NC School Community Health Alliance
December 4, 2012
Magdalena Fernandez, MPP
Regional Migrant Health Coordinator, Mid-Atlantic
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Latinos in SBHC
Latinos in America
What is culture?
Health Care
Interpretation
Migrant Health 101
Resources
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Average percentage of Hispanics served at SBHC:
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Range of percentage of Hispanics Served at SBHC: 0%-55%
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10%
SBHCs with highest Hispanic Patient Population:
◦ First Health Montgomery County
◦ Southern HS Wellness Center
◦ Blue Ridge Site 1
◦ Blue Ridge Site 2
◦ Blue Ridge Site 3
◦ Blue Ridge Site 4
◦ Greene County
(55%)
(20%)
(20%)
(20%)
(30%)
(20%)
(15%)
In millions
50.5
35.3
22.4
14.6
1980
Source: Pew Hispanic Center.
1990
2000
2010
In percent
Growth,
2000-2010
U.S. Total
Source: 2010 U.S. Census.
43
South Carolina
Alabama
Tennessee
Kentucky
148
145
134
122
Arkansas
North Carolina
Maryland
Mississippi
114
111
106
106
South Dakota
Delaware
Georgia
Virginia
103
96
96
92
Hispanic Population Growth, 2000-2010
90% growth or more
70% to 89% growth
40% to 70% growth
Less than 40% growth
Source: 2010 U.S. Census.
1,590 Counties
With More Than
45% Growth
Source: Pew Hispanic Center
Population in millions
46.8
43
35
4.0
0
1950
22
15
1960
1970
1980
1990
2000
2010
2020
2030
2040
2050
2060
Population in millions
128
Middle "Baseline" Immigration
105
57
50.5
35
4.0
0
1950
22
15
1960
1970
1980
1990
2000
2010
2020
2030
2040
2050
2060
Which term to you use first to describe yourself?
Country of origin
52%
Latinos 16 to 25
3rd generation
20%
41%
32%
Source: 2009 National Survey of Latinos
22% 3%
21%
15%
American
24%
72%
1st generation
2nd generation
Hispanic or Latino
33%
50%
Mostly/Only Spanish
Latinos 16 to 25
23%
2nd generation
3rd generation
9%
Mostly/Only English
20%
48%
1st generation
Equally
20%
2% 7%
Source: 2009 National Survey of Latinos
56%
26%
70%
91%
26%
Percent of Latino Youths using Spanglish at all when talking to friends or family
Most of the time
Some of the time
Mostly/Only English
Latinos 16 to 25
23%
47%
70%
1st generation
22%
47%
69%
2nd generation
3rd generation
26%
20%
Source: 2009 National Survey of Latinos
53%
37%
78%
57%
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
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Food
Dress
Traditions
Gender
Music
Language
Art
Religion
Values
Surface culture
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History
Identity
Collective memory
Relation to environment
Concept of time
Space
The glasses through
which we see life
Deep culture
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Space
Volume
Tactile
Eye contact
Timing
Direct/ indirect
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Silence
Saying “no”
Linear/ circular
Small talk/ business
Appropriate topics
Smiling
Gestures
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Gender roles in the US
Gender roles over time
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Dress
Occupation
Work roles
Family roles
Children
Spouse
Physical violence
Power dynamics
The Maya of Morganton
 What is food????
 Who prepares it?
 With whom do you eat?
 Where do you eat
 How is it eaten?
 When is it eaten?
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Race as a cultural construct
Race vs. ethnicity
Race and class in Brazil
◦ 500 different race-color terms
•Many do not identify as Hispanic
•Over 20 recognized Mayan
languages in Guatemala
•Mam, K’iche, Kanjobal
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Language
Navigating the US health System
Fear
Traditional healing
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Interpretation vs. Translation
 Spoken and Written
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Role of Interpreter
How to work with interpreters
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
Farming in all federal government branches include:
A) Cultivation and tilling of the soil
B) 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)
3
11
9
1
4
8
5
7
6
10
2
Farmworker
Demographics1
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.htm
5. Federal Poverty Level in 2008 Household size 1. Health Assistance Partnership.
http://www.hapnetwork.org/medicaid/fpl-2008.html
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Increase in the number of H-2A
workers
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More males traveling alone
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Fewer families traveling together
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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)
Photo © Ed Zuroweste
Source: Passel, 200
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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
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Heat stress
Equipment &
automobile accidents
Lacerations from
sharp equipment and
hand tools
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Falls from ladders
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Eye injuries
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Musculoskeletal
injuries
Insect/rodent/snake
bites
Photo by Farmworker Justice
Pesticide exposure in
the fields and at home
Photo © Earl Dotter
Gastrointestinal
diseases
 Intestinal
parasites
 Urinary tract
infections
 Conjunctivitis
 Lead poisoning
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Photos by Farmworker Justice
Diabetes
 Hypertension
 Cancer
 HIV/AIDS
 Tuberculosis
 Obesity
 Asthma
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Photo by Farmworker Justice
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Anxiety
Stress
Depression
Substance abuse
Domestic violence
Contributing factors:
 Separation from
families
 Isolation
 Discrimination
 Fear due to
immigration status
According to a 2008 NC study, 40% of farmworker
participants reached the threshold for potential
clinically-significant depression
• 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
• 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
Photo © Erin Bascom
• 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
Photo © Earl Dotter
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Bilingual staff
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Post clinic schedules in multiple languages
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Walk-in appointments
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Mobile health units
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Patient education materials in English and other
languages geared towards lower literacy levels
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Outreach workers/promotores de salud
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Partner with community-based organizations and
local immigrant-serving institutions
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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
Health center and
voucher programs
include:
Primary care services
Preventive services
Emergency services
Pharmacy services
Outreach and enabling
services
Service Delivery Challenges
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
Operations
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Integration of walk-in patients
into appointment system
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Provision of transportation in rural
areas
Costs
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MHCs must remain competitive
despite the escalating costs in the
health care industry
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Lack of insurance coverage of the
population
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Many MSFWs will not be eligible
for Medicaid or enrollment in the
state health insurance exchanges
enacted under the ACA due to
immigration status
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Outreach and enabling services
are not reimbursable
Photo by Tony Loreti for Migrant Health Promotion
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Cultural adaptations
◦ Culturally sensitive education
◦ Appropriate language and literacy levels
◦ Address cultural health beliefs & values
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Mobility adaptations
◦ Portable medical records & Bridge case management
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Appropriate service delivery models
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Case Management
Lay health promoters (Promotoras)
Outreach & enabling services
Coordination with schools and worksites
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
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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
1. 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
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Farmworker Justice
www.farmworkerjustice.org
Health Outreach Partners
www.outreach-partners.org
Migrant Clinicians Network
www.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 Coordinators
fernandezm@ncchca.org
Regional Migrant Health
Coordinators Coverage Areas
NCFH 2012
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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