Improving Tuberculosis Treatment in the Migrant Farmer Community Through Fotonovelas

Louis Carrillo

 History of TB
Drug Resistance & Adherence Prevention Framework Educational Tool Development

Evaluation Methods & Results

Implications

'Tis call'd the evil: A most miraculous work in this good king; Which often, since my here-remain in England, I have seen him do. How he solicits heaven, Himself best knows: but strangely visited people, All swoln and ulcerous, pitiful to the eye The mere despair of surgery, he cures, Hanging a golden stamp about their necks, Put on with holy prayers: and 'tis spoken, To the succeeding royalty he leaves The healing benediction.
Macbeth, Act 4, Scene 3, 167-1771
http://shakespeare.palomar.edu/editors/images/R eynolds-Beaufort-bw.gif

Public Health Dr. H.M. Biggs Mandatory Reporting in New York Public Education Sputum destruction Residence visits and Sanitation http://www.craigleithhill.co.uk/images/Mycobacter Sputum submission to labs ium_tuberculosis_Ziehl-Neelsen_stain_02.jpg Sanatoriums to isolate and care for patients
2

Medicine
Dr. Robert Koch2 Identification of Mycobacterium tuberculosis 1882 Kochs Postulates Staining techniques of sputum Laboratory Diagnosis Basis of TB skin test Nobel Prize http://foodinthelibrary.com/IMGs/
3f05369v.jpg http://lh5.ggpht.com/_hh8AmqK287k/S y_OHU2ozYI/AAAAAAAAAmg/5ZZXHeOU90/tb%201904.jpg

 Streptomycin
Discovered by Dr. Waksman in 1944 1952: Nobel Prize, widespread drug resistance

Isoniazid (I)& Pyrazinamide (P/Z or PZA)

1950s

Ethambutol (E)
1960s

Rifampin (R)
1970s

Used for active (contagious) disease & latent infections (LTBI)

TB TB TB

TB
TB

Isoniazid

Works Great When Followed

TB
TB TB TB TB Rifampin

 AIDS and defunding of TB infrastructure allowed a resurgence in the 80s3 Worldwide disparity4
Impoverished, malnourished, cramped & homeless

Country

Mortality

Prevalence

Incidence

22 High Burden Countries (HBC) 1,100,000

World Total 1,300,000

11,000,000 7,600,000
14,000,000 9,400,000

HBC % of World

85%

79%

81%

 MDR-TB (Multidrug Resistant Tuberculosis)

Resistance to Isoniazid & Rifampin 2008 Est. 440,000 cases

XDR-TB (Extensively Drug Resistant Tuberculosis)

Injected drugs
Capreomycin, Kanamycin or Amikacin

Quinolones
Gatifloxacin or Moxifloxacin

58 Countries have reported a case

 Past treatment was a strong indicator

Isoniazid resistance5 1/1,000,000

Rifampin resistance5 1/100,000,000 Mutations5
Environmental pressure/selection
http://www.science.marshall.edu/murraye/341/snps/Human%20Genetics%20M THFR%20SNP%20Page.html

TB TB TB

TB
TB

Isoniazid

TB

TB TB TB TB Rifampin

Non-Compliance

Compliance

Factors
Self administered medicine, psychiatric problems, asymptomatic patients, severe side effects Time issues Health literacy, knowledge, attitudes10

Best followed treatments are:

Simple Cheap Quick short treatment duration, short procedure time

Non-Factors
Age, Socioeconomic Status (SES), Race

 Six - Twelve months Two- four pills Side Effects

Rashes Gastrointestinal (GI) complications Body Fluid Coloration (red or orange) Peripheral Neuropathy (Nerve damage) Hepatitis (Liver inflammation) Hyperbilirubinemia jaundice Thrombocytopenia malaise Polyarthalgia (Joint pain) Optic Neuritis blindness

 DOTS (Directly Observed Therapy Short-course)

Government commitment. Lab involvement. Six to eight months of treatment. An uninterrupted supply of anti-TB drugs. A recording and reporting system (patients and program).

DOTS +
Vulnerable populations (HIV, MDR-TB, destitute) Primary care invigoration Care from all levels Empower communities Promote research

 Multidrug pills New shorter therapies However not everyone is benefiting

 TB decline is concentrated in American born population. Foreign born now about 60% of cases 39 million foreign born persons in USA

U.S. Born

Foreign Born

Hispanics 30% of cases in USA

 Florida and Kentucky in 2005-2006

Rural farming communities

Findings11
Low TB knowledge Belief that BCG Vaccine made one immune Money and access as barriers Adherence attitudes

Spanish materials were developed to bridge gaps

 Health education tool for low literacy populations for various diseases
Usually developed with and evaluated by community
Diabetes in Hispanic youth12 Alzheimers13 HIV in migrant farmers14 Chicago TB in Hispanics15

Project Advisory Committee founded in 2009 for fotonovela & other materials for population
Evaluation showed the need for new chapters, summary, and factsheet

Primary Prevention Preventing spread to others

Secondary Prevention

Tertiary Prevention

SocietalTB PH Infrastructure, Immigration concerns

CommunityAccess to treatment, DOTS program

RelationshipHCW trust, Household members

IndividualHIV/AIDS, Diabetes, Malnourished, Health literacy/beliefs

Primary Prevention

Secondary Prevention Prevent Activation of LTBI

Tertiary Prevention

SocietalTB PH Infrastructure, Immigration concerns

CommunityAccess to treatment, DOTS program

RelationshipHCW trust, Family support

IndividualImmune system, Health literacy/beliefs

Primary Prevention

Secondary Prevention

Tertiary Prevention Prevent development of wasting & resistance

SocietalTB PH Infrastructure, Immigration concerns

CommunityAccess to treatment, DOTS program

RelationshipHCW trust, Family support

IndividualImmune system, Health literacy/beliefs Previous infection

 CDC

SNTC
Health departments and healthcare workers throughout region and nation Community members & organizations

 New chapter on adherence for HCWs to use

Side effects and solutions Demonstrate a collaborative relationship with health care worker (HCW)

Summary for individual chapter distribution Factsheet on the back

 Not limited by a researchers paradigm Product development evaluation strengths

Colloquialisms Opinions before a mass distribution Gauge message absorbtion

Project used them in previous phases, keeps with program aims

 Get a sense on health beliefs (pre-test)

Medication and Wellness

Summary and Quickfacts Objectives

Does this summary make sense ? Do the summary and quickfacts pique your interest?

 Chapter Objectives
Is this story realistic? What did you think about the HCW?

Every section
The design (culturally, linguistically, visually) What have you learned from this section? Clearness?

 IRB approval #436-2009

Two researchers to Farmworkers Self-Help Inc. Script was used as guidelines

Discussion was held, recorded and transcribed entirely in Spanish

 Every phrase was coded

In MS Word, codes were arranged into themes to describe the groups opinion
These themes were organized into the specific evaluation objectives of each section
Highlight positive/negative and solutions

 Farm Workers Self-Help Inc

9 Participants

Country Gender ofResponses Responses Birth Responses Years Age of Group Education Responses
3 2 1 0

57 46 35 24 3 1 2 0 1 0

8 7 6 5 4 3 2 1 0

Male

USA

Female

No Response Mexico

Participants mentioned: BCG Immunity

Less risk here and now

Health= when you feel well Misconceptions on transmission

Summary Objectives Clearness of the summary as an introduction

Themes Found

Language is appropriate level Problems: Diagnostic tests and LTBI Solutions: Explaining the test and LTBI Stating BCG vaccine vs vaccine Summarys ability to Characters identified situate participants in the Story paraphrased by particpants story Importance of the message for the community Awareness about TB is needed because of immunity misconception

Quickfacts Objectives Clearness and completeness of the message

Themes Found Appeared to be the necessary information No additions recommended

Ease of understanding
Perceived knowledge gain

Literally: easy to understand

Symptoms The importance of knowing symptoms in case something happens Extra-pulmonary TB

Chapter Objectives Clearness and completeness of the message Attractiveness of the design and stories

Feelings generated through images

Themes Found Summary leads into chapter Side effects clear Solutions are understandable Adherence is important Story is interesting & easy to understand Story is easy to follow Layout was no problem The HCW is trustworthy Creates an environment where Juan could explain his problems

Chapter Objectives Themes Found Acceptability of materials Story is realistic Pleased to see the materials included their culture No problems with language or appearance Importance of the The need for awareness is high in this community message for the A good health message in general community Materials could be passed along to those who might be sick Perceived risk Community is susceptible to drug resistance due to non-compliance Confusion about what role BCG plays in immunity status with TB

Importance of Adherence pie a la letra to the letter tomarlo la medicina y las doces que estn recomendando take the medicine and the doses that are recomended

Community Non-Compliance somos mas destronados we are more antiauthority

pero mucho de nosotros no lo hacemos

but alot of us do not do it

 Pre-test findings concurrent with adherence literature

Awareness of resistance threat

Well received

 Strengths
Generalizability in focus group Collaborative relationship recognized in fotonovela Y entonces como aqu, lo dice pues, que bueno, sean cosas que nos incluyan, lo a, la cultura de aqu. And like here, you say you know, how good, there are things that include us, the culture here.

Focus group limitations

Not everyone participates

Barriers to implementation
Literacy levels Investment of HCW BCG Misconception

 Public Health contribution

Widely distributed fotonovela
Federally Qualified Healthcare Centers (FQHC) now involved in TB screening and treatment.

Focus group with an underserved population gathering data on health, medication & BCG perceptions

A.G. Holley NOT FQHC

 AV format
Case Control comparison of tool vs. standard of care in migrant populations

 MPH
Monitoring community within a framework Inform and empower community through partnerships Tool to help TB care in disparished individuals and communities Link communities to HCW by bridging gaps Evaluate quality and accessibility of health education materials Reach out to communities in written form Focus groups for insight of community perceptions

 Core
Research & Literature summary Social Ecological Framework Community Participation Focus group execution (SBS Research) Educational tool as part of informational campaign Presentation of data and suggestions

 TB and medication Adherence Fotonovelas Results, Conclusions & Recommendations

 Parents

SNTC staff
Donna Wegener, MA Dr. Alba Burns, MD, MS Lolia Fernandez, MPH Dr. Paula Hamsho-Diaz, MD, MA

Tuberculosis is a social disease with a medical aspect. Sir Dr. William Osler Founding Professor of Medicine, John Hopkins

http://blog.lib.uiowa.edu/hardin/files/2007/11/osler-desk.jpg

 1. Shakespeare, William. The Trajedy of Macbeth. [Online] http://shakespeare.mit.edu/macbeth/full.html. 2. Yancey, Diane. Tuberculosis. s.l. : Twenty First Century Books, 2001. 3. Nebraska Department of Health & Human Services. History of Tuberculosis. Nebraska Department of Health & Human Services website. [Online] 2011. http://www.hhs.state.ne.us/cod/tuberculosis/TB History.htm. 4. World Health Organization. Global Tuberculosis Control . Geneva : WHO Press, 2010.

 5. Enarson, Donald, Chiang, Chen-Yuan and Murray, John. Global Epidemiology of Tuberculosis. [book auth.] William Rom and Stuart Garay. Tuberculosis. Philadelphia : Lippincott Williams & Wilkins, 2004, pp. 13-27. 6. Interventions to Enhance Patient Adherence to Medication Prescriptions. McDonald, Heather, Garg, Amit and Haynes, Brian. 22, s.l. : Journal of the American Medical Association, 2002, Vol. 288. 7. Pharmacokinetics of TB Drugs. Stambaugh, Jerry. Lantana : Southeastern National Tuberculosis Center, 2011. 8. Organization, World Health. DOTS-Plus and the Green Light Committee. Paris : Stop TB Working Group, 2003.

 9. Ashkin, David. Lantana : s.n., 2011. 10. CDC. Reported Tuberculosis in the United States, 2009. Division of Tuberculosis Elimination. Atlanta : Department of Health and Human Services, CDC, 2010. 11. SNTC. Vivir a todo pulmn!: A Needs Assessment Focusing on Tuberculosis and the Spanish-speaking, Foreign-born. Atlanta : CDC, 2006. 12. Evaluation of Sweet Temptations, a Fotonovela for Diabetes Education. Unger, Jennifer, Molina, Gregory and Baron, Melvin. 3, s.l. : Hispanic Health Care International, 2009, Vol. 7.

 13. HIV Prevention with Mexican Migrants: Review Critique and Recommendations. Organista, Kurt, Carrillo, Hector and Ayala, George. 4, s.l. : JAIDS: Journal of Acquired Immune Defiency Syndromes, 2004, Vol. 37. 14. The Effect of a Cultural Intervention on Adherence to Latent Tuberculosis Infection Therapy in Latino Immigrants. Alinger, Rita, et al. 2, s.l. : Public Health Nursing, 2010, Vol. 27. 15. Fotonovelas: A Health Literacy Tool for Educating Latino Older Adults About Dementia. Valle, Ramon, Yamanda, Ann-Marie and Matiella, Ana. 1, s.l. : Clinical Gerontologist, 2006, Vol. 30. 16. Morgan, David. Focus Groups as Qualitative Research. s.l. : SAGE, 1997. 0761903437.