Mindy GrayGeorge Washington

University

POLICY BRIEF

Place Photo Here,Otherwise Delete Box

July 8 2013

Health Disparities Among Hispanics in Loudoun

County, Virginia

AS OF 2010, HISPANICS & LATINOS ACCOUNTED FOR ABOUT 12% OF LOUDOUN COUNTY’S POPULATION.Between 2000 and 2010, the population of Hispanics in Loudoun County increased from 10,089 to 38,576, representing a 282.4% increase of this population. Loudoun County, as a whole, has shown an 84.1% increase in the number of residents in the last decade, and is currently the fifth fastest growing county in the United States (“Loudoun county 2010,” 2011). Hispanics make up the second fastest growing population in the region, and, according to Doctor David Goodfriend, Director of the Loudoun County Health Department, many of these Hispanic individuals are recent immigrants to the area. Most of Loudoun County’s growth, writes Gibson (2011) is concentrated in the eastern areas, particularly in Sterling, where the “percentage of Hispanics has risen from 11 percent to 33 percent” in the last ten years. The distribution by county can be seen below.

Mindy GrayGeorge Washington

University

BACKGROUND

July 8 2013

(“Loudoun county race,” 2011)

THE HISPANIC POPULATION CONTINUES TO GROW

Across the United States, minorities, as a whole, have a “higher prevalence of diabetes, strokes, and other largely preventable diseases and conditions than their white counterparts” (Bahls, 2011). Since 2007, writes Bahls, inpatient care for Hispanics and Latinos with heart failure has gotten worse, which is perpetuated by “socioeconomic, language, and cultural barriers” that contribute to more hospital admissions and poorer health outcomes (2011). Hispanics and Latinos historically have had lower health coverage rates than whites, a finding that was confirmed by Doctor Goodfriend of the Loudoun County Health Department. The Loudoun County Free Clinic is available for Loudoun County residents who have a household income “at or below 200% of the federal poverty level” (“Loudoun county free,” 2009). Doctor Goodfriend said that many of the patients that are seen at the clinic are minorities, and many Hispanic families visit the clinic for services that the clinic provides. These families can obtain services for children’s dental, family planning, STD screening, communicable disease services (personal communication, July 2, 2013), as well as diagnostic and laboratory testing, referrals, and education and nutrition classes (“Loudoun county free,” 2009). Unfortunately, according to Loudoun County’s Free Clinic website, they have only eight paid full-time staff, five paid part-time staff, and mostly rely on volunteers that “provide care for more than 15oo patients” (“Loudoun country free,” 2009). The population of Loudoun County is expected to reach over 405,000 by 2020; it is difficult to see how a small staff will be able to accommodate such a large population, especially when the number of Hispanic citizens is expected to continue to increase disproportionately. Goodfriend believes that Hispanics have less access to care, confounded by language

DISPARITIES IN THE HISPANIC POPULATION ARE PREVALENT ACROSS THE UNITED STATES

“LOUDOUN COUNTY IS NOT A STABLE COMMUNITY”- Doctor David Goodfriend, Director of the Loudoun County

The Hispanic and Latino culture is very diverse, making up individuals from several countries, including Cuba, Mexico, Puerto Rico, the Dominican Republic, South or Central America, or “other Spanish cultures regardless of race” (Perez-Edcamilla & Putnik, 2007). Doctor Goodfriend has identified that many of Loudoun County’s Hispanics are from South and Central America

Gibson explains that the Hispanic population tripled to over 38,000 residents in the last ten years (Gibson, 2011). This has been particularly reflected in school enrollments; in 2000, 78% of Loudoun students were non-Hispanics but in 2010, this number fell to 61% (Gibson, 2011). As a result, by 2019, it is expected that Loudoun County would need 21 additional schools to accommodate this growing population. Additionally, many schools have had to adapt to non-English speakers. Sugarland Elementary School in Sterling created a program called Sheltered Instruction Observation Protocol, or SIOP, an initiative funded by the U.S. Department of Education, Gibson explains (2010). The program was designed to assist non-English speaking students to succeed in school. Unfortunately, Sugarland Elementary is the only school to implement such a program and its teachers are the only adults trained in this type of education in the area. Sugarland’s enrollment is 59% Hispanic students (Gibson, 2010). Between 2000 and 2010, the number of students learning English as a second language in Loudoun County increased from 506 to 5191 (Gibson, 2010). It is expected that Hispanic population will continue to grow, continuing to make up a large percentage of Loudoun County in future years. So far, the school has seen better outcomes not just for non-English speaking students, but Angela Robinson, the school’s principal said that they “started to see all kids do better” (Gibson, 2011). In 2009, 91% of Hispanic third graders passed their state history test. The year prior, this statistic was 78%, says Gibson (2011).

There are clearly benefits to the SIOP program, and expanding the curriculum to incorporate healthy eating habits, the importance of physical activity, and including the students’ families, who may not speak English, in this learning can potentially create a generation of minority students who have the knowledge to make better health decisions. They also have the benefit of speaking more than one language, which is an asset to providing education to others in several ways. The

“THESE KIDS ARE NOT WITHOUT KNOWLEDGE; THEY’RE WITHOUT LANGUAGE”- Angela Robinson, Principal of Sugarland Elementary School

Doctor David Goodfriend is the director of the Loudoun County Health Department. His office, located in Leesburg, Virginia, operates under the Virginia State Department of Health. His office is responsible for performing health assessments across Loudoun County, and the county is currently preparing for this year’s public health assessment. Doctor Goodfriend mentioned that Hispanic population in Loudoun County tends to be younger in age (personal communication, July 2, 2013).

IN LOUDON COUNTY, MORBIDITY & MORTALITY RATES ARE NOT REPRESENTATIVE OF THE POPULATIONDoctor David Goodfriend discussed the fact that much of the mortality data from recent years represents those who were long-term residents of Loudoun County. He reported that the data

was lacking for recent immigrants, because this population has seen a greater influx in the last few years; therefore, the causes of mortality specifically for the younger Hispanic population “won’t show up in current mortality rates, but thirty years from now, it will” (Dr. David Goodfriend, personal communication, July 2, 2013). Dr. Goodfriend identified one potential issue: when Central and South American individuals migrate to areas like Northern Virginia, they change their diets very quickly and significantly, increasing their risk for obesity and cardiovascular problems. One challenge is determining how to incorporate statistics other than mortality and morbidity rates (personal communication, July 2, 2013).

Currently, the number one cause of death in Loudoun County is a result of malignant neoplasms (cancer) (“Loudoun county, Vvirginia,” 2009) These deaths make up 26.57% of deaths in the region. Heart and cardiovascular disease rank number two, but this number is believed to be greater, says Dr. Goodfriend. Inaccurate data is a result of an unstable community (Dr. Goodfriend, personal communication, July 2, 2013) and as a result of the use of convenience surveys, the predominant way in which Loudoun County obtains its health data. The county does

not currently have the financial resources to more accurately collect data. The local health department found that Whites, women, parents, English speakers, and those of higher incomes responded through “open-ended community surveys,” the way in which Dr. Goodfriend reports that health data was collected (personal communication, July 2, 2013). State delegator Kenneth Plum reported in 2013, that Northern Virginia’s major health issues were a result of “tobacco use, poor diet and exercise, abuse of alcohol and drugs, firearms, and motor vehicles” (Plum, 2013). Loudoun County must address the way in which it collects its data to ensure its numbers and statistics are accurate and reflect the true diversity and health

needs of the community.

(“Loudoun county, Vvirginia,” 2009)

The traditional Hispanic diet generally consists of foods with less total fat and more fiber when compared to US diets, and, according to Mercado & Fileti (2010) Hispanics in their home country typically eat a variety of vegetables, starches, fruits, beans, seeds and nuts. “The quality of the Hispanic diet has been shown to decline as US habits are acquired,” (Mercado & Fileti, 2010). Because many Hispanics families also fall below the poverty line, they must resort to inexpensive food choices; Hispanic families often choose fast food, as a quick and inexpensive way to access food. According to Fryar & Ervin, Hispanics between the ages of 20 and 39 got 14.5% of their caloric intake from fast food (2013).

Loudoun County does not currently have any Hispanic or Latino supermarkets, limiting the availability of indigenous foods that Hispanic immigrants have access to. This forces the Hispanic citizens to acculturate quickly, especially if they are used to cooking with ingredients that are not found in the United States, or at least not in the local region.

The Office of Minority Health, an agency within the Centers for Disease Control and Prevention, has reported that socioeconomic factors, lifestyle behaviors, social environment, and access to preventive health-care services all work together to contribute to racial and ethnic health disparities. Education has been correlated with health risks, such as obesity, lack of physical activity, and smoking; furthermore, recent immigrants in general have an increased risk, according to the Office of Minority Health, “for chronic disease and injury, particularly those who

“JUST 40.7% OF HISPANICS SAID THEIR BLOOD PRESSURE WAS UNDER CONTROL”- Centers for Disease Control & Prevention

WHAT IS ACCULTURATION?

Mansfield, Peugh, Torres & Wells (2010) define acculturation as “the process by which individuals of one cultural group, typically a minority group, adapt their culture of origin to the

culture of another group.” This can affect “language preference, the adoption of attitudes, values, customs, beliefs, and behaviors of another culture” (Mansfield et al, 2010). As Doctor Goodfriend mentioned, (personal communication, July 2, 2013) Hispanics are acculturating very quickly and drastically into the Northern Virginia lifestyle, which is associated with “increased fat intake, decreased fiber intake and less physical activity,” leading to a potentially increased risk for chronic diseases (Dave et al, 2010). Loudoun County can assist the Hispanic community by assessing the degree in which families are acculturating and determining nutritional values and attitudes, while educating the Hispanic

population on proper nutrition and can offer community outreach programs to educate this population.

Health fairs can incorporate healthy eating tips for Hispanics, and volunteers and staff members of the Loudoun Free Clinic can be educated on foods common in Hispanic culture. Clinic staff must be trained on providing culturally sensitive care and, if possible, providers who are Spanish-speakers should be available to create

INADEQUATE NUTRITION & LANGUAGE AS BARRIERS TO CAREGwynn & Gwynn have found that the greatest nutritional concerns amongst Hispanics in the United States is related to “the excessive consumption of calories, probably accompanied by low physical activity” (n.d.). In particular, individuals immigrating from Mexico have been found to have higher deficiencies in vitamin A, folic acid, vitamin C, iron, and calcium (Gwynn & Gwynn, n.d.). The research has also shown that Hispanic women have a greater risk for obesity, write Gwynn & Gwynn (n.d.). Furthermore, studies have found that Mexican Americans are two to four times more likely to have non-insulin dependent diabetes, and are more likely to suffer from cardiovascular illness. The Centers for Disease Control and Prevention found that 26.1% of Hispanics in the United States have high blood pressure, and of this population, 30.4% are not “taking a medication that could reduce their risk for heart attack and stroke” (“Cardiovascular disease is,” 2013). The CDC has created educational resources to assist the Hispanic population in taking control of their heart health, which are available through the CDC and the “Million Hearts Campaign.” Unfortunately, many Spanish-speaking constituents would unlikely be able to visit the CDC’s website and access these publications

without the appropriate translation. Furthermore, much of the CDC’s advice encourages patients to speak with their primary care physicians about what kind of treatment plan should be put in place; if a Hispanic patient relies on a clinic for care, he or she probably has little time and many other immediate issues to attend to during these short and

focused meetings with the clinic physician or staff. There is also the issue of making this information available to these patients – are all of the staff at the free clinic aware of these educational materials? Are the clinic staff aware that they should be screening their patients for, diabetes, cardiovascular disease, and other comorbidities? If the staff is relying on the current numbers reported for which diseases are prevalent, they may miss some key health issues that a patient may not know about which to ask.Dr. Goodfriend admits that focus-groups that are aimed at addressing community health issues attract those who have a specific concern and minorities are often not represented (personal communication, July 2, 2013). Because many Hispanics do not speak English, they are not aware of these community meetings, cannot participate because of language barriers, or lack the knowledge to express their concerns at a town hearing. Clearly, the county needs to find a way to attract a broader range of citizens in the community, in addition to finding

ways to educate, in an effective and efficient way, Hispanic patients on healthy nutrition.

There are clearly many factors involved that contribute to health disparities among the Hispanic population, across

the United States, and in Loudoun County, Virginia. However, Loudoun County has many resources and there

are several ways the region can address the growing concern of health disparities among Hispanics in Northern

BARRIERS THAT CURRENTLY PREVENT HISPANIC RESIDENTS FROM APPROPRIATELY ACCESSING CARE, IN SUMMARY:

Loudoun County currently does not currently have an accurate way to collect data, ensuring that health concerns related to Hispanics are not represented truthfully, thereby eliminating the potential to address these concerns. This is due to financial and time constraints set by the Virginia Department of Health.

Because a large percentage of the Hispanics in Loudoun are recent immigrants, mortality reporting for recent years is more reflective of older citizens who lived in Loudoun County for many years, rather than for the younger Hispanic population.

Schools like Sugarland Elementary School in Sterling currently offer a Sheltered Instruction Observation Protocol (SIOP), an effective, innovative educational program designed to teach non-English students. Unfortunately, this is the only program of its type and there is little evidence to determine if lesson planning includes health education.

The Loudoun County Free Clinic has a limited number of staff and relies on volunteers for many of its services and may not be able to accommodate the rapidly growing Hispanic (and other minority) population in the near future.

Hispanics that are new to the area must acculturate quickly and change their diets drastically, leading to poorer health outcomes. There are currently no Hispanic or Latino food markets in Loudoun County.

There are several issues that currently need to be addressed in Loudoun County to ensure that

Hispanics’ health needs are appropriately identified by the local government, that students and their families are educated in making healthy choices, especially since they do not have access to the

same food choices as they did in their home country, and that the Loudoun County Free Clinic,

WHAT CAN BE DONE TO REDUCE DISPARITIES IN CARE FOR THE HISPANIC POPULATION IN LOUDOUN COUNTY: AN OVERVIEW.

The Virginia Department of Health must increase Loudoun County’s budget to allow them to collect data that truly reflects the area’s population. Doctor David Goodfriend reported that the town currently uses convenience samples at town hall meetings to determine residents’ perceived health issues in the county. Unfortunately, these meetings are not necessarily representative of the local population either. Using mail surveys and following up with a telephone call from a local representative can potentially bring in more responses. The local department of health must also translate these surveys into Spanish, so that Spanish-speaking residents can fully understand and participate in these surveys. Client perception surveys are beneficial because they offer “the capacity to elicit the views of numerous individuals, many of whom would not otherwise participate in the program evaluation process” (“Program evaluation and,” n.d.). The county could also utilize online resources, in both Spanish and English, to attract Internet users in the area.

Expanding the SIOP program to include other schools in the region to ensure that Hispanic children are proficient in English while also expanding the curriculum to include healthy eating and nutrition would begin this generation’s students on a path towards making good health choices, and would also allow them to take this information home to their parents and families. Including families through educational programs (such as seminars or groups after school or work hours) and teaching them similar information that the children learned would also bolster this knowledge.

The Loudoun County Free Clinic must determine how much longer it can sustain the number of citizens it serves, given the expected increase in population. Recruiting additional volunteers or hiring more paid staff may be necessary in the upcoming years to accommodate the growth of minority constituents in Loudoun County. Resources that the Centers for

The local government should consider offering incentives for citizens to open up Hispanic or Latino food markets. Another alternative is offering foods that are commonly sold in Hispanic countries in local Farmers Markets, which are numerous in Loudoun County.

Offering continuing education classes tailored specifically to the Hispanic population could teach families healthy alternatives to fast food and offer food suggestions that are similar to unavailable foods in the region.

Unfortunately, many of these possible solutions or ways in which to reduce health disparities in

Loudoun County will prove to be very expensive. For instance, convincing the Virginia Department of

Health to allocate additional funds for data collection is not an easy task, nor is expanding education programs for both students and their families.

However, given the rapidly expanding population, particularly among minorities, it is also clear that

keeping Loudoun County’s residents healthy should be a priority and is essential to preventing chronic illness and disease that will ultimately cost more than many of the preventative measures that are

listed above.

I met with Doctor David Goodfriend at his office on July 2, 2013. Doctor Goodfriend is the director of the Loudoun County Health Department, which is located in Leesburg. Dr. Goodfriend was incredibly friendly, open, and amenable to feedback and questions, and was happy to provide any information that was needed at this meeting.

Dr. Goodfriend started off by discussing what his office was responsible for. Loudoun County’s health department is state-run under the Virginia Department of Health, and there are several activities that the Loudoun County Department of Health is required to partake in. These include permitting and inspecting restaurants, permitting and inspecting pools, inspecting and approving wells and septic systems, attending to other town nuisances and complaints. Finally, the office is also responsible for signing death certificates and confirming that the deceased body is free of any communicable disease (personal communication, July 2, 2013).

Doctor Goodfriend also discussed the free clinic, also in Leesburg, which provided services to the lowest income individuals in Loudoun. As mentioned, the clinic provides dental services, family planning, STD screenings, services for tracking and preventing the spread of infectious disease, particularly tuberculosis and the flu. He said that generally, they had about twelve cases of TB each year (personal communication, July 2, 2013). Doctor Goodfriend discussed the importance of the clinic having a “surveillance role” through which they followed up on disease progression and assessed patients that had been seen (personal communication, July 2, 2013). He referred me to the Virginia Department of Health to get the specific results of the surveillances.

With regard to the office’s legislative action, Ddoctor Goodfriend did mention that they were very limited in what they could do; however, he did mention that if they felt something was a significant enough issue, they could send it up to the Virginia State Departments for discussion. He said that this happened rarely, but the county ordinance was able to “provide feedback upward” (personal communication, July 2, 2013).

One thing that the department was preparing for was the public health assessment, which I mention multiple times in my policy brief. During this assessment, the office uses present and prior statistics, focus groups, information from the Virginia Health Department, and information gathered that shows what the community believes are issues regarding health. As discussed, however, doctor Goodfriend said that this data was not collected in the most accurate of ways due to financial constraints, and within the 5000 or so responses that were received, there was an overwhelming majority of surveys from White females and mothers who were English speaking (personal communication, July 2, 2013). The data changed drastically, he said, because Loudoun was considered unstable and because immigrants were coming into the area rapidly, thereby ensuring that their voices were not being heard within these surveys or during focus groups or town hall meetings. Doctor Goodfriend identified that they were currently considering “how to incorporate statistics other than mortality and morbidity rates” (personal communication, July 2, 2013). However, it did not seem like the county was in a position to accurately collect data throughin any other means.

DOCTOR DAVID GOODFRIEND: A POTENTIAL ADVOCATE FOR THE COMMUNITY

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