Improving Access to Healthcare for Immigrants: Lessons Learned

Through Research and Practice

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.