Ensuring Telehealth Access For North Carolina Farmworkers

There are more than two million farmworkers in the United States and approximately 100,000 in North Carolina alone. A significant portion of these workers—83 percent as of 2016—are Hispanic or Latinx, and many are migrants. Despite forming a major cornerstone of US life and the economy, farmworkers do not have equal access to the resources and services that non-farmworkers do to maintain their overall health and well-being. One area with particularly pronounced disparities is health care; farmworkers experience a variety of barriers to care, including a lack of health coverage, disparate access to providers, language barriers, and discrimination from providers and employers. This lack of access has consequences not only for the workers themselves but also for their families.

Barriers to health care access depend on how established a worker and their family are in a given location. “Consistent” populations, which include non-migrant workers and migrant workers with long-term residences, may seek care more frequently than “transient” populations. The latter includes workers that have US work visas, undocumented workers, and other workers who move around frequently or are difficult to locate. Research has shown that migrant workers avoid seeking care due to immigration status concerns. Strategies for improving access to routine and as-needed health care are crucial for farmworkers, who may experience a variety of occupational, environmental, and social stressors.

Telehealth, defined as the asynchronous or synchronous transfer of health information between patient and provider, is a tool that can bridge some of the gaps in health care access by reducing barriers that may exist for in-person health visits. Despite an increase in telehealth use during the COVID-19 pandemic, there are still disparities, particularly among rural and low-income populations including farmworkers who may lack access to consistent internet connections or devices that can perform the necessary functions for a virtual visit, such as cell phones, smartphones, or laptops.

Research has shown that patients, including farmworker patients, are receptive to virtual care, and researchers believe that telehealth can increase access to primary care in particular. Studies have also found that Latinx people, a demographic that overlaps with farmworkers, are willing to use telehealth if their provider offers it and they understand how it works. Despite demonstrated interest among farmworkers and the fact that they are increasingly gaining access to cell phones and smartphones, telehealth has yet to be widely adopted by this population.

Where Do Farmworkers Seek Care?

Many farmworkers seek care at community health centers and migrant health centers, which provide access to care regardless of patients’ ability to pay. Using the 2020 Uniform Data Set maintained by the Health Resources and Services Administration (HRSA), I identified HRSA-recognized community health centers in North Carolina that served farmworkers and the health centers that opted to provide access to care via telehealth during 2020 (see exhibit 1). The data show that out of 42 HRSA-funded health centers operating 364 clinical sites in North Carolina, 27 organizations served farmworkers and their dependents across 307 clinic sites. Twenty-five of those entities offered real-time telehealth (videoconferencing) for patients. Although the data specify which grant recipients offered telehealth and how many farmworkers those grant recipients served, the data are not conducive to identifying which individual clinic sites administered telehealth to farmworkers.

Exhibit 1: Out of 42 federally qualified health centers/lookalikes in North Carolina, 27 serve farmworkers and dependents, of which 25 administer telehealth to patients

Source: Author’s analysis of HRSA Uniform Data Set data from 2020.

When I contacted one of the centers, it became clear through my conversation with an outreach coordinator that long-term adoption of telehealth for farmworkers is a challenge. Although the health center saw an increase in telehealth use among farmworkers in 2020, it gradually shifted back toward in-person visits to prioritize access to dental care and other preventive services. Some seasonal workers and their families might visit up to four times per year, while transient workers are harder to follow up with because of how frequently their contact information changes. For this reason, farmworkers are described as a “hard-to-reach” population. The health center leaves their contact information at work sites so workers can initiate contact with them rather than the other way around. Telehealth will not overcome all of these barriers to health service delivery, but it is an important option to explore for increasing access to care.

How To Reach Farmworkers

Audio-only or telephonic telehealth is a proposed alternative to video telehealth, as it does not require internet access and may also be appropriate for farmworkers who prefer phone over internet or otherwise cannot use video visits. In 2015, North Carolina farmworkers were more likely to obtain health information via radio, television, or telephone than other electronic methods. Additionally, a recent issue brief from the Assistant Secretary for Planning and Evaluation Office of Health Policy notes that Latinx people were among the lowest uptake groups for video telehealth in 2021 despite using telehealth more frequently than White people in general. However, members of transient populations are more likely to experience phone number turnover.

A potential solution could be helping workers that do own smartphones set up a Voice over Internet Protocol (VoIP) account to receive and send calls. WhatsApp, a VoIP application, was one of the most commonly used apps by farmworkers with access to the internet in 2018, although a preexisting phone number is needed to sign up. Theoretically, using VoIP applications such as Google Voice or Skype would allow farmworkers to generate a phone number or username that would remain consistent across devices, but additional research is needed to determine the feasibility in real-world application. Another limitation in considering this strategy is that not all farmworkers have smartphones.

Expanding access to broadband would open up opportunities to engage with farmworkers in a variety of ways. One-third of farm camps in North Carolina lacked broadband in 2020, and a recent survey by Latino advocacy group AMEXCAN found that farmworkers themselves identify a need for internet access. Allocating funding to the provision of hotspots or installing internet infrastructure in migrant camps would be particularly useful for supporting access for farmworkers.

Digital Health Equity

In addition to allowing more people to take advantage of health services, access to telehealth is a part of the larger statewide fight for digital equity. The North Carolina Farmworker Health Project (NCFHP), operating within the state Department of Health and Human Services, held a webinar October 20, 2021, explaining their work to bridge the digital divide. The NCFHP supports eight outreach programs, including a partnership with the North Carolina Agromedicine Institute to equip migrant housing with internet connectivity. They have also developed a mobile hotspot lending program wherein health outreach workers deliver cellular network hotspots to farms. One of the NCFHP’s local partners is Surry Medical Ministries, which has worked with a local broadband provider to outfit two farms with fiber internet as of October 2021. However, state-run programs such as these are designed to be short term. Continuing to invest in these programs and expand their scope at the local level would allow for the wider implementation of broadband and for farmworker communities to get the care they need.

Nonetheless, developing the necessary infrastructure for internet access remains a challenge. Recent reporting by North Carolina Health News highlighted barriers that range from how housing is built to the fact that many migrant camps are far off the road or hidden by other structures. A 2015 study found that out of 180 camps, more than one-third were hidden. Hidden camps were also more likely to have more than 20 residents, which would place greater pressure on the internet connection. These barriers lead to higher costs for broadband implementation. Examining how many migrant camps are hidden in the state as well as ways to finance infrastructure in these camps is crucial to expanding access.

Areas For Future Research

Expanding access to telehealth is especially relevant for farmworkers with families, as children’s health is often dependent on the health of their parents. Workers with families may have slightly improved access to health services; farmworkers who were partnered or had children have been found more likely to have US-based health insurance, making them “consistent” populations. As I was told by a health center representative, farmworkers bring their families when they present for care at health centers. More research is needed on the downstream impact of access to telehealth on farmworker families. Developing initiatives to specifically serve children of farmworkers or child farmworkers could also be beneficial.

Gender is also an important consideration when devising strategies to increase access to telehealth. General trends have shown that telehealth users are more likely to be female. Women are also more likely to seek primary care than men, although they may seek care later than men. However, there is not sufficient research on whether the same trends exist among farmworkers—approximately one-third of farmworkers are women, but the majority of research about this population is centered on men. A variety of unique factors contribute to adverse physical and mental health outcomes for female farmworkers. Researchers have found that gender is a determinant in work hours: One study found that women work fewer days than men and are more likely to work seasonally rather than year round. Gender is also a determinant in pay and exposure to risk. Wives of male farmworkers, called “farmer spouses,” and farm homemakers may perform particular tasks at work sites such as irrigation or driving machinery, but downplay their risk of injury or exposure to pesticides because they see their work on the farm as minor in comparison to housework. Female farmworkers are also at risk of sexual harassment and assault, a risk that has been explored in research and the media. Additional research is necessary to gain a better understanding of how care-seeking behavior, occupational risk, and daily activities translate into telehealth use for farmworkers of all genders.

The past two years have shown that telehealth is here to stay. Even though there has been a “modest decline” in telehealth use since the early stages of the COVID-19 pandemic, policies are being introduced at the local and national levels to expand access on more than a temporary basis. North Carolina Medicaid recently announced that several telehealth flexibilities introduced during the pandemic are now permanently codified in the program, including behavioral health—an area that the health center representative said would be beneficial for workers to have access to. Thus, farmworkers should be taken into account when developing clinical policy, payment policies, and community infrastructure to support telehealth access.

Considerations For Policy And Care Delivery

Remote care should not replace current outreach efforts; continuing targeted in-person outreach at work sites is crucial to ensuring that farmworkers get all of the services they need. In addition to providing face-to-face care at these site visits, providers could explore ways to incorporate technology. Some rural areas in other states have developed mixed models in which people travel to local sites to receive telemedicine from providers who may be more distant or provide specialized services. This may be particularly useful for farmworkers, many of whom have chronic conditions and some of whom have expressed satisfaction with specialized telehealth visits.

Policy makers should continue funding preexisting state initiatives and investing in infrastructure development as they have done in recent months. The most recent North Carolina state budget expanded the criteria for participation in the Growing Rural Economies with Access to Technology program and implemented the Completing Access to Broadband program, both of which aim to develop broadband infrastructure in underserved areas. State lawmakers and county commissioners have also used COVID-19 funds for fiber installation in the past. A more targeted policy that addresses the lack of broadband in migrant camps could further expand access and supplement preexisting programs managed by the North Carolina Department of Health and Human Services. Policy makers should also consider providing greater resources to local health centers, particularly for telehealth use. Recipients of the Community Health Grant from the state Office of Rural Health are permitted to use those funds for telehealth services and equipment, but a broader, non-application-based approach to distribution could potentially support more centers. Policy makers should also consider investing in additional research on farmworker families and female farmworkers, which could be undertaken by the North Carolina Policy Collaboratory. Lawmakers should also consider modifying migrant housing regulations to require access to internet, a policy that is presently missing at the state and federal levels.

Farmworkers should not be left out of the broader conversation surrounding telehealth, and it is important that North Carolina continues to work toward ensuring health care access for all.

Author’s Note

The author is an undergraduate researcher on the “Exploring Equitable Access to Care and Outcomes Using Telehealth in the Transition to Medicaid Managed Care” team at the Duke-Margolis Center, which is researching impacts of telehealth on access to care.