1. 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

2. 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

3. My Journey

4. 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

5. The Immigrant Health Initiative Principal Investigators Dutchess County Department of Health Funders: Collaborators:

6. 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.

7. Study Design Target areas with high concentrations of immigrants – RuralEastern DutchessSample size 120-150 – UrbanCity of PoughkeepsieSample 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.

8. Demographics 290 immigrants entering US within 10 yrs – 141 (48.6%) RuralEastern Dutchess – 149 (51.4%) UrbanCity 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%

9. Region of Origin Characteristics TotalEastern DutchessPoughkeepsie p Value N = 290N = 141 (48.6%)N = 149 (51.4%) Region of Origin Mexico59.7%41.8%76.5% 0.000 Central America 26.9%47.5%7.4% 0.000 Guatemala23.8%46.1%2.7% South America 9.0%9.9%8.1% Caribbean3.1%0.0%6.0% Africa0.7%0.0%1.3% Asia0.7%

10. “No one has ever taken this much interest in my life and in my experiences. Thank you” Sara

11. Socio-Economic Characteristics Characteristics TotalEastern DutchessPoughkeepsie p Value N = 290N = 141 (48.6%)N = 149 (51.4%) Residence in U.S.< 1 year3.4% 3.5% 1-5 years52.4%46.3%58.9% 0.035 6-10 years44.1%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%

12. Seeking Healthcare Services

13. Accessing Health Care

14. Gender Differences in Seeking Health Care

15. 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).

16. 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

17. Barriers to Accessing Health Care Question TotalEastern DutchessPoughkeepsie p value N = 246N = 141N = 149 Difficulty getting to the doctor25.0%33.0%18.3%0.014 Reasons for difficultyN = 58N = 35N = 22 Transportation70.2%97.1%17.1%0.000 Getting time off from work15.8%8.6%17.1% Miscellaneous29.8%8.6%39.0%

18. 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

19. Factors Influencing Choice of Healthcare Providers TotalEastern DutchessPoughkeepsie p value N = 233N = 109N = 137 Speak my language37.3%45.0%27.7%0.007 Like the way I am treated36.9%35.8%34.3% Affordable29.2%21.1%32.8%0.045 Most convenient25.8%38.5%13.1%0.000 Only one I know of18.9%13.8%21.2% Does not require documentation16.3%25.7%7.3%0.000 Other8.6%7.3%10.2%

20. Reported Health Problems in Country of Origin and in U.S. Total Population (N = 290) p Value Country of OriginU.S. Hypertension7.6%11.0% Diabetes2.8%6.2% Heart disease2.1%2.4% Cancer0.0%0.7% Sexually transmitted diseases (STD)0.7%2.8% HIV0.0% Depression9.7%18.3%p = 0.004

21. 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%).

22. 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

23. Reasons for Sadness and Depression

24. Practice Kinship Circles of Support Principal Investigator

25. 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.”

26. 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.

27. Kinship Circles of Support Group

28. Topics of Discussion Importance of accessing health care for the entire family Nutrition and healthy eating Chronic disease prevention Stress reduction techniques Lifestyle changes

29. 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.

30. 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

31. Healthcare Centers Number of Hispanic Patients Served 2009Last 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%)

32. 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.

33. Lessons Learned

34. 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.