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Improving Access to Health Care: Improving Access to Health Care: Evaluation of the Montgomery Evaluation of the Montgomery

County Migrant Hispanic CoalitionCounty Migrant Hispanic Coalition

MarMaríía de Lourdes Ga de Lourdes Góómez, MPHmez, MPHUniversity of Kentucky University of Kentucky College of Public HealthCollege of Public Health

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Purpose of the StudyPurpose of the Study

The purpose of this study is to evaluate: The purpose of this study is to evaluate:

• Access to health care for the Hispanic Access to health care for the Hispanic population in Montgomery County, Kentucky population in Montgomery County, Kentucky

• The promotion of cultural and linguistic The promotion of cultural and linguistic competency among health care providers competency among health care providers who serve this population who serve this population

33

BackgroundBackground

• Part of a four-year project Part of a four-year project funded by the United funded by the United States Department of States Department of Agriculture (2001-2005) Agriculture (2001-2005) “Coalitions to improve “Coalitions to improve health access for health access for Hispanics in rural Hispanics in rural Kentucky and Tennessee”Kentucky and Tennessee”

• Coalition approachCoalition approach

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Coalition MembershipCoalition Membership• Montgomery County Health Montgomery County Health

DepartmentDepartment

• Montgomery County UK Montgomery County UK Cooperative Extension ServiceCooperative Extension Service

• Mary Chiles HospitalMary Chiles Hospital

• Rural Family Care Clinic Rural Family Care Clinic (Federally funded Rural Health (Federally funded Rural Health Clinic)Clinic)

• Montgomery County Public Montgomery County Public School SystemSchool System

• Chamber of CommerceChamber of Commerce

• Industrial AuthorityIndustrial Authority

• City and County GovernmentCity and County Government

• Northeast AHEC (Area Health Northeast AHEC (Area Health Education Center)Education Center)

• Law EnforcementLaw Enforcement

• Faith CommunityFaith Community

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Overview of the LiteratureOverview of the LiteratureCoalition EvaluationCoalition Evaluation

• The literature of coalition development and evaluation is largely The literature of coalition development and evaluation is largely descriptivedescriptive

• Presents an array of methodologies, measures and case studies Presents an array of methodologies, measures and case studies applied for researchers and practitionersapplied for researchers and practitioners

• One study reported that little empirical evidence existed supporting One study reported that little empirical evidence existed supporting effectiveness (Butterfoss et al., 1993) effectiveness (Butterfoss et al., 1993)

• Another study emphasized the effectiveness of coalitions by Another study emphasized the effectiveness of coalitions by presenting reports of coalition processes and outcomes; this data presenting reports of coalition processes and outcomes; this data is used to provide feed-back to coalitions (Francisco et al., 1993)is used to provide feed-back to coalitions (Francisco et al., 1993)

• Evaluation plays a key role in developing and sustaining Evaluation plays a key role in developing and sustaining coalitions. (Butterfoss & Francisco, 2004)coalitions. (Butterfoss & Francisco, 2004)

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Health ProblemHealth Problem

• Agriculture Industry employs between 3 and 5 Agriculture Industry employs between 3 and 5 migrant farmworkers (Magana & Hovey, 2003) migrant farmworkers (Magana & Hovey, 2003)

• Migrant farmworkers are considered a Migrant farmworkers are considered a vulnerable populationvulnerable population

• Many do not have access to either health care or Many do not have access to either health care or health insurance. Lack of preventive care is also health insurance. Lack of preventive care is also noted noted

• Language and cultural barriers, immigration Language and cultural barriers, immigration status, financial issuesstatus, financial issues

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Overview of the LiteratureOverview of the LiteratureCoalition Evaluation ModelCoalition Evaluation Model

Level 1: Level 1: Processes that sustain/renew Processes that sustain/renew coalition functioningcoalition functioning

Level 2: Level 2: Programs/activitiesPrograms/activities

Level 3: Level 3: Changes in health access/status Changes in health access/status or the communityor the community

Butterfoss & Francisco (2004)Butterfoss & Francisco (2004)

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Study DesignStudy Design

Two types of study were conducted for the Two types of study were conducted for the evaluation:evaluation:

• New data collected from self-administered New data collected from self-administered questionnaire among coalition membersquestionnaire among coalition members

• Data available from administrative records Data available from administrative records of coalition meetings and programs in the of coalition meetings and programs in the community level were examined (historical community level were examined (historical records) records)

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SampleSample

• Self-administered survey:Self-administered survey:Convenience sample of 35 members of the Convenience sample of 35 members of the Migrant coalition Migrant coalition

• Administrative records included:Administrative records included: Coalition minutes, events, meetings, grant Coalition minutes, events, meetings, grant

proposals, agendas, newspapers, items proposals, agendas, newspapers, items produced by the coalition such as produced by the coalition such as brochures, flyers, and a scrapbook brochures, flyers, and a scrapbook

• Counting of health services provided by the Counting of health services provided by the health department from years 2001-2005 health department from years 2001-2005

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Montgomery County Migrant Montgomery County Migrant Hispanic CoalitionHispanic Coalition

Fall 2003Fall 2003

1111

Data collectionData collection• Thirty-five questionnaires were mailed to coalition members.Thirty-five questionnaires were mailed to coalition members.

• The Chair of the Migrant Coalition provided a list with the names of The Chair of the Migrant Coalition provided a list with the names of members. members.

• The survey was designed shaping key measures and included questions The survey was designed shaping key measures and included questions defined in five parts (59 questions):defined in five parts (59 questions):

1.1. Perception of access to health care (3 questions)Perception of access to health care (3 questions)2.2. Impact in the community (9 questions)Impact in the community (9 questions)3.3. Coalition functioning: Ten domains were considered. Purpose, structure, Coalition functioning: Ten domains were considered. Purpose, structure,

leadership, roles and responsibilities, communication, decision making, leadership, roles and responsibilities, communication, decision making, conflicts, membership, diversity, and involvement (33 questions)conflicts, membership, diversity, and involvement (33 questions)

4.4. The role of the coalition as an organization (10 questions) The role of the coalition as an organization (10 questions) 5.5. Demographics (4 questions) Demographics (4 questions)

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Data collectionData collection• Administrative records were provided by the Community Administrative records were provided by the Community

Specialist Interpreter from the health departmentSpecialist Interpreter from the health department

• Database of health services were provided by the Nurse Database of health services were provided by the Nurse Supervisor from the health departmentSupervisor from the health department

• Documentation was classified in chronological orderDocumentation was classified in chronological order

• Documentation was categorized in two domains: 1) Access Documentation was categorized in two domains: 1) Access to health care and 2) Cultural and Linguistic competencyto health care and 2) Cultural and Linguistic competency

• Database of health services was summarized in two Database of health services was summarized in two categories: 1) Hispanic and 2) Non-Hispanic health services categories: 1) Hispanic and 2) Non-Hispanic health services

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Evaluation /MeasuresEvaluation /MeasuresButterfoss and Francisco (2004) Butterfoss and Francisco (2004)

model model Coalitions Growth and Coalitions Growth and developmentdevelopmentLevel 1Level 1Coalition Infrastructure, Coalition Infrastructure, Function, and ProcessesFunction, and Processes

Outcomes/ProgramsOutcomes/Programs

Level 2Level 2Coalition Programs and Coalition Programs and InterventionsInterventions

Health access changesHealth access changes

Level 3Level 3Health and Community Health and Community Change OutcomesChange Outcomes

Processes that sustain and Processes that sustain and renew coalition infrastructure renew coalition infrastructure and function.and function.

Programs intended to meet Programs intended to meet target activities, or those that target activities, or those that work directly toward the work directly toward the partnership’s goal partnership’s goal

Changes in health status or Changes in health status or the community.the community.

Evaluation questionEvaluation questionTo what degree toward its To what degree toward its major goal did the coalition major goal did the coalition grow and develop? grow and develop?

Evaluation questionEvaluation questionWhat new programs were What new programs were implemented to improve implemented to improve access to health care, access to health care, including cultural and including cultural and linguistic? linguistic?

Evaluation questionEvaluation questionWhat type of health access What type of health access changes occurred for the changes occurred for the Hispanic populationHispanic population

Measures the level of Measures the level of coalition growth and coalition growth and developmentdevelopment

Measures fidelity and Measures fidelity and success of program success of program implementationimplementation

Measures actions that have Measures actions that have achieved the coalition’s goal achieved the coalition’s goal and objectives.and objectives.

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Data AnalysisData Analysis

1. 1. Survey:Survey:• The data were entered and verified using EPI-Info The data were entered and verified using EPI-Info

Version 6.0Version 6.0• Descriptive statistics were run using SASDescriptive statistics were run using SAS

version 9.1version 9.1

2. Documentation:2. Documentation:• Qualitative methods were used to review and assess Qualitative methods were used to review and assess

the existing documentation in order to assign the the existing documentation in order to assign the correspondent domain/measures: Health access and correspondent domain/measures: Health access and Cultural-Linguistic Competency improvement.Cultural-Linguistic Competency improvement.

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ResultsResults

15 out of 35 surveys 15 out of 35 surveys were returned. were returned. Response rate of 42.8%Response rate of 42.8%

• Gender: Gender: 12 females, 2 males. 1 12 females, 2 males. 1 missingmissing

• Race: Race: 10 White, 4 Latinos. 1 10 White, 4 Latinos. 1 missingmissing

AgencyAgency MembersMembers

Health DepartmentHealth Department 33

EducationEducation 33

Cooperative Cooperative Extension ServiceExtension Service

22

Hospital or ClinicHospital or Clinic 22

Local governmentLocal government 11

Religious groupReligious group 11

Concerned citizensConcerned citizens 11

MissingMissing 22

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ResultsResults

Members assessment of access to health care. TheyMembers assessment of access to health care. Theyreported main barriers and health disparities face by thereported main barriers and health disparities face by theHispanic communityHispanic community

Barriers to Hispanics Seeking Healthcare

86%

57% 57% 50%

0%10%20%30%40%50%60%70%80%90%

Lack of HealthInsurance

Language barriers Not knowing thesystem

Cultural barriers

Perc

enta

ge o

f Coa

litio

n M

embe

rs

Coalition perception: Top five health disparities coalition has addressed among Hispanics in

Montgomery County

93%

57%43% 43% 36%

0%20%40%60%80%

100%

Perc

enta

ges

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Results Results Impact of the CoalitionImpact of the Coalition

• Nearly all respondents (93%) agreed the coalition has made contributions to Nearly all respondents (93%) agreed the coalition has made contributions to the community and has provided cultural awareness for serving Hispanic the community and has provided cultural awareness for serving Hispanic residents.residents.

• Almost three quarters (73%) felt the coalition has improved their cultural Almost three quarters (73%) felt the coalition has improved their cultural competency and they have an adequate level of cultural competency; as the competency and they have an adequate level of cultural competency; as the self-reported examples:self-reported examples:

– Referred them to the proper agencies in the community and helping Referred them to the proper agencies in the community and helping them with translations.them with translations.

– Participated in focus group to understand the barriers faced by Participated in focus group to understand the barriers faced by Hispanics.Hispanics.

– Immersion program, Spanish classes and reading Spanish materials.Immersion program, Spanish classes and reading Spanish materials.– Spanish LanguageSpanish Language– Community has become more aware of other cultures.Community has become more aware of other cultures.– Understanding of immigration laws. Better knowledge of farmworkers Understanding of immigration laws. Better knowledge of farmworkers

needs and Mexican culture.needs and Mexican culture.

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Results Results Impact of the coalitionImpact of the coalition

Most significant outreach programMost significant outreach program 1st1st Health FairsHealth Fairs

2nd 2nd Health EducationHealth Education3rd3rd Screening testsScreening tests4th 4th ESL (English as a Second Language) classesESL (English as a Second Language) classes5th5th HANDS (Health Access Nurturing Developing Services)HANDS (Health Access Nurturing Developing Services)

• 93% of coalition members felt confident that the coalition has been personally 93% of coalition members felt confident that the coalition has been personally helpful to themhelpful to them

• 85% felt pleased with the coalition effort 85% felt pleased with the coalition effort

• 40% of coalition members said they were not bilingual at all40% of coalition members said they were not bilingual at all

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ResultsResultsHealth Access ProgramsHealth Access Programs

• Four Health Fairs Four Health Fairs

• Fit Kids Day camp targeting immunizations and screening tests for childrenFit Kids Day camp targeting immunizations and screening tests for children

• Issue of Health Directory in SpanishIssue of Health Directory in Spanish

• Healthy Kentucky grant awarded for prevention servicesHealthy Kentucky grant awarded for prevention services

• Flyers in Spanish in the community promoting health services and Flyers in Spanish in the community promoting health services and immunizationsimmunizations

• Joint Meetings: Research materials, funding opportunities Joint Meetings: Research materials, funding opportunities

• HRSA Application grantsHRSA Application grants

• Social Services as the benevolent fund to help Hispanic familiesSocial Services as the benevolent fund to help Hispanic families

2020

Results Results Cultural Linguistic CompetencyCultural Linguistic Competency

• Interpreter hired at the health departmentInterpreter hired at the health department

• Spanish immersion program in Morelia, Mexico; 2 nurses from the Montgomery County Spanish immersion program in Morelia, Mexico; 2 nurses from the Montgomery County Health DepartmentHealth Department

• Spanish Language Training for health providersSpanish Language Training for health providers

• Cultural competency trainingsCultural competency trainings

• Cultural Competency conferences sponsored by the Migrant CoalitionCultural Competency conferences sponsored by the Migrant Coalition

• Medical Interpretation conferencesMedical Interpretation conferences

• Cultural Simulation Exercise “Reality Workshop”Cultural Simulation Exercise “Reality Workshop”

• Spanish classes at Morehead State UniversitySpanish classes at Morehead State University

• ESL (English as a Second Language) classes – Adult Training Education (school ESL (English as a Second Language) classes – Adult Training Education (school system)system)

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Cultural Competency TrainingCultural Competency Training

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ResultsResults Community Level: Community Level:

• Spanish teachers hired by the Montgomery Spanish teachers hired by the Montgomery County Public School System for each County Public School System for each elementary school year 2005-2006 (3)elementary school year 2005-2006 (3)

• ESL (English as a Second Language) through the ESL (English as a Second Language) through the Adult Education training (school system)Adult Education training (school system)

• Screening health services provided at the Screening health services provided at the outreach level Health Fairs: 255 over the 4 years.outreach level Health Fairs: 255 over the 4 years.

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LimitationsLimitations• The survey response was small (n=15)The survey response was small (n=15)• Possible bias of the general assessment of coalition development. Possible bias of the general assessment of coalition development.

Responses may be from the more involved membersResponses may be from the more involved members• Small number of responses do not allow exploring the relationship Small number of responses do not allow exploring the relationship

between variables: race, age, gender, representationbetween variables: race, age, gender, representation• Data of medical records or Hispanic Epidemiological databases were Data of medical records or Hispanic Epidemiological databases were

not availablenot available• Data of number of health services is only from the health Department. Data of number of health services is only from the health Department.

Health services provided by the Mary Chiles Hospital and the Rural Health services provided by the Mary Chiles Hospital and the Rural Family Health Clinic were not available. Hence, the results in health Family Health Clinic were not available. Hence, the results in health services may be higherservices may be higher

• Accurate demographic information of Hispanic population was not Accurate demographic information of Hispanic population was not availableavailable

• Evaluation conducted only for the Montgomery Coalition one of the 3 Evaluation conducted only for the Montgomery Coalition one of the 3 coalitions participating in the USDA grant. Simultaneous evaluation of coalitions participating in the USDA grant. Simultaneous evaluation of the three coalitions may provide comparisons and enhance the the three coalitions may provide comparisons and enhance the process and feed-back process and feed-back

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ConclusionsConclusions• Three levels of measures were applied to evaluateThree levels of measures were applied to evaluate

1) Processes of coalition functioning 2) Processes of program 1) Processes of coalition functioning 2) Processes of program activities/outcomes 3) Changes in access to health servicesactivities/outcomes 3) Changes in access to health services

• Findings suggest that the Migrant Coalition has accomplished Findings suggest that the Migrant Coalition has accomplished favorable outcomes while serving the target population. favorable outcomes while serving the target population.

• Significant progress has been made to the missionSignificant progress has been made to the mission• Coalition members feel the work of the coalition is very successful Coalition members feel the work of the coalition is very successful

and they are engaged in strategic planning, addressing health and they are engaged in strategic planning, addressing health needs, and gaps in primary care.needs, and gaps in primary care.

• The Migrant Coalition has matured and developed and is ready for The Migrant Coalition has matured and developed and is ready for the continuation of the project if funded by HRSA in May 2006, the continuation of the project if funded by HRSA in May 2006, Rural Health Outreach Program.Rural Health Outreach Program.

• Promotora program is one of the major outcomes to be Promotora program is one of the major outcomes to be implemented in the near future.implemented in the near future.

• The implementation of health access activities, social programs, The implementation of health access activities, social programs, quality of care, and bilingual environment reported serve as quality of care, and bilingual environment reported serve as evidence of the effectiveness of the Montgomery County Migrant evidence of the effectiveness of the Montgomery County Migrant Hispanic Coalition.Hispanic Coalition.

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Implications for Public HealthImplications for Public Health• Collaborative efforts of community partners and academia make possible Collaborative efforts of community partners and academia make possible

significant changes in health problems through outreach worksignificant changes in health problems through outreach work• The model of this coalition can serve as a model for other rural communities The model of this coalition can serve as a model for other rural communities

with increasing Hispanic workerswith increasing Hispanic workers• Cooperative Extension is an important collaborator with Public Health Cooperative Extension is an important collaborator with Public Health

agencies developing a unique model of partnership agencies developing a unique model of partnership • Health organizations are facing new challenges as language and cultural Health organizations are facing new challenges as language and cultural

issues to provide quality of health servicesissues to provide quality of health services• There is a need for addressing health access for underserved and There is a need for addressing health access for underserved and

vulnerable populations. There are about 44 million uninsured people in the vulnerable populations. There are about 44 million uninsured people in the U.S U.S

• The Hispanic population is growing and the media age is relatively young, The Hispanic population is growing and the media age is relatively young, 25.9 years, representing a big impact in the work force, public health 25.9 years, representing a big impact in the work force, public health system and managed of health caresystem and managed of health care

• Health status indicators and health survey data are needed for new Health status indicators and health survey data are needed for new approaches of interventions and policies at the community levelapproaches of interventions and policies at the community level

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RecommendationsRecommendations

• Developing strategies to bring more health Developing strategies to bring more health practitioners to the coalition, for example the practitioners to the coalition, for example the medical community in the areamedical community in the area

• Strategies for recruitment Latinos. Strategies for recruitment Latinos. • Develop Hispanic Epidemiological database, for Develop Hispanic Epidemiological database, for

example Injuriesexample Injuries• Provide orientation for new members.Provide orientation for new members.• Promote fundraising Promote fundraising • Continue assessment of the Hispanic health needs Continue assessment of the Hispanic health needs

in Montgomery County (qualitative and quantitative in Montgomery County (qualitative and quantitative studies)studies)

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AcknowledgementsAcknowledgements

• Funding provided by the Southeast Center Funding provided by the Southeast Center Center for Agricultural Health and Injury Center for Agricultural Health and Injury Prevention, College of Public Health Prevention, College of Public Health University of Kentucky through grant from University of Kentucky through grant from USDA (agreement number 2001-36201-USDA (agreement number 2001-36201-11289) and NIOSH/CDC11289) and NIOSH/CDC