Using a Needs Assessment to Measure Farmworker Health Disparities: A Michigan Case

Rene P. Rosenbaum, PhDSheila F. LaHousse, PhD

November, 201020th Annual Midwest Stream Farmworker Health Forum Austin, TX

Presentation Outline

• Learning objectives• Needs assessment review of concepts and

steps• Health disparities and Indicators• Analyzing farmworker health disparities using

a needs assessment

Learning Objectives

1. Review steps used in conducting a health needs assessment.

2. Understand the concept of indicators and their importance in measuring disparities and assessing progress toward their elimination.

3. Apply the Behavioral Risk Factor Survey to conduct disparities research that targets the farmworker population.

1. Needs Assessment

Introductory review of key concepts and implementation steps

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)

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

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.

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 indicatorOutcome: Preliminary plan for data collection in Phase 2

Pre-assessment activities of a project

OrganizationAssessment InstrumentsAssurance of Human RightsSelection of InterviewersTraining of Interviewers

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 FindingsOutcome: Criteria for action based on high-priority needs

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

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

2. Measuring and Tracking

Health Disparities through Health Indicators

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

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

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

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 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

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

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

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

Sources on Health Indicators

• Publications: Health Indicators: A Review of Reports Currently in Use (July 2008) www.cherylwold.com

• Institute of Medicine Committee Reporthttp://iom.edu/Reports/2008/State-of-the-USA-

Health-Indicators-Letter-Report.aspx• Institute of Medicine, Health Indicators: a 4-Part

Webinar Series http://www.nlm.nih.gov/nichsr/healthindicators/

3. Using State and National

Comparison Data to Track Health Disparities

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 2000 (for a nationwide comparison) – REACH 2001-2002 (for Hispanic/Latino nationwide

comparison)– Michigan BRFSS 2006-2008 (for a state-wide comparison)

SettingOceana 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

Local State Health Departments

Oceana County is located in district #10

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

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.

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

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

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

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

Sample ProcedureData 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 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

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

Sample Characteristics Migrant (n=180) Seasonal (n=120)

Marital 71% Married 68% Married

Median # of kids

2 children 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

Results

Socio-Demographics and Access to Care

No Health Care Coverage

Source: OFHS Survey, National data from BRFSS 2000; State and District data from the Michigan BRFS 2006-2008Note: Results are reported as percentages.* Median %

Education

Source: OFHS Survey, National data from BRFSS 2000; National Hispanic/Latina data from REACH 2001-2002Note: Results are reported as percentages.* Median %

Annual Income

Source: OFHS Survey, National data from BRFSS 2000; National Hispanic/Latina data from REACH 2001-2002Note: Results are reported as percentages.* Median %

Summary of ResultsSocio-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

Clinical Preventive Services

Mammography

Source: OFHS Survey; National data from BRFSS 2000, 2002; National Hispanic/Latina data from REACH 2001-2002; State and District data from the Michigan BRFS 2006-2008Note: Results are reported as percentages.*Median %; ^ % who received mammogram in past 2 years^^ % who received mammogram and a clinical breast exam in past year

Pap Smear Test

Source: OFHS Survey; National data from BRFSS 2000; National Hispanic/Latina data from REACH 2001-2002; State and District data from the Michigan BRFS 2006-2008Note: Results are reported as percentages.* Median %

Prostate Cancer Screening

Source: OFHS Survey; National data from BRFSS 2002; State and District data from the Michigan BRFS 2006-2008Note: Results are reported as percentages. * Median %^ State data is reported for a PSA in the last year for men 50+ years of age.

Oral Health Utilization

Source: OFHS Survey, National Hispanic/ Latino data from BRFSS 2002; State and District data from the Michigan BRFS 2006-2008. Note: Results are reported as percentages.* Median %

Summary of ResultsClinical 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.

Cardiovascular Disease Risk Factors

Diabetes

OFHS Survey; National Hispanic/ Latino data from REACH 2001-2002; State and District data from the Michigan BRFS 2006-2008. Note: Results are reported as percentages.* Median %

% Responded “yes”

Cholesterol

Source: OFHS Survey; BRFSS 2001; REACH 2001-2002. No state data to compare to.Note: Results are reported as percentages.* Median %

% Responded “yes”

Hypertension

Source: OFHS Survey; BRFSS 2001; REACH 2001-2002. No state data to compare to.Note: Results are reported as percentages. * Median %

% Responded “yes”

Obesity

Source: OFHS Survey; National Hispanic/ Latino data from REACH 2001-2002; State and District data from the Michigan BRFS 2006-2008. Note: Results are reported as percentages.* Median %

Cigarette Smoking

Source: OFHS Survey; National Hispanic/ Latino data from REACH 2001-2002; State and District data from the Michigan BRFS 2006-2008.Note: Results are reported as percentages.* Median %

Daily Fruit and Vegetable Intake

Source: OFHS Survey; National Hispanic/ Latino data from REACH 2001-2002; State and District data from the Michigan BRFS 2006-2008. Note: Results are reported as percentages.* Median %; ** More than 5 servings of fruits and vegetables a day

Summary of ResultsChronic 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.

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.

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.

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.

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