March 2007

Grant Results

National Program

Old Disease, New Challenge: Tuberculosis in the 1990s

SUMMARY

The State of Florida Department of Health and Rehabilitative Services established a system for tuberculosis (TB) testing, assessment and treatment services for its migrant farmworker population in Northeast Florida and attempted to set up the model in South Florida and to track TB treatment as farmworkers move north.

The project was part of the Robert Wood Johnson Foundation (RWJF) national program, Old Disease, New Challenge: Tuberculosis in the 1990s.

Key Results

  • Among active cases of TB, 93 percent of farmworkers in Northeast Florida completed therapy.
  • Among latent cases, 77 percent of traveling migrants in Northeast Florida completed therapy; and 86 percent of seasonal farmworkers remaining in North Florida completed therapy.
  • Trusting relationships developed between health department staff and the migrant community.
  • In the course of screening for and treating TB, many other health problems were identified in the migrant worker population.
  • The project as a whole demonstrated to staff the effectiveness of directly observed treatment (DOT) in increasing treatment completion rates for latent TB.
  • Outreach education efforts reached providers and migrant workers in Northeast Florida, South Florida and states to the north.
  • A network of communication with providers in northern states was in place by the time the grant closed.

Funding
RWJF supported this work with a $1.1-million grant from January 1994 through December 1996.

 See Grant Detail & Contact Information
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THE PROBLEM

The migrant farm worker population in Florida has an alarmingly high rate of TB infection and cases. In 1992, 70 percent of the African-American migrant farm worker population tested positive for TB infection, as did 20 percent of the Hispanic migrant farm worker population. Due to the nature of their work, the migrant farm workers do not have a regular provider of health care and do not receive health care on a regular basis.

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THE PROJECT

The State of Florida Department of Health and Rehabilitative Services had five objectives for the project:

  • Implement in North Florida an extensive outreach screening program for migrant and seasonal farmworkers. The main objective that could be evaluated was completion of therapy on 95 percent of active cases and completion of preventive therapy on 60 percent of traveling farmworkers and 90 percent of those remaining in Florida.
  • Replicate the North Florida model of testing, assessing and treating TB in the South Florida counties of Palm Beach, Glades and Hendry using both directly observed therapy (DOT) for active cases and directly observed preventive therapy (DOPT) for latent cases.
  • Coordinate DOT across state lines as migrants moved north by interfacing with public health providers and providing training in states receiving the migrant workers.
  • Develop and maintain a patient information management system for the collection and control of comprehensive records of skin testing and of latent and active TB cases. The system was designed to receive input from and provide output to upstream health care providers concerning TB cases.
  • Establish a health education program for outreach workers and interested members of the medical community to assure that educating farmworkers is an integral part of TB intervention programs and that medical providers have the most accurate information on tuberculosis.

The state of Florida provided $238,519, which funded additional staff for outreach, X-ray, nursing services and clerical support as well as TB physician services, X-ray interpretation and medical supplies.

The state also provided $170,203 to fund the project coordinators for project oversight and TB surveillance. The health department provided in-kind support for medical records and database management, clerical support, and nursing and physician services.

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RESULTS

  • The department conducted a widespread program of outreach screening and therapy. Initially, outreach and medical staff conducted screening exclusively in the fields through physical assessments, skin and blood tests, and X-rays. Because of constraints on farmworkers' time and problems with access to the state's mobile X-ray unit, the department began to transport farmworkers to weekly night clinics from 1994 throughout the project. At the clinics, medical staff were able to begin treatment for active disease and a wider range of health care services, including counseling and education on HIV and sexually transmitted diseases (STDs). In 1996, the state purchased a portable X-ray unit allowing for more testing in the fields.
    • Among active cases, 93 percent of farmworkers completed therapy, almost meeting the objective of 95 percent.
    • Among latent cases, 77 percent of traveling migrants completed therapy (exceeding the objective of 60 percent); and 86 percent of seasonal farmworkers remaining in North Florida completed therapy (almost meeting the objective of 90 percent).
  • Trusting relationships have developed between health department staff and the migrant community. This enabled project staff to continue to conduct night clinics and to provide TB, HIV and STD screening and education to high-risk individuals in the community.
  • The project as a whole demonstrated to staff the effectiveness of DOT in increasing treatment completion rates for latent TB. It has prompted department staff to consider a new, less-costly model for delivering this therapy for latent cases by utilizing lay health providers trained from within the migrant community. As of the close of the grant, it was seeking funding for this model.
  • There were problems with replicating the model of testing, assessing and treating TB in the South Florida counties of Palm Beach, Glades and Hendry. There were significantly larger number of farmworkers in the tri-county region (20,000+), which meant there was less information on crew organization and locations, complicating outreach and lessening initiation and completion of DOPT. The counties switched to a system emphasizing widespread X-ray evaluation to identify and contain active TB over DOPT for latent cases.
  • Coordination of DOT across state lines as migrants moved north did not occur as planned. The plan initially was to have two project outreach workers travel north with the migrants and work with public health providers in receiving states, providing training in and continuation of the DOT/DOPT services. However, few patients remained on therapy when leaving Northeast Florida in 1994, so it did not make financial sense for the outreach workers to travel north.

    Some agencies in states north of Florida agreed to support continued DOT/DOPT with their own staffs. In 1995, a plan to have a nurse travel and coordinate follow-up care fell through when the nurse quit.

    In 1995 and 1996 the Florida health department coordinated care with upstream providers based on historic knowledge of farmworker crew travel patterns.

    After the grant ended, the health department contracted with North Carolina Primary Health Care Association to employ an upstream coordinator. In South Florida, staff identified New York as the state to which most local farmworkers traveled and obtained an agreement with providers in the state to facilitate continuing care of South Florida migrants.
  • Although the patient information management system worked well in Florida, it was not implemented in states to the north. Many providers in these states were not computer proficient and their system managers were reluctant to introduce and support an additional layer of data management.
    • The existence of the database and its enhanced structure to collect data beyond TB enabled extensive analysis for all the years of the project by contracted biostatisticians at the University of Florida.
  • Outreach education efforts reached providers and migrant workers in Northeast Florida, South Florida and states to the north.
    • In Northeast Florida, outreach education was most intensive during the project's first year, 1994. Project staff field-tested TB training modules developed by the Centers for Disease Control and Prevention. They provided training to 20 providers at the local Migrant Health Center, to Department of Labor OSHA staff, and to providers serving high-risk nursing home populations. Annual in-services have been held for health department staff to review TB transmission and the department's TB infection-control plan.

      Night clinics began to regularly offer farmworkers group discussions and viewings of culturally sensitive videos on TB and HIV, and one-on-one counseling sessions with trained HIV counselors.

    • In South Florida, project staff combined outreach education efforts with the gathering of data on farmworker residences and worksites to address information shortages which hampered initial project outreach. They mapped high-risk neighborhoods, screened residents and provided TB education to 977 individual in 1995 and 420 in 1996. Then, they began working in ESL (English as a Second Language) classes and community organizations serving farmworkers and foreign-born individuals.

    • The Florida health department signed a contract for a coordinator who trained outreach workers in TB and DOT/DOPT procedures in North and South Carolina. The coordinator delivered presentations on the project to providers during site visits to clinics; reviewed and distributed bilingual and other patient education materials; assisted in TB policy improvement and promoted provider use of a TB clinic system. Working with the North Carolina TB Task Force and various farmworker organizations, she helped develop community education strategies and a migrant care resource manual for distribution to regional providers.
  • A network of communication with providers in northern states was in place by the time the grant closed. It allows the Florida health department to track and monitor treatment completion for active and latent TB cases outside the state.

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LESSONS LEARNED

  1. Health departments attempting an interstate, interagency project of this scope should first have a thorough understanding of the technological capabilities, organizational structures and financial limitations of the agencies with which they partner. (Project Director)
  2. When tracking a migrant population across state lines, include agencies in other states as full partners in providing services to the population, or subcontract for their services and compensate for them from the outset. This will assure greater cooperation and effectiveness. (Project Director)
  3. The importance of flexibility in reaching migrant farmworkers-in clinic hours, staff scheduling, travel and duty assignment-needs to be clear from the outset when hiring staff. (Project Director)
  4. Project staff members need to have a commitment to serving migrant farmworkers. Only this will enable them to accept the changes needed to accommodate the health care needs of this population. (Project Director)

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AFTER THE GRANT

  • Partner with St. Vincent's Medical Center in Jacksonville, Fla., to provide limited primary care to the farm workers.
  • Provide technical assistance to other Florida counties attempting to develop similar projects.
  • Locate funding to continue the DOT program after the RWJF grant concludes. A legislative budget request was submitted to the Florida Legislature in the fall of 1996 in hopes of securing funding for July 1997 through June 1998, but it was not approved.

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GRANT DETAILS & CONTACT INFORMATION

Project

TB Control in the East Coast Migrant and Seasonal Farm Workers in Florida

Grantee

Florida Department of Health and Rehabilitative Services, Putnam County Public Health Unit (Palatka,  FL)

  • Amount: $ 1,154,315
    Dates: January 1994 to December 1997
    ID#:  023611

Contact

Project Director: Cheryll D. Lesneski
(904) 329-0420

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Carter RL, Lesneski C, Loor R, Gauch L, Campbell K, Sun Y and Knight C. "Adherence to Directly Observed Therapy Among Florida's Migrant and Seasonal Farm Workers." Unpublished.

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Report prepared by: Marie P. Lyons
Reviewed by: Marian Bass
Program Officer: Marilyn Aguirre-Molina
Evaluation Program Officer: James Knickman

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