A Seattle pilot targets foreign-born DOPT
Outreach aimed at three hard-to-reach groups
With a mandate to work harder to provide treatment for latent TB infection, many TB control programs are trying to make inroads into foreign-born communities, where latent infection often abounds.
But along with the usual obstacles (namely, how do you convince someone who doesn’t feel bad to take a six- to nine-month course of medicine?), programs are finding that some recent newcomers make for tougher audiences than did preceding groups of refugees and immigrants.
"Our recent refugee patterns have shifted from Southeast Asia to Eastern Europe to countries in the former Soviet Union and to Africa," says Charles Nolan, MD, head of the King County/ Seattle TB control program. "Our track record for accessing and motivating these new populations isn’t nearly as good [as for Southeast Asians]."
In Seattle and other cities, the problem has spurred the formation of projects that target the harder-to-reach foreign-born populations. In Washington, DC, for example, the Non-Profit Clinic Consortium, which provides free health care to the poor and the foreign-born, is planning to fund outreach to immigrant groups too wary even to visit a free clinic.
In New York City, the Task Force on Immigrant Health reports terrific completion rates for preventive therapy among Dominicans, Ecuadorans, and Haitians — three communities that are traditionally underserved by existing programs elsewhere in the city.
Targeting three tough groups
In Seattle, the Harborview Health Center International Clinic has decided to increase uptake of preventive therapy for the three groups of refugees most in need of it: Somalis, Russians and Ukrainians, and Bosnians and Albanians.
Among the three groups, all of them recent arrivals to Seattle’s checkerboard of foreign-born populations, the current rates for completion of preventive therapy are truly dismal, says Nolan, with less than 50% uptake and less than 50% completion. Among the Eastern Europeans, the rates are even worse, at only about 20%. To meet the challenge, Nolan has teamed up with Carey Jackson, MD, International Clinic medical director, whose job it will be to hire and train outreach workers recruited from the three problem-child populations.
Under Jackson’s direction, three newly-hired outreach workers are being trained in screening, education, and case-management services. At the same time, Jackson and others are convening and sitting in on focus groups as the groups try to help doctors understand which cultural barriers are standing in the way of preventive therapy.
How to say hello’ in Bosnian
Along with training and educating outreach workers, Jackson says he hopes to educate members of the health care community as well. "We need to learn the simple things, like how to say hello’ in Bosnian," he says. "Even though I followed the coverage of the war in the newspapers, I don’t know how the Bosnians look at it. I don’t know what their struggles are. I don’t yet know how they view other refugee groups."
Nolan gives a thumbs-up to Jackson’s anthropologically slanted approach. "Carey’s got a lot to teach us," Nolan says. "He says we have to learn to listen to these patients, not just tell them what we, the people in authority, think they ought to do."
As for the focus groups Jackson’s convening, they are showing that when different groups of refugees and immigrants are compared side-by-side, there are both similarities and differences in the kinds of problems that crop up when it comes to TB.
Take eating arrangements, for example. In cultures that share food from a common platter — Ethiopians, for example, who tear off bits of injera and use it to scoop up morsels from a common plate — when someone is found to have "TB infection," generally he or she is swiftly banished from the common table. Instead of sharing food with the family, the person is "handed a fork and a knife and told to go eat on the other side of the room," says Jackson. "It’s like you have the flu, and no one wants to touch your eating utensils — not a comfortable feeling." Knowing ahead of time about food-related taboos makes it easier to confront them effectively, he adds.
Other barriers relate to shades of meaning that English-speaking providers, even with the help of an interpreter, have a hard time relaying correctly. As many physicians have learned the hard way, many cultures view a diagnosis of TB as inevitably fatal; thus, any news to do with TB may be met with panicky resistance or outright denial.
The problem is exacerbated by the fact that it’s hard for non-native speakers to relay the critical difference between "TB disease" and "TB infection," a distinction that doesn’t even come across easily in English, Jackson says. ("That’s why we needed to come up with HIV and AIDS — as a way of conveying the two states are very different," he adds.) Only someone fluent in the nuances of a culture can take the time to sit and talk patiently, perhaps drawing pictures or making clear in other ways that latent TB infection is not the same as having TB disease.
Distrust of government agencies also figures into the problems that TB controllers must contend with, Jackson says. Distrust seems especially acute among Eastern Europeans and people from the former Soviet Union, many TB controllers say. "The Russians avoid us like the plague," says Jackson.
Training workers is a difficult process
A Bosnian man recently hired as a TB outreach worker illustrates the problem. The man used to be a veterinary assistant; his job back home consisted mainly of his ordering farmers to shoot TB-infected cattle. "His approach to people here so far hasn’t been all that different," sighs Jackson.
That brings Jackson to the hardest part of the project so far — training and supervising the community outreach workers. "It takes a lot," he says. "These people aren’t professionals; their concepts of goal-setting, their problem solving-ability abilities, and their productivity measures all need a lot of work. You’ve got to be right there telling them exactly what they can and can’t do."
Eventually, it’ll be worth all the effort, Jackson says. "The magic the outreach worker can do — it’s a kind of thing you get in the intonations of the voice, the ingratiating looks," he says. "It’s knowing how to be persuasive within a culture."
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