Increasing LTBI Treatment Adherence Among Refugees: Utilizing a Peer Support Model

The United States has a long tradition of The Overview offering refuge to those fleeing persecution Since Fall 2007, the International Rescue Committee in Salt Lake City (IRC- and war. Last year, the International Rescue SLC), in collaboration with the state and local health departments, has Committee's 22 regional offices helped implemented a Latent Tuberculosis Infection Treatment (LTBI) Program resettle over 9,000 newly arrived refugees in uniquely designed to educate, facilitate and support newly arrived refugee the U.S. and provided services to 28,000 clients in successfully adhering to and completing four to nine months of LTBI refugees, asylees and victims of human treatment. The foundation of the LTBI Program is based on the premise that trafficking. IRC staff members and with a better understanding of LTBI and the need and value for treatment, volunteers believe that refugees’ greatest clients will be empowered to make the decision to receive, adhere to and resources are themselves. We help them complete treatment. The LTBI Program offers education and support in the translate their skills, interests and past form of the Peer Support Worker (PSW). Adapted from the “Peer Support for experiences into assets that are valuable in LTBI Treatment Adherence and Completion” Curriculum and Guide created by their new communities. the Charles P. Felton National Tuberculosis Center, the PSW component ensures that every refugee client receives culturally and linguistically The IRC supports newly arrived refugees by appropriate support at the onset of treatment. In conjunction with IRC-SLC 24- providing immediate aid, including food and month comprehensive approach to resettlement, which includes case- shelter. Through a network of staff members management, employment services, housing support, acculturation activities, and volunteers we provide access to the and health education and coordination, the LTBI Program is able to fully tools of self-reliance: housing, job placement support refugee clients during their course of treatment. and employment skills, clothing, medical attention, education, English-language IRC-SLC LTBI Program collected data during Fiscal Year 2009 (FY09), classes and community orientation. Each running from October 2008 to September 2009. During this time period, 592 resettlement office serves as a free, one- refugee clients were resettled by the IRC-SLC. 157 refugee clients were stop center for refugees’ needs during their referred into the LTBI Program by having either a positive QuantiFERON-TB pivotal first months in the U.S. (QFT) or Tuberculin Skin Test (TST) result. Collected data shows a total of 270 clients which includes the 113 refugee clients that mid-treatment at the onset In addition to integrating refugees into the of data collection. Prior to implementation of the LTBI Program, the rate of U.S., the IRC’s resettlement network LTBI treatment participation among refugees in Utah was roughly 68% with provides comprehensive immigration incomplete information regarding treatment completion. Data analysis at the services to assist refugees and asylees on end of FY09 showed a treatment participation rate of 95%. their path to becoming permanent residents or U.S. citizens. The Goals  Provide culturally and linguistically appropriate education regarding TB, LTBI and treatment options to refugee clients referred into the LTBI program, thus empowering clients to make educated decisions regarding their course of treatment

 Provide refugee clients with culturally and linguistically appropriate social support through a trained Peer Support worker to facilitate full participation in and completion of treatment

From Harm To Home | theIRC.org IRC-SLC LTBI Program (Cont’d) 2

The Process “Increase the Refugees entering the United States go through a rigorous proportion of contacts screening both prior to and post arrival. 1. Prior to arrival - refugees are screened for TB/LTBI and other high-risk 2. Those classified as Class B1/B2 under the CDC persons with latent classification system were referred to Salt Lake Valley Health Department (SLVHD) upon arrival tuberculosis infection and assigned a Public Health Nurse (PHN). who complete a According to CDC Protocol for Class B TB, the course of treatment” PHN will follow up with obtaining history and sputum sample, attending Chest Clinic, and to 85%. proceeding with treatment if required. - Healthy People 2010 Objective 14-13 3. Those with no TB classification will receive a QFT or PPD at their post arrival health screening. If positive, refugee client will receive a Chest X-ray (CXR) to rule out active TB.

4. Once CXR is complete, PHN is assigned and an intake is scheduled with the client and a PSW. Education with the option of treatment will follow.

5. Treatment is facilitated through regular med pick-ups held at IRC two Mondays a month. This allows refugee clients to meet with a PHN and pick up their treatment for the month while a PSW is present. Pick up at SLVHD is also an option for those with scheduling conflicts. Treatment adherence is based on self reporting.

6. Course of treatment is tracked through the LTBI Program tracking data base.

The Challenges Refugee clients cite many barriers to access and subsequently, adherence to treatment. The four barriers that the LTBI Program addressed during FY09 included: 1. Language - Refugees come from all over the world, the majority of whom speak limited or no English. Hospitals and clinics often have limited access to interpreting services especially for languages of populations new to the United States. No communication often means no follow up and no treatment. 2. “I am not sick.” – Refugees may come from a cultural environment where an individual only takes medicine when they feel physically ill. 3. Priorities – Newly arrived refugee clients are incredibly busy. They go to school. They fulfill public assistance requirements. They are actively searching for employment while knowing that their financial and medical assistance period will be expiring shortly. With so many responsibilities, treatment for an illness that currently show no signs or symptoms fall low on the priority list. 4. Transportation – With no car and little understanding of the transportation systems in the United States, traveling around the city can be confusing and stressful for an individual with limited English.

The LTBI Program also faced non refugee client related challenges. The foremost challenge has been obtaining a long term commitment from the Peer Support Worker. Due to the limited hours that the job requires, the PSW often hold a second job or is enrolled in school. They often move on to full time jobs leaving their LTBI caseload to a new PSW who has not yet had the time or opportunity to build that Peer-Client relationship.

From Harm To Home | theIRC.org/SLC IRC-SLC LTBI Program (Cont’d) 3

From Harm To Home | theIRC.org/SLC IRC-SLC LTBI Program (Cont’d) 4

The Peer Support Worker Peer Support Workers are recruited from the community based on their communication skills both in English and their native language, their history and experience as a refugee, and their ability to both learn and educate others about LTBI and treatment. Specific duties of the Peer Support Workers may include but are not limited to:  Improve refugee client-provider communication by relaying medical information in terms accessible to the refugee client

 Assist refugee clients in accomplishing treatment related tasks such as receiving CXR, attending nurse intake, and participating in med pick-up

 Provide social support to facilitate participation and completion of treatment

 Communicate refugee client health needs to IRC Health Program staff

During FY09, the LTBI Program employed five trained PSW. These five PSW covered eight languages – Somali, Kirundi, Kiswahili, French, Burmese, Karen, Nepali, and Arabic. Initial training of PSW included LTBI/TB education presented by the local health department, PSW responsibilities and logistics, Peer- Client relationship specifically addressing confidentiality and boundaries, and role-play scenarios. PSW meet weekly with an IRC Health Program staff member and attend monthly forums for on-going training.

The PSW has been the foundation of the LTBI program, addressing Barriers 1, 2, and 3 (stated above). Through a shared language, culture and experience, the PSW is able to make the LTBI information linguistically and culturally appropriate for the client. The shared cultural and refugee experience allows a relationship where the client feels comfortable asking questions and sharing their concerns regarding treatment. Through education and training, the PSW can address these questions directly or refer the client to an IRC Health Program staff member should the question fall beyond the knowledge acquired during training. As one component of IRC-SLC’s comprehensive approach to resettlement, the PSW also assists in addressing non-LTBI related concerns during treatment. Because LTBI treatment may fall below priorities such as housing, financial assistance, or employment search, those priorities must be addressed. The PSW supports the client by referring them back to the appropriate IRC staff member to address these concerns.

The Results The LTBI Program collected data from October 2008 to September 2009. During this time period, IRC- SLC resettled 592 refugees in Salt Lake City, the majority of which were Bhutanese, Burmese (includes Karen, Chin, Karenni), Iraqi and Somali. Eritreans, Cuban, Iranians, Burundians, Congolese, Rwanda, Sudanese and Afghan were also resettled in smaller numbers.

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Of the 592 refugee clients that received health screenings FY09, 157 received a positive PPD or QFT. 113 were mid treatment at the onset of data collection bringing the LTBI Data FY09 total amount of clients in data set to 270. Collected data tracked client referral into the LTBI program; if a client did not need treatment due to a history of LTBI treatment; if a client declined treatment; if a client stopped mid-treatment; if a case was closed due to pregnancy or move (out of state); and if a client completed treatment. The Bhutanese showed the highest rate of participation and adherence. Of the total number of referrals, 11% did not need treatment due to a negative PPD or a history of LTBI treatment. The majority of these referrals were B1/B2. The other 89% of referrals completed treatment bringing treatment completion rate for the Bhutanese to 100%. The Burmese also showed a high rate of completion. 20% of total referrals did not need treatment due to a negative PPD or a history of LTBI treatment. The majority of these referrals were B1/B2. 24% had cases that were closed due to pregnancy or move. 5% declined treatment. 5% stopped mid- treatment. 46% of total referrals

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completed treatment. Actual completion rate was not calculated due to restraints on data set. The Iraqi population, at 25%, had the highest percentage of clients that stopped mid- treatment. 12% declined treatment. 17% had cases that were closed to pregnancy or move (out of state). 46% of total referrals completed treatment. Actual completion rate was not calculated due to restraints on data set. 31% of the Somali referrals had cases closed due to pregnancy or move. 3% did not need treatment due to a negative PPD or a history of LTBI treatment. The majority of these referrals were B1/B2. 9% declined treatment. 3% stopped mid-treatment. 54% of total referrals completed treatment. Actual completion rate was not calculated due to restraints on data set. The Other group included Burundian, Cuban, Eritrean, Iranian, and Vietnamese refugees. This group had the highest percentage of clients whose cases were closed due to pregnancy or move (out of state). 15% stopped mid-treatment. 15% declined treatment. 32% of total referrals completed treatment. Actual completion rate was not calculated due to restraints on data set. Prior to implementation of the LTBI program by IRC-SLC, participation rate among refugee clients were at a low of 68%. There was little follow up due to barriers faced by both refugee clients and the local health department. Coordination by IRC-SLC and the component of PSW has provided the opportunity to overcome barriers on all sides. SLVHD has been able to gain greater knowledge of the refugee resettlement process, barriers facing refugee clients and cultural understanding of refugee populations. Clients have gained a better understanding of TB/LTBI and healthcare system within the United States.

Med Pick Up has been the main way to gauge patient understanding and compliance. LTBI treatment has always been offered as an option. Clients can choose to decline or accept treatment. If clients accept treatment, they accept the responsibility of coming to IRC on a monthly basis to meet with a PHN. All IRC clients receive an initial bus orientation from their home to IRC. IRC holds two med pick-ups a month. Rate of pick up was calculated by language - 90% for Nepali, 81% for Burmese, 59% for Somali, 49% for Arabic, and 85% for other. These rates do not include those that go to SLVHD for pick up due to scheduling conflicts. The Recommendations

From Harm To Home | theIRC.org/SLC IRC-SLC LTBI Program (Cont’d) 7

The combination of the PSW component and collaboration between IRC Health Program staff and SLVHD has resulted in a tremendous increase in LTBI follow-up, treatment, and completion. The PSW have been extremely successful working with and supporting the Burmese and Bhutanese population. However, data suggests that each population requires its own unique approach to treatment. The Somali and Iraqi groups are currently under assessment due to lower than average participation and completion rates. The LTBI Program looks forward to addressing more culturally specific barriers to participation and adherence as it continues to meet the TB/LTBI treatment needs of newly arrived refugees in Salt Lake City.

Prepared by: Ashley Nguyen Health Program Coordinator International Rescue Committee 231 East 400 South, Suite 50 Salt Lake City, UT 84111 801 328 1091 ext. 122

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