1. 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

2. Presentation Outline Learning objectives
Needs assessment review of concepts and steps
Health disparities and Indicators
Analyzing farmworker health disparities using a needs assessment

3. Learning Objectives
Review steps used in conducting a health needs assessment.
Understand the concept of indicators and their importance in measuring disparities and assessing progress toward their elimination.
Apply the Behavioral Risk Factor Survey to conduct disparities research that targets the farmworker population.
The Michigan Behavioral Risk Factor Survey (MBRFS) is a statewide, random-digit dialed telephone survey of adult residents aged 18 years and older that collects information on health risk behaviors, preventive health practices, and health care access, primarily related to chronic disease and injury. Data from surveys have been combined recently to have a large enough sample to generate health indicators and risk estimates by community health assessment regions and local health departments. These developments now make it possible to compare these data to similar data collected for farmworkers in a particular local area, or to particular racial and ethnic groups. In 2004 and 2005, as part of the Oceana Farmworker Health Study, a farmworker health needs assessment was conducted by Michigan State University and Northwest Michigan Health Services Inc., who is a Migrant Health Center Program grantee. This session will involve the audience in a presentation seeking to inform the participants on the following issues: 1) describe the procedures used in conducting the needs assessment employed in the Oceana Farmworker Health Study (OFHS), 2) describe some of the findings of the study and 3) measure health disparities for this farmworker population by comparing the findings from the OFHS needs assessment to findings from the MBRFS. Among the health risk factors and conditions to be compared are : risk behaviors for chronic disease (such as cigarette smoking, fruit and vegetable intake),health status and selected chronic conditions (such as oral health, diabetes, high bold cholesterol, and hypertension) clinical preventive services (such as mammography and pap smear test, prostate cancer screening, and access to care).

4. 1. Needs Assessment
Introductory review of key concepts and implementation steps

5. 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)
They focus on the ends (i.e., outcomes) to be attained, rather than the means (i.e., process).

6. 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

7. 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.

8. 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
If health centers are intending to conduct a comprehensive needs assessment, directors are encourage to thinking in terms of a three phase comprehensive needs assessment procedure
Procure a project manager- the key person in planning and managing a needs assessment.
Form a Needs Assessment Committee that is representative of those organizations, and individuals critical to the study.. The active use of a Needs Assessment Committee is one important method for obtaining expert advice and gaining commitment to the process and using the results.
Determine a report schedule
Reach consensus on the goals (desired outcomes) of greatest importance to the target groups.
Refine the list of goals to the top 3-5 goals
Brainstorm a list of majro concerns/factors for each of the goals
Decide on the major concerns for each goal
Indentify indicators that could verify that the concern exists—An indicator is data that can verify that a concern exits
Determine what kind of information would be helpful to more clearly define the need and where to get the data.
Set the priorities of each concern as a focus on gathering if data. Project mapping can be use to provide a visiual map of all the conderns and indicators related to a goal.

9. Pre-assessment activities of a project
Organization
Assessment Instruments
Assurance of Human Rights
Selection of Interviewers
Training of Interviewers

10. 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
A target group is the focus on the needs assessment. Determine the scope of the needs assessment—eg. All the labor camps with migrants in the county? Determine target groups: for example , parents, seasonal, migrants, males, female workers,
A) Specify a desired outcome based on the program’s goals. B) Collect data to determine the current state of the target group in relation to the desired outcomes. C) Formulate needs statements based on discrepancies between current and desired outcomes.
List concerns (need areas) in rank order of importance and within each area of concern separately rank identified needs. To determine priorities of each need, examine both the difficulty to correct the need and the degree of criticality.
Determine general and specific causes of high priority needs. Ask: Why does this need persist? Identify the factors that are amenable to intervention with control of your program . Need-causes-consequences-difficulty to correct, criticality.
Summarize and document findings by need with an explanation of the major causes. Share the results with the Needs Assessment Committee, and other key stakeholders

11. 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
Step 1: Set Priorities of Needs
Criteria for assigning priorities among needs are based on several factors:
The magnitude of the discrepancies between current and target conditions;
Causes and contributing factors to needs;
The degree of difficulty in addressing the needs;
Risk assessment—the consequences of ignoring the needs;
The effect on other parts of the system or other needs if a specific need is or is not being met;
The cost of implementing solutions; and
Other factors that might affect efforts to solve the need
Step 2: Identify Possible Solutions
Set criteria ( or standards) for judging the merits of alternative solution strategies
Generate and examine potential solutions
What is---Possible Solutions---What Should be
Step 3. Select Solutions:
Evaluate and rate each solution separately against the evaluation criteria
Compare each solution and on the basis of all the information, select one or more solutions.
Step 4: Propose Action Plan
The plan should include description of the solutions, rtionale, proposed timelines, and resource requirements
Step 5: Prepare Report
At the end of this phase, the report should include : Description of the needs assessment process;
Major outcomes (identified needs);
Priority needs (and criteria used to determine such priorities)
Action Plan (with the data and criteria used to arrive at the solution strategies; and
Recommendaitons for future needs assesments.
Step 3. Select n

12. 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

13. 2. Measuring and Tracking Health Disparities through Health Indicators

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Types of common health indicators
Morbidity/Health Status
Health related quality of life-poor health days
Obesity-Body Mass Index
Diabetes, asthma, and other chronic diseases
Health Behaviors
Not smoking
Regular physical activity
Diet and nutrition
Access to Health Care
Insurance coverage
Regular sources of care
Receipt of preventive services
Physical and social environment
Area base measures, e.g., income, poverty, population density, housing, environmental pollution
Individual /family income, education, social supports
Health System Performance Indicators
Access (e.g., supply of providers, cultural barriers)
Costs (e.g., total health expenditures, prescription drug costs
Quality of care (e.g., effective care—e.g., receipt of recommended screening, treatment, readmission rates

21. Sources on Health Indicators
Publications: Health Indicators: A Review of Reports Currently in Use (July 2008)
Institute of Medicine Committee Report
Institute of Medicine, Health Indicators: a 4-Part Webinar Series

22. 3. Using State and National Comparison Data to Track Health Disparities

23. 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 (for a nationwide comparison)
REACH (for Hispanic/Latino nationwide comparison)
Michigan BRFSS (for a state-wide comparison)
The collection of indicator data from the sample of farmworkers used in the study reported here was part of a larger in-depth study that involved face-to-face structured interviews and a clinical exam administered at the County migrant health clinic. This study had a representative sample of adult migrant and seasonal, men and women agricultural workers in the area, age 18 years or older. The Hispanic farmworker population is estimated to be around 5,000 for the County. The total sample included 300 participants (n=180 migrant workers; n=120 seasonal workers).
The prevalence of risk factors, chronic conditions, and access to and use of preventive health care services was examined and stratified by migrant and seasonal farmworker status and gender. OFHS sample frequencies are presented in comparison to BRFSS and REACH data. The following indicators were analyzed: breast and cervical cancer, protrate cancer, diabetes, hypertension, cholesterol, obesity, nutrition, tobacco use, oral health, access to health care, education, and income.

24. 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
Rural area, labor market for agriculture and tourism (lake Michigan)
Existing industry is largely food processing, (freezing, canning and packing)
Farmworker estimate does not include family members, this estimate was derived from MSU University extension
RESEARCH SETTING:
Oceana County, population 26,873, is an important area for the production of labor intensive agriculture in Michigan and the nation. For nearly a century it has been an upstream destination for Mexican/Mexican Americans migrant workers from Texas and Mexico. In addition to the migrant farmworker component, the agricultural labor force in Oceana County has a significant seasonal farmworker component, comprised of local residents.

25. Local State Health Departments
Oceana County
is located in
district #10
Prepared by Chris Fussman
Finalized: August 4, 2009
Health Indicators and Risk Estimates by Community Health Assessment Regions & Local Health Departments
Michigan Behavioral Risk Factor Survey Combined
Selected Tables
Chronic Disease Epidemiology Section
Division of Genomics, Perinatal Health, and Chronic Disease Epidemiology
Bureau of Epidemiology
Michigan Department of Community Health

26. 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 Extension- Oceana 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

27. 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.

28. Determine target groups
Three strata
1. Migrants living in licensed labor camps
2. Migrants not living in licensed labor camps
3. Seasonal agricultural workers
Response postcards distributed
Target sample size: 300 (150 from strata 1, 50 strata 2, 100 strata 3)
Industries
Field/Orchard
Dairy/Livestock
Food Processing (Packing, Sorting)
Horticulture (Nurseries, Christmas Trees, Greenhouses)
Participants Individuals that self-identify as a migrant or seasonal agricultural worker age 18 or older and who were employed in agriculture for any length of time within the previous 12 months

29. 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

30. 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

31. 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

32. 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, non-licensed 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

33. Sample Characteristics
Migrant
(n= 180)
Seasonal
(n= 120)
Age-mean
35 years
34 years
Gender
59% Women
41% Men
63% Women
37% Men
Self-identify 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
Our study is unique in its ability to capture these two populations, which may need to be treated differently.
Later on in the presentation we will include national and statewide data for comparison purposes.

34. Sample Characteristics
Migrant (n=180)
Seasonal (n=120)
Marital
71% Married
68% Married
Median # of kids
2 children
Have HS Diploma
Women: 23%
Men: 20%
Women: 31%
Men: 17%
Preferred Reading Language
56% Spanish
14% English
30% Both
74% Spanish
6% English
20% Both
Median Family Income
$10,000 - $14,999
$10,000-$14,999
Women more often than men were more likely to have a h.s. diploma or h.s. equivalency (GED)
Seasonals were more likely to complete schooling in Mexico.
M W: 59% (n=101)
S W: 87% (n= 70)
M M: 65% (n=69)
SW: 81% (n= 42)

35. Results

36. Socio-Demographics and Access to Care

37. No Health Care Coverage
Source: OFHS Survey, National data from BRFSS 2000; State and District data from the Michigan BRFS
Note: Results are reported as percentages.
* Median %

38. Education
Source: OFHS Survey, National data from BRFSS 2000; National Hispanic/Latina data from REACH
Note: Results are reported as percentages.
* Median %

39. Annual Income
Source: OFHS Survey, National data from BRFSS 2000; National Hispanic/Latina data from REACH
Note: Results are reported as percentages.
* Median %

40. 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

41. Clinical Preventive Services

42. Mammography
Source: OFHS Survey; National data from BRFSS 2000, 2002; National Hispanic/Latina data from REACH ; State and District data from the Michigan BRFS
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

43. Pap Smear Test
Source: OFHS Survey; National data from BRFSS 2000; National Hispanic/Latina data from REACH ; State and District data from the Michigan BRFS
Note: Results are reported as percentages.
* Median %

44. Prostate Cancer Screening
Source: OFHS Survey; National data from BRFSS 2002; State and District data from the Michigan BRFS
Note: Results are reported as percentages. * Median %
^ State data is reported for a PSA in the last year for men 50+ years of age.

45. Oral Health Utilization
Source: OFHS Survey, National Hispanic/ Latino data from BRFSS 2002; State and District data from the Michigan BRFS
Note: Results are reported as percentages.
* Median %

46. 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.

47. Cardiovascular Disease Risk Factors

48. Diabetes % Responded “yes”
OFHS Survey; National Hispanic/ Latino data from REACH ; State and District data from the Michigan BRFS
Note: Results are reported as percentages.
* Median %

49. Cholesterol % Responded “yes”
Source: OFHS Survey; BRFSS 2001; REACH No state data to compare to.
Note: Results are reported as percentages.
* Median %

50. Hypertension % Responded “yes”
Source: OFHS Survey; BRFSS 2001; REACH No state data to compare to.
Note: Results are reported as percentages.
* Median %

51. Obesity
Source: OFHS Survey; National Hispanic/ Latino data from REACH ; State and District data from the Michigan BRFS
Note: Results are reported as percentages.
* Median %

52. Cigarette Smoking
Source: OFHS Survey; National Hispanic/ Latino data from REACH ; State and District data from the Michigan BRFS
Note: Results are reported as percentages.
* Median %

53. Daily Fruit and Vegetable Intake
Source: OFHS Survey; National Hispanic/ Latino data from REACH ; State and District data from the Michigan BRFS Note: Results are reported as percentages.
* Median %; ** More than 5 servings of fruits and vegetables a day

54. Summary of Results Chronic Disease Risk Factors Obesity
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
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.

55. 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.

56. 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.

57. 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.

58. Acknowledgements
Grant Number 25-P-91468/1-01 Center for Medicaid and Medicare, Hispanic Health Services Research Program, September 2001-September 2004
Julian Samora Research Institute and Department of CARRS, Michigan State university