Abstract
The North Carolina Farmworker Health Program (NCFHP) implemented an emergency program in response to North Carolina migrant and seasonal farmworkers’ urgent need for Internet access for health information, family connections, and telehealth services during COVID-19 isolation and quarantine. This article describes the NCFHP Internet Connectivity Project implementation and evaluation from June 2020 to December 2021. The project placed 448 devices across the state and provided Internet access to more than 3184 farmworkers during the 2021 peak farming season. (Am J Public Health. 2022;112(11):1551–1555. https://doi.org/10.2105/AJPH.2022.307017)
Rural communities are less likely to have access to the Internet as part of the “digital divide,” and previous evidence suggests even larger gaps in Internet access among migrant and seasonal farmworkers (hereafter, “farmworkers”).1–3
The North Carolina Farmworker Health Program (NCFHP) launched the Internet Connectivity Project as an emergency effort to get Internet access to farmworkers in the COVID-19 pandemic. Internet access is not a required utility under North Carolina’s migrant housing standards. Farmworker housing, typically provided by the employer in North Carolina, is often situated in remote4 locations in rural areas where poor cell phone reception and limited options for Internet connectivity contribute to the “digital divide.”3 North Carolina’s 1921 registered farmworker housing units are often concrete or metal, and large numbers of farmworkers in one location can significantly contribute to issues with bandwidth and signal. Led by a full-time project coordinator (N. D. R. until January 2022 and subsequently J. R. S.), NCFHP developed and implemented three models of Internet connectivity solutions for farmworkers.
This strategy provided an emergency, temporary solution to farmworkers with poor or no Internet connection during coronavirus outbreaks and isolation or quarantine orders. Community health workers (CHWs) were trained and provided with mobile hotspots to distribute directly to farmworkers, and they collected them at the end of the season, like a library lending model. Each hotspot provided Internet for up to 10 to 20 devices at any given time.
This strategy was to reimburse permanent Internet connectivity solutions through set-up of wired connections for farmworker housing (e.g., via fiber or cable installation). The NCFHP partnered with the North Carolina Agromedicine Institute to recruit and provide reimbursements to growers up to $1000 per housing unit for the set-up of Internet services. This was initiated in July 2020, but the state contract was not executed until October 2020. Qualifying purchases included routers, antennas, infrastructure build-out, and service plans.
The third strategy was to establish Internet hubs via a fixed rugged cellular network router and antenna capable of providing Internet access for up to 100 devices. This model was ideal for locations requiring more than a hotspot to provide access to more than 20 farmworkers or for farms without the option of wired connection because of availability and reach of local Internet service providers. This was initiated in December 2020, with state procurement in March 2021 and installations in summer 2021.
To enhance the models, the NCFHP partnered with the North Carolina Broadband Infrastructure Office to develop a farmworker housing intake process to identify the ideal Internet connectivity model for various locations. East Carolina University’s Laupus Health Sciences Library developed Spanish-language digital literacy training and videos for farmworkers.5 The NCFHP also partnered with community and governmental organizations to form the North Carolina Agriculture Digital Alliance.
This project took place as a statewide program in North Carolina between June 2020 and December 2021. The population served were the approximately 80 000 farmworkers in North Carolina, more than 85% of whom earn at or under the federal poverty line, and their families.6 Farmworkers experience health inequities including substandard housing conditions, lack of protective equipment, exposure to extreme heat, lack of sanitary cooking and eating facilities, and occupational risks.4,6,7
The project’s goal was to support farmworkers in gaining access to telemedicine, social support, family connection, emergency communication, and educational opportunities. Health care, connection to families, contact tracing, vaccine rollout, and health education are hindered by lack of Internet access. The coronavirus pandemic resulted in outbreaks among farmworkers and limited the availability of protective equipment.8 Many agencies paused in-person CHW outreach early in the pandemic, and Internet access became critically important.3
We used a utilization-focused evaluation that included English- and Spanish-language semistructured qualitative interviews with farmworkers (n = 29), CHWs (n = 8), and farm owners or managers (n = 4). Figure 1 shows the project served more than 3100 farmworkers and distributed more than 400 devices. Thematic analysis of the interview transcripts revealed details of the project’s impact (Box 1). The evaluation also yielded information regarding implementation of Internet connectivity solutions, reimbursement of growers, the important role of CHWs, and advice for practitioners.
FIGURE 1— North Carolina Farmworker Internet Connectivity Project Outcomes: 2021
BOX 1— Interviews With Farmworkers (FW) and Outreach Workers (OW): The North Carolina Farmworker Health Program Internet Connectivity Project, 2020–2021
| Preproject Implementation Themes | |
| Limited Internet access | “No, I’d never had Internet here until this time when they offered it [Internet] to us.” ‒FW |
| Health outreach and services limitations | “We are in a very rural area. Even ourselves, we just received a new mobile clinic, and we were like we have to start using the EHR [electronic health record] once we go out and everything. But it’s like, in half of the camps we visit, we have no service.” ‒OW |
| Postproject Implementation Themes | |
| Reliable Internet access | “They’re grateful because that was another bill that they didn’t have to worry about for the duration of their time here. . . . I think it helped them financially as well.” ‒OW |
| [Health] information access | “We give them education about CDC [Centers for Disease Control and Prevention] and NCDHHS [North Carolina Department of Health and Human Services], or various Spanish links where they can get actual reliable information . . . not getting too overwhelmed with searching a bunch of stuff on Google.” ‒OW |
| “You can find information about taking care of yourself, how to protect yourself, what to do, what medicine to take and which not to. Yes, it’s truly been useful.” ‒FW | |
| Medical services access and delivery | “If that patient that we test has COVID and [has] to quarantine, at least they’ll have a way to connect back home, and do telephone health visits with their provider . . . they can be seen via telehealth. With the assistance of the hotspot, that kind of eliminates the barrier of them having to come to the clinic.” ‒OW |
| “When we were offered the hotspots . . . there was better reception in the camps to carry out the medical video calls. The other service that I didn’t mention is mental health and those consultations are also by video calls with the therapist.” ‒OW | |
| Communication with family | “It’s helped me communicate with my mother, who’s in Guatemala. Sometimes it’s so hard to live so far away, but thanks to the service you’re giving us, the Internet, sometimes even though we’re so far away we don’t feel it.” ‒FW |
| Education access | “They gave us the device and set it up. . . . I was able to take some classes thanks to the Internet. And I’m so happy, because my girls can now use it for school. The little one is three years old and she’s going to start receiving remote classes, too.” ‒FW |
Of the three types of Internet connectivity solutions, hotspots were the easiest to deploy and were cost-effective (∼$39.99 per month for Internet services [most hotspot devices were provided at minimal cost on the contract], compared with $1000 per housing unit for grower reimbursement and ∼$2400 for Internet hubs’ router, antenna installation, and $39.99 per month for service). The total cost of providing Internet devices and access was approximately $124 662 during the peak farming season. Participants highlighted the ease in distributing, setting up, and training farmworkers to use the devices. Establishing Internet hubs proved to be an excellent alternative for farms with large numbers of farmworkers and an ideal medium-term solution, particularly in areas lacking wired Internet connection options. However, notably, service may only be available in a communal location (e.g., a picnic area). Future projects should include extenders for the signal to reach the rooms where farmworkers reside.
Reimbursing growers for permanent Internet connectivity was the most challenging because of the lack of broadband infrastructure in farmworker housing. Growers found the cost to run wires and install Internet to be prohibitively expensive in many cases—if Internet service was even available.
CHWs found it important to designate a farmworker with knowledge on how to use the hotspot to oversee the device, have a plan for the farmworker to return the device at the farming season’s end, and develop and distribute flyers with information for farmworkers on how to access the Internet.
The evaluation also indicated that public health practitioners should consider the following: (1) understand the pros and cons between the three types of Internet solutions; (2) identify specific Internet service providers that offer reliable Internet services for farmworker housing in different areas; (3) know that a state-level project can benefit from negotiated prices for equipment on state-projects; however, be aware that state procurement can easily delay the project; and (4) cultivate partnerships with CHWs and growers, as this was critical to our project’s success.
There were no adverse effects identified.
This project demonstrates the feasibility of delivering Internet connectivity in a global public health emergency to farmworkers, and the models that are presented can be applied in other settings. However, as the project is led by a state agency, it is limited in its ability to sustain Internet connectivity for all farmworkers. Leadership by organizations that serve farmworkers and growers is critical for implementing Internet solutions during emergencies like the pandemic, testing long-term Internet solutions, and establishing alliances to promote digital equity in the agricultural community.
Basic utilities and infrastructure are already patterned by race and resources in North Carolina, where there is inequitable access to clean water and sewer systems.9–11 There is an urgent need to ensure that rural broadband does not follow the same pattern of other utilities. Digital equity issues in a public health emergency can be ameliorated by policies, systems, and resources promoting broadband that include the needs of farmworkers. In the meantime, a state health agency, with dedicated partnerships and strong connections to CHWs, was able to address the urgent Internet connectivity needs of farmworkers in a pandemic by working in partnership with CHWs.
ACKNOWLEDGMENTS
Research reported in this publication was supported by the National Library of Medicine of the National Institutes of Health under award G08LM013198. The North Carolina Farmworker Health Program Internet Connectivity Project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) as part of an award totaling $914,750 with 0% financed with nongovernmental sources.
We thank Robin Tutor Marcom for her comments on the manuscript and contribution to coordination of evaluation activities. We thank Paula Acevedo for conducting interviews and Marcos Díaz for graphic design.
Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, nor does it necessarily represent the official views of, or an endorsement by, HRSA, HHS, or the US government. For more information, please visit HRSA.gov.
CONFLICTS OF INTEREST
J. G. L. Lee is an unpaid member of the governing board of the North Carolina Farmworker Health Program, Office of Rural Health, North Carolina Department of Health and Human Services.
HUMAN PARTICIPANT PROTECTION
The East Carolina University and Medical Center institutional review board approved this study (UMCIRB 19-001817). Informed consent was obtained from all study participants.
