evaluative research to determine (in order of priority): • To generate a comprehensive list of topics surrounding management of TB in the primary care settings. • After a list has been generated, to review for clarity and accuracy and completeness. Below is a general guide for leading our focus groups. We may modify this guide as needed as each focus group will inform the subsequent groups. Before the group begins, conduct the informed consent process, including compensation discussion. I. Introduction (10 m)
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Welcome participants and introduce yourself. Explain the general purpose of the discussion and why the participants were chosen. Discuss the purpose and process of focus groups Explain the presence and purpose of recording equipment and introduce observers. Outline general ground rules and discussion guidelines such as the importance of everyone speaking up, talking one at a time, and being prepared for the moderator to interrupt to assure that all the topics can be covered. Review break schedule and where the restrooms are. Address the issue of confidentiality. Inform the group that information discussed is going to be analyzed as a whole and that participants' names will not be used in any analysis of the discussion. Read a protocol summary to the participants.

Seattle & King County Public Health Department. and practices of primary care providers who see foreign-born patients at risk for latent and active tuberculosis (TB). please don’t feel bad about it. PhD3 (ncd4@cdc. we encourage you to respond directly to the comments other people make. Centers for Disease Control and Prevention. Carey Jackson2 (jackson. To achieve even lower rates of tuberculosis in the U.871 TB cases within the U. taking notes and be here to assist me if I need any help. attitudes.pang@metrokc. we may call on you directly.c@u.gov) 1.S. If we do this. Washington. attitudes. especially among the foreign born. In 2003. Nickolas DeLuca. participation and remarks private. Discussion Guidelines: We would like the discussion to be informal. (If assistants present) Helping are my assistants ______ and _______.Project Title: Primary Care Management of Latent and ActiveTuberculosis Among Immigrant Populations: A Study of Barriers and Facilitators Project Dates: 2003 . 3. 53% of the 14. Seattle. 2. please let us know. Atlanta. J. Seattle.S and the Centers for Disease Control is implementing a plan to do so. were foreign-born.washington. will require identifying and implementing strategies that can further reduce the incidence of tuberculosis.2007 Method: Focus group Topic: LTBI. Understanding current knowledge. and Africa. If we seem to be stuck on a topic.edu). prevention and control efforts and successful innovations for addressing barriers and limitations will help make the elimination of TB feasible. it’s just our way of making sure we obtain everyone’s perspective and opinion is included. If you don’t understand a question. we will be tape recording the discussion. Asia. listen. MD1 (jenny. we may interrupt you and if you aren’t saying much. The Advisory Council for the Elimination of Tuberculosis (ACET) [1] has called for a renewed commitment to eliminating tuberculosis from the U. We hope you’ll feel free to speak openly and honestly. Washington. University of Washington.S. Tuberculosis is occurring at a historic low incidence in the United States. They will be . practice. Georgia This study is intended to elicit and clarify the knowledge. We are here to ask questions.gov). because we don’t want to miss any of your comments. The highest risk populations for latent and active TB are immigrants from Latin America. treatment adherence Target Audience: Health care providers who serve foreign-born populations Principal Investigator(s): Jenny Pang. We do ask that we all keep each other’s identities. As discussed. and make sure everyone has a chance to share. No one outside of this room will have access to these tapes and they will be destroyed after our report is written. so there’s no need to wait for us to call on you to respond. In fact.

I’ll start. Centers for Disease Control and Prevention. Washington. but not to have a discussion of these topics. This will help us understand the issues providers face in screening and managing TB. • Per our focus group training for interactive process you can then: 1. What comes to mind when you think about managing TB in your setting? • The group will provide a list of initial topics.gov).pang@metrokc.c@u.Project Title: Primary Care Management of Latent and ActiveTuberculosis Among Immigrant Populations: A Study of Barriers and Facilitators Project Dates: 2003 . but the conversation will quickly move on. The topics will be discussed in detail in subsequent interviews that you and other providers may take part in. Seattle. After the responses from this prompt have been exhausted. J. 3. If there is some confusion during the discussion about how a topic is relevant clarifying comments will be requested.edu). MD1 (jenny. where you practice. PhD3 (ncd4@cdc. Atlanta.washington.gov) 1. move on. Georgia Let’s begin. treatment adherence Target Audience: Health care providers who serve foreign-born populations Principal Investigator(s): Jenny Pang. Let’s get started! • The initial question:  Today we are here to talk about TB. Let’s find out some more about each other by going around the room one at a time. II. Take a topic that was just brought up and prompt the group for more information: . Nickolas DeLuca. Tell us your first name and the job you have. Seattle. This focus group’s task will be to generate a list of relevant topics. Topic Generation (50-90 minutes) The focus group facilitator will explain: This group is convened to generate a comprehensive list of topics surrounding management of TB in the primary care settings. Seattle & King County Public Health Department. Carey Jackson2 (jackson.2007 Method: Focus group Topic: LTBI. 2. University of Washington. Washington. and the communities you serve.

The following is a guideline for topic generation. MD1 (jenny. Seattle.2007 Method: Focus group Topic: LTBI. J.c@u. Tell me the factors related to the vaccine. you can bring up a subject from our list to prompt the group:  What about the TB skin test? What factors come to mind? (In this way.gov) 1. the patient population.. and reimbursement (e. Atlanta. clinic resources (e. therefore eliciting the most authentic data possible. pharmacy). Georgia  The BCG vaccine was mentioned a lot. The list below is a menu of items that explores many areas: the clinical encounter. Centers for Disease Control and Prevention.edu).) • Record the topic list on a chart or white board for reference and give constant prompts to make certain this is a complete list of potentially relevant topics. The actual process may vary according to each group’s progress and the experience of previous groups. co-pays) concerns.Project Title: Primary Care Management of Latent and ActiveTuberculosis Among Immigrant Populations: A Study of Barriers and Facilitators Project Dates: 2003 . 2. Remember: We will not address every issue with every group and we may address issues not on this list as they arise. The goal is for the participants’ experience to lead the way. knowledge of guidelines and standard of care. This process is not pre-scripted but interactive in its nature. Issues for focus group exploration: I.gov). 2. University of Washington. Seattle. information systems. Nickolas DeLuca.washington. Carey Jackson2 (jackson.. Washington. treatment adherence Target Audience: Health care providers who serve foreign-born populations Principal Investigator(s): Jenny Pang.g. Seattle & King County Public Health Department. Alternatively. you will explore a series of questions to be followed by relevant prompts to clarify the item. 3. Washington.pang@metrokc. Knowledge • Perception that the TB skin test can be trusted to screen for latent TB in a population given BCG (Bacille Calmette-Guerin) vaccine .g. radiology. PhD3 (ncd4@cdc.

Attitudes • • • • • • • • • • • • • Perception that TB is a significant problem locally in the target community (Mexican.pang@metrokc. MD1 (jenny. Practice • Documenting screening and results Preferred channels to receive information. Washington. 2. color.gov). 3. appearance etc. etc) • Perception that prevention is an important aspect of their practice Perception that screening and managing latent TB is an easily coordinated within the structure of their primary care setting Perception that latent TB screening and management is within the purview of the primary care physician Physician view of patient populations’ perspective on TB Perception that patients are willing to take the medication Influence of interpreters on TB related issues in primary care Influence of family and community on patients diagnosed with latent or active TB Observations about impact of DOT in TB management • Stigma in their community of being associated with TB versus convenience of referring it to TB clinic Importance of LTBI screening and management in primary care How the emergence of a TB blood test (QuantiFERON) vs.c@u.washington. Nickolas DeLuca. superiors and/or thought leaders III. Georgia • • • • • Opinions about the role of BCG in protecting people against TB and its role in the diagnosis and treatment of LTBI • Opinions about the TB skin test and how to interpret it • Awareness of CDC/ATS guidelines Ability to explain latent TB infection Treating and managing side-effects of INH Identifying at risk patients for active TB Ability to work up pulmonary and extra-pulmonary TB II. Carey Jackson2 (jackson. University of Washington. and trainings • Report on ease of obtaining and paying for INH by patients . Perception of BCG Perception of attitudes of colleagues. guidelines. Seattle.2007 Method: Focus group Topic: LTBI. PPD for diagnosis would affect their ability to manage TB patients The effect of TB drug formulation on adherence: route. Centers for Disease Control and Prevention. PhD3 (ncd4@cdc. Seattle & King County Public Health Department. treatment adherence Target Audience: Health care providers who serve foreign-born populations Principal Investigator(s): Jenny Pang. J. Filipino. Seattle.gov) 1. Vietnamese. Atlanta.edu). Washington.Project Title: Primary Care Management of Latent and ActiveTuberculosis Among Immigrant Populations: A Study of Barriers and Facilitators Project Dates: 2003 .

and duration of treatment Ability to have proper isolation protocols for an infectious patient How LTBI patients are monitored Diagnostic procedures What has convinced them to change opinions and practice patterns in the past IV. MD1 (jenny. PhD3 (ncd4@cdc. Washington. 2.c@u. Washington. Centers for Disease Control and Prevention.) V. Nickolas DeLuca. Georgia • • • • • Feedback on systems for charting PPD status. 3.gov) 1.gov). Seattle. Closing (10 m) • • • Closing remarks Thank the participants Issue their compensation if available or explain the payment process if not . dates of screening. J. Atlanta. review for clarity and accuracy and completeness. University of Washington.edu).pang@metrokc.2007 Method: Focus group Topic: LTBI.Project Title: Primary Care Management of Latent and ActiveTuberculosis Among Immigrant Populations: A Study of Barriers and Facilitators Project Dates: 2003 . Seattle. treatment adherence Target Audience: Health care providers who serve foreign-born populations Principal Investigator(s): Jenny Pang. Seattle & King County Public Health Department.washington. Carey Jackson2 (jackson. Issues surrounding local health department TB clinics • • • Barriers and facilitators to utilizing TB clinic expertise • Co-managing patients with the local TB Clinic Providers' relationship with the local health department’s TB clinic Physician sense of comfort in contacting local TB expertise and how to improve this relationship (After a list has been generated.