nc school community health alliance december 4, 2012 magdalena fernandez, mpp regional migrant...
TRANSCRIPT
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
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
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
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
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
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
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
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 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 [email protected]
Resources for Training and Technical Assistance
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