Perspectives of Vietnamese, Sudanese and South Sudanese immigrants on targeting migrant communities for latent tuberculosis screening and treatment in low‐incidence settings: A report on two Victorian community panels

Abstract Background Tuberculosis (TB) elimination strategies in Australia require a focus on groups who are at highest risk of TB infection, such as immigrants from high‐burden settings. Understanding attitudes to different strategies for latent TB infection (LTBI) screening and treatment is an important element of justifiable elimination strategies. Method Two community panels were conducted in Melbourne with members of the Vietnamese (n = 11), Sudanese and South Sudanese communities (n = 9). Panellists were provided with expert information about LTBI and different screening and health communication strategies, then deliberated on how best to pursue TB elimination in Australia. Findings Both panels unanimously preferred LTBI screening to occur pre‐migration rather than in Australia. Participants were concerned that post‐migration screening would reach fewer migrants, noted that conducting LTBI screening in Australia could stigmatize participants and that poor awareness of LTBI would hamper participation. If targeted screening was to occur in Australia, the Vietnamese panel preferred ‘place‐based’ communication strategies, whereas the Sudanese and South Sudanese panel emphasized that community leaders should lead communication strategies to minimize stigma. Both groups emphasized the importance of maintaining community trust in Australian health service providers, and the need to ensure targeting did not undermine this trust. Conclusion Pre‐migration screening was preferred. If post‐migration screening is necessary, the potential for stigma should be reduced, benefit and risk profile clearly explained and culturally appropriate communication strategies employed. Cultural attitudes to health providers, personal health management and broader social vulnerabilities of targeted groups need to be considered in the design of screening programs.


| INTRODUC TI ON
The World Health Organization's (WHO) End TB Strategy aims to radically reduce the global incidence of tuberculosis (TB) by 2035 as a precursor to elimination. 1 An adaptation of the End TB Strategy for low-incidence settings provides an action framework for accelerating efforts towards TB elimination in these settings. 2 Most cases of active TB disease in low burden countries such as Australia are caused by the reactivation of previously latent TB infection (LTBI). 3 People with LTBI does not have symptoms, cannot transmit the infection, and, thereby, pose no immediate risk to others. 4 Rather than being a stable state, LTBI is a spectrum from viable organisms actively replicating in a host to a status where the infection has been cleared or rendered 'quiescent'. 5 Therefore, the defining feature of LTBI is that it is not an active disease, but is a state of risk for developing TB disease in the future. This distinction has important epidemiological, socio-cultural and ethical dimensions. 6,7 For most people with LTBI, the risk of developing active disease over their lifetime is low, with the risk of reactivation being dependent on their age and the time since infection. 8 Consequently, LTBI is both a potential disease and an inconsequential infection in the vast majority of people who carry the mycobacteria.
Australia has agreed to establish and work towards a set of predefined targets, as recommended by the WHO's Framework towards tuberculosis elimination in low-incidence countries. 9 In response, the Australian National Tuberculosis Advisory Committee (NTAC) has formulated a new Strategic Plan for TB Control that positions diagnosis and treatment of LTBI as a pathway to TB elimination in Australia. 10 Recent migrants (<2 years) from low-and middle-income countries are at substantially higher risk of active TB than non-migrants. 11 The epidemiological evidence indicates LTBI screening should target groups who are at highest risk of TB infection, such as immigrants from high-burden settings. 12 The cooperation of these affected communities is essential if LTBI screening and future TB elimination are to occur. In a qualitative study, Australian providers reported that migrant groups have difficulty understanding LTBI and can perceive LTBI screening as discriminatory. 13 Australian TB programs are beginning to consider the implications of the elimination agenda for how TB services are provided in their respective jurisdictions. 14 Yet the socio-cultural dimensions of targeted LTBI screening have not been comprehensively assessed in Australia. 15,16 In this paper, we report on two community panels, formed of members of the Vietnamese and Sudanese and South Sudanese communities who live in Melbourne, Australia. Panel members were asked to consider and provide recommendations on what policy options for targeted LTBI case-finding and treatment were seen as feasible and accepted as legitimate and fair. TB is a disease commonly associated with high levels of misunderstanding and social stigma in Vietnam 17,18 and Sudan. 19,20 Evidence also suggests that experiences of health care in an individual's country of origin influences patterns of post-migration health service utilization. 21 In Vietnam, for example, a complex set of beliefs and attitudes to TB treatment service providers can undermine treatment adherence and effectiveness.
State-provided TB health services in Vietnam are perceived by Vietnamese citizens as being too rigid, authoritarian and unable to respond to the needs of individuals; especially a preference for treatment flexibility and privacy. 18 In Sudan, the prolonged period of ongoing civil conflict and political instability has had significant implications for the TB burden, and for TB control strategies, with large numbers of displaced, marginalized populations relying on weakened health infrastructure and an insufficient volume of health personnel. 22 Reports suggest that many refugees and migrants from Africa do not prioritize engaging with healthcare providers in Australia, 23 or other comparable high-income countries. 24 The intersection of migration and TB service provision has been identified as a determinant of the success or otherwise of the End TB Strategy. 25 Current Australian policy is to pre-screen migrants for active TB prior to obtaining travel approval. 26 Because of their elevated risk of disease activation, children under 11 are tested for LTBI during this process, but LTBI testing is not included in other standard immigration pathways. Refugees arriving in Australia have alternative pathways not involving immigration medical examination and have existing recommendations for post-arrival screening that includes LTBI. As TB programs begin to pursue elimination, key decisions need to be made as to the most appropriate setting for the LTBI testing of migrants to take place, and how best to communicate with potential participants to inform them about the potential benefits and risks of LTBI screening. Whether LTBI screening was conducted pre-migration as a mandatory part of standard immigration processes or provided as a non-mandated service after arrival in the new country would distribute the burdens of testing differently. Similarly, different communication strategies aimed at raising awareness about the elevated incidence of LTBI among migrants have different social risks and levels of effectiveness. For example, community-specific campaigns (in non-English language media), and English language posters and leaflets targeted to geographic areas associated with specific migrant communities may not penetrate to explained and culturally appropriate communication strategies employed. Cultural attitudes to health providers, personal health management and broader social vulnerabilities of targeted groups need to be considered in the design of screening programs.

K E Y W O R D S
Australia, deliberative methodologies, latent tuberculosis, migrant health, population screening reach everyone who might benefit from participation. In contrast, a broad advertising campaign to improve LTBI testing uptake could reach migrants who are no longer closely connected with their cultural community, but increase the risk of racial vilification and public stigma because of reach to non-target audiences. More established members of migrant communities in new host countries are key stakeholders to recent immigrants and can influence their knowledge, attitudes, perceptions and behaviours. 27 Against this background, experience shows that effective targeted population screening depends on the alignment of the program with stakeholder values, 26 and perceptions of the benefits and harms of participation.
Involving members of a targeted community in a high-quality dialogue about key issues such as these can guide program design, leading to increased support for the resulting policy and greater service or program utilization. This project is part of a larger implementation study conducted and funded by the Victorian Department of Health and Human Services to assess the feasibility and impact of shifting to a policy of TB elimination in this Australian State. 12,15 2 | ME THODS

| Design
In a community panel project, a group of community representatives meets for 2-5 days to carefully examine an issue of public significance. 28 We convened 2 community panels, each lasting 2 days. The are recruited to capture the diversity of experiences and backgrounds in a community, and the deliberation processes organized to redress power imbalances as much as is feasible. 35 When conducted in this way, community panels can capture and reflect key community concerns and arguments about current and proposed policy directions-that is, what should be done to address a specific issue. 28

| Recruitment and selection
We contracted an independent professional research service to recruit panel participants. The recruitment company contacted potential participants using randomly generated list-based samples of mobile and fixed-line telephone numbers located in specific geographic areas, a targeted social media advertising strategy, and pas- Highest educational attainment Bachelor degree 3 3 Postgraduate degree 2 0 Socio-economic status of suburb a

| Participant characteristics
Both panels were comprised of participants of mixed genders and ages (Table 1)

| Procedures
Community panel participants were asked to consider and respond to the questions in Figure 1. Each panel commenced with an orientation session to introduce the process, the questions for considera-

| Data collection and analysis
The two deliberative panels are the units of analysis in this study. All

| PART A-pre-migration or post-migration LTBI testing
The Vietnamese and Sudanese/South Sudanese Community panels both voted in support of introducing mandatory LTBI testing to pre-migration processes by consensus verdicts.

| Pre-migration LTBI testing strategy
The key reasons both groups gave for supporting the pre-migration wanting to come to Australia take (and pay for) the LTBI test as part of migration processes was seen as being more cost-efficient. In contrast, many of the participants in the Sudanese and South Sudanese panel came to Australia through the refugee migration pathway, so convenience was not so important. For them, the extra cost to the migrant of the pre-migration testing strategy was of some concern, but the group still wanted testing to be mandatory. They held it was better to protect their communities from imported disease as part of the process of people coming to live in Australia.

| Post-migration LTBI testing strategy
Both groups saw some value in the GP-based post-migration LTBI testing strategy. Participants were of the view that involving local community-based health services in LTBI case-finding and treatment

| PART B-preferred communication strategies
The panels were also asked to consider how Victorian health services should seek to engage with migrant communities on the need to address the burden of LTBI. Acknowledging the strong preference of both groups for testing in the country of origin, we asked the panels to provide recommendations on appropriate strategies to inform their community in Melbourne about LTBI and the opportunities for testing and treatment in Australia. In coming to a final verdict, each panel member was allowed two votes in support of their favoured approaches to communication so that we could assess the acceptability, or otherwise, of different combinations of strategies.
This scoring system means that the highest score a specific strategy could receive was 11 for the Vietnamese panel and 8 for the Sudanese and South Sudanese panel. Table 3 indicates that there was strong support in both groups for a community-specific communication strategy including tailored messages in appropriate languages and on community-specific radio and social media platforms about LTBI risks, testing and treatment. The key reasons were because this strategy would be more likely to reach people who were not proficient in English, while also working to address intra-community stigmatization by providing a platform for education about LTBI and TB. However, the panels reached different conclusions as to the acceptability and effectiveness of combining this strategy with broad and/or locally targeted campaigns to raise awareness in their communities in Victoria.

| The Vietnamese panel
As well as a non-English language community-specific campaign, led them to recommend that it should not be implemented unless it could be done in a way which did not identify any specific country of origin. This concern about the risks of racial stereotyping extended to how community-specific messages were implemented. The group took the position that any non-English language awareness-raising campaign tailored to Vietnamese and other migrant communities should all be rolled out simultaneously so that no group feels they are being singled out and unfairly targeted.

| D ISCUSS I ON
The Vietnamese and Sudanese and South Sudanese panels involved in this study were highly supportive of testing migrant groups for LTBI, consistent with previous research indicating that new migrants accept most forms of infectious disease screening. 36,37 The key concern shared by the panels was the possibility that LTBI screening could lead to social harms such as stigma, both within their own communities, and against their communities from other Australians. The strong preference for testing to occur pre-migration was not simply about imposing the burden and costs of testing onto others, but was seen as a way of making sure that all new migrants were tested for LTBI, and that these activities were performed in a setting removed from the view of the broader Australian public. Despite differences between the groups in perceptions of the degree to which they identified themselves as being part of Australian society, both panels also expressed uneasiness about the potential for any communication strategy to identify and single out specific cultural groups-increasing the risk of negative public discourses, racial vilification and social stigma. Pre-migration testing was thereby seen as a means to mitigate many, if not all, of the social risks of targeted LTBI screening.
Failing that, and acknowledging that members of migrant communities who had been residents for some time could also benefit from LTBI testing, the recommendation was that any broad socio-demographic and ethnic groups within each community. 36,42 Negotiations and efforts to clarify who the LTBI screening service should be designed to benefit needs to be a central element of these discussions. 7 Both groups who took part in the study expressed a strong preference for LTBI screening to occur pre-migration because, from their perspective, off-shore testing would maximize the benefits for incoming migrants while minimizing the impact on local migrant communities. Although it was not described in these terms, the groups wanted to balance effectiveness and risk of harm in communication by ensuring that the risk for LTBI and the benefits of testing and treatment were well understood by their community, but that this understanding was supported in a way that did not simultaneously promote stigmatization and discrimination. 43 That post-migration screening would reach fewer migrants was seen as a major limitation for this strategy, reflecting the importance the panels place on maximizing effectiveness but also to equity of access to health benefits.
Previous qualitative studies in the UK suggest that the optimum approach in high-migrant receiving countries is most likely to offer screening in a range of settings. 42 While not the preferred strategy, opportunistic screening for TB and LTBI in primary care was acceptable to both panels involved in this study. Previous work in the UK suggests that testing for LTBI during GP consultations can be an effective non-coercive strategy for increasing participation by high-risk groups in post-migration screening. 44 Both groups noted that the provision of accessible and appropriate information to migrants was essential to testing acceptance (both pre-and post-migration). In this context, the accessibility of the information is a function of its format and comprehensibility such that all users can access the content on an equal basis; and appropriateness means the information is correct and fits the goals of the communication.

| Data limitations
Members of the Vietnamese and Sudanese and South Sudanese communities living in Melbourne without a high level of English language fluency were effectively excluded from the study due to the use of English language in recruitment materials and during panel proceedings. For the Vietnamese group, in particular, older age groups were under-represented such that participants spoke of and considered the needs of older members of their community, rather than these perspectives being represented by first-hand accounts in discussions. A further limitation is that community panels are comprised of small groups of 'engaged community members' whose views may not represent the complete range of perspectives held within otherwise internally heterogeneous cultural groups. We did not systematically collect data about the amount of time each participant had lived in Australia. Rather individuals identified themselves during discussion as recent, first or second-generation migrants, with many of the Vietnamese Australian participants having been born in Australia. However, because both panels were comprised of individuals with a range of ages, backgrounds and migration histories, and because both panels came to broad agreement on their preferred LTBI screening and health communication strategies, it seems likely that many of the issues and concerns raised by participants would be shared by members of the same cultural communities living elsewhere.

| CON CLUS IONS
Migration is a varied process that has implications for both migrants and TB service providers. 25 Policies on migration-related TB screening vary considerably across low-incidence settings indicating uncertainty concerning effective methods for migrant TB screening. 47 Challenges faced by migrants such as communication problems, loss of social support, discrimination and acculturation can be aggravated by fear of a positive TB diagnosis. 48,49 There has been little prior research focused on the specific experience of new migrants and their views on ways forward. 36 Our findings are not necessarily generalizable to other migrant groups or other national or health system settings. Nevertheless, as health authorities and TB programs in low-incidence setting begin to plot a pathway to elimination, the current study highlights the critical importance and social value of incorporating a strong focus on community engagement and partnership with migrant organizations in both the design and implementation of acceptable and effective strategies for LTBI case-finding and treatment in migrant communities. 50

ACK N OWLED G EM ENTS
We thank members of the Vietnamese, Sudanese and South Sudanese communities for taking part in this study, sharing their insights and helping us to understand.

Justin Denholm is the Director of the Victorian Tuberculosis
Program. All other authors have no conflicts of interest to declare.

AUTH O R CO NTR I B UTI O N S
CD designed the study, ran data collection and analysis processes, and led the drafting and revision of the manuscript. SMC contributed to study design, participated in data analyses and made significant contributions to the drafting and revision of the manuscript. KD, KS, and KW developed the evidence presented to panellists, participated in data collection and contributed to and revised the drafted manuscript. JH contributed to data collection and made significant contributions to data analysis and the drafting and revision of the manuscript. JD designed the study, participated in data collection, contributed to data analysis, made significant contributions to the drafting and revision of the manuscript.

DATA AVA I L A B I L I T Y S TAT E M E N T
There are no data available for sharing because of conditions imposed by the Ethics approval under which this research was conducted.