Imagine going to your doctor and being handed a paper with a bunch of scribbles. There is nothing familiar on the page as you try to figure out what it means. You have no idea what it says and your only clues are from a confusing visit with limited understood communication. This struggle is one that foreign-born persons face often. Foreign-born persons are those who are born outside of their country of residence. These include undocumented and lawfully present refugees and immigrants.
In 2018, it was estimated that 10 million people fell ill with tuberculosis worldwide. During that same year, 1.5 million people died from tuberculosis. It is the second cause of infectious disease around the world despite being both preventable and curable. From 2010-2018 foreign-born persons accounted for 65% of nationwide tuberculosis cases per year. In Minnesota they made up 82% of the cases.
The main causes of tuberculosis among foreign-born persons include: Many come from areas common for tuberculosis; it is often overlooked by health providers in children and adolescents; and a lack of latent tuberculosis screening. A major cause of the disproportionate rates of tuberculosis cases among foreign-born persons in Hennepin County that must be addressed is the lack of proper latent tuberculosis screening, which leads to a late diagnosis.
There are many historical factors that have contributed to the high rates of tuberculosis cases among foreign-born persons in Minnesota, including a lack of insurance, social economic disadvantages, and environmental concerns. Noncitizens are significantly more likely than citizens to be uninsured. Lack of insurance can cause inability to seek needed care, including preventable care, due to the risk of unaffordable medical costs. Lack of education materials, translators, and availability of providers who practice cultural humility cause a barrier to proper health care and influence the quality of care that patients receives. Tuberculosis progression is more likely to occur in an overcrowded area because of tobacco smoke exposure and indoor air pollutants.
How can Minnesota do better?
How can the Minnesota Legislature increase successful screening and timely diagnosis of latent tuberculosis among foreign-born persons in Hennepin Count? Active tuberculosis can form if latent tuberculosis remains untreated and becomes active. The Minnesota Department of Health TB Prevention and Control Program aims to reduce the incidence of tuberculosis through leadership and expertise. They facilitate screening for those at high risk for tuberculosis, provide education for health care providers and the public, and provide tuberculosis medications statewide. In order to effectively reach the foreign-born population, who are at high risk for tuberculosis, they should be providing this website and their education materials in more languages. Currently the program only offers Somali and Hmong translations of general tuberculosis informatics. If they were able to provide materials in Vietnamese and Lao, they would be able to address the languages of the five top countries of origin for foreign-born tuberculosis cases in Minnesota from 2014-2018.
Providing a website and education materials can improve health literacy for foreign-born persons who are not proficient in English. Access and utilization of health care, patient-provider relationship, and self-care are influenced by health literacy. Low health literacy is associated with poorer health outcomes and limited use of health care services. By offering translated materials, improved health literacy can help improve health outcomes and promote the use of health care services, such as tuberculosis screening. Treatment after such screening can prevent active tuberculosis.
This model would initially increase costs for the state as they will have to hire the appropriate translators to translate the website, informatics, and educational material. They will also have to spend money to print the materials needed and to distribute them in the communities. However, it would ultimately result in cost savings due to decreased spending in treating and managing tuberculosis cases.
Administratively, they have had success reaching foreign-born populations in the past as their program performance has increased every year since 2015 in evaluations and latent tuberculosis infection treatment. They have translated materials in the past, making them familiar with the process.
Karen Chen is a master of public health administration & policy candidate at the University of Minnesota.
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