Real-world decision-making for post-exposure management of drug-resistant TB

Effective post-exposure management is essential to control drug-resistant TB (DR-TB). However, little is known about how health care workers (HCWs) make decisions on post-exposure management in resource-constrained settings.

We conducted a qualitative study using semi-structured interviews with 22 HCWs in the Western Cape, South Africa. Data were analysed thematically and interpreted using the Situated Clinical Decision-Making Framework (SCDMF) to explore how contextual conditions, knowledge, and clinical cues influence judgement and action in practice.

Four interrelated themes were identified: crowded living conditions in informal settlements; stigma and non-disclosure of TB status; incomplete or delayed clinical information; and limited formal training on DR-TB post-exposure management. These factors constrained HCWs' access to reliable social and clinical cues, limited their ability to assess exposure risk, and made consistent application of guidelines challenging. In response, HCWs relied on experiential knowledge, clinical intuition, and peer consultation to manage uncertainty. Real-world conditions frequently diverged from the SCDMF's assumptions of enabling contexts, timely information, and accessible professional knowledge.

HCWs' decision-making for DR-TB post-exposure management is shaped by systemic constraints that necessitate adaptive but informal practices. Strengthening diagnostic turnaround times, formal training, and context-sensitive strategies to address stigma is critical to support consistent, evidence-based post-exposure DR-TB care.