Tuberculosis (TB) is a serious health threat to migrant farm workers in the Midwestern United States. This article describes characteristics of migrant culture and lifestyle, economic, and health challenges that may impact screening, diagnosis, and adherence with complex medication regimens associated with TB. A brief overview of TB discusses the historical perspective of the disease and describes the stages, transmission, and incidence among migrant populations. Several theoretical models, such as the Health Belief Model (HBM) and social cognitive theory, were considered by the authors to guide understanding of migrant beliefs about TB. A qualitative research study conducted with 23 Hispanic migrants with latent TB infection is presented. Discussion of the research findings describes environmental, cognitive, and social factors that were barriers to screening, diagnosis, and treatment. The article concludes with a description of recent migrant health clinic updates designed to improve the workers’ health status and considerations for environmental and educational change.
Key words: farm workers, Mexican culture, migrant health care, reciprocal determinism, social cognitive theory, tuberculosis
Migrants are frequently unable to complete the nine month course of treatment for latent TB.
The lives of Hispanic farm-workers are often difficult and dangerous. As they travel to follow the nation’s harvest, they face economic, environmental, health care, and political uncertainties. Among the risks is the life threatening disease of tuberculosis (TB). Migrants are frequently unable to complete the nine month course of treatment for latent TB. The authors, volunteers at a medical clinic in Northeastern Ohio, conducted a study to better understand the barriers to treatment and propose nursing recommendations to improve medication regimen adherence among migrant farm workers exposed to TB. The findings from this study might also apply to the treatment of other health risks endemic among migrant populations.
In this article, we explain a research project among Hispanic migrants diagnosed with latent TB infection. Background information reviews characteristics of Hispanic migrant culture, challenges faced by the workers, and an historical perspective of TB. Several models, such as the Health Belief Model (HBM) and social cognitive theory were considered as the theoretical framework for this study of migrants with latent TB. A qualitative study using the social cognitive theory as a guiding framework is presented. Discussion of the research findings describes environmental, cognitive, and social factors that were barriers to screening, diagnosis, and treatment. The article concludes with a description of recent migrant health clinic updates designed to improve the workers’ health status and considerations for environmental and educational change.
Review of Literature
Social and cultural behaviors combine with biological and environmental factors to affect an individual’s health (Norris, 1998). All of these factors are important for understanding medication adherence of the migrant population. This section summarizes important concepts in the literature related to characteristics of the migrant culture, challenges faced by migrants, and tuberculosis. Also included is perspective related to these challenges noted by the first author (Wyss) during the years she volunteered and conducted research in migrant camps.
Characteristics of the Migrant Culture
Migrant culture includes many people of Mexican heritage. This population is a very diverse group. A common term used to describe Spanish-speaking populations, including people of Mexican heritage, is Hispanic (Zoucha & Purnell, 2003). Hispanics have grown in population since 2003 by a greater percentage than any other ethnic group in the United States. Today, they make up about 14% of the U.S. population (Schmid, 2006). Many Hispanic people prefer to be identified by descriptors specific to their cultural heritage, such as Mexican, Mexican American, Latin American, Spanish American, Chicano, and Latino (male) or Latina (female). Mexican culture has been considered a blend of Spanish (white) and Indian (Native American) or African people.
Recent immigrants are more likely to live in poverty, are more pessimistic about their future, and are less educated than previous immigrants.
According to Zoucha and Purnell (2003), cultural heritage is a factor that contributes to the lifestyle of Hispanic migrant workers. Recent immigrants are more likely to live in poverty, are more pessimistic about their future, and are less educated than previous immigrants. Many Mexican Americans, especially from lower socioeconomic groups are present-oriented. They do not consider a steady income important and do not try to plan for the future. The trend has been to live in the here and now; present time is more important than future time. For them, the future is indefinite, but the present is accepted (Degazon, 2004).
Typical family dominance pattern is patriarchical. Machismo, in the Mexican culture, views men as having strength, valor, and self-confidence. Men are viewed as wiser, braver, stronger, and more knowledgeable regarding important matters. Females are responsible for decisions within the home and for maintaining family health. Women are expected to be devoted mothers and receive great respect from their husbands and children. The children are highly valued as they ensure the continuation of the family and culture (Lagana & Gonzalez, 2003). Blended communal families are becoming the norm in lower socioeconomic groups. Many live in extended families to make ends meet. The norm is for pregnant women to marry and Mexicans are more likely to marry at a young age. Common law marriages are frequently practiced and readily accepted with many living together their whole life (Figueredo, 2002). The family is central to most Mexicans and individuals have gained strength from family ties and relationships.
To many Mexicans, good health means the ability to keep working and have a general feeling of well being.
Because a fatalistic worldview and an external focus of control are closely tied, negative feelings are considered impolite and migrants are reluctant to complain or place blame (Figueredo, 2002). If a person becomes ill, "it’s the way things are" or "God’s will". To many Mexicans, good health means the ability to keep working and have a general feeling of well being. Good health, to many Mexican Americans, is to be free of pain, able to work and able to spend time with the family, both a gift from God and from living a good life (Spector, 2004, Wyss, 2003).
Challenges for Migrant Workers: Lifestyle, Economics, and Health
Review of the literature and participant observation by the author (Wyss) uncovered many challenges for migrant workers that could potentially impact their ability to adhere to a TB medication regimen. This section briefly discusses three major challenges the migrants face related to lifestyle, economics, and health.
Lifestyle challenges. Uncertain living arrangements, isolation, job insecurity, and hard labor impact the migrant lifestyle (Migrant Clinicians Network, 2006). Generally, migrants travel in large extended families and arrive from places like Brownsville, Texas (near the Mexican Border), Mexico, or Bellglade, Florida. They tend to return year after year.
Family status of migrants varies. Although many live in family groups, other groups are composed of single men who travel without family support systems. The majority are young (two-thirds under the age of 35 and over one-fourth age 21 or younger). Agriculture has traditionally been one of the few industries in the nation where workers under age 16, and some as young as 10 or 11, are part of the work force (Bechtel, Davidhizar, & Spurlock, 2000).
The migrants in this study lived in several camps surrounded the growers’ fields. Because of the annual pattern established, they were provided the same housing at the camps and were permitted to leave personal belongings (furniture and appliances) in their rooms. The assigned buildings often lacked private bathrooms and the majority of the migrant families shared a shower/sink/commode with others.
Economic factors. Mexico experienced financial and political problems in the 1980s that has led to critically high unemployment and an inability to pay its foreign debt (Gonzalez & Kuipers, 2004). These problems resulted in an unstable situation that led to an influx of immigrants seeking jobs in the United States. Many of these immigrants place little value on education because it is not considered beneficial in obtaining a job. Once in the United States, they look for work similar to what they did in Mexico (Figueredo, 2002). Many Mexicans and Mexican Americans work as seasonal migrant laborers and may relocate several times each year as they "follow the sun." Sometimes their unwillingness or inability to learn English has been related to their intent to return to Mexico; however, this may have hindered their ability to obtain better jobs (Zoucha & Purnell, 2003; Zoucha, 2000).
Many [Mexican] immigrants place little value on education because it is not considered beneficial in obtaining a job.
Individuals working in farm labor tend to be either newly arrived immigrants with few connections, or individuals with limited opportunities or skills. Employment in construction and meat packing is also common. Most earn an annual income of $7,500 per year (Migrant Clinicians Network, 2006), which was the norm for migrants as long ago as 1990 (Barger & Reza, 1994). The specific migrants included in this study averaged from about $250 to $300 per week during the growing season, usually May through September (Director of Migrant Center, personal communication, July 29, 2003).
...most current migrant farm workers are either American citizens or are employed legally through work permits.
Although they rarely have access to occupational rehabilitation or disability benefits, many immigrants are eligible for Medicaid, food stamps, and the Women, Infants, and Children Program (WIC) if they live in one area long enough to secure these benefits. However, many who paid into Social Security are unable to prove their claim for benefits because of their immigration status. It once was true that some segments of American agricultural industry relied heavily on undocumented workers, but most current migrant farm workers are either American citizens or are employed legally through work permits (Migrant Clinicians Network, 2002).
Health challenges. Hispanic migrants and seasonal farm workers suffer from a disproportionate number of medical problems compared to the general population
Hispanic migrants and seasonal farm workers suffer from a disproportionate number of medical problems compared to the general population.
While delivery of health care to minority groups is a challenge across the United States, it is especially difficult for migrant farm workers. Diagnosis and treatment of TB is challenging in migrant farm workers because of their highly mobile existence. Overall, these farm workers often have a Third World health care status (Bechtel, Davidhizar, & Spurlock, 2000).
Poss (1998, 1999, 2000) noted that because migrant farm workers are at high risk for TB, it is important to ensure that they receive appropriate screening for diagnosis and subsequent treatment. TB screening requires the administration of purified protein derivative (PPD) skin tests that must be read in 48 to 72 hours. Treatment then requires nine months of uninterrupted, carefully monitored, chemoprophylaxis with isoniazid (INH).
Adherence to the medication regimen is a major concern because of the length of treatment. A pilot study (Wyss, 2002) tested 356 individuals and found 59 positive TB tests (new or previous). These 59 individuals were diagnosed with latent TB. Each was encouraged to take INH for nine months. Less than half were willing to begin the medication. In the 2003 growing season, all migrants who did not already test positive for TB (n = 223) were retested. Those with positive cases of latent TB (n = 23) were interviewed to determine reasons why they did or did not take INH (Wyss, 2003). In sum, lack of adherence to a TB medication regimen poses a major health challenge to the migrant population (Wyss, 2002, 2003).
...lack of adherence to a TB medication regimen poses a major challenge to the migrant population.
Brief historical perspective. Over its long history, Mycobacterium tuberculosis (TB) has been called phthisis, consumption, English Disease, White Plague, and decay. Evidence of TB has been found in the spines of Egyptian mummies thousands of years old, demonstrating that the disease was common in ancient Egypt. Hippocrates, the ancient Greek physician, identified phthisis (which means wasting) as the most widespread and invariably fatal disease of his time. Attempts at cures varied. The Romans recommended bathing in human urine, eating wolf livers, and drinking elephant blood. Depending on the era of the diagnosis, some were told to rest or exercise, eat or abstain from food, and travel to the mountains or live underground. In general, "consumption" was not seen as contagious, but as hereditary (National Institute of Allergy and Infectious Diseases, 2002).
TB infection began to decline in incidence around the turn of the 20th century. Although this decrease may have been due to the waning of the epidemic, at least some of the decline was due to isolation (quarantine) of the sick in sanatoria and aggressive education about spitting, sleep, fresh air, and exercise for everyone (National Institute of Allergy and Infectious Diseases, 2002).
In 1908, French scientists Albert Calmette and Camille Guerin developed a vaccine against TB. The vaccine, Bacille Calmette Guerin (BCG), was first administered in 1921. Since then, millions have been inoculated. However, it is no longer used in the United States because research demonstrated that it would prevent TB infections in the brain of children, but was nearly useless in preventing adult pulmonary TB. In 1944, Dr. Waksman was the first to use antibiotics (streptomycin) to treat TB. A host of other drugs has since been developed. With effective use of medication, the sanatoria were closed by the 1950s (National Institute of Allergy and Infectious Diseases, 2002).
According to the American Thoracic Society (2000, 2002), TB remains one of the deadliest and most opportunistic diseases in the world. Gibbs (2005) notes someone in the world dies of TB every 18 seconds. The World Health Organization (WHO) estimates that each year, tuberculosis kills more than two million people. They estimate that between 2000 and 2020, nearly one billion people will be newly infected, two hundred million will get sick, and thirty-five million will die from TB. WHO attributes this to the breakdown in health services, the spread of HIV/AIDS, and the emergence of multi-drug resistant TB. The disease has always occurred disproportionately among disadvantaged populations which often have high rates of illiteracy, poor health knowledge, and feelings of powerlessness when confronting the health system (ASCM Framework for Action, 2006). The tragedy of TB is that it can be cured with a series of daily antibiotics, but when treatment is interrupted (not finished), it can lead to the rise of multi-drug resistant TB. This type of TB is more difficult and more expensive to treat (Walsh, 2005).
Stages. Tuberculosis occurs in two stages, latent infection and active disease. Latent TB infections usually begin in the alveoli where the tubercle bacillus multiplies. After the first few weeks of infection, the disease can spread from the lower lungs through the blood stream to other parts of the body. At that point, the immune response kills most of the bacilli and usually halts the spread of disease. The person now has a TB infection which can be detected by completing the TB skin test. It can take from two to ten weeks for the infected person to develop a positive reaction to the TB skin test. These persons are not counted as having TB and instead are known as having latent TB infections (CDC, 2006a).
TB remains one of the deadliest and most opportunistic diseases...someone in the world dies of TB every 18 seconds.
Five percent of persons who have been infected with Mycobacterium tuberculosis will develop active TB disease in the first year or two after infection. Another five percent will develop disease at some time later in life (CDC, 2000). Only people with active TB disease of the lungs or airway can spread it.
Transmission. Transmission of TB occurs when an infected person coughs, sneezes, sings, spits, or speaks. Bacteria that cause the disease are then propelled into the air. The tiny particles can be airborne for several hours. If another person inhales air containing these droplet nuclei (even a few), transmission can occur. The bacteria move through the respiratory system, down the trachea into the lungs and along the branches of the bronchi until they reach the alveoli, the small air sacs. The most susceptible locations for infection are the upper lungs, kidneys, the brain, and the bones (CDC, 2005).
Transmission is most likely to occur when individuals are in close proximity for extended periods of time or in closed air spaces with poor ventilation (CDC, 2006b). Risk of transmission increases when a person with decreased immune function shares the air for a prolonged period of time with a person with untreated TB. Without treatment, a person with active disease can infect ten to fifteen people a year (National Institute of Allergy & Infectious Disease, 2002).
TB incidence among migrant populations. People identified as high risk for exposure to TB are those with close contact with persons known or suspected to have TB, including foreign persons from areas where TB is common, residents and employees of high-risk congregate settings, and health care workers who serve high-risk clients (CDC, 2000). According to the Centers for Disease Prevention and Control (CDC)(2001), incidence of TB among foreign-born persons living in the United States has been increasing. In 1999, 43% (7,553) of the 17,531 U.S. TB cases reported were among foreign-born persons. Unfortunately, this data represented only the legal residents in the country. During 1994-1998, approximately 3.9 million legal immigrants entered the United States (16.5% from Mexico and 5% from seven countries in Central America). It is estimated though, that 2.7 million persons from Mexico and Central America lived in the USA without documentation of citizenship or visas. Persons from these countries likely contributed substantially to the incidence of TB in the United States (CDC, 2001).
Theoretical models were explored as a way to guide the understanding of the complex issue of medication adherence among members of a fluid population, such as migrants. Among those considered as a guiding framework for this study was the Health Belief Model, initially developed to explain the widespread failure of people to participate in programs to detect or to prevent TB disease (Becker, 1974; Hochbaum, 1958; Strecher & Rosenstock, 1997; Rosenstock, 1960). However, the HBM has been criticized as an inconsistent predictor of adherence (i.e., could not successfully predict an individual’s actions in adhering to a medical regimen) (Rankin & Stallings, 2001) and thus it was ultimately concluded that this model was not the most appropriate as a framework for the current study.
Bandura (1998) asserts that the social cognitive model explains the means, resources, and support needed to change risky behavior. This section briefly describes the basic tenets of the social cognitive model and explains why we selected it to guide our understanding of migrants’ beliefs about medication adherence. A description of the research study follows discussion of these theoretical considerations.
Social Cognitive Perspective
The social cognitive framework, as conceptualized by Bandura (1986, 1997, 1999) involves the reciprocal relationships among cognition/personal, behaviors, and the environment. These are interdependent causal factors, but each has the capacity to affect the others in reciprocal relationships. The triadic reciprocal relationship is called reciprocal determinism and this concept is depicted in the Figure. The cognitive/personal determinant includes factors such as beliefs about one’s competence; causes of success and failure; and a sense of control, values, and goals. The environmental component includes factors such as the cultural context, exposure to a disease, and social support. The behavior (or the performance) of the individual includes medication adherence and coping responses. The three components have a reciprocal relationship (i.e., each affects the other).
Figure 1: Reciprocal Determinism
The social cognitive model is the basis of self-regulatory beliefs and actions and the capacity of humans to be self-directed (Zimmerman, 2000). Two beliefs that guide self-regulatory actions are self-efficacy and attributions. Self-efficacy beliefs refer to a person’s confidence about his or her capability to carry out actions to accomplish specific tasks ( Bandura, 1997, 1998). These beliefs are important because, unless people believe they can influence their circumstances, there is little motivation to act. For health behaviors, this belief is important as to whether or not the client follows the prescriptive regimen. Attributional beliefs are causes given by a person for one’s outcome or performance and as such, the beliefs influence actions and expectations. Three dimensions of attributions, locus of causality; stability; and controllability, are used to understand the specific causes one gives for an outcome. Causality is internal (people attribute the outcome to themselves), or external (attribute outcomes to forces outside themselves). An understanding of these beliefs can provide caregivers with important information regarding the sources of health behavior, including preventive practices, coping behaviors, risk behavior, adherence, and self-help.
Choice of Model
...on the whole, migrant workers did not believe they were sick [thus] the negative impact of the disease was not a factor for motivation.
A theory was required that could examine multiple factors found in the difficult and often chaotic lifestyles of the migrants. Also, initial observations by the first researcher noted that, on the whole, migrant workers indicated they did not believe they were sick. Thus, the negative impact of the disease was not a factor for motivation. The environment was an important component, because of the presence of both physical and social factors in the migrant camps. The primary strength of the social cognitive theory has been the assumption that human thoughts and feelings developed in reaction to environmental factors, but at the same time influenced the environment (Bandura, 1997). The context of the migrant camp included all of these factors. Consideration of the above factors supported the selection of the social cognitive model over the HBM to examine the migrant workers’ beliefs about medication adherence.
Method. This ethnographic study was conducted using a qualitative perspective to provide a framework for studying the meaning, patterns, and experiences of a defined cultural group such as the migrants in a holistic fashion. Ethnographic observations were used to examine the situation from the migrants’ perspective. Through fieldwork (interviews and observations) the researcher came to better understand the Mexican-American culture and the impact of cultural communication within the migrant population. Through extensive exposure to the migrant population, the researcher gained understanding of how members viewed their world and how they structured their experiences. The aim was to learn (hear) what this group believed. A primary goal was to gain an emic perspective (insider’s view), informed by etic perspective (outsider’s interpretation). The key concern was to understand the phenomenon (migrants’ beliefs) from their perspective (Merriam, 1998; Gall, Borg, & Gall, 1996; Streubert Speziale & Rinaldi Carpenter, 2003).
Setting. The setting for this study was an area of four commercial farms in the Midwestern United States. These farms employ 300 to 400 seasonal migrants and laborers.
Population and sample. The population for this study was individuals who migrated to work for growers in the area, or seasonal workers. One large farm employed nearly 75% of the migrant population, a second employed 25%, and the last two employed only five to ten workers at a time. The migrants resided in the camps for at least five to six months each year. The majority had earned incomes well below the poverty line (Personal communication, Director of the Migrant Center, July 29, 2003).
The Mantoux skin test was utilized to test all individuals employed by the four farms described above. Approximately three hundred individuals were tested over a period of several weeks. Those with positive Mantoux tests and non-active TB had a physical examination, chest x-ray, and blood work for liver enzymes. Twenty-three clients who had a final diagnosis of latent TB, using these diagnostic criteria, were chosen as informants. The researcher met with each individual and asked him or her to be part of the study (Bogdan & Biklen, 2003). Each was asked to take INH daily for nine months and interviews (described below) were conducted to determine beliefs and likelihood of adherence with preventive health measures. Interviews lasted approximately one hour and observations continued for several more months.
Protection of human subjects. Informants were not asked to sign permission or be taped as the migrants were fearful of deportation. The study was verbally explained and informants were asked if they would be willing to participate and if note taking was permissible. All verbally agreed. The institutional review board suggested that an interpreter (a migrant who spoke excellent English as well as Spanish) be paid to assist in this process. This method of consent was appropriate to the circumstances and approved by the University of Akron Institutional Review Board.
Data collection and site access. Written permission from the migrant center director was obtained and the center requested permission from growers to collect data in their camps. A windshield survey of the camp was completed. This helped to define the trends, stability, and changes that affected the community (Shuster & Goeppinger, 2004). The director and the researcher visited selected migrants in the evening or at lunch to ask them to be a part of the study. This technique enhanced acceptance of the researcher in the camps.
Following these steps, the researcher became as much a part of the migrant culture as possible. Participant observation included attending clothing sales, adult education classes, picnics, soccer matches, and working in the health clinic. This immersion allowed for observation of characteristics, conditions, verbal/nonverbal communication, activities, and environmental conditions (Polit Beck & Hungler, 2001).
Interviews took place in the migrants' own environmental settings. These were conducted in the late evenings after migrants had had time to get home and shower off the muck (thick, black topsoil common in the area). The main purpose of the interviews was to obtain insight into the migrants'reasoning for taking or not taking the required medication. Questions were open-ended and less structured. Demographic questions were asked first, then the rest of the interview was conducted using predetermined questions as a guide. Depending on the answers and situation at hand, more questions were raised and/or new topics and ideas introduced (Streubert Speziale & Rinaldi Carpenter, 2003).
To start each interview, five issues were addressed (Merriam, 1998). The investigator’s motives and intentions were explained. Respondents were informed that pseudonyms would be used and that they would not need to sign anything. Next, they were assured that all statements would be kept in confidence. Each respondent was informed that participation was voluntary and they would continue to receive free care, even if they did not agree to be interviewed. Finally, the logistics of the process were explained (i.e., each interview would be thirty to sixty minutes and could be broken up at their convenience).
Validity/Reliability. Ensuring validity and reliability in qualitative research involved conducting the investigation in an ethical manner. In qualitative studies, the researchers must paint depictions using enough detail to show that their conclusions make sense (Burns & Grove, 2001). One assumption in the qualitative perspective is that reality is holistic, multidimensional, and ever changing. Reality is not a single, fixed, objective phenomenon waiting to be discovered (Burns & Grove, 2001).
Validity was established by spending considerable time with participants and collecting data over a prolonged period. As a volunteer, the researcher was part of the migrant community for seven years. A pilot study was conducted in 2002, and in the summer of 2003, the researcher spent almost every day from late April through early October with the informants. Interviews were conducted in a natural setting to reflect migrants’ life experiences more accurately. Reflections, introspection, and self-monitoring (disciplined subjectivity) were documented in a jotted note field book.
Methods to enhance validity also involved utilizing multiple sources of data, and confirming data findings. This was accomplished by returning after data was collected and working with select individuals to determine their reactions to the study themes. In this group, a holistic understanding or a plausible explanation of the motivation for medication adherence was reviewed (Bogden & Biglen, 2003). Reliability was assured by demonstrating that the results made sense and were consistent and dependable. The researcher attempted to provide enough detail to readers to compare this study with other similar situations (Merriam, 1998).
Data analysis was guided by the social cognitive model. In this discussion of the analysis of participant observation and interviews, we note examples of environmental factors and cognitive/emotional beliefs of informants that may have affected medication adherence.
The environmental component of the reciprocal determinism model (see figure) may include barriers to screening, treatment, and post-treatment support and monitoring of clients with TB and their families. These factors can be physical or social. Physical barriers to the above factors for migrants were: financial status, seasonal work, daily work schedule, and transportation. Social factors that could serve as barriers included family support, coworkers, members of the community, and health professionals. The following quotes from migrant interviews illustrate how their environment combined with these physical and social factors.
The fluid lifestyle of migrant culture presented complex barriers to the treatment process...a major negative factor was the work schedule.
The fluid lifestyle of migrant culture presented complex barriers to the treatment process. For example, one migrant stated, "I haven’t gone for the medication, because I haven’t gotten my x-ray or blood work. I was supposed to catch a ride with the crew leader, but I did not get off work in time. I didn’t feel like I could ask again." Another stated, "There was too much rain, we are just not making much money." These two examples set the tone for what life is like for migrant farm workers. Even when x-rays, blood work, and medication were free for the migrants, other physical factors impacted treatment
A major negative factor was the work schedule. One informant stated, "It is such a hardship to get to the clinic. If they only had evening hours, it would be easier. I missed a whole day going into town to get the x-ray and blood work. I was unaware of how to get there. No one spoke Spanish there." and "Hard to miss work. If evening hours I would tell my boss I gotta go because I had worked all day." The difficulty of accommodating the work schedule was compounded for some by the cultural factor of the language barrier. These statements illustrate barriers in the environment that hindered the migrants from obtaining screening and treatment.
The findings of this study suggested that social aspects in the environment were a supportive factor for the migrants, especially for those with families.
The findings of this study suggested that social aspects in the environment were a supportive factor for migrants, especially for those with families. One woman explained that, as a couple, she and her husband motivated and supported each other and, as a family, they helped each other out. She stated, "We remind each other, we go to the doctor at the same time." A man received support from his wife by calling her once a week from a pay phone. She told him as long as they would give him medicine, he should take it, because it would not hurt him. He took the medicine for a month, but did not return to continue. One possibility for this outcome was that the medication could not be taken with use of alcohol. In late night observation in the clinic, this gentleman was frequently noted drinking beer (Wyss, 2003; Gilliam, 2006).
The personal cognitive component of the social cognitive perspective includes a sense of efficacy, attributions, and anxiety. One belief that emerged from the data was the extent to which the migrants believed they had control over getting TB or being cured. The following quotes illustrate the differences noted in these beliefs.
A low sense of self-efficacy might be interpreted from the statements below.
"I haven’t gone for the medication, because I haven’t gotten my x-ray or blood work. I was supposed to catch a ride with the crew leader, but I didn’t get off work in time. I didn’t feel like I could ask again. I had no control over the disease or treatment."
"I felt out of control, when they took my blood. They took a lot and I was scared. They explained to me what they were doing, but I was still scared."
The response, "I didn’t feel like I could ask again" to leave work to go to treatment could have indicated a weak sense of efficacy. This may have been a reality or it may have been the belief was stronger than the reality. The statement noting fear of a blood draw reflected a physiological source of a low sense of efficacy, fear, or anxiety.
In contrast, one migrant expressed a stronger sense of efficacy by stating that he intended to follow instructions. He stated, "No, I don’t think I had anything to do with getting the disease." When asked about control over the disease, or treatment, he responded, "I’ll follow the instructions to the letter. I’ll do what they tell me." This response reflected the influence of an attributional belief about a sense of control, either internal or external. This statement suggested that the informant believes that he has control over his treatment. Another informant offered an interesting belief about control. Although he did not know what the disease was or how he got it, when asked about disease or treatment, he concluded that "I guess I had control, if I do what they say, I’m in control. I have control over the disease and treatment, because I have to take my medicine."
When asked about any permanent health problems, one man stated, "I have none, I’m perfect." He was also asked about his support systems and commented, "My wife or no one has influence on me!" This suggested an unrealistic sense of control and infallibility, or a fatalistic belief about the disease. The belief may have reflected a norm found in certain aspects of the Hispanic culture that men are expected to be physically strong, not show pain (physical or emotional), and be able to drink without getting drunk. They also should attempt to dominate others, or at least not let others become dominant (especially women) (Figueredo, 2002).
Analysis of data that considered environmental factors and cognitive/emotional beliefs and behaviors through use of the social cognitive perspective provided a richer understanding of barriers migrants face during the complex TB treatment regimen. This data suggested important questions for reflection, such as, to what extent might the environment be adapted to minimize these external barriers? Secondly, to what extent can social cognitive beliefs, such as a strong sense of efficacy, help migrants to overcome barriers? The following section discusses considerations for nurses drawn from the study findings.
Nursing Implications: Environmental and Educational Considerations
The overall goal is that migrants become less fatalistic through an understanding that their personal actions can impact their future.
The reciprocal determinism model from the social cognitive perspective was a useful framework to evaluate factors that affected migrant beliefs and adherence. Data analysis identified areas of possible change for the future. All changes should incorporate cultural sensitivity. This section describes actual changes that occurred as a result of the authors’ research and suggests possible nursing implications related to educational outreach. See the Table for a specific description of the clinic’s progress since the initial pilot study.
As of 2005, several changes have been made at the medical clinic serving these migrant clients that might be considered for similar populations. These changes have altered environmental factors to encourage prompt diagnosis of TB in the migrant population and enhance subsequent medication adherence. They include:
- Expansion of clinic services to include evening hours (this has been two evenings a week)
- Collaboration between health care providers and growers to allow access to a full crew of migrants during work hours to permit administration and reading of Mantoux skin tests
- Inclusion of an interpreter at the clinic and on the bus during x-rays and blood-work (this was expanded to two paid interpreters at all times)
- Provision of transportation to an outside facility for testing (pick up and drop off in each camp)
- Expansion of the legal clinic to continue to assist migrants to gain permanent resident status in the United States.
In addition to altering the environment, medication adherence could be expanded through educational outreach. General education development (GED) and English as a second language (ESL) classes offer migrants an opportunity to improve their educational status. This may make them more likely to evaluate their health status for the future. Other informal educational activities could be aimed at explaining long-term consequences of TB, with emphasis that individual behavior could prevent or ameliorate negative outcomes. The overall goal is that migrants become less fatalistic through an understanding that their personal actions can impact their future.
The above changes have slowly improved testing efficiency and increased medication and follow-up adherence rates. These nursing implications could be considered for other migrant populations facing high incidences of TB infection. In addition, because so many factors of care were related to culture and environment, it may be that these study results could be applied to other diseases that typically affect migrant populations.
Although recent advances in treatment of TB have been generally successful in decreasing incidence in the United States, infection rates among Hispanics remain high. For the second consecutive year (2005 through 2006), more TB cases were reported among Hispanics than any other racial/ethnic group (CDC, 2005). This qualitative study used the social cognitive model as a theoretical guide to examine the beliefs of 23 migrant workers diagnosed with latent TB. Cultural factors, living conditions, length of treatment, and adherence were examined using participant observation and open ended interviews.
The most significant barriers may have been feelings of lack of control over the disease process and treatment options available to migrants.
Several environmental factors were identified as barriers to diagnosis and adherence with treatment. The most significant barriers may have been feelings of lack of control over the disease process and treatment options available to migrants. To address these barriers, possible nursing implications recommended include: increased access to medical care; improved collaboration between employers and caregivers; culturally sensitive treatment options, such as increased use of Spanish language translators; and educational interventions to increase feelings of control and self-efficacy among migrants. The proposed changes are part of a long-term process designed to enhance medical care among Hispanic migrants in this Northeastern Ohio sample. However, insights gained in this study related to barriers to screening, diagnosis, and treatment may apply to other settings and disease processes associated with migrant workers. Further research with this population can encourage continued refinement of treatment interventions and better understanding of cultural variables that will gradually decrease incidence of TB infection and improve health status of migrant workers and their families.
Lora L. Wyss, PhD, RN, CNS
Lora Wyss completed her diploma in nursing in Canton, Ohio and earned Bachelors and Masters degrees in nursing from George Mason University in Fairfax, VA. She recently completed her PhD in curriculum and instruction at the University of Akron. For the past sixteen years, Lora has been a nursing professor and is currently an assistant professor of nursing of Malone College in Canton, Ohio. She has served as the volunteer health coordinator of a migrant clinic for the last seven years. Her dissertation research area of interest was migrant medical adherence.
M. Kay Alderman, Ed. D
Kay Alderman is a professor in the department of Educational Foundations and Leadership at the University of Akron. Her area of specialty is educational psychology, specifically motivation. Kay teaches undergraduate and graduate courses and directs doctoral dissertations. She is the author of the book, Motivation for Achievement: Possibilities for Teaching and Learning. Prior to attaining her doctorate, Kay was a health and physical education teacher in Houston, Texas.
Article published November 16, 2006
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