Presentation on theme: "Rene P. Rosenbaum, PhD Sheila F. LaHousse, PhD November, 2010"— Presentation transcript:
1 Using a Needs Assessment to Measure Farmworker Health Disparities: A Michigan Case Rene P. Rosenbaum, PhDSheila F. LaHousse, PhDNovember, 201020th Annual Midwest Stream Farmworker Health ForumAustin, TX
2 Presentation Outline Learning objectives Needs assessment review of concepts and stepsHealth disparities and IndicatorsAnalyzing farmworker health disparities using a needs assessment
3 Learning ObjectivesReview 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 AssessmentIntroductory review of key concepts and implementation steps
5 Key ConceptsA “need” is a discrepancy or gap between “what is” and “what should be.”Desired state minus Current state =Need100% 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 ConceptsA 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 ConceptsThere 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 assessmentStep 2-Identify major concerns or factors–focus on desired outcomesStep 3- Develop measurable need indicators in each area of concernStep 4- Consider data sourcesStep 5 Decide on preliminary priorities for each needs indicatorOutcome: Preliminary plan for data collection in Phase 2If health centers are intending to conduct a comprehensive needs assessment, directors are encourage to thinking in terms of a three phase comprehensive needs assessment procedureProcure 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 scheduleReach consensus on the goals (desired outcomes) of greatest importance to the target groups.Refine the list of goals to the top 3-5 goalsBrainstorm a list of majro concerns/factors for each of the goalsDecide on the major concerns for each goalIndentify indicators that could verify that the concern exists—An indicator is data that can verify that a concern exitsDetermine 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 OrganizationAssessment InstrumentsAssurance of Human RightsSelection of InterviewersTraining of Interviewers
10 Steps in Phase II-data gathering & analysis Step 1- Determine target groupsStep 2- Gather data to define needs (to formulate needs statements)Step 3- Prioritize Needs-Based on dataStep 4- Identify & analyze causesStep 5- Summarize FindingsOutcome: Criteria for action based on high-priority needsA 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 needsStep 2- Identify and evaluate possible solutionsStep 3- Select one or more solutionsStep 4- Propose action Plan to implement solutionsStep 5- Prepare written reports and oral briefings to communicate the methods and results of the needs assessmentOutcome: Action plan(s), written and oral briefings, and final reportStep 1: Set Priorities of NeedsCriteria 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; andOther factors that might affect efforts to solve the needStep 2: Identify Possible SolutionsSet criteria ( or standards) for judging the merits of alternative solution strategiesGenerate and examine potential solutionsWhat is---Possible Solutions---What Should beStep 3. Select Solutions:Evaluate and rate each solution separately against the evaluation criteriaCompare each solution and on the basis of all the information, select one or more solutions.Step 4: Propose Action PlanThe plan should include description of the solutions, rtionale, proposed timelines, and resource requirementsStep 5: Prepare ReportAt 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; andRecommendaitons for future needs assesments.Step 3. Selectn
12 Summary There is no one correct needs assessment model or procedure Make sure needs focus on desired outcomesInvestigate what is known about the needs of the target groupDevelop measurable needs indicators to guide the data collection processPerform a causal analysis to understand why the needs existsPropose an action plan to implement solutionsPrepare 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.Indicatorsverify that a concern exists (baseline)measure progress and achievements; they provide early warning signals when thing go wrongsupport 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 groupWhen the magnitude of the disparities by specific groups is measured by examining rates across comparison groupsTrends in disparitiesWhen 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 clearMeasureable-change is objectively verifiableAchievable (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 levelState 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 SystemSurveys (Behavioral Risk Factor Survey, Nutrition Examination Survey, local surveys, etc.)Disease surveillance systemsHealth services administration dataOther
20 Types of common health indicators Morbidity/Health StatusHealth related quality of life-poor health daysObesity-Body Mass IndexDiabetes, asthma, and other chronic diseasesHealth BehaviorsNot smokingRegular physical activityDiet and nutritionAccess to Health CareInsurance coverageRegular sources of careReceipt of preventive servicesPhysical and social environmentArea base measures, e.g., income, poverty, population density, housing, environmental pollutionIndividual /family income, education, social supportsHealth System Performance IndicatorsAccess (e.g., supply of providers, cultural barriers)Costs (e.g., total health expenditures, prescription drug costsQuality 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 ReportInstitute 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 MichiganAnnual agricultural crop production valued at $39 milPopulation 26,873 (2000 Census)County 11% HispanicState = 3% Hispanic5,400 ≈ farmworkersRural 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 extensionRESEARCH 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 Countyis located indistrict #10Prepared by Chris FussmanFinalized: August 4, 2009Health Indicators and Risk Estimates by Community Health Assessment Regions & Local Health DepartmentsMichigan Behavioral Risk Factor Survey CombinedSelected TablesChronic Disease Epidemiology SectionDivision of Genomics, Perinatal Health, and Chronic Disease EpidemiologyBureau of EpidemiologyMichigan Department of Community Health
26 Create a Needs Assessment Committee Project PartnersMichigan State University (PI)Northwest Michigan Health Services, Inc.Migrant Health Clinic (Shelby)Project CollaboratorsFamily Independence Agency in Oceana CountyWest Michigan Mental Health SystemMichigan State University Extension- Oceana CountyTelamon Corporation, Inc.- Migrant Head StartMichigan Department of Career DevelopmentInterviewers & VolunteersFamily Independence AgencyWest Michigan Mental Health SystemWomen, Infants & Children ProgramPlanned Parenthood ClinicLocal 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 strata1. Migrants living in licensed labor camps2. Migrants not living in licensed labor camps3. Seasonal agricultural workersResponse postcards distributedTarget sample size: 300 (150 from strata 1, 50 strata 2, 100 strata 3)IndustriesField/OrchardDairy/LivestockFood 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 SystemProcedures 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 compositionPersonal demographicsHealth Services UtilizationSelf-Reported Health ConditionsDoctor-Reported Health ConditionsWork HistoryIncome and Living ConditionsWorkplace Health ConditionsField SanitationWork Related InjuriesBehavior Risk Assessment
32 Sample Procedure Data Collection Procedure: a representative sample of 300 randomly selected agricultural workers ages 18 or older over a three-year periodThree strata: licensed labor camp migrants, non-licensed labor camp migrants, and seasonal workersMultistage stratified random sample of workers2-2.5 hours long interviews followed by a referral to the local migrant health clinic for a physical examinationAccuracy and completeness of interview and physical exam data checked and rechecked
33 Sample Characteristics Migrant(n= 180)Seasonal(n= 120)Age-mean35 years34 yearsGender59% Women41% Men63% Women37% MenSelf-identify as:51% Mexican35% Hispanic8% Mexican American2% Chicano(a)2% Latino(a)3% Other63% Mexican25% Hispanic4% Mexican American0% Chicano(a)3% Latino(a)6% OtherOur 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)Marital71% Married68% MarriedMedian # of kids2 childrenHave HS DiplomaWomen: 23%Men: 20%Women: 31%Men: 17%Preferred Reading Language56% Spanish14% English30% Both74% Spanish6% English20% BothMedian Family Income$10,000 - $14,999$10,000-$14,999Women 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)
37 No Health Care Coverage Source: OFHS Survey, National data from BRFSS 2000; State and District data from the Michigan BRFSNote: Results are reported as percentages.* Median %
38 EducationSource: OFHS Survey, National data from BRFSS 2000; National Hispanic/Latina data from REACHNote: Results are reported as percentages.* Median %
39 Annual IncomeSource: OFHS Survey, National data from BRFSS 2000; National Hispanic/Latina data from REACHNote: 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
42 MammographySource: OFHS Survey; National data from BRFSS 2000, 2002; National Hispanic/Latina data from REACH ; State and District data from the Michigan BRFSNote: 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 TestSource: OFHS Survey; National data from BRFSS 2000; National Hispanic/Latina data from REACH ; State and District data from the Michigan BRFSNote: 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 BRFSNote: 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 BRFSNote: 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 TestBoth seasonal and migrant women 18+ are getting pap tests comparable to national average in 2001.Prostate Cancer ScreeningA lower percentage of FW men compared to BRFSS men nationally reported having had a PSA test within the past two years.Oral HealthCompared 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.
48 Diabetes % Responded “yes” OFHS Survey; National Hispanic/ Latino data from REACH ; State and District data from the Michigan BRFSNote: 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 ObesitySource: OFHS Survey; National Hispanic/ Latino data from REACH ; State and District data from the Michigan BRFSNote: Results are reported as percentages.* Median %
52 Cigarette SmokingSource: OFHS Survey; National Hispanic/ Latino data from REACH ; State and District data from the Michigan BRFSNote: 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 SmokingCigarette 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 IntakeCompared 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 FactorsDiabetesMore 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.CholesterolThe 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.HypertensionThe 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 SignificanceOFHS 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 ImplicationsBased on the OFHS findings on FW health disparities the following public health research areas should be given priority:Obesity preventionDiabetes awarenessIncrease access to adequate health care coverageIncreasing access to healthy foodIncreasing access to dental services for menTobacco use for menProstrate cancer screening for men 40+Health disparity research is needed to track health status and improvements in the health of America’s FW.
58 AcknowledgementsGrant Number 25-P-91468/1-01 Center for Medicaid and Medicare, Hispanic Health Services Research Program, September 2001-September 2004Julian Samora Research Institute and Department of CARRS, Michigan State university