Patient acceptance of preventive antibiotic treatment for tuberculosis: a qualitative study

Background: Tuberculosis (TB) preventive treatment is a key component of TB control in low-incidence settings, but uptake remains low. Objective: To explore factors influencing patient decisions to accept or decline preventive treatment for TB infection. Design: Qualitative study using semi-structured interviews, analysed with the Theoretical Domains Framework (TDF). Setting: Routine clinical TB prevention services at two hospitals in London, UK. Participants: Adults (18+) diagnosed with TB infection and offered preventive treatment. Methods: Semi-structured interviews were audio-recorded and transcribed verbatim. The TDF was applied to analyse transcripts using a combined inductive thematic analysis and deductive framework approach. Themes were also mapped to the Capability, Opportunity and Motivation model of Behaviour (COM-B) domains. Results: Twenty-five participants (median age 34 years; 64% male) were included; 56% accepted treatment, 28% declined, and 16% were undecided. Influences on decision-making mapped to 12 of 14 TDF domains. Facilitators of treatment acceptance included perceived risk of TB (beliefs about consequences), desire to protect others' health (social influences and goals), confidence in treatment adherence (beliefs about capabilities), and routine integration strategies (behavioural regulation). Barriers to treatment acceptance included low perceived individual risk and doubts about necessity or effectiveness (beliefs about consequences), concerns about side effects and treatment burden (environmental context and resources) and anticipated stigma (social influences). Knowledge had a mixed influence, primarily shaping perceived necessity, but did not determine decisions alone. Social, environmental and emotional factors further influenced decisions, with participants balancing anticipated benefits against perceived burden and uncertainty across multiple interacting domains. Conclusions: Decisions to accept preventive TB treatment are driven by interacting capability, opportunity and motivation factors rather than knowledge alone. Interventions to improve shared decision making should address perceived risk, treatment burden, self-efficacy and social influences.