Abstract
The majority of active tuberculosis (TB) cases in the United States occur through re-activation of latent TB infection among foreign-born individuals. While screening of at-risk individuals through community partnerships is recommended, it is not commonly accomplished. A community-academic partnership developed a TB screening intervention at an adult education center serving a large foreign-born population in Rochester, Minnesota. The intervention was co-created with grant support by diverse stakeholders through a community based participatory research partnership. The intervention was sustained beyond the grant interval through adaptation of staffing inputs, a robust partnership with sustained dialogue around TB and operational issues, and adaptation of governance through co-ownership of the intervention by the adult education center and the public health department. Eight years of data demonstrate that adult education centers may be effective venues for sustaining partnerships to address TB prevention among at-risk communities.
Keywords: Tuberculosis, Adult Education Center, Community Based Participatory Research, Sustainability
INTRODUCTION
Approximately two-thirds of active TB cases in the United States (US) occur in foreign-born individuals, predominantly through reactivation of latent TB infection (LTBI) in the first 5–10 years after arrival.1 US guidelines recommend testing for and treating LTBI among people from countries where TB is common.2 Immigrants arrive to the US 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 US.3 In order to overcome the multifaceted barriers to screening in these populations, the Centers for Disease Control and Prevention (CDC) recommend forging community partnerships within at-risk communities to prevent TB in the US,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 under-documented, 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 (CBPR) approach from 2006 to 20098, was found to be feasible, worthwhile, and superior to previous conventional screening programs at the same site.9 Intervention development and cross-sectional evaluation was 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 (MN) 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 2,500 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 was the founding community partner of Rochester Healthy Community Partnership (RHCP), which has a mission to promote health through CBPR10. CBPR 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, who 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 re-tested 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.
TB Skin testing was performed according to CDC guidelines13; a positive test was recorded for skin reactions of 10 millimeters 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 x-ray, 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 ruled out for active disease. 72 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.
Table.
2009 to 2017
| Year | TB skin tests performed | Positive TB skin tests | Evaluated at Health Department* | LTBI medications started | LTBI medications completed |
|---|---|---|---|---|---|
| 2009 | 272 | 48 | 43 | 29 | 23 |
| 2010 | 32 | 3 | 3 | 1 | 0 |
| 2011 | 112 | 25 | 18 | 14 | 12 |
| 2012 | ** | 9 | 8 | 7 | 6 |
| 2013 | 68 | 10 | 9 | 6 | 3 |
| 2014 | 38 | 10 | 8 | 6 | 6 |
| 2015 | 79 | 12 | 9 | 7 | 7 |
| 2017 | 17 | 4 | 3 | 2 | *** |
| Total | 121 | 101 | 72 | 57 |
LTBI = Latent tuberculosis infection
Patients were not started on LTBI medications for the following reasons: interferon-gamma release assay negative, medical contraindication to therapy, pregnancy, or patient declined.
Missing data (not recoverable from original data set).
Patients currently receiving treatment.
DISCUSSION
This case study demonstrates that a TB prevention program can be effectively sustained at adult education centers that serve immigrant populations who are at risk for the disease if partnership capacity exists. The intervention has been sustained for 8 years without extramural support because of 4 factors. First, the collaborative formative work conducted through a CBPR approach identified that fear and stigma about TB were common barriers to testing, thereby opening the door to dialogue about these concerns8. Second, this formative work resulted in an intervention framework built by Hawthorne learners and staff in a way that promotes participation and actionable health decisions related to TB prevention. Third, the intervention was adapted in ways that allowed flexibility of staffing certain phases of the intervention (e.g., classroom education) by different stakeholders. Finally, co-”ownership” of the TB screening program by Hawthorne, the public health department, and RHCP leveraged the unique strengths and resources of each organization towards a common goal.
After the first year of the program, which formed the basis for the original proof of concept study, the number of learners screened was variable from year to year. This variability reflected many factors, including variation in the number of times per year the screening was offered (ranged from 1–3), variability of student enrollment numbers, and availability of partners for classroom TB education. The program paused for a year in 2016 due to administrative changes at the site.
The TB prevention program is an example of a sustainable model of community partnerships within at-risk communities to prevent TB through a participatory approach. However, this study is limited by its focus on individual client data rather than organizational constructs of sustainability.
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 to sustain these TB prevention efforts.
IMPLICATIONS FOR POLICY AND PRACTICE
Forming and sustaining community-based partnerships for tuberculosis prevention among at-risk communities is feasible.
Adult education centers that serve large foreign-born populations are effective venues for partnership work to prevent tuberculosis.
A participatory approach with stakeholders helps to sustain community-based tuberculosis prevention efforts.
ACKNOWLEDGEMENTS
The authors would like to thank all of the partners responsible for sustaining the TB screening program, including Hawthorne Education Center staff and volunteers, Olmsted County Public Health Department, Winona State University Department of Nursing, and other RHCP community and academic partners.
The National Institutes of Health (NIH) supported the initial intervention development of this project through a Partners in Research grant (R03 AI082703) and a Clinical and Translational Science Award (grant UL1-RR-024150) to Mayo Clinic.
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