Caring for the Latino Population in

School Based Health CareNC School Community Health Alliance

December 4, 2012

Magdalena Fernandez, MPPRegional Migrant Health Coordinator, Mid-Atlantic

Latinos in SBHC Latinos in America What is culture? Health Care Interpretation Migrant Health 101 Resources

Agenda

Average percentage of Hispanics served at SBHC: 10%

Range of percentage of Hispanics Served at SBHC: 0%-55%

SBHCs with highest Hispanic Patient Population:◦ First Health Montgomery County (55%)

◦ Southern HS Wellness Center (20%)◦ Blue Ridge Site 1 (20%)◦ Blue Ridge Site 2 (20%)◦ Blue Ridge Site 3 (30%)◦ Blue Ridge Site 4 (20%)

◦ Greene County (15%)

NCCHCA School Based Health Center Operational Assessment

U.S. Hispanic Population Four Decades of Growth

14.6

22.4

35.3

50.5

1980 1990 2000 2010

In millions

Source: Pew Hispanic Center.

States with Greatest Hispanic Population Growth, 2000-2010

In percent

Source: 2010 U.S. Census.

  Growth, 2000-2010

U.S. Total 43   South Carolina 148Alabama 145Tennessee 134Kentucky 122

 Arkansas 114North Carolina 111Maryland 106Mississippi 106

 South Dakota 103Delaware 96Georgia 96Virginia 92

90% growth or more

Hispanic Population Growth, 2000-2010

70% to 89% growth40% to 70% growthLess than 40% growth

Source: 2010 U.S. Census.

Latino Population Growth, 2000-2009

1,590 CountiesWith More Than

45% Growth

Source: Pew Hispanic Center

4.015

22

3543

46.8

0

1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 2060

11-fold Hispanic Growth since 1950: Driven by post-1970 Immigration

Population in millions

50.5

35

2215

4.0

57

128

105

0

1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 2060

Middle "Baseline" Immigration

Hispanic Growth Likely to Continue(Largest “Minority” Since ~2001)

Population in millions

Generational Differences

The First Term Latino Youths Use To Describe Themselves

52%

72%

41%

32%

20%

22%

21%

15%

33%

3%

24%

50%

Latinos 16 to 25

1st generation

2nd generation

3rd generation

Country of origin Hispanic or Latino American

Which term to you use first to describe yourself?

Source: 2009 National Survey of Latinos

What Language Do You Watch TV In?

23%

48%

9%

20%

26%

20%

2%7%

70%

26%

56%

91%

Latinos 16 to 25

1st generation

2nd generation

3rd generation

Mostly/Only Spanish Equally Mostly/Only English

Source: 2009 National Survey of Latinos

Spanglish Usage Peaks among Second Generation

23%

22%

26%

47%

47%

53%

20% 37%

78%

69%

70%

57%

Latinos 16 to 25

1st generation

2nd generation

3rd generation

Most of the time Some of the time Mostly/Only English

Source: 2009 National Survey of Latinos

Percent of Latino Youths using Spanglish at all when talking to friends or family

To be culturally competent doesn’t mean you are an authority in the values and beliefs of every culture. What it means is that you hold a deep respect for cultural differences and are eager to learn, and willing to accept, that there are many ways of viewing the world.

--Okokon O. Udo

Cultural Competency

What is Culture?

Surface culture Deep culture

◦ Food◦ Dress◦ Traditions◦ Gender◦ Music◦ Language◦ Art◦ Religion◦ Values

History Identity Collective memory Relation to

environment Concept of time Space The glasses through

which we see life

Communication Space Volume Tactile Eye contact Timing Direct/ indirect

Silence Saying “no” Linear/ circular Small talk/ business Appropriate topics Smiling Gestures

Gender

The Maya of Morganton

Gender roles in the US Gender roles over

time

Dress Occupation Work roles Family roles Children Spouse Physical violence Power dynamics

What is food???? Who prepares it? With whom do you eat? Where do you eat How is it eaten? When is it eaten?

Food

Race as a cultural construct Race vs. ethnicity Race and class in Brazil

◦ 500 different race-color terms

Race

Hispanic vs. Latino

Indigenous Identity in Latin America•Many do not identify as Hispanic•Over 20 recognized Mayan languages in Guatemala• Mam, K’iche, Kanjobal

Language Navigating the US health System Fear Traditional healing

Cultural Competency in Health Care

Interpretation vs. Translation Spoken and Written

Role of Interpreter How to work with interpreters

Interpretation

Migrant Health 101

Section 330g of the Public Health Service Act

Migratory Agricultural Worker◦ Principal employment is in agriculture◦ Has been so employed within the last 24

months◦ Establishes a temporary home for the purpose

of such employment.

Seasonal Agricultural Worker◦ Principal employment is in agriculture on a

seasonal basis◦ Does not migrate

Legislation

Farming in all federal government branches include:

A) Cultivation and tilling of the soilB) Production, cultivation, growing, & harvesting

of any commodity grown on, in or as adjunct to the land

C) Preparation & processing for market and delivery to storage or market, to carriers for transportation to market (performed by a farmer or on a farm)

Definition of Agriculture

Highest Migrant Impact States

1

42

3

5

67

8

9

10

11

1. Findings from the National Agricultural Workers Survey (NAWS) 2007 - 2009. Demographic and Employment Profile of United States Farm Workers. 2. Kandel W. Profile of Hired Farmworkers, A 2008 Update. Economic Research Service, US Department of Agriculture; Washington, DC; 2008. Economic Research Report No. 60. * Note: Kandel uses a combination of NAWS and others data. 3. Martin P. Immigration reform: implications for agriculture University of California, Giannini Foundation. Agricultural and Resource Economics Update. 2006;9(4).

Farmworker Demographics1

Farmworker Demographics1

4. Per Capita Personal Income in 2008. U.S. Dept. of Commerce, Bureau of Economic Analysis. Released March 2012. http://bber.unm.edu/econ/us-pci.htm5. Federal Poverty Level in 2008 Household size 1. Health Assistance Partnership. http://www.hapnetwork.org/medicaid/fpl-2008.html

Farmworker Demographics1

Increase in the number of H-2A workers

More males traveling alone Fewer families traveling together More established in rural

communities as seasonal workers Less trans-border crossing Engaged in other industries during

the off season (construction, meat processing, dairy and others)

Source: Passel, 2006Photo © Ed Zuroweste

Farmworker Migration Today

Farmworker Health Overview

Agriculture is one of the most hazardous occupations in the United States1

In 2010, 323 farmworkers died of work-related injuries2

About 20% of farmworkers and their families went to a C/MHC in 20113

1. CDC, NIOSH, Workplace and Safety Health Topics: Agricultural Safety, http://www.cdc.gov/niosh/topics/aginjury/

2. Bureau of Labor Statistics, Census of Fatal Occupational Injuries, http://www.bls.gov/iif/oshwc/cfoi/cftb0252.pdf

3. HRSA UDS Data 2011

Work-Related Health Risks

Heat stress Equipment &

automobile accidents Lacerations from

sharp equipment and hand tools

Falls from ladders Eye injuries Musculoskeletal

injuries Insect/rodent/snake

bites

Photo by Farmworker Justice

Work-Related Health Risks

Pesticide exposure in the fields and at home

Photo © Earl Dotter

Illnesses Related to Unsanitary Conditions and Substandard Housing

Gastro-intestinal diseases

Intestinal parasites

Urinary tract infections

Conjunctivitis Lead poisoning Photos by Farmworker

Justice

Chronic Conditions

Diabetes Hypertension Cancer HIV/AIDS Tuberculosis Obesity Asthma

Photo by Farmworker Justice

Mental Health

Anxiety Stress Depression Substance abuse Domestic violence

According to a 2008 NC study, 40% of farmworker participants reached the

threshold for potential clinically-significant depression

Contributing factors: Separation from

families Isolation Discrimination Fear due to

immigration status

Barriers to Care and Healthy Lifestyles

• Cultural issues such as language, literacy, medical knowledge, health care practices and beliefs, and dietary practices

• Social support absent because of social exclusion or isolation

• Food insecurity and/or lack of access to healthy foods

Photo © Earl Dotter

Barriers to Care and Healthy Lifestyles

Photo © Erin Bascom

• Poverty, with unreliable transportation, lack of insurance, inability to buy services and supplies, and substandard housing

• Limited job security increases the possibility that workers will remain in a dangerous or questionable job to remain employed• Unavailability of sick leave• Fear of employer retaliation

• Constant mobility causing discontinuity of care

• Immigration status of patient and/or family members

• Racism that motivates policies or actions that frighten members of particular racial/ethnic groups.

• Confusion about US health systems

Barriers to Care and Healthy Lifestyles

Photo © Earl Dotter

What Can Health Centers Do to Help?

41

• Bilingual staff

• Post clinic schedules in multiple languages

• Walk-in appointments

• Mobile health units

• Patient education materials in English and other

languages geared towards lower literacy levels

• Outreach workers/promotores de salud

• Partner with community-based organizations and

local immigrant-serving institutions

• Provide transportation services

Photo by Migrant Health Promotion

330 (e) Community Health Center

330 (g) Migrant Health Center Voucher Programs

330 (h) Health Care for the Homeless

330 (i) Public Housing

Public Health Section 330 Programs

Required Services for 330(g) Programs

Health center and voucher programs include: Primary care servicesPreventive servicesEmergency servicesPharmacy servicesOutreach and enabling services

Culture and Language• Provision of multi-lingual services (i.e. reception,

health education, patient education, prescription instructions, health center promotional information, medical visit, etc.)

• Meeting Culturally and Linguistically Appropriate Services (CLAS) standards

• Recruitment and retention of qualified bilingual and bicultural staff

• Relevant training and continuing education of staff• Fear/lack of trust

Demand• Exceeds capacity• Staff capacity• Seasonal fluctuations

Service Delivery Challenges

Service Delivery ChallengesOperations

• Integration of walk-in patients into appointment system

• Provision of transportation in rural areas

Costs• MHCs must remain competitive

despite the escalating costs in the health care industry

• Lack of insurance coverage of the population

• Many MSFWs will not be eligible for Medicaid or enrollment in the state health insurance exchanges enacted under the ACA due to immigration status

• Outreach and enabling services are not reimbursable

Photo by Tony Loreti for Migrant Health Promotion

Cultural adaptations◦ Culturally sensitive education◦ Appropriate language and literacy levels◦ Address cultural health beliefs & values

Mobility adaptations◦ Portable medical records & Bridge case

management Appropriate service delivery models

◦ Case Management◦ Lay health promoters (Promotoras)◦ Outreach & enabling services ◦ Coordination with schools and worksites

Adaptations to Mobility and Culture

Continuity of care is the most challenging issue in the provision of quality of care for FWs because: • FWs may seek care only when it is necessary

• Once treatment begins, FWs may move

• If FWs seek care when they arrive in the next community, they may not remember the name or dose of the medication they are taking

• FWs may take records with them, but often lose them

• Communication between MHCs and other providers is difficult

Service Delivery Challenges

Outreach and Enabling Services Support Primary Care Providers

Pablo Feliz1. What aspects of the health

center team worked well in serving Pablo?

2. What did not work well for the team regarding Pablo’s case?

3. What could the team do differently in the future to be more effective.

Farmworker Health Network

Farmworker Justice www.farmworkerjustice.org

Health Outreach Partners www.outreach-partners.org

Migrant Clinicians Networkwww.migrantclinician.org

Migrant Health Promotion www.migranthealth.org National Association of Community Health Centers

www.nachc.com

National Center for Farmworker Health www.ncfh.org

Regional Migrant Health Coordinatorsfernandezm@ncchca.org

Resources for Training and Technical Assistance

Regional Migrant Health Coordinators Coverage Areas

NCFH 2012

Recognize areas of need in region Connect clinics to resources Provide support to new sites Monitor federal legislature Anticipate and facilitate migratory

transitions from state to state

Coordinator Role