Using a Needs Assessment to
Measure Farmworker Health
Disparities: A Michigan Case
Rene P. Rosenbaum, PhD
Sheila F. LaHousse, PhD
November, 2010
20th Annual Midwest Stream Farmworker Health Forum
Austin, TX
Presentation Outline
• Learning objectives
• Needs assessment review of concepts and
steps
• Health disparities and Indicators
• Analyzing farmworker health disparities using
a needs assessment
Learning Objectives
1. Review steps used in conducting a health needs
assessment.
2. Understand the concept of indicators and their
importance in measuring disparities and
assessing progress toward their elimination.
3. Apply the Behavioral Risk Factor Survey to
conduct disparities research that targets the
farmworker population.
1.
Needs Assessment
Introductory review of key concepts and
implementation steps
Key Concepts
• A “need” is a discrepancy or gap between “what
is” and “what should be.”
• Desired state minus Current state =Need
• 100% of residents have healthcare coverage
(Desired state)
• 40.9% of migrants in Oceana County MI have no
heath care (Current state)
• 59.1% of migrants in Oceana County MI need
Healthcare coverage (Need)
Key Concepts
• A health “needs assessment” identifies gaps
between the desired health/care of MSFWs
and their current health/care, examines their
nature and causes, and sets priorities for
future action to improve programs, services,
or other elements.
• It is a systemic approach and decision making
process that focuses on ends (i.e., outcomes)
to be achieved, progresses through a series of
phases, and uses a set of established
procedures and methods to determine needs
Key Concepts
• There is no one correct needs assessment
model or procedure.
• Needs Assessments are focused on particular
groups in a system.
• Ideally, needs assessments are initially
conducted to determine the needs of the
people for whom the organization or system
exists. However, a “comprehensive” needs
assessment includes both needs identification
and the assessment of potential solutions.
Phases and steps in needs assessment:
Phase 1-Exploring “What Is”
• Step 1-Prepare management plan for needs
assessment
• Step 2-Identify major concerns or factors
• –focus on desired outcomes
• Step 3- Develop measurable need indicators in
each area of concern
• Step 4- Consider data sources
• Step 5 Decide on preliminary priorities for each
needs indicator
Outcome: Preliminary plan for data collection in Phase 2
Pre-assessment activities of a
project
Organization
Assessment Instruments
Assurance of Human Rights
Selection of Interviewers
Training of Interviewers
Steps in Phase II-data gathering &
analysis
• Step 1- Determine target groups
• Step 2- Gather data to define needs (to
formulate needs statements)
• Step 3- Prioritize Needs-Based on data
• Step 4- Identify & analyze causes
• Step 5- Summarize Findings
Outcome: Criteria for action based on high-priority needs
Steps in Phase III-making decisions
•
•
•
•
•
Step 1-Set priority of needs
Step 2- Identify and evaluate possible solutions
Step 3- Select one or more solutions
Step 4- Propose action Plan to implement solutions
Step 5- Prepare written reports and oral briefings
to communicate the methods and results of the
needs assessment
Outcome: Action plan(s), written and oral briefings, and
final report
Summary
• There is no one correct needs assessment model
or procedure
• Make sure needs focus on desired outcomes
• Investigate what is known about the needs of the
target group
• Develop measurable needs indicators to guide
the data collection process
• Perform a causal analysis to understand why the
needs exists
• Propose an action plan to implement solutions
• Prepare written report
2.
Measuring and Tracking
Health Disparities through
Health Indicators
What are health disparities?
• Health disparities are differences in the incidence,
prevalence, mortality, burden of disease and other
adverse health conditions or outcomes that exist among
specific groups in the United States. In Michigan, as in
the United States, racial and ethnic minority populations
carry a disproportionately heavy burden due to health
disparities. This burden is manifested in increased risk
for disease, delayed diagnosis, inaccessible and
inadequate care, poor health outcomes and untimely
death, much of which are preventable.
Source: 2007 Health Disparities Report to the Michigan Legislation, Michigan Department
of Community Health
Do Disparities exist?
• Getting into the health care system (access to care) and
receiving appropriate health care in time of the services
to be effective (quality care) are key factors in ensuring
good health outcomes.
• The 2009 National Healthcare Disparities Report finds
that disparities related to race, ethnicity, and
socioeconomic status still pervade the American health
care system.
• Disparities are observed in almost all aspects of health
care including all dimensions of health care quality, all
dimensions of access to care, across many levels of types
of care, across many clinical conditions, across many
settings, and within many subpopulations.
Source: 2009 National healthcare Disparities Report
How can we know?
 We can use Healthcare Indicators: they are
statistical measures and other sources of evidence
(measurable variables) of existing conditions,
behaviors, characteristics of a target population, etc.
Indicators
 verify that a concern exists (baseline)
 measure progress and achievements; they provide
early warning signals when thing go wrong
 support effective decision making through out the
processes of planning, implementation, monitoring,
reporting, and evaluation of an intervention
How do we quantify the
magnitude of disparities?
• Rate relative to reference group
When the magnitude of the disparities by specific
groups is measured by examining rates across
comparison groups
• Trends in disparities
 When the magnitude of the disparities by specific groups
(e.g., racial, ethnic, socioeconomic) is measured by
examining rates across a comparison group at different
points in time
How do you choose high quality
indicators?
• More and more organizations who fund
interventions are demanding accountability of
their achievements in terms of concrete results
and calling for smart indicators:
– Specific-what is being measured is clear
– Measureable-change is objectively verifiable
– Achievable (or acceptable, applicable, appropriate)
– Relevant (or reliable, realistic)
– Time-bound- completed within a timeframe
Where do health indicators come from?
• Health indicator reports are complies at every jurisdictional level
– State and local level-by health departments, foundations,
universities, human services providers, etc.
– National-Federal government, foundations, partnerships, etc.,
– International-United Nations, OECD, WHO, etc.
• Data sources for indicators in these reports are many:
•
•
•
•
•
National Vital Statistics System
Surveys (Behavioral Risk Factor Survey, Nutrition Examination Survey, local
surveys, etc.)
Disease surveillance systems
Health services administration data
Other
Types of common health indicators
• Morbidity/Health Status
• Physical and social environment
 Health related quality of life Area base measures, e.g., income,
poor health days
poverty, population density,
housing, environmental pollution
 Obesity-Body Mass Index
 Individual /family income,
 Diabetes, asthma, and other
education, social supports
chronic diseases
• Health System Performance Indicators
• Health Behaviors
 Access (e.g., supply of providers,
 Not smoking
cultural barriers)
 Regular physical activity
 Costs (e.g., total health
 Diet and nutrition
expenditures, prescription drug
• Access to Health Care
costs
• Insurance coverage
 Quality of care (e.g., effective care—
• Regular sources of care
e.g., receipt of recommended
• Receipt of preventive services
screening, treatment, readmission
rates
Sources on Health Indicators
• Publications: Health Indicators: A Review of
Reports Currently in Use (July 2008)
www.cherylwold.com
• Institute of Medicine Committee Report
http://iom.edu/Reports/2008/State-of-the-USAHealth-Indicators-Letter-Report.aspx
• Institute of Medicine, Health Indicators: a 4-Part
Webinar Series
http://www.nlm.nih.gov/nichsr/healthindicators/
3.
Using State and National
Comparison Data to Track
Health Disparities
Study Design: Tracking Health
Disparities
• FWs are thought to be at greater health risk and suffer
more health problems at a disproportionate rate to the
general population.
– Little comparable baseline data exists to confirm these claims.
• Selected demographic, health status and health care
indictor data collected from the Oceana Farmworker
Health Study (OFHS) were compared to indicator data
from:
– BRFSS 2000 (for a nationwide comparison)
– REACH 2001-2002 (for Hispanic/Latino nationwide
comparison)
– Michigan BRFSS 2006-2008 (for a state-wide comparison)
Setting
Oceana County, Michigan
• The 3rd leading user of farm labor in
Michigan
• Annual agricultural crop production
valued at $39 mil
• Population 26,873 (2000 Census)
• County 11% Hispanic
– State = 3% Hispanic
• 5,400 ≈ farmworkers
Local State Health Departments
Oceana County
is located in
district #10
Create a Needs Assessment Committee
Project Partners
 Michigan State University (PI)
 Northwest Michigan Health Services,
Inc.
– Migrant Health Clinic (Shelby)
Project Collaborators
 Family Independence Agency in Oceana
County
 West Michigan Mental Health System
 Michigan State University ExtensionOceana County
 Telamon Corporation, Inc.- Migrant
Head Start
 Michigan Department of Career
Development
Interviewers & Volunteers
 Family Independence Agency
 West Michigan Mental Health
System
 Women, Infants & Children
Program
 Planned Parenthood Clinic
 Local Employers
Reach consensus on goal(s) of
greatest importance
Project Goal :
To improve health outcomes and reduce health
disparities in the farmworker population through
research to measure health needs, with a particular
focus on problems in accessing medical care and
participating in Medicaid.
Determine target groups
• Three strata
• Industries
– 1. Migrants living in
– Field/Orchard
licensed labor camps
– Dairy/Livestock
– 2. Migrants not living in
– Food Processing (Packing,
licensed labor camps
Sorting)
– 3. Seasonal agricultural
– Horticulture (Nurseries,
workers
Christmas Trees,
• Response postcards
Greenhouses)
distributed
• Participants Individuals that
Target sample size: 300 (150
self-identify as a migrant or
from strata 1, 50 strata 2,
seasonal agricultural worker
100 strata 3)
age 18 or older and who were
employed in agriculture for any
length of time within the
previous 12 months
Oceana Farmworker Health Study
Design
Adopted the general design and methodology in the
California Agricultural Worker Health Survey; included
questions from the Behavioral Risk Factor Surveillance
System
Procedures included a health and risk behavior survey of
randomly selected migrant and seasonal agricultural
workers and a physical examination, including lab work, for
survey participants.
Guided by a multidisciplinary, participatory approach
Outline of Main Survey
Instrument Used
•
•
•
•
•
•
•
•
•
•
•
Household composition
Personal demographics
Health Services Utilization
Self-Reported Health Conditions
Doctor-Reported Health Conditions
Work History
Income and Living Conditions
Workplace Health Conditions
Field Sanitation
Work Related Injuries
Behavior Risk Assessment
Components of Physical
Examination
• Biometrics- height, weight, blood pressure,
temperature, pulse rate, respiratory rate
• Lab Tests- urine dip, hemoglobin,
cholesterol, fasting blood sugar,
PAP smear (females) , STIs,
PPD/Tuberculosis Skin Test
Sample Procedure
Data Collection Procedure:
 a representative sample of 300 randomly selected
agricultural workers ages 18 or older over a three-year
period
Three strata: licensed labor camp migrants, nonlicensed labor camp migrants, and seasonal workers
Multistage stratified random sample of workers
2-2.5 hours long interviews followed by a referral to
the local migrant health clinic for a physical
examination
Accuracy and completeness of interview and physical
exam data checked and rechecked
Sample Characteristics
Migrant
(n= 180)
Age-mean 35 years
Seasonal
(n= 120)
34 years
Gender
59% Women
41% Men
63% Women
37% Men
Selfidentify
as:
51% Mexican
35% Hispanic
8% Mexican American
2% Chicano(a)
2% Latino(a)
3% Other
63% Mexican
25% Hispanic
4% Mexican American
0% Chicano(a)
3% Latino(a)
6% Other
Sample Characteristics
Migrant (n=180)
Seasonal (n=120)
Marital
71% Married
68% Married
Median #
of kids
Have HS
Diploma
2 children
2 children
Women: 23%
Men: 20%
Women: 31%
Men: 17%
Preferred 56% Spanish
Reading 14% English
Language 30% Both
74% Spanish
6% English
20% Both
Median
Family
Income
$10,000 - $14,999
$10,000-$14,999
Results
Socio-Demographics and
Access to Care
No Health Care Coverage
Source: OFHS Survey, National data from BRFSS 2000; State and District
data from the Michigan BRFS 2006-2008
Note: Results are reported as percentages.
* Median %
Education
Source: OFHS Survey, National data from BRFSS 2000; National Hispanic/Latina data
from REACH 2001-2002
Note: Results are reported as percentages.
* Median %
Annual Income
Source: OFHS Survey, National data from BRFSS 2000; National Hispanic/Latina
data from REACH 2001-2002
Note: Results are reported as percentages.
* Median %
Summary of Results
Socio-demographics and Access to Care
• Reported education, household
income, and insurance coverage levels
were markedly lower in the FW
population than in the general BRFSS
population and general REACH
Hispanic population
Clinical Preventive Services
Mammography
Source: OFHS Survey; National data from BRFSS 2000, 2002; National Hispanic/Latina
data from REACH 2001-2002; State and District data from the Michigan BRFS 20062008
Note: Results are reported as percentages.
*Median %; ^ % who received mammogram in past 2 years
^^ % who received mammogram and a clinical breast exam in past year
Pap Smear Test
Source: OFHS Survey; National data from BRFSS 2000; National Hispanic/Latina data
from REACH 2001-2002; State and District data from the Michigan BRFS 2006-2008
Note: Results are reported as percentages.
* Median %
Prostate Cancer Screening
Source: OFHS Survey; National data from BRFSS 2002; State and District
data from the Michigan BRFS 2006-2008
Note: Results are reported as percentages. * Median %
^ State data is reported for a PSA in the last year for men 50+ years of age.
Oral Health Utilization
Source: OFHS Survey, National Hispanic/ Latino data from BRFSS
2002; State and District data from the Michigan BRFS 2006-2008.
Note: Results are reported as percentages.
* Median %
Summary of Results
Clinical Preventive Services
• Mammography
– The percent of FW women aged 50+ years who reported ever having had
a mammogram in the past was higher than for REACH Hispanic women
and BRFSS women who reported having a mammogram in the past two
years. This discrepancy is most likely due to the different range for years
reported. However, these data are presented to provide insight into
general trends for FW women in comparison Hispanics and the
population as a whole.
• Pap Smear Test
– Both seasonal and migrant women 18+ are getting pap tests comparable
to national average in 2001.
• Prostate Cancer Screening
– A lower percentage of FW men compared to BRFSS men nationally
reported having had a PSA test within the past two years.
• Oral Health
– Compared to the general population, a lower number of FW reported
having been to the dentist in the past year. FW men were least likely to
have been to the dentist in the past year compared to all groups.
Cardiovascular Disease
Risk Factors
Diabetes
% Responded “yes”
OFHS Survey; National Hispanic/ Latino data from REACH 2001-2002;
State and District data from the Michigan BRFS 2006-2008.
Note: Results are reported as percentages.
* Median %
Cholesterol
% Responded “yes”
Source: OFHS Survey; BRFSS 2001; REACH 2001-2002. No state data to compare to.
Note: Results are reported as percentages.
* Median %
Hypertension
% Responded “yes”
Source: OFHS Survey; BRFSS 2001; REACH 2001-2002. No state
data to compare to.
Note: Results are reported as percentages.
* Median %
Obesity
Source: OFHS Survey; National Hispanic/ Latino data from REACH 20012002; State and District data from the Michigan BRFS 2006-2008.
Note: Results are reported as percentages.
* Median %
Cigarette Smoking
Source: OFHS Survey; National Hispanic/ Latino data from REACH 20012002; State and District data from the Michigan BRFS 2006-2008.
Note: Results are reported as percentages.
* Median %
Daily Fruit and Vegetable Intake
Source: OFHS Survey; National Hispanic/ Latino data from REACH 2001-2002; State and
District data from the Michigan BRFS 2006-2008. Note: Results are reported as percentages.
* Median %; ** More than 5 servings of fruits and vegetables a day
Summary of Results
Chronic Disease Risk Factors
• Obesity
–
•
Cigarette Smoking
–
•
The prevalence of obesity was higher among migrant and seasonal FW
than in the general BRFSS and REACH Hispanic populations. The
prevalence of obesity was higher among men and woman FW than in the
general BRFSS and REACH Hispanic populations. Migrant and women FW
had the highest prevalence of obesity among all groups.
Cigarette smoking was more common among FW men than among REACH
Hispanic men, and less common among FW women as compared to
REACH Hispanic women. FW men were 5 times as likely to smoke as
compared to FW women. Although more seasonal FW than migrant FW
reported smoking, fewer FW stratified by work status smoked than did the
general BRFSS population.
Fruit and Vegetable Intake
–
Compared to the general population and to the Hispanic population, many
fewer FW reported eating the recommended serving of fruits and
vegetables daily.
Summary of Results (cont’d)
Chronic Disease Risk Factors
• Diabetes
– More FW women than REACH Hispanic women and the general BRFSS
population reported ever having been told by their doctor they have
diabetes. Fewer FW men than REACH Hispanic men and the general BRFSS
population reported ever having been told by their doctor they had
diabetes. More seasonal FW than migrant workers reported ever having
been told by their doctor they have diabetes.
• Cholesterol
– The percentage of REACH Hispanics and the general BRFSS population who
reported having been told by a health professional that they had high
blood cholesterol was higher than among the FW population. More
migrants than seasonal FW reported having been told by a health
professional that they had high blood cholesterol.
• Hypertension
– The percentage of REACH Hispanics and the general BRFSS population who
reported having been told by a health professional that they had high
blood pressure was higher than among the FW population. More
migrants than seasonal FW reported having been told by a health
professional that they had high blood pressure.
Significance
• OFHS data demonstrate that for the majority of health and
socioeconomic indictors FW populations do not fare as well as the
median average for the nationwide BRFSS and the REACH Hispanic
populations.
• OFHS data demonstrate that obesity, cigarette smoking, and lack of
adequate daily fruit and vegetable intake puts FWs at a higher risk for
chronic disease compared to Hispanics nationally and the general
population in the U.S.
• FW women are more likely to receive preventive services comparable
to Hispanic women and women nationally whereas FW men are less
likely to receive preventive services compared to Hispanic men and
men nationally.
Implications
• Based on the OFHS findings on FW health disparities the following
public health research areas should be given priority:
• Obesity prevention
• Diabetes awareness
• Increase access to adequate health care coverage
• Increasing access to healthy food
• Increasing access to dental services for men
• Tobacco use for men
• Prostrate cancer screening for men 40+
• Health disparity research is needed to track health status and
improvements in the health of America’s FW.
Acknowledgements
• Grant Number 25-P-91468/1-01 Center for
Medicaid and Medicare, Hispanic Health
Services Research Program, September 2001September 2004
• Julian Samora Research Institute and
Department of CARRS, Michigan State
university