Sustainability of a Tuberculosis Screening Program at an Adult Education Center Through Community-Based Participatory Research
Journal of Public Health Management and Practice. Nov/Dec 2019;25(6):602-605
Background: Approximately two-thirds of active tuberculosis (TB) cases in the United States occur in foreign-born individuals, predominantly through reactivation of latent TB infection (LTBI) in the first 5 to 10 years after arrival.1 The US guidelines recommend testing for and treating LTBI among people from countries where TB is common.2 Immigrants arrive to the United States in a variety of ways, which precludes a uniform system of detection such that most immigrants diagnosed with active TB in one study never received prior LTBI testing in the United States.3 To overcome the multifaceted barriers to screening in these populations, the Centers for Disease Control and Prevention recommends forging community partnerships within at-risk communities to prevent TB in the United States,4 but perhaps due to limited resource allocation, these partnerships have not been prevalent.
We describe the sustainability of a TB-screening intervention at an adult education center that serves a large foreign-born population at risk for the disease. Sustainability is defined as a program continuing to be delivered after a defined period of time while adapting in order to continue producing benefits for individuals.5 Sustainability planning has been highlighted as an underdocumented yet core component of the dissemination and implementation of successful health promotion interventions.5–7
The TB-screening intervention, derived through a community-based participatory research approach from 2006 to 2009,8 was found to be feasible, worthwhile, and superior to previous conventional screening programs at the same site.9 Intervention development and cross-sectional evaluation were grant-funded. Here, we describe the longitudinal implementation of the intervention, from 2009 to 2017, through participatory mechanisms that extended beyond the funding period.
Methods:
Setting and participants
The TB-screening program takes place at Hawthorne Education Center, the adult education center for the Rochester (Minnesota) public school district. In addition to serving its primary purpose as a school, Hawthorne contains features of a community center, providing a health clinic, instruction for social and environmental adjustment after immigration, citizenship, and financial counseling, among other services.
Hawthorne serves a large foreign-born population through English language classes and other programs. More than 70 languages are spoken at home among approximately 2500 Hawthorne learners; 85% live below the federal poverty level. Most Hawthorne learners have elevated TB risk, including recent emigration from regions of the world where TB is endemic, including sub-Saharan Africa, Latin America, and Southeast Asia.
Partnership description
Hawthorne is the founding community partner of Rochester Healthy Community Partnership (RHCP), which has a mission to promote health through community-based participatory research.10 Community-based participatory research is an approach to research where community and academic partners work together in an equitable fashion through every phase of the research process.11 Since its inception in 2004, RHCP has become productive and experienced at deploying data-driven programming and evaluation with immigrant populations.10
In 2006, Hawthorne leaders approached RHCP academic partners to address the concern of TB at the school. Several cases of active TB had been diagnosed among Hawthorne learners, prompting an environment of fear and TB-related stigma. Previous attempts at voluntary TB screening at Hawthorne resulted in very low participation rates (<10 per session). RHCP partners collaboratively explored the mechanisms of these health-seeking behaviors with Hawthorne learners and staff.8 This precipitated an effective partnership between Hawthorne learners and staff, academic partners, and the local public health department to initiate and sustain a TB-screening program at the school.
Intervention
Longitudinal implementation of the intervention was based on lessons learned from initial screening of 259 Hawthorne learners in 2009.9 Prior to every screening opportunity, members of the Hawthorne staff, Olmsted County TB Clinic (situated at the Olmsted County Public Health Department), and/or nursing students from Winona State University conducted approximately 15 minutes of TB education in each classroom. This included the viewing of a 7-minute TB education video that was previously developed and tested by RHCP at Hawthorne.12 Facilitators then described TB-testing procedures at Hawthorne, answered questions, and left a sign-up sheet in the classroom. In total, these discussions served to propagate the atmosphere of open dialogue around TB at Hawthorne in the face of learner turnover that is typical for adult education centers from year to year.
Names from the sign-up sheets were shared with the TB clinic, which cross-referenced names with a database. Those who had recent TB skin tests, who had previous positive test results, and/or who had been treated for TB were informed by TB clinic staff that they would not be retested in this screening program. Students who were eligible for TB screening after TB clinic review were contacted by Hawthorne staff to provide them with the date and time of TB screening. Screening took place at the school in response to a strong preference among learners to conduct the test in that safe and convenient space.
Tuberculosis skin testing was performed according to the Centers for Disease Control and Prevention guidelines13; a positive test was recorded for skin reactions of 10 mm or larger. The skin tests were administered and read by trained registered nurses from the TB clinic. Individuals with positive tests were immediately counseled, and appointments were made at the TB clinic, where subsequent diagnostic and therapeutic interventions, including a clinical examination, chest radiography, and 9 months of isoniazid therapy were delivered at no cost to the student.
Data analysis
The following data were collected by Olmsted County TB Clinic staff for each individual screened for TB at Hawthorne: TB skin test result, patient seen at the Olmsted County TB Clinic (Y/N), result of interferon-gamma release assay test (if applicable), LTBI medication started (Y/N), and LTBI medication completed (Y/N). These results were stored in a secure registry that is maintained for the clinic. Results were reported using descriptive statistics. Analysis and dissemination of these data were approved by the Mayo Clinic Institutional Review Board.
Results:
The results of the TB-screening program from 2009 to 2017 are shown in the Table. Among more than 618 tests completed at Hawthorne during this interval, 121 tests were positive. Among these patients with positive test results, 101 completed evaluation at the public health department, and all patients were ruled out for active disease. Seventy-two patients were started on medication for LTBI; 57 of these patients have completed the medications to date. The reasons for not treating the additional 19 patients who completed evaluation included negative interferon-gamma release assay testing, medical contraindication to therapy, pregnancy, or patient choice to decline the medication.
Conclusion:
This case study demonstrates a framework for sustaining partnerships to address TB prevention among communities at risk for the disease. Adult education centers that serve large foreign-born populations are effective venues for this partnership work. A participatory approach with stakeholders helps sustain these TB prevention efforts.