The Influencing Factors Of Effective Tuberculosis Prevention and Control among University Students in Heilongjiang Province, China: A Fuzzy-Set Qualitative Comparative Analysis

Technical Summary: Influencing Factors of Effective Tuberculosis Prevention and Control among University Students in Heilongjiang Province, China

Problem Statement
Tuberculosis (TB) remains a critical public health challenge in China, with university students representing a high-risk demographic due to dense living conditions, academic stress, and potential immune suppression. Despite policy interventions, clustered outbreaks continue to occur, and a significant gap persists between estimated new cases and diagnosed patients. Existing research often isolates individual factors or focuses on single institutions, failing to capture the complex, non-linear interplay between individual psychology and the institutional environment that drives TB prevention and control (TBPC) effectiveness. Furthermore, Heilongjiang Province faces unique challenges, including high population mobility, numerous land ports, and a relatively high TB burden, necessitating a localized, multi-dimensional analysis of TBPC efficacy.

Methodology
This study employed a cross-sectional design utilizing Fuzzy-Set Qualitative Comparative Analysis (fsQCA) to identify configurational pathways leading to effective TBPC among university students.

• Data Collection: Between November and December 2024, data were collected from 840 valid respondents across five universities in Heilongjiang Province (787 online, 103 paper-based). The sample included paired data from students and faculty to assess both individual and institutional levels.
• Variables:
  • Outcome: TBPC effectiveness, measured via a modified Knowledge, Attitudes, and Practices (KAP) scale.
  • Antecedents (Individual Level): Self-efficacy, risk perception, optimistic bias, worry, TB-related stigmatization, and media exposure.
  • Antecedents (Institutional Level): University TBPC mechanisms, social environment, and infectious disease management systems.
• Analytical Approach: The study moved beyond traditional linear regression. Data were calibrated into fuzzy sets (0 to 1) using percentile-based anchors (5th, 50th, 95th). A necessity analysis was conducted to identify single necessary conditions, followed by a sufficiency analysis using a truth table to identify multiple conjunctural causal pathways. The analysis utilized an intermediate solution to distinguish between core and peripheral conditions, with consistency thresholds set at ≥0.8 for sufficient conditions and ≥0.9 for necessary conditions.

Key Results

1. No Single Necessary Condition: The necessity analysis revealed that no single factor (individual or institutional) is a necessary condition for effective TBPC. Effectiveness is not dictated by isolated elements but by specific combinations of conditions.
2. Five Distinct Driving Paths: The fsQCA identified five distinct configurations (C1–C5) that lead to high TBPC effectiveness, with an overall solution consistency of 0.880. These paths were categorized into two core archetypes:
   • Individual Emotional Perception Type (Configurations C1, C2, C3): These paths demonstrate that high effectiveness can be achieved even with suboptimal institutional environments (e.g., poor social environment or weak management systems) if students possess strong individual psychological drivers. Key drivers in these paths include high worry, risk perception, self-efficacy, and stigmatization, often coupled with robust university mechanisms. This suggests that strong emotional and cognitive engagement among students can compensate for macro-level deficiencies.
   • Macro-Institutional Orientation Type (Configurations C4, C5): These paths highlight that effective TBPC can be maintained even with lower individual risk perception or optimistic bias, provided there are strong institutional supports. Configuration C5 showed the highest consistency, indicating that a combination of high self-efficacy, worry, stigmatization, media exposure, a supportive social environment, and robust institutional management systems yields the most effective outcomes.
3. Role of Media and Stigmatization: Media exposure emerged as a core condition in three of the five high-consistency configurations. Interestingly, TB-related stigmatization, typically viewed as a barrier, acted as a supplementary driver in all effective pathways when combined with worry and risk perception, suggesting it can trigger proactive protective behaviors in specific contexts.
4. Current Status: Descriptive statistics indicated that while students possessed moderate-to-high KAP scores, the institutional environment (screening coverage, management systems) was suboptimal. Over 30% of respondents reported no TB screening at enrollment, and media exposure regarding TB was generally low.

Key Contributions

• Configurational Framework: The study provides a theoretical framework demonstrating that TBPC effectiveness is a result of "equifinality"—multiple distinct combinations of conditions can lead to the same high-performance outcome.
• Dual Pathway Identification: It delineates two primary strategies for intervention: one focused on enhancing individual emotional and cognitive drivers (psychological approach) and another focused on strengthening institutional and social infrastructure (systemic approach).
• Re-evaluation of Stigmatization: The research challenges the binary view of stigmatization, suggesting that in conjunction with worry and risk perception, it can function as a mechanism driving protective behavior, though this requires careful management to avoid negative health outcomes.
• Media as a Lever: The findings underscore media exposure as a critical, often overlooked, core condition that bridges individual perception and institutional messaging.

Significance and Claims
The paper claims that effective TB prevention and control in universities cannot be achieved through isolated interventions but requires a differentiated, multi-dimensional strategy that accounts for the complex interplay between student psychology and institutional capacity.

• For Policy: The study argues for the necessity of "precise and differential" strategies. For institutions with weak infrastructure, interventions should prioritize boosting individual psychological drivers (e.g., enhancing risk perception and self-efficacy). Conversely, where individual perception is low, strengthening the institutional management system and social environment is paramount.
• For Practice: The authors suggest that universities should leverage media platforms to create a positive "media ecology," integrate risk communication with psychological counseling, and establish tripartite health promotion systems.
• Limitations: The authors modestly note that the findings are specific to Heilongjiang Province and may not be directly generalizable to regions with different epidemiological or policy contexts. Additionally, the theory-driven nature of fsQCA may have excluded other potential influencing factors not captured in the initial framework.

In conclusion, the study posits that optimizing TBPC in higher education requires moving beyond linear cause-and-effect models to embrace a configurational approach that recognizes the synergistic potential of both individual emotional states and institutional governance.