https://doi.org/10.1177/1049732317731317 Qualitative Health Research 2017, Vol. 27(14) 2116–2127 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732317731317 journals.sagepub.com/home/qhr Research Article Tuberculosis (TB) is historically known as one of the leading infectious causes of global mortality. An esti- mated 10.4 million new TB cases and 1.4 million TB fatalities were reported in 2015 (World Health Organization [WHO], 2016a). However, one third of the global population is infected with Mycobacterium tuber- culosis and at risk of reactivation (Glaziou, Falzon, Floyd, & Raviglione, 2013), where up to 10% may progress to active TB disease during the lifetime (Zumla, Raviglione, Hafner, & von Reyn, 2013). Because M. tuberculosis is transmitted through aerosol droplets from an individual with active pulmonary TB disease to a susceptible indi- vidual (Zumla et al., 2013), early identification of high- risk population groups and initiation of anti-TB chemotherapy are key to curtail M. tuberculosis transmis- sion and improve global TB control. Globally, health care workers (HCWs) are recognized to have an increased risk of infection with M. tuberculosis in the workplace. When compared with the general popu- lation, HCWs’ annual incidence rate ratios are estimated between 1.4 and 5.4 across TB incidence regions classi- fied as low (<50 per 100,000 people), intermediate (50-99 per 100,000 people), and high (>100 per 100,000 people; Baussano et al., 2011). Occupational categories with clinical responsibilities related to direct patient care influence overall risk of M. tuberculosis infection or dis- ease (Institute of Medicine Committee on Regulating Occupational Exposure to Tuberculosis, 2001; Menzies, Joshi, & Pai, 2007). The threat of nosocomial M. tubercu- losis transmission has been linked to the number of active TB patients and the application of infection control mea- sures in the health institution (Menzies et al., 2007). Infection control measures, including administrative con- trols, environmental controls, and personal respiratory protection, however, may not be consistently imple- mented in health institutions of low- and middle-income countries (Jones-López, & Ellner, 2005; Pai, Kalantri, Aggarwal, Menzies, & Blumberg, 2006). 731317QHR XX X 10.1177/1049732317731317Qualitative Health ResearchChapman et al. research-article 2017 1 University of Florida, Gainesville, USA 2 Hospital Regional Universitario José María Cabral y Báez, Santiago de los Caballeros, Dominican Republic 3 O&M Medical School, Santo Domingo, Dominican Republic 4 National Tuberculosis Program, Santo Domingo, Dominican Republic Corresponding Author: Helena J. Chapman, Department of Environmental and Global Health, University of Florida College of Public Health and Health Professions, P.O. Box 100188 and Division of Infectious Diseases and Global Medicine, University of Florida College of Medicine, PO Box 103600, Gainesville, Florida 32610, USA. Email: hchapman@ufl.edu The Role of Powerlessness Among Health Care Workers in Tuberculosis Infection Control Helena J. Chapman 1 , Bienvenido A. Veras-Estévez 2 , Jamie L. Pomeranz 1 , Eddy N. Pérez-Then 3 , Belkys Marcelino 4 , and Michael Lauzardo 1 Abstract Due to their occupational exposure in health care settings, health care workers (HCW) have increased risk of Mycobacterium tuberculosis infection. They face challenges to remain up-to-date with evidence-based clinical practices and translate educational information into actions in infection control practices. Our purpose was to examine this “knowledge-action” gap about how HCWs understand their occupational M. tuberculosis risk and use recommended infection control measures in clinical practices in the Dominican Republic (DR). We conducted 10 focus groups with 40 physicians and nurses at two tertiary-level DR institutions. Using grounded theory methods, we developed a theoretical model to describe the decision-making process related to adherence to M. tuberculosis infection control measures in clinical practice. Findings highlight intrinsic and extrinsic factors that influenced the observed knowledge-action gap related to M. tuberculosis infection control practices in two DR health institutions. Keywords Dominican Republic; focus groups; grounded theory; health care providers; hospitals; infection control; infectious disease transmission; Mycobacterium tuberculosis; occupational exposure; qualitative; tuberculosis