improving access to healthcare for immigrants: lessons learned through research and practice
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Improving Access to Healthcare for Immigrants: Lessons Learned Through Research and Practice. The Immigrant Health Initiative Solange Muller, MPH Audrey Waltner, MPH Hank Schmidt, MD PhD APHA 2013. Presenter Disclosures. Solange T. Muller. No relationships to disclose. - PowerPoint PPT PresentationTRANSCRIPT
Improving Access to Healthcare for Immigrants: Lessons Learned
Through Research and Practice
The Immigrant Health Initiative
Solange Muller, MPHAudrey Waltner, MPH
Hank Schmidt, MD PhD
APHA 2013
Presenter Disclosures
The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:
Solange T. Muller
No relationships to disclose
My Journey
Immigration to the Hudson Valley, New York
• The foreign-born population in Dutchess County has experienced a 43% increase in the last 10 years (8.4% in 2000 to 12% in 2010).
• In spite of increasing population, under-represented in patients presenting for care.
• New York Medical College study 2007– 7 counties in Lower Hudson Valley– Barriers to access to health care– Recommended further study
The Immigrant Health Initiative
• Principal Investigators• Dutchess County Department of Health• Funders:
• Collaborators:
Research Goals
• Collect current data on the health status of the recent immigrant population from both rural and urban settings.
• Examine potential barriers impacting preventive, primary, and specialty care access.
• Develop new interventions to address existing barriers and to improve the overall health status of the recent immigrant population.
Study Design• Target areas with high concentrations of immigrants
– Rural Eastern Dutchess Sample size 120-150– Urban City of Poughkeepsie Sample size 150-180
• Target population – individuals > 18 years old who entered the U.S. in the last 10 years
• 100 question survey in Spanish– Demographics– Personal health– Healthcare seeking behaviors– Barriers to access
• Field tested as a pilot and optimized– Administered by Principal Investigator and 2 trained assistants
• Targeted Recruitment: ESL classes, farms, restaurants, convenience stores, gathering places for immigrants, health center waiting rooms, immigrant homes.
Demographics• 290 immigrants entering US within 10 yrs
– 141 (48.6%) Rural Eastern Dutchess – 149 (51.4%) Urban City of Poughkeepsie
• 81% undocumented• Mean age 33, Median age 31• Female 54.5%, Male 45.5%• Race/Ethnicity
– Hispanic/Latino 92.4%– White 1.7%– Black 2.8%– Other 1.0%
Region of Origin
CharacteristicsTotal Eastern Dutchess Poughkeepsie
p ValueN = 290 N = 141 (48.6%) N = 149 (51.4%)
Region of Origin Mexico 59.7% 41.8% 76.5% 0.000
Central America 26.9% 47.5% 7.4% 0.000
Guatemala 23.8% 46.1% 2.7%
South America 9.0% 9.9% 8.1%
Caribbean 3.1% 0.0% 6.0%
Africa 0.7% 0.0% 1.3%
Asia 0.7% 0.7% 0.7%
“No one has ever taken this much interest in my life and in my experiences. Thank you”
Sara
Socio-Economic Characteristics
CharacteristicsTotal Eastern Dutchess Poughkeepsie
p ValueN = 290 N = 141 (48.6%) N = 149 (51.4%)
Residence in U.S. < 1 year 3.4% 3.4% 3.5%
1-5 years 52.4% 46.3% 58.9% 0.035
6-10 years 44.1% 50.3% 37.6% 0.033 Undocumented status 81.0% 80.0% 83.7% Came to the U.S. alone 61.3% 65.7% 57.1% Knew someone upon arrival 83.0% 89.4% 77.0% 0.007 Employed 68.9% 78.7% 59.5% 0.000 Live with someone 88.6% 88.7% 88.6% Have children < 18 years 63.7% 54.3% 72.5%
Seeking Healthcare Services
Accessing Health Care
Gender Differences in Seeking Health Care
Seeking Health Care: Females
• Females were much more likely to engage in preventive health or routine healthcare visits than males (34.2% vs 19.7%).
• The rate of never going to the doctor was much higher among males than females (28.8% vs 3.8%).
• In general, females were much more likely than males to seek any type of healthcare services (OR 8.7, 95% CI 3.08 – 24.58, p<0.001).
Other Factors in Seeking Health Care
• Residence in the US > 5 years– (OR=3.3, 95% CI 1.39 – 7.92, p<0.008)
• Living with children under 18 years old– 90.8% preventive health visits
• 84.8% became aware of services via word of mouth– As opposed to other vehicles: advertising
Barriers to Accessing Health Care
QuestionTotal Eastern Dutchess Poughkeepsie
p value
N = 246 N = 141 N = 149
Difficulty getting to the doctor 25.0% 33.0% 18.3% 0.014
Reasons for difficulty N = 58 N = 35 N = 22
Transportation 70.2% 97.1% 17.1% 0.000
Getting time off from work 15.8% 8.6% 17.1%
Miscellaneous 29.8% 8.6% 39.0%
Language as a Barrier
• In multivariate analysis, speaking English was not a significant factor in seeking health care.
• However, English speaking immigrants were twice as likely to engage in preventive care
• Language was more important in rural setting– Subjects selected health center based on Spanish
language speaking providers– Often traveled farther to see these providers
Factors Influencing Choice of Healthcare Providers
Total Eastern Dutchess Poughkeepsie
p value
N = 233 N = 109 N = 137
Speak my language 37.3% 45.0% 27.7% 0.007
Like the way I am treated 36.9% 35.8% 34.3%
Affordable 29.2% 21.1% 32.8% 0.045
Most convenient 25.8% 38.5% 13.1% 0.000
Only one I know of 18.9% 13.8% 21.2%
Does not require documentation 16.3% 25.7% 7.3% 0.000
Other 8.6% 7.3% 10.2%
Reported Health Problems in Country of Origin and in U.S.
Total Population (N = 290)p Value
Country of Origin U.S.Hypertension 7.6% 11.0% Diabetes 2.8% 6.2% Heart disease 2.1% 2.4% Cancer 0.0% 0.7% Sexually transmitted diseases (STD) 0.7% 2.8% HIV 0.0% 0.0% Depression 9.7% 18.3% p = 0.004
Use of Herbal Treatments• Almost two thirds of immigrants acknowledged use of
herbal remedies (63.4%) in country of origin and 36.6% acknowledged use in the U.S.
• Over half of those who used these remedies in the U.S. indicated they did not admit use of herbal remedies to their doctor.
• Nearly half (47.1%) said their doctor did not ask about use of herbal remedies because the doctor was not interested in knowing about herbal remedies (21.6%), or the doctor would want them to take Western medicines instead (21.6%).
Behavioral Health Issues
• 81 % of immigrants interviewed reported having experienced feelings of sadness and depression.
• The sadness is related to missing family and feeling isolated
• 58.7% talk to friends or family • 15.3 % go to church or pray• 18.5% reported depression• 1.7% reported going for counseling
Reasons for Sadness and Depression
Practice
Kinship Circlesof Support
Principal Investigator
Proyecto Madre transforms into Kinship Circles of Support
• Expansion of the work based on the following recommendations of the Immigrant Health Initiative study:“Develop novel pathways that take advantage of a significant female gender bias in initial health care involvement among immigrants, for the purpose of engaging entire family units in affordable easily accessible, primary care that leads to regular preventive health visits and establishment of a medical home
“ Develop services that target the unique circumstances of immigrants dealing with loss and stress of separation from family, community and culture.”
Kinship Circles of Support
The objective of the Kinship Circles Groups is to improve the health of immigrant families, in particular women, and to enhance access to resources.
Additionally, the Kinship Circles Groups will connect these individuals and families to their local communities to ease the stress and loss resulting from loss of family, community and culture.
Kinship Circles of Support Group
Topics of Discussion
• Importance of accessing health care for the entire family
• Nutrition and healthy eating
• Chronic disease prevention
• Stress reduction techniques
• Lifestyle changes
Method
• Questionnaire administered before and after one year of the program.
• Purpose: to examine change in knowledge, health seeking behaviors, healthy lifestyle
• Paired data collected for 12 subjects.
Impact• Knowledge increased on diabetes, hypertension,
cholesterol, depression.
• All participants and their spouses had a preventive physical exam.
• Changes in their food and beverages choices.
• Improvement in Body Mass Index (BMI)
• Supportive relationships and shared experiences
Healthcare CentersNumber of Hispanic Patients Served
2009 Last 12 Months
Eastern Dutchess 765/7,929 (9.6%) 953/7989 (11.9%)
Poughkeepsie 1,246/2,246 (55.5%)
2,016/5,152 (39.1%)
Conclusions
• Kinship Circles of Support succeed in health care involvement for the whole family.
• Sharing among the participants led to connections, support, minimizing feelings of loss and isolation.
• Involvement empowers immigrant women to be leaders and help fellow immigrants in the community.
Lessons Learned
References and Permissions• The Health of Recent Immigrants to the Lower Hudson Valley and the
Challenges Faced by Those Who Serve Them, School of Public Health, New York Medical College, August 31, 2007.
• Permission granted by the Community Foundation of Dutchess County to use the photograph of the two immigrants.
• Permission granted by Catholic Charities to use the photograph of the immigrant women in the Kinship Circles of Support group.
• Permission granted by Hudson River HealthCare to use the statistics on Hispanic patients in the health centers in Eastern Dutchess and Poughkeepsie.
• A study of the Health Care of Recent Immigrants in Dutchess County, New York. Hank Schmidt, MD PhD, Audrey M. Waltner MPH, Solange T. Muller, MPH. February 2011.