Volume 19, Issue 1Spring 2013

The Migrant Health News SourcestreamlineOne of the most persistent struggles

encountered by Health Center Programgrantees is the effort to find and keep goodclinicians. In working with grantees, MigrantClinicians Network hears concerns about thedifficulty of attracting well-trained clinicianswho are compassionate and passionate. Wealso monitor trends that contribute to thechallenges of recruitment and retention ofprimary care clinicians. MCN has developedtools and resources that support grantees in

maintaining their clinician staffing goals. Thisarticle discusses current challenges andstrategies in clinician recruitment and reten-tion, highlighting valuable resources that canbe used by health center program grantees.

THE CHALLENGEWhile many clinicians actively seek workwith underserved patient populations, it canbe difficult to recruit to a setting that isremote, understaffed, and clinically challeng-

ing. HRSA-funded health centers have alwayscompeted with hospital systems, privatepractices, training programs and other set-tings to attract clinicians to their locations.Other factors in the ever-changing health-care landscape which contribute to persist-ent clinician vacancies include the following:• Some research points to increased vacan-

cies for physicians, nurse practitioners,

Where have all the clinicians gone?Candace Kugel, FNP, CNM, MS

continued on page 5

2 MCN Streamline

Since 1990 MCN has developed a strongfoundation of work in family violence pre-

vention. Early programs focused on educat-ing and empowering women to confrontthis issue. Materials for clinicians to use inscreening for domestic violence and identify-ing services for women who may be in dan-ger were also developed by MCN. After anumber of years in this field, it becameapparent that there was a paucity ofresources for working directly with migrantmen to prevent violence.

Beginning in 2005, MCN discovered,through field research with migrant men atvarious locations throughout the UnitedStates, that approximately 60% thoughtrape was a big problem in their communityand 67% thought partner abuse was a bigproblem; 77% of the men surveyed statedthey would like to help prevent rape andpartner abuse in their community.1

Over the next year MCN worked withexperts across the country to design anintervention strategy specifically targetingmigrant men. The intervention, calledHombres Unidos Contra la Violencia Familiar(Men United Against Family Violence), wasdesigned to address factors that most oftenaffect this population, including: language,literacy, cultural protective factors andimportantly, the risks that victims face.

Unlike many family violence interventionsdirected at men, MCN decided to focus onviolence prevention among men who werenot known to have engaged in violent acts.This approach, known as “primary preven-tion,” is able to impact the focus populationbefore violence occurs. Most programs avail-able to Latino migrant men are offered asbatterer intervention programs through thejudicial system or through other secondaryand tertiary methods. Hombres Unidos pro-vides a safe space for men to talk about vio-lence prevention before it is known as a seri-ous issue.

Hombres Unidos is an interventiondesigned for Latino migrant men over theage of 17. It focuses on the Latino migrantand recent immigrant population becausethis population represents the most sociallyisolated group of Latinos in the UnitedStates. Latino migrant men face considerablesocial and cultural isolation due to languagebarriers, economic limitations, and immigra-tion concerns. Aside from poverty being apredominant characteristic, a majority of thispopulation is foreign born. These men are

adapting to a migration (mobile) lifestyle aswell as trying to assimilate into a U.S.lifestyle. This suggests that many internalizednorms and values from their countries of ori-gin persist while in this country, such asmale-dominated relationships, and thesocialization that women accept or tolerateabuse as a form of male privilege and thatabuse is thus not recognized as a grave act.2

Hombres Unidos was designed through anintensive collaboration among experts in theSexual and Intimate Partner Violence (S/IPV)field that included victims’ services organiza-tions and MCN. This collaborative body,known as the Hombres Unidos LeadershipConsortium, participated in a literaturereview, program design and development,and an evaluation process. While S/IPV proj-ects often focus on services to those whohave been violated, the Hombres UnidosContra la Violencia Familiar project wasdesigned to incorporate the presumptionthat program participants have no history ofviolence in familial or intimate partner rela-tionships. This presumption allows the mento keep their focus on building a positiveview of masculinity and gaining a positivesocial identity amongst their peers as non-perpetrators and worthy contributors and

leaders in their community. Participants arenot criticized or shamed for long-held beliefsor past behaviors regarding domestic rela-tionships, which helps to create the safespace instrumental to group dialogue.

PROGRAM DESIGN:Hombres Unidos is a five-session primary pre-vention intervention. Through effective part-nerships and community organizing,Hombres Unidos engages Latino migrant menin group dialogue, facilitated by their peers,to learn about S/IPV together. By using apeer educational approach wherein Latinomales explore knowledge, attitudes, behav-iors, and beliefs (KABB) about intimate part-ner violence (IPV) and define healthy rela-tionships through group dialogue, partici-pants take ownership of the issue them-selves, gain the skills and vocabulary toencourage others to develop healthy rela-tionships, and become advocates againstIPV. The Hombres Unidos curriculum is theresult of a five-year program focused onPreventing Sexual and Intimate PartnerViolence within Racial/Ethnic MinorityCommunities, initiated by the Centers for

Hombres Unidos Provides Critical Primary Prevention ServicesAdrian Velasquez; Candace Kugel, CRNP, CNM; Jillian Hopewell, MPA, MA and Deliana Garcia, MA

continued on page 3

MCN Streamline 3

Disease Control and Prevention. Men are recruited to the program by

male health promotores (community healthworkers). These promotores are familiar withthe local population and are known in theircommunities for their knowledge of educa-tion on other health issues. Viewed as peersand community members, the promotoresrecruit 10-15 men per workshop. Taking thegeographic and social isolation of Latinomigrant men into consideration, the pro-gram usually takes place in participant livingquarters or community gathering areaswhere access to the location is easy and reli-able transportation is not needed.Confidentiality is discussed and agreed uponand ‘house rules’ established to create anappropriate environment for emotionallycharged topics. Participant retention isencouraged by having the workshop partici-pants decide upon a meeting time.

Hombres Unidos was developed to incor-porate protective factors against violenceperpetration present within the Latino cul-ture. Hoffman3 cites many of them, includ-ing placing family needs above one’s own,cooperating with others through teamwork,respecting authority figures, and valuinginterpersonal relationships more than materi-al gain or status. Hombres Unidos goesbeyond this, incorporating language and lit-eracy considerations in its design. It is dia-logue-based with few printed materials.Literacy is not presumed. The printed mate-rials, including evaluation tools, incorporateimages and color schemes to minimize anydiscomfort by low-literacy participants.

Participation in Hombres Unidos is offeredto Latino migrant men of any sexual orienta-tion. The content of the curriculum and thediscussion environment allow groups to haveunrestricted discussions about any intimatepartner relationship. Confidentiality agree-ments and house rules agreed to by all par-ticipating group members facilitate a safespace for open discussion without the pres-sure of disclosing relationship status.

Each session lasts two hours, with activi-ties and discussion in which each participanthas the opportunity to contribute. Each par-ticipant attends every session and is given acertificate for completion during the fifthsession as well as a small gift (usually a $10gift card) to celebrate his achievement withfamily members.

Each session presents new topics andinformation for the participants. Session onebroadly covers the topic, “MaleSocialization.” During session two, “DefiningViolence and Abuse,” men discuss differentforms of violence. Session three, “Power andViolence,” guides the men in understandingthe role that power, or the lack of power,

has in contributing to violence and abuse.During session four, “Developing Tools andSkills to Prevent and Respond to Violence,”each participant collaborates with his fellowworkshop participants to develop techniquesto prevent violence at a personal level andwithin their community. For session five,“Promise & Celebration,” participants areasked to invite guests to celebrate their com-pletion of the workshop. During this finalsession, men are asked to make a publicpromise to not condone or tolerate violencein their community.

CREATING THE PROGRAM: The initial development of the programoperated on the presumption that menwould be unwilling to engage in a frank dis-cussion of interpersonal behavior. A secondpotential barrier was the expectation that itwould be difficult to find male promotores desalud willing and able to engage peers onthese issues while retaining the participantsfor five sessions. To address both of thesepotential barriers, MCN selected project sitesthat had functional male promotores alreadyrecognized and trusted by the men of thecommunity and who had basic training inhealth promotion and group education. Thisstrategy allowed the program to focus oncontent and evaluation. Small incentives forparticipation were offered (snacks during thesessions and a $10 phone card for comple-tion).

Funding from the Centers for DiseaseControl and Prevention (CDC) in 2005 made initial implementation possible. Threelocations capable of field testing the malepromotores training model were identifiedand selected as implementation sites forHombres Unidos. Staff from these sitesformed an Advisory Council to inform staffand the Leadership Consortium about therealities of the program occurring on-site.The sites identified local resources for in-kind gifts of space and equipment as well as sources for snacks and beverages for participants.

After the initial launch, ongoing implemen-tation has been made possible by supportfrom the Office on Violence Against Womenand by organizations that approached MCNfor replication. The most current iteration ofthe curriculum is being implemented in NewMexico, Pennsylvania, Texas and Washington.Further collaborations are part of MCN’sstrategic communications plan and fundingsources are being sought for expanded cur-riculum implementation.

EVALUATIONMCN has used several methods to evaluatethe intervention and outcomes using both

process and outcomes evaluation. In 2010,the Robert Wood Johnson Foundation selectedHombres Unidos for RWJ’s “StrengtheningWhat Works Initiative,” to strengthen the eval-uation of program activities that focus on pre-vention of intimate partner violence in immi-grant and refugee communities in the UnitedStates. MCN has improved the evaluationcapacity of the Hombres Unidos curriculumand has a strong understanding of the suc-cesses as measured by quantitative and quali-tative data.

After every session, facilitators fill out afacilitator survey form. This analysis tool pro-vides an understanding of participantinvolvement during each activity. Facilitatorsare asked to identify and describe activitiesthat were the most and least successful.Observations on participant behavior andbehavioral change are also measured usingthis survey.

A pre- and post-session survey instrumentis incorporated as an activity during the firstand fourth sessions. The survey is read aloudto the participants as literacy levels areunknown and not assumed. Participantsmark their responses on individual surveysusing color schemes to assist with possibleliteracy limitations. For example, the answeroptions are a green oval marked “Yes” foragreement and a red oval marked “No” fordisagreement in response to the idea or situ-ation that is read to them. Using this level ofevaluation, MCN is able to analyze andmeasure changes in participants’ KABB.From 2007 to 2010, each workshop reflect-ed statistically significant KABB change in thepositive direction for participants. From theoriginal 12-question survey one questionasked “If your friend was hitting his partner,would you tell him that this was unaccept-able behavior?” Out of 309 overall partici-pants, 56.63% said that they would inter-vene when surveyed prior to participating inHombres Unidos, while 79.29% said theywould speak up after the Hombres Unidosintervention, demonstrating significantchange.

Beginning in 2012, MCN conducted fol-low-up interviews in which MCN spoke withprevious workshop participants, facilitatorsand facilitator supervisors. During one ofthose interviews, Susan Bauer, the ExecutiveDirector at Community Health Partners inIllinois, a 2007-2010 implementation site,stated, “One of our current Board members wasa facilitator for Hombres Unidos when he was apromotor. He would always talk about howtransformational it was. Not just for the partici-pants but for him. It’s such a great program!”

Sandra Ortsman at Enlace Comunitario in

n Hombres Unidos Provides Critical Primary Prevention Services continued from page 2

continued on page 7

4 MCN Streamline

On June 15, 2012, the Obama administra-tion announced an initiative known as

Deferred Action for Childhood Arrivals(DACA). Deferred action will give certainundocumented youth temporary permissionto remain in the United States for two yearsand to apply for work authorization.Although it neither provides a path to citi-zenship nor confers legal status, DACA canhave a positive impact on access to health-care for eligible farmworker youth.

Who is eligible for DACA?1

Not all undocumented youth are eligible forDACA. Applicants must be at least 15 yearsold (with an exception for youth who are indeportation proceedings or have a removalorder), have arrived in the U.S. before theyturned 16 years old, and be under age 31 asof June 15, 2012. They also need to haveresided in the U.S. continuously for the fiveyears prior to June 15, 2012, and mustundergo a background check. In addition,applicants must either meet an educationrequirement (have graduated or obtained acertificate of completion from high school;obtained a GED; or currently be in school,which includes traditional secondary andpost-secondary education and adult educa-tion and vocational education) or be “anhonorably discharged veteran of the CoastGuard or Armed Forces of the UnitedStates.”

How will it impact access to healthcare?In general, DACA will positively impact farm-workers’ access to healthcare. Immigrantsgranted deferred action, who previouslyavoided medical care due to their fear ofrevealing their undocumented status or fearof detention by law enforcement, may nowbe more willing to access healthcare foremergency or preventative care. Also, withvalid work authorization and without thethreat of deportation looming over them,farmworkers will be better able to avoid dan-gerous living and working conditions whichcontribute to poor health outcomes.

On August 30, 2012, shortly after the USCitizenship and Immigration Services(USCIS) began accepting applications forDACA, the US Department of Health andHuman Services announced that DACArecipients will not be eligible for enrollmentin Medicaid/CHIP or the Pre-ExistingConditions Insurance Program (PCIP),2 thetemporary government sponsored high riskinsurance pool. Because DACA recipients arenot eligible for PCIP, they will not be eligibleto enroll in the state health insurance

exchanges in 2014. DACA recipients are alsonot eligible for Medicaid/CHIP coverageunder CHIPRA (Child Health InsuranceProgram Reauthorization Act of 2009),which allows states to provide coverage toexpanded categories of children and/orpregnant women.3 Due to these limitationsin insurance coverage, those granteddeferred action may continue to rely onhealth care providers who serve the unin-sured as a primary source of preventativehealthcare.

DACA and farmworkersWhile the impact of DACA on farmworkers isnot yet fully known, data from the NationalAgricultural Workers Survey suggest that anestimated 54,000 farmworkers could poten-tially qualify.4 Even though many farmwork-ers have heard about DACA, there is a lot ofmisinformation about application costs andthe application process itself. There are sev-eral challenges that may deter eligible farm-workers and their family members fromapplying for deferred action under DACA.• Proof of Continuous Residency: As part of

the application process, applicants mustshow that they have continuously residedin the US from June 15, 2007 to June 15,2012. Although USCIS states that anapplicant does not need to show proof forevery month, obtaining documentedproof for a five year period can provechallenging for farmworkers who maymigrate with the harvest and have a limit-ed paper trail.

• Education: The education requirement ofDACA may be difficult for many farm-workers to achieve. Despite migrant edu-cation programs, farmworkers often lackaccess to educational resources. Frequent

mobility, high poverty levels, and limitedEnglish proficiency as well as the limitednumber of adult education programs inrural areas make it difficult for farmwork-ers to obtain the minimum educationrequirements of a high school diploma orGED certificate.

• Cost of Application: The $465 fee for theDACA and work permit application is a sig-nificant financial investment for many farm-workers and their families. Few fee exemp-tions will be granted to applicants. To quali-fy for a fee exemption, the applicant musthave an income less than 150% of the fed-eral poverty level AND either (a) be underage 18 and homeless or without parentalsupport, (b) have accrued $25,000 in med-ical expenses during the last year, or (c)have a serious chronic disability.

For more information about Deferred Actionfor Childhood Arrivals, please contact AlexisGuild at aguild@farmworkerjustice.org. Youcan also visit the websites of U.S. Citizenshipand Immigration Services at www.uscis.gov/childhoodarrivals or Farmworker Justice atwww.farmworkerjustice.org. n

References1. For more information, see USCIS: Consideration

of Deferred Action for Childhood Arrivals –Frequently Asked Questions. www.uscis.gov/childhoodarrivals

2. CMS–9995–IFC2, Federal Register, Vol, 77, No. 169.http://www.gpo.gov/fdsys/pkg/FR-2012-08-30/pdf/2012-21519.pdf

3. CMS letter to State Health Officials, August 28,2012. http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-12-002.pdf

4. Gosia Wozniacka, DACA Can Help Low-WageWorkers Too, Not Just Students, Huffington Post,August 25, 2012. http://www.huffingtonpost.com/2012/08/25/daca-low-wage-workers_n_1830243.html

Access to Healthcare for Immigrant YouthAlexis Guild, Farmworker Justice

Photo co

urtesy of E

arl D

otter

MCN Streamline 5

physician assistants and nurses as a resultof the expansion of health centers underthe Affordable Care Act.1 Estimates arethat the expansion of healthcare servicesunder the Affordable Care Act has createda 38% increase in the need for primarycare physicians from 2000 to 2020.2

• The supply of primary care providers inthe United States, especially physicians,grows more limited as increasing numbersof specialists are trained.3, 4

• Primary care providers typically do not stayin the same position for the long term, sothat staff turnover creates a need for healthcenters to be constantly recruiting.

RECRUITMENT AND RETENTION RESOURCESWhile the real solutions to these challengesmay lie beyond the domain of the individualgrantee, their pressing task is providing services to a vulnerable and underservedpopulation. To assist with that objective, following is a collection of resources andstrategies that are new, recently revised ortime-honored.

Recruitment and Retention Planning Tools:Recruitment and retention of clinicians istypically overseen by the organization’s Chief Medical Officer (CMO), with the assis-tance of the Chief Executive Officer (CEO),Human Resources Department and others.The Board of Directors needs to be keptinformed of clinical staffing needs and plans.• Start by taking MCN’s online Recruitment

and Retention Self-Assessment Survey athttp://www.migrantclinician.org/survey/fillsurvey.php?sid=4. This brief question-naire, revised in 2012, serves as a quickself-assessment for health center leader-ship to determine readiness for effectiverecruitment and retention of clinical staffand provides a score indicating the levelof preparation.

• For more in-depth planning, use the MCNRecruitment and Retention Review Tool,online at http://www.migrantclinician.org/files/MCN-R&Rreviewtool_2012_0.pdf.This recently revised tool provides aroadmap for evaluating aspects of theorganization that relate to clinicianrecruitment and retention and the devel-opment of an improvement plan. Itincludes the self-assessment survey men-tioned above, as well as a ClinicianRetention Interview tool.

• As part of self-assessment, the NationalHealth Service Corps Retention Calculatorat http://nhsc.hrsa.gov/currentmembers/membersites/retainproviders/ can determine retention rates within anorganization.

• The National Association of CommunityHealth Centers’ Recruitment and RetentionToolkit is another guide for health centersto use in finding and keeping strong clini-cal staff. See http://www.nachc.com/client/documents/CLINICAL%20RECRUIT-MENT%20AND%20RETENTION%20TOOLKIT_final1.6.11.pdf

• Develop an organizational Recruitment andRetention Plan to define the need, goalsand actions that will be undertaken.Sample plans can be found in MCN’s ToolBox http://www.migrantclinician.org/toolsource/94/recruitment-and-retention/index.html, “Recruitment and Retention”under the “Human Resources” heading.

Recruitment Resources • MCN has gathered links to a wide variety

of recruitment resources in our Tool Boxunder the heading of “ProfessionalPractice and Development.” These includeprofession-specific (nurse practitioners,pediatricians, family physicians, etc.) jobbanks and recruitment services that relate tospecific work settings (rural, regional, etc.).

• The National Health Service Corps (NHSC),one of the primary recruitment resourcesfor Health Center Program grantees, nowallows recruiting sites to register onlineand conducts Virtual Job Fairs. For eligibility information and to register go to http://nhsc.hrsa.gov/corpsexperience/virtualjobfair/.

• Similar to NHSC, the NURSE Corps LoanRepayment and Scholarship Programs provides assistance to Registered Nursesand advanced practice nurses who workat Critical Shortage Facilities. For moreinformation, see http://www.hrsa.gov/loanscholarships/nursecorps/index.html.

• Develop partnerships with clinician training programs to provide a ready pool of potential recruits. Serving as aclinical rotation site for students and partnering with residency programsthrough HRSA’s Teaching Health CenterGraduate Medical Education Program areexamples of “pipeline” approaches torecruitment.

• Consult State or regional Primary CareAssociations for information about otherrecruitment avenues such as state loanrepayment programs or internationalmedical graduates (J-1 Visa Waiver Program).

Retention Resources• Focus on keeping your current clinical

staff by monitoring their satisfaction.MCN’s Clinician Retention Interview toolmentioned earlier can be used for thatpurpose. A similar tool is the StayInterview,5 which asks employees ques-

tions like “What do you like most aboutworking here?” and “On a scale of 1 to10, how would you rate your intention toleave?”

• Based on the needs and career goals ofclinical staff, provide them with opportu-nities to teach, conduct a support groupfor patients, take unpaid leave to workinternationally, job share, exercise mid-day, or work part-time. Remember thatnot everyone will be motivated by thesame incentives or rewards.

• Cultivate an organizational culture andpractice environment that reflects theorganization’s mission and quality health-care. Clinicians who have strong leader-ship and a voice in decision-making aremore likely to feel ownership in theorganization and pride in their associationwith it.

While this article has focused on the chal-lenges and difficulties associated withrecruitment and retention of clinicians,HRSA-funded health centers have much tooffer to dedicated clinicians who are interest-ed in meaningful work. By seeking out thosewho are interested in working with multi-cultural underserved patients and providingthem with the resources that they need toprovide quality care, the organization, clini-cians and patients will all benefit.

In this document, unless otherwise noted, theterm “grantees” is used to refer to organiza-tions that receive grants under the HealthCenter Program as authorized under section330 of the Public Health Service Act, asamended. It does not refer to FQHC Look-Alikesor clinics that are sponsored by tribal or UrbanIndian Health Organizations, except for thosethat receive Health Center Program grants. n

References1. NACHC, RGC, and GWU. ACCESS Transformed:

Building A Primary Care Workforce for the 21stCentury. 2008. http://www.nachc.com/client/documents/ACCESS%20Transformed%20full%20report.PDF

2. NACHC. The Struggle to Build a Strong Workforce atHealth Centers. Fact Sheet, November 2009.http://www.nachc.com/client//WorkforceFS.pdf

3. Accreditation Council for Graduate MedicalEducation. “Number of Accredited Programs by Academic Year.” https://www.acgme.org/ads/public

4. Andrilla C.H., Curtin T., Hart L.G., Rosenblatt R.A.Shortages of Medical Personnel at CommunityHealth Centers: Implications for PlannedExpansion. Journal of the American MedicalAssociation, 1042-9. 2006.

5. Finnegan, Richard P. The Power of Stay Interviewsfor Engagement and Retention. 2012. http://www.c-suiteanalytics.com/

n Where have all the clinicians gone? continued from page 1

6 MCN Streamline

In 2005, an increase in the incidence oftuberculosis (TB) was noted in the north-ern Mexico state of Chihuahua. A total of500 new cases were reported. This wasreflected in an increase of Multi-Drug-Resistant TB in the neighboring U.S. state ofNew Mexico. This compelled the healthauthorities of both countries to initiate abinational health agreement.

Early in 2007, the New Mexico Office ofBorder Health (NM OBH) noted the impor-tance of TB, which had for some time beenaffecting the residents of the border areas ofLuna County, New Mexico, and Palomas,Chihuahua.

In that same year, NM-OBH with fundingfrom the United States-Mexico Border HealthCommission, initiated a three-year strategicplan titled “Public Health Plan for theCounty of Luna and Palomas, Chihuahua,”focused on nine health topics of whichtuberculosis was a priority.

This resulted in the signing of a bilateralagreement between the health authorities ofChihuahua and New Mexico to addressissues of mutual concern.

In response to the strategic plan, the New Mexico Office of Border Health con-vened a meeting of decision makers fromboth sides of the border and various agencies interested in fighting TB. Thismeeting resulted in the establishment of the Binational Committee on Tuberculosis.The Committee held several meetings todevelop the Binational Pilot Project for theMonitoring and Control of Tuberculosis in theBorder Region of New Mexico-Chihuahua.

The proposal was sent to the UnitedStates-Mexico Border Health Commission torequest funding. The commission funded theproject, using Migrant Clinicians Network asthe financial and technical agency in 2009.

MCN recently completed a summary ofthree years of activity for the Binational PilotProject for the Monitoring and Control ofTuberculosis in the Border Region of NewMexico-Chihuahua for the period September1, 2009 to August 31, 2012.

This project took place in the state ofChihuahua, Mexico, an area that is 100%rural, hard to access, geographically exten-sive with communities distant from eachother and where the incidence of tuberculo-sis is high. The health infrastructure is limitedand migration is high due to proximity to theUnited States’ border along New Mexico.

During three years of intensive work, theproject established its own infrastructure andcoordination with the hiring of a local coor-dinator, the acquisition of computer equip-

ment, the search for office space withinChihuahua’s Jurisdiction No. 5, and thestrengthening of the communicationbetween the project and key public healthofficials of the State of Chihuahua. The training of the coordinator and staff, as well as the creation of a memorandum ofunderstanding between the authorities ofboth countries, was an integral part of theinitial work.

A technical committee was formed, andincluded the director of the Sanitary DistrictNo 5, the Chief of Epidemiology, the ProjectCoordinator, the Director of the Office ofBorder Health in New Mexico andChihuahua, and MCN.

The Jurisdiction and the MycobacteriaProgram of the State of Chihuahua workedjointly in the intensive search of active casesand contact investigation, using purified pro-tein derivative PPD, chest X-Rays, and spu-tum samples to perform bacilloscopies andcultures. All of these were done according tothe Mexican treatment protocols. Once anactive case was identified, the project fol-lowed the patient with MCN’s TBNet pro-gram and with home visits for the adminis-tration of treatment in conjunction of theDOT nursing network (Directly ObservedTherapy).

A total of 47 cases were supervised by theproject, starting with 16 patients in treat-ment and reaching 31 patients in the lastyear. A total of 2,231 home visits were done.

New adherence strategies were imple-mented for patients with high risk of aban-doning treatment, Multi-Drug Resistance,and Co-morbidities. The first strategy wasthe use of food incentives, which not onlycontributed to better nutrition for thepatient but put the responsibility of takingthe medications on the patient, who had tocomply in order to receive the food.

Another strategy was the implementationof home visits. Home visit nurses gave per-sonal attention to the patient and estab-lished a warmer and closer relationship thatwas an important factor in the patient’s will-ingness to continue and finish the treatment.

A significant component of the programwas to provide education about tuberculosisto three target groups: patients, cliniciansand the general public. The following sum-marizes the educational approaches takenwith each of these three groups: • Patients: Through lectures in strategic

places like rehabilitation centers, nursinghomes, health fairs, and individual visits,instructions were provided to patients andrelatives. Emphasis was placed on preven-tion and transmission of the disease. Atotal of 17 such lectures were held.

• Health Personnel: There were two train-ing sessions for medical and nursing per-sonnel in the areas of Ciudad Juárez andNuevo Casas Grandes in Chihuahua, withthe participation of 150 doctors and nurs-es interested and dedicated to the area ofTuberculosis. Included in these sessionswere specialists from the United Statesand Mexico.

• General Public: Installation of three bill-boards (two in Ciudad Juárez and one inNuevo Casas Grandes) highlighted theimportance of going to the doctor andidentifying the symptoms of Tuberculosis.

Through coordination and education onmatters of tuberculosis, communication wasstrengthened with other health entities inthe area, such as Social Security and theDepartment of National Defense, with theobjective of working jointly in the intensivesearch for active cases of TB.

The infrastructure created by this projectprovides the basis for true binational cooper-ation in TB care and serves as a foundationfor future joint work to address this publichealth concern effectively on both sides ofthe border. n

Border Health Innovations in Tuberculosis ManagementBertha Armendariz, MD

Promotional billboard to educate the border population about TB.

MCN Streamline 7

New Mexico stated that a participantinvolved in their first workshop is now afacilitator for Hombres Unidos. This is the firstdocumented case of a participant who laterfacilitated the program. Additionally, inter-viewed participants have shared with us thelessons learned and applications taken fromthe intervention.

Gabriel, a participant during a 2008 imple-mentation in Pennsylvania, recalled using askill he had learned from an activity duringan argument he was having with his wifeover the phone. He mentioned that emotionswere escalating during the argument andalthough he doesn’t consider himself violent,he told his wife that he was getting angryand needed to step away from the situationbefore he would say something he wouldregret. At that moment, he hung up thephone and returned her call at a later time.

SPREADMigrant Health Promotion and EnlaceComunitario became the first organizationsto replicate Hombres Unidos without MCNoversight, but with MCN-led training andtechnical assistance to retain program fideli-ty. Migrant Health Promotion aims toimprove health in border and farmworkercommunities by implementing health out-reach education to community members.Enlace Comunitario is a domestic violencevictims services organization dedicated toimproving the lives of the immigrant com-munity in Albuquerque, New Mexico. Bothorganizations were selected as implementa-tion sites because of their outreach experi-ence and their partnership with victims serv-ices organizations (Enlace Comunitario is adirect service provider).

Experience has shown that HombresUnidos is a program which can be replicatedin any area of the country where a migrantpopulation is present. The recruitment andimplementation methodology is very specificto the population and should be maintainedduring replication.

The program has reached nearly 300 partic-ipants over the past year in programs run byorganizations other than MCN. Although theoutcomes of the intervention at Enlace andMigrant Health Promotion have yet to be for-mally evaluated, anecdotal evidence providedby these sites indicates successful curriculumreplication. As Hombres Unidos is culturally spe-cific to Latino migrant men, the programcould also be replicated with migrant men inwork environments other than farm work.

One of the participants in Hombres Unidoshad the following to say about the program:

The Hombres Unidos workshop was a verygood experience for everyone involved. Weall learned to calm ourselves in tense situa-

tions. For example, they stressed the impor-tance of counting to ten before reacting toany sort of conflict. As a result of theHombres Unidos workshops we all learnedhow to control our emotions. Furthermorethis workshop served as a base to help oth-ers who have problems with their anger; forexample, I was recently in Mexico and I wasin a situation where a companion of minewas being very loud and a bit violent. I inter-vened and explained to him that he shouldnot take his problems out in the open insuch a loud and disrespectful way. I told himthat he has to take care of his problems at apersonal level and not out in public. Thanksto the Hombres Unidos workshop I hadsome guidance in counseling this man inhow to deal with his emotions.

For more information about Hombres Unidos,including what is required to replicate the

program at your site, please contact AdrianVelasquez at avelasquez@migrantclinician.org or 512-579-4505. n

References1. Community Health Education Concepts and the

Migrant Clinicians Network: Survey ofRelationships between Men and WomenEvaluation Report, September 2007

2. Saltijeral, M. T., Ramos, L. L., & Esteban. Mujeresmaltratadas: Una aproximación sobre los tipos deviolencia y algunos efectos en la salud física ymental. Paper presented at Foro Internacional dePrevención y Violencia Doméstica. PNUD,Sociedad Mexicana de Criminología, FundaciónMexicana de Asistencia a Víctimas, Gobierno delEstado de Jalisco, Guadalajara, Jalisco, 1996

3. DHHS, Maternal & Child Health Bureau, YouthViolence Prevention in Latino Communities: AResource Guide for MCH Professionals. Newton,MA; Children’s Safety Network, EducationDevelopment Center, Inc, 1999

n Hombres Unidos Provides Critical Primary Prevention Services continued from page <None>

8 MCN Streamline

ENVIRONMENTAL / OCCUPATIONAL HEALTH SECTION

The Migrant Clinicians Network (MCN) and the National Associationof State Departments of Agriculture (NASDA) Research Foundationannounce the availability of three pesticide educational comic books in Spanish. These full color publications are available free ofcharge and can be ordered via http://www.migrantclinician.org/ orderpesticidecomics.

The comics include the following titles:1. Aunque Cerca… Sano educates parents about children’s risks to

pesticide exposure and ways to minimize these risks. 2. Lo Que Bien Empieza... Bien Acaba helps women of reproductive

age and pregnant women in rural and urban areas understand therisks associated with pesticide exposure and ways to minimizeexposure.

3. Poco Veneno... ¿No Mata? offers family-based information onwhat pesticides are, why one should be concerned about pesticideexposures, how to minimize pesticide exposures and how torespond to a pesticide poisoning.

The comic books were developed by MCN and partners to help edu-cate farmworkers and their families as well as other Spanish-speakingpopulations about pesticides and ways to minimize exposures. Theyoffer protective concepts through illustration and conversation-style

text and are an effective way to disseminate health information topopulations with limited formal education.

These MCN comic books are printed and distributed by theNASDA Research Foundation under Cooperative Agreement X8-83456201, awarded by the U.S. Environmental Protection Agency. n

The material presented in this portion of Streamline is supported entirely by a grant from the Environmental Protection Agency, Office of Pesticide Programs, Grant # X8-83487601.

Comic Books Back by Popular Demand

Migrant Clinicians Network is pleased toannounce the availability of our newclinical guidelines for acute pesticideexposure and accompanying exposureassessment form. These resources arecritical for use in health centers that carefor farmworkers, the population mostoverexposed to pesticides. The tools wereadapted from guidelines drafted by DennisPenzell, DO, MS, a former medical directorat a federally funded health center inFlorida. Dr. Penzell treated and managedfarmworker patients who were poisoned inone of the largest pesticide poisoningincidents in the United States. The new toolsinclude a listing for data collection for acutepesticide exposed patients. The contents ofthe data collection were adapted from aresource created by Matthew Keifer, MD,MPH, director of the National Farm MedicineCenter and an occupational medicinespecialist renowned for his research andclinical work with farmworkers and pesticides.This data collection listing will be included in the forthcoming Recognition andManagement of Pesticide Poisonings, 6th ed. These tools were reviewed by MCN’sexpert advisory committee on environmentaland occupational health.

New Pesticide Resources Available

MCN Streamline 9

In the southwest corner of North Carolina,Blue Ridge Community Health Services

(BRCHS) is taking steps to improve access toand quality of care for migrant patients.

Migrant Clinicians Network (MCN) andBRCHS began a year-long collaboration inNovember 2012 to establish the health cen-ter as an Environmental and OccupationalHealth Center of Excellence, focusing onimproving the health of the region’s agricul-tural workers and their families in the pri-mary care setting. The health center partner-ship program is the cornerstone of MCN’sEnvironmental and Occupational Health(EOH) program initiative and is supportedthrough a cooperative agreement with theU.S. Environmental Protection Agency (EPA),Office of Pesticide Programs as part of theNational Strategies for Healthcare Providers:Pesticide Initiative.

Blue Ridge Community Health ServicesBased in Hendersonville, NC, with satellitelocations in Brevard and four school-based

clinics, BRCHS has served the residents ofHenderson and Transylvania counties formore than 50 years. The center was the firstfederally-funded migrant health center in thecountry. It now serves patients from the sur-rounding counties of Buncombe, Polk, andother western North Carolina counties.

Residents in the region face a shortage ofprimary care providers. Henderson County isdesignated as a Health Professional ShortageArea for primary care, dental care, and men-tal health care. In addition, the low-incomeand farmworker populations are designatedas Medically Underserved Populations.BRCHS offers adult and pediatric primarycare, dental, pharmacy and behavioralhealth care. In addition to these services, thecenter provides community health educationand outreach to migrant labor camps duringthe growing season.

With more patients expected to accesscare under the Affordable Care Act (ACA),the need for primary care providers in theregion will increase. BRCHS is taking aproactive approach to address the expected

growth in their patient population, partner-ing with the Mountain Area HealthEducation Center (MAHEC), Pardee Hospitaland the MAHEC Hendersonville FamilyMedicine Residency Program to increase thenumber of newly graduated doctors enter-ing the family residency program inHendersonville. Made possible through agrant under the ACA “Teaching HealthCenter” program, BRCHS will assume opera-tions of the MAHEC outpatient clinical site.More doctors participating in the MAHECfamily residency program will meanincreased access for patients who face barri-ers to accessing healthcare.

The North Carolina Employment SecurityCommission estimated close to 4,000migrant and seasonal farmworkers (MSFWs)worked in Henderson and Transylvania coun-ties in 2011. Including dependents, an esti-mated 11,300 farmworker family membersare present..1 Apples and Christmas tree pro-duction are the main source of work for

ENVIRONMENTAL / OCCUPATIONAL HEALTH SECTION

From the Field to the Exam Room: Blue Ridge Community Health Center Partners with MCN to Improve Care for Migrant Patients

Michael Piorunski

continued on page 11

10 MCN Streamline

ENVIRONMENTAL / OCCUPATIONAL HEALTH SECTION

I N M E M O R I A M

Remembering a Tireless Community AdvocateMCN staff was greatly saddened to hear of the recent death of Ana Alexandra Oviedo Medina, a Community OutreachCoordinator for Blue Ridge Community Health Services, and former Henderson County Educational System immigrantadvocate and ESL Parent Liaison.

Ana was 28 years old, a native of Torreon, Mexico, and the daughter of Pastor Alfredo Oviedo and Alejandra Oviedo. Sheattended the University of North Carolina at Charlotte where she majored in Political Science and Spanish.

Ana’s obituary says, “Ana loved doing work for the community and advocating for those without a voice. Her favoriteactivities were going to church; her son’s, nephews’ and brother’s soccer games; and shopping with her mother. Ana wasintolerant of injustice and spoke up against it.”

“Ana was a counselor to many. She always had time to listen to others and offer support. Ana liked to empower womenand enjoyed being lovable to babies and children.”

MCN staff worked with Ana to help bring environmental and occupational health services to Blue Ridge CommunityHealth Center and to provide ongoing continuity of care to Blue Ridge patients through the use of MCN’s Health Network.

MCN staff who worked with Ana say that she was “full of life and this is a huge loss for her family and the community ofBlue Ridge. We feel lucky to have known her and will miss her as we continue to work on behalf of the patients she served.”

Ana loved doing

work for the

community and

advocating for

those without

a voice...

MCN Streamline 11

ENVIRONMENTAL / OCCUPATIONAL HEALTH SECTION

farmworkers in the region. Workers also har-vest strawberries, bell peppers and grapes.

Integrating Environmental andOccupational Health (EOH) intoPrimary CareMCN’s EOH program focuses on developingsimple, practical adaptations to partner cen-ters’ clinical systems to support the integra-tion of EOH into the primary care setting,based on the unique needs and conditionsat each individual health center.

For BRCHS, an immediate need wasimprovement in the identification of migrantpatients. In recent years, BRCHS and othermigrant health centers have seen a decline intheir migrant patient populations, partly dueto a climate of fear among immigrant popu-lations in North Carolina and other states.2

Together, BRCHS and MCN establishedthe improvement of identifying migrantpatients as a primary goal of the partnership.

”MCN helped us come up with a realisticwork plan,” said Milton Butterworth,Director of Community Engagement atBRCHS. Butterworth and Medical DirectorShannon Dowler, MD, played key roles inidentifying and supporting the achievementof improvement goals.

The identification of migrant and farm-worker patients is important from an envi-ronmental and occupational health angle.MCN’s Chief Medical Officer (CMO), EdZuroweste, MD, says that it’s important forclinicians to utilize this information to thinkdifferently about potential causes and man-agement of illness and injury. In his role asCMO, Dr. Zuroweste oversees the clinicalcontent of MCN’s EOH program. He alsoparticipated in an MCN site visit to BRCHS inNovember 2012.

“It was important for us to improve ourrates of identification of MSFW at our gate-ways, the organization’s front desks, andseamlessly make the provider aware of thepatient’s occupation,” Butterworth said.

Agricultural work is among the most haz-ardous occupations, with farmworkers beingthe population most overexposed to pesti-cides. During the three-year period from2008-2010, hired farmworkers were fivetimes more likely to suffer fatal occupationalinjuries than were workers in all civilianindustries combined.3

“Making the clinician aware that a patientor a member of the patient’s family works inagriculture and is a migrant is the funda-mental first step in providing quality care,”Zuroweste said.

BRCHS will focus on improving documen-

tation of migrant patients in their ElectronicHealth Records (EHR) as part of this effort.

Alongside this goal MCN and BRCHS willwork together to integrate EOH throughoutthe medical practice, incorporating measuresand guidelines to identify and documentpatients’ EOH concerns. MCN will aid BRCHSduring the next year to incorporate MCN’sPesticide Exposure Clinical Guidelines andEOH screening tools into the clinical practice.

“During this process MCN has helped us identify for ourselves some ways we could integrate what we learned about EOH issues faced by our mobile [patients],”Butterworth said.

Butterworth says that improving the iden-tification of EOH risks[?] in the clinic settingas well as integrating components of theEOH guidelines into the EHR will enableBRCHS to better address the full range ofissues in treating migrant and seasonal farm-workers in the long term.

TrainingIn November and February, MCN providedon-site clinical trainings for all BRCHS stafffacilitated by expert faculty in migrationhealth, EOH and pesticides. These trainingsprovided the clinical foundation for improve-ment of clinicians’ skills in the recognitionand treatment of EOH problems, with anemphasis on pesticide exposure. Expert clini-cal faculty included MCN’s Zuroweste andJames Roberts, MD, MPH – one of thenation’s leading experts on pesticides andauthor of the EPA’s forthcoming Recognitionand Management of Pesticide Poisonings,6th Edition. All clinical staff received continu-ing education units for their participation inthe trainings and an overview of resourcesavailable to support the clinical and commu-nity treatment of patients’ EOH problems.

OutreachAs a critical component of care for migrantpopulations, MCN and BRCHS will jointlydevelop guidelines for outreach staff to aidin the identification of migrant patients andthe documentation of EOH risks during outreach encounters. BRCHS boasts a robustoutreach program. To support the center’soutreach efforts, MCN provided 2,000copies of each of three Spanish-languagepesticide comic books. The comics educatefarmworkers and their families about pesticides and ways to minimize pesticideexposure.

During the year-long EOH Program partnership MCN will assist BRCHS in assessing their progress in achieving theirquality improvement goals. The work ofBRCHS with MCN has helped to create a“culture of care [within the center] thatfocuses on the EOH needs of our patients,”Butterworth said.

To learn more about MCN’s EOH ProgramInitiative or to download MCN’s EOH clinicaltools and resources, please visit our websitewww.migrantclinician.org. n

References

1. Agricultural Employment Services, 2010 Estimateof Migrant and Seasonal Farmworkers during PeakHarvest by County,” NC Employment SecurityCommission, 2011

2. Galewitz, P. Migrant Health Clinics Caught inCrossfire of Immigration Debate. (2012, June 6).Kaiser Health News. http://www.kaiserhealthnews.org/Stories/2012/June/07/migrant-health-clinics-immigration-debate.aspx

3. Villarejo D. 2012. Health-related Inequities Among Hired Farm Workers and the Resurgenceof Labor-intensive Agriculture. Kresge Foundation,Troy, MI, 78p.

MCN Pesticide Exposure Clinical Guidelines, Assessment Form and Other Resources

MCN has a number of resoruces for primary care clinicians to better incorporateoccupational health into their practices. All of these resources have been developed inconjunction with MCN’s Environmental and Occupational Advisory Committee.

MCN Occupational and Environmental Health Screening Questions for Primary Care

http://www.migrantclinician.org/files/MCNConsensusQuestionsENG_SPA.pdf

MCN Acute Pesticide Exposure Guidelines:http://www.migrantclinician.org/files/PesticideGuidelines_2013_website.pdf

MCN Pesticide Exposure Assessment Form:http://www.migrantclinician.org/files/PesticideExpAssessment_Feb15.pdf

n From the Field to the Exam Room continued from page 9

12 MCN Streamline

Migrant Clinicians NetworkP.O. Box 164285 • Austin, TX 78716

Non Profit Org.U.S. PostagePA I D

PERMIT NO. 2625Austin, TX

Acknowledgment: Streamline is published bythe MCN and is made possible in part throughgrant number U30CS09742-02-00 from HRSA/Bureau of Primary Health Care. Its contents aresolely the responsibility of the authors and donot necessarily represent the official views ofHRSA/BPHC. This publication may be repro-duced, with credit to MCN. Subscription infor-mation and submission of articles should bedirected to the Migrant Clinicians Network,P.O. Box 164285, Austin, Texas, 78716. Phone:(512) 327-2017, Fax (512) 327-0719. E-mail:jhopewell@migrantclinician.org

Kristine McVea, MDChair, MCN Board of Directors

Karen Mountain, MBA, MSN, RN Chief Executive Officer

Jillian Hopewell, MPA, MADirector of Education, Editor

Editorial Board — Marco Alberts, DMD, DeSotoCounty Health Department, Arcadia, FL;Matthew Keifer, MD, MPH, National FarmMedicine Center (NFMC), Marshfield ClinicResearch Foundation, Marshfield, WI; KimL. Larson, PhD, RN, MPH, East CarolinaUniversity, Greenville, North Carolina

National Farmworkers Health ConferenceMay 8-9, 2013San Diego, CA

National Association of Community Health Centerswww.nachc.com

National Worker Health and Safety ConferenceDecember 11-12, 2013

Baltimore, MDNational Council for Occupational Safety and Health

www.coshnetwork.org

• • • • • •Clinician Orientation to Migration Health Series

Migrant Clinicians Network

Patient Centered Medical Home for Patients on the MoveJune 12th, 2013 1-2pm EST

Women’s Health and MigrationJuly 17th, 2013 1-2pm EST

Quality and Meaningful Use in Migration HealthAugust 7th, 2013 1-2pm EST

To register for one or all of these go to http://www.migrantclinician.org/orientation

calendar