Task oriented groups: Research, clinical practice, and administration: How can we change our communities? How can we better the health of Mexican immigrants in our communities?
Working in small groups, participants discussed potential avenues for community action within their home settings with a goal to formulate an action plan for collaboration across and within institutions to better the health of Mexican immigrants in their respective communities. They responded to the general questions: How can we change our communities? How can we better the health of Mexican immigrants in our communities?
Using the 21 Focus Areas of Healthy People 2010 (Table 1) as a guide, each group identified the organizational strengths and the organizational areas of need with respect to one or several Focus Areas. Each participant was charged to identify mechanisms for working within his/her institution/community and develop an action plan for addressing specific Healthy People 2010 Focus Areas.
Participants in the Research, Clinical Practice, and Administration groups, led by two facilitators, worked for approximately one hour and then returned to the larger group to summarize findings and recommendations. The following represents the charge to and a summary of comments from each of the groups.
Facilitator. Dr. Carolyn Cason*
All 21 HP2010 Focus Areas were considered relevant for the Task Oriented Group on Research. Participants were charged to identify their organizational and individual Strengths and Areas of Need in researching issues relative to Hispanic health needs. The goal was to identify the major health problems of Hispanic immigrants in their setting and respond to the following questions for discussion: What outcome criteria are available and useful? What funding sources are available? What, in spite of the inherent restrictions of lack of money and time, can researchers do to conduct and disseminate research on these areas?
Participants in the Task Oriented Group on Research represented the states of Texas, Georgia, Pennsylvania, Kentucky, North Carolina, South Carolina, Connecticut, Oregon and Kansas. Research interests varied from broad areas of emphasis such as health promotion and prevention and mental health among Hispanic populations to addressing specific clinical sub-populations among Hispanics including pregnant migrant women, children and families with Down’s syndrome, the elderly, adolescent risk reduction, breast cancer and HIV/AIDS among women. The heterogeneity of Hispanic populations was underscored by the variety of sub-populations with which the group members worked, from Mexicans to persons from Ecuador, Guatemala, the Dominican Republic, and from South American countries.
Two major themes emerged from the discussion:
* The first theme related to issues in conducting research among Hispanic populations.
* The second theme centered on how to establish collaborations to facilitate research.
Conducting Research Among Hispanic Populations
Reaching the population of Hispanics for clinical research and intervention projects was an area of concern. A number of participants described the problem of nonHispanic gatekeepers within their communities who serve to protect individuals and communities from methodological abuse and over-researching of ethnic neighborhoods. These individuals, whether Hispanic or non-Hispanic, make it more difficult for investigators to reach Hispanic subjects. Agencies and individuals within agencies such as police chiefs within community police departments also serve as gatekeepers. Participants shared a number of strategies for gaining access to Hispanic populations and overcoming concerns of gatekeepers. The complexity of maintaining inter-institutional relationships, such as university affiliations with gatekeeper agencies within the community, was cited as a primary concern. Developing and maintaining trust in the relationships was considered to be a paramount goal. Expressing the desire to potential subjects to learn about their culture as well as providing subjects with researcher information such as business cards were also mentioned as part of the development of relationships built on trust and understanding.
Other strategies included the following: * incorporating gatekeepers as consultants and/or partners in grant proposals
* providing a needed service directly to patients or to the agency serving patients in exchange for access to patients or data (direct clinical services or assisting with agency needs such as statistical analysis of data)
* working with pastors in community churches or other religious organizations on projects relevant to the community’s needs
* using waiting room times to collect data or initiate programmatic interventions.
A related aspect of working with Hispanic populations is the use of culturally appropriate teaching and informational materials. Similarly, participants recognized the importance of providing materials to accommodate low education populations, as low as fourth grade reading levels. Several participants acknowledged the difficulty in getting materials translated into Spanish. However, it was also noted that little to no research has been done on effectiveness of materials deemed to be culturally appropriate. (See Table 2 for additional resource materials in Spanish).
A related issue is the importance of accurate translation of materials and accuracy in communication as part of the data collection process. The difficulty in achieving reliability and agreement across sub-cultural groups in meaning of words was highlighted by participants.
A second issue is overcoming cultural errors in working with Hispanic populations. Researchers should seek consultation to avoid errors in sensitive cultural areas such as man-woman relationships and sexuality education of children and adolescents. Participants suggested recruitment of individuals from the community under study to serve as interpreter and/or educator.
Developing Collaborative Relationships At Home and Across Borders
A major aspect of promotion of health and prevention of disease is continuity of care. For immigrant populations, breaks in service from one country to another increase the individual’s vulnerability for illness. Based on suggestions from Mexican government representatives, participants felt establishment of patient databases, which could be accessed across borders and across institutions, would facilitate better health care. Participants noted the importance of shared information particularly for chronic illnesses such as diabetes and HIV/AIDS.
The concept of shared databases is rooted in the development of collaborative relationships across institutions and across borders. Suggested mechanisms to enhance research collaboration include faculty exchange programs with Mexican universities as well as institutional exchange programs between hospitals and health care facilities. Attendance at relevant international conferences widens the collegial network and provides opportunities for connectedness across interest areas. Participants noted that a way to begin research partnerships is to offer to add research questions to existing research programs and share findings across borders with similar population groups.
Participants also recognized that collaborative researchers across institutional and national boundaries should proceed with caution. It was noted that researchers need to recognize the importance of maintenance of rigor in design and data collection methodology often difficult to achieve in cross-disciplinary, cross-institutional projects. Researchers need to build in basic training and assure shared assumptions for all participants in collaborative projects.
A natural potential partner participants recognized is the local Mexican consulate. Mexico has 42 consulates in the United States, usually serving major metropolitan areas. Each consulate has a representative from the Mexican Communities Abroad Program. While the primary initiatives of the Mexican Communities Abroad Program have been supportive to the cultural needs of immigrants in the US, the Mexican government is cognizant of the need to develop programs in health. Individuals and resources within the Mexican Consulates are robust potential programmatic and research partners for health professionals and health institutions in the United States.
Summary and Recommendations
In addition to the above areas of discussion, participants in the Task Oriented Group on Research generated the following recommendations: 1) Create a list serve of conference attendees to facilitate collaboration and interchange between participants; and 2) Plan a 3rd International “Crossing Borders” Conference which would develop a formal research agenda for Hispanic/Migrant/Immigrant research. Include in the program a synthesis of research with the goal of identifying “best practices” in caring for Hispanic populations. These clinically-focused “best practices” could be topics for the 4th and 5th “Crossing Borders” Conferences.
Facilitators: Mary Elaine Jones, RN, PhD Delia Solis, MS, RD
The Clinical Practice group emphasis was on promoting responsible health behavior and health communication with special reference to the clinical Healthy People 2010 focus areas of Nutrition, Overweight, Obesity, Diabetes, and Nutritionally-related phenomena. Participants were charged to address the health care encounter and identify Strengths (what do clinicians do well with regard to communication and facilitating responsible health behavior) and Areas of Need (what do clinicians need to know and what skills do they need in order to meet the mandates of HP 2010 in the clinical area?) What, in spite of the inherent restrictions of language barriers, can clinicians do to encourage responsible health behaviors? What do we know about changing or supporting health habits, especially food-related behaviors?
Seventeen conference attendees represented the states of Texas, California, Alabama, New Jersey, Oregon, Kansas, and New Mexico. Group members were engaged in direct clinical care with Hispanic patients, faculty in schools of nursing, and researchers responsible for program evaluation.
Participants agreed that clinicians are challenged to provide care to immigrant Mexican populations located in encapsulated communities and to disseminate health information to patients who often do not speak English. The major theme that emerged from the discussion was the need for clinicians to shift from an authoritative position to a facilitative position in working with Mexican, particularly immigrant, populations. A corollary was the need for the locus of control to shift from the provider to the patient. Mechanisms and skills necessary to reach out to natural communities to provide education were identified. A number of teaching and background informational nutritional resources for clinicians were also identified.
Working with Natural Communities of Mexican Immigrants
Participants agreed that reaching out to immigrant communities is a challenging enterprise. A first step is to identify the target community. Engaging in an assessment of the community includes examining the strengths of the community. Strengths of Mexican immigrant communities include the family, churches, schools, and existing social organizations. Assessment from a clinical perspective should include strengths that derive from the traditions of the Mexican culture.
While participants recognized the inherent barrier of gatekeepers within their settings, a number of effective strategies were described to overcome this barrier. The importance of establishing a trusting relationship and working within organizations already trusted by the people was emphasized as a necessary ingredient in working with immigrant communities.
Identifying natural leaders within the community also was seen as key to overcoming gatekeeper barriers. For example, a number of clinical programs have developed promotora programs. Women who are known and trusted in the target community are trained, supervised, and paid by health professionals to provide selected services, such as prenatal and early child care education, to patients in the community. The promotora serves as a liaison between the community and the health care clinic. Variations of this concept include training volunteer mothers within communities who serve as knowledgeable health resources to neighborhoods.
The use of promotoras to target specific health problems within the Hispanic community was described as a strategy. An example in north Texas is the development of a program, which addresses nutrition and heart health. Entitled “Salud para tu corazon,” one goal is to teach about heart health while maintaining a healthy Mexican diet. The intent is to increase the community’s knowledge about what constitutes a healthy diet by building on the strengths of the Mexican diet. Participants recognized that the ideas learned from a heart program could easily be transferred to other health problems such as diabetes. A number of resources for professionals interested in working with patients where diet is a consideration were noted.
Participants re-iterated the importance of understanding the culture and the community in doing health teaching and programming. Counseling about the importance of exercise was discussed as a case-in-point. Health professionals often tell patients to “Go for a walk” without first identifying the patient’s personal resources and the resources within the neighborhood. Professionals need to determine if the patient perceives the neighborhood to be safe for walking, for example. Patients often equate exercise as a formal exercise program in a gym. By contrast, building on cultural understandings of the importance of family participation in sports, health professionals can encourage women to walk around the park while their families participate in soccer games, for example.
A number of specific efforts to reach Hispanic communities were described by participants. Health screenings proved to be effective at natural gatherings of the community such as Sunday afternoon following Catholic mass, as well as sports events such as basketball and soccer tournaments. The radio was seen as a useful resource for promoting health and health resources. Participants agreed that changing or modifying health behaviors at the individual level required time, stressing the positives in what patients already do, and incorporating the family and family values in the counseling plan.
Working with natural communities may also require that health professionals advocate for policy changes within communities. The most effective strategy is empowering community members to identify their problems and assisting them to lobby for policy changes. One participant described a housing community that lacked access to medical care. Once empowered to teach about basic health care issues of cleanliness, exercise, and diet, the group advocated for increased safety for children crossing busy intersections. These changes, emanating from the community and solved by community members, are seen as more long lasting.
Accessing resources available through the Mexican government’s Communities Abroad Program located in each of the Mexican Consulates was seen as an important resource. Participants noted the importance of language and the ability to communicate but also recognized the need for culturally appropriate translation into Spanish of teaching materials. Teaching materials for patients are available through the Mexican government on the salient health problems facing immigrant Hispanics and a number of participants planned to evaluate these materials for use in their home communities.
Nutritional Issues Among Immigrant Hispanics: Resources for Patients and Professionals
Dr. Luis Vargas, Physician and Anthropologist and Conference Speaker, noted that diabetes is a health problem in Mexico. “The only empirical study we have is the study done on Pima Indians in Arizona and in Mexico.. (The difference in the two populations).. in the States, they are much more overweight, much more diabetic than in Mexico despite being of the same genetic background.” Diet plays a significant role, as US diets are more bread-based and fast-food-based than in Mexico. Differences in exercise and use of processed foods were also suggested as playing a role; Mexicans get more exercise in their country and use less processed foods.
Dr. Vargas noted that obesity is a problem in Mexico. In a study he conducted, one in five school children were obese or overweight in Mexico City. Preliminary data from Mexico’s National Survey of Nutrition for the year 1999 suggests that growth retardation and iron deficiency anemia are the principal nutrition problems of children five year and under; overweight, obesity and iron deficiency anemia are the major problems of childbearing age women (Instituto National de Salud Publica, 1999). This survey also will have data on rural populations. Initial data from the national survey is published in Cuademos de Nutrition, a non-profit journal published in Spanish by Fomento de Nutrition A.C. The journal is sold by subscription and on newsstands. (For more information, the email address is cuadernos(&fns.org,mx). The publication is directed to the general public as well as nutritionists, providing practical information for public consumption and for health professionals.
Clinicians working with immigrant Hispanic communities can increase their effectiveness in increasing access to health care and dissemination of health information by working within natural communities and with existing neighborhood organizations and initiatives. Health professionals can be the bridge to assist natural leaders within immigrant Hispanic communities to first identify their needs and then helping them to advocate for policy changes affecting health and safety. A willing partner in this endeavor is representatives of the Mexican government housed in the Communities Abroad Programs in each of the 42 Mexican Consulates in the United States. A number of teaching resources are available which can assist clinicians, particularly in the area of nutrition and health.
Administration Facilitators: Ferne Kyba, RN, PhD Mary Lou Bond, RN, PhD
The Administration Task-Oriented group addressed the broad issue of access to quality health services. Participants were charged to identify Organizational Strengths and Organizational Areas of Need in assuring access to services for Hispanic immigrants. Questions included as follows: What, despite the inherent restrictions of state/federal funding mechanisms such as Medicaid/Medicare and Title V funding, can organizations/administration do to assure access to health care? What community collaborations might be developed? What non-traditional mechanisms could be developed? Four conference attendees participated in the Administrative Task-Oriented group representing public health agencies and private clinic initiatives in the states of Colorado, Alabama, and Texas. Six major areas of need for organizations to assure access and delivery of quality health care for Hispanic immigrants emerged from the discussion. These included the following:
* development of resources to meet financial need
* development of culturally competent health professionals
* emphasis on skills of communication and collaboration
* provision of culturally appropriate educational materials and resources
* building on knowledge and expectations of health and health care within the Hispanic population
* development of inter-organizational linkages.
Development of Resources to Meet Financial Need
Access to health care for immigrant Hispanics was seen as a major issue requiring significant resources. Public programs use a variety of strategies to meet the demand for services including the development of coalitions and partnerships with private agencies that can assist with resources at the community level. Programs that do not receive public funds are challenged to seek funding through foundations and grant-making agencies. However, participants noted that as the demand for services has risen, agencies are taxed by the never-ending search for funding to maintain programming. Creative mechanisms to access funds were seen as paramount to an administrator’s role in maintaining programming. The group emphasized the need to share creative ideas across state and agency boundaries for replication of programs as well as funding sources.
Development of Culturally Competent Health Professionals
Cultural competence was seen as a need across all health professions. The group agreed that cultural competence is more than speaking the language but includes understanding the cultural beliefs and values of the people. A number of issues relative to cultural and linguistic competence were identified. Health agencies have difficulty recruiting health professionals who are proficient in the Spanish language as a minimum. Many agencies historically relied on interpreters, particularly volunteer interpreters, according to group members. The current Standards for Cultural and Linguistic Competence published by the Office of Minority Health, US Department of Health and Human Services, provide a blueprint of fourteen standards for organizations in order to build culturally competent health care workers and organizations and require agencies to assure adequate language services. Four of the standards address language assistance services for people with limited English proficiency. These standards are consistent with HHS’ Office of Civil Rights written policy to ensure that individuals with limited English proficiency can access critical health and social services (Ross, 2001). Both the Standards and the Office of Civil Rights policy provide a mandate for organizations to develop linguistic and cultural competence among health professionals.
Under-representation of Hispanics in the health workforce was seen as a major problem for health care delivery. A contributing factor is the high rate of school dropout particularly among Hispanics in the US. Representatives described community initiatives directed at preventing high school dropout and supporting Hispanics in their elementary careers in order to develop “pipelines” of students for university study. The need for health professional role models and mentors for secondary school students requires additional resources. The Area Health Education Centers (AHEC), located in all states in the US, provide mentoring programs directed at diverse and underserved populations and are a resource for communities. Participants also advocated for federal traineeships targeting the Hispanic population for undergraduate scholarship assistance in the health professions, particularly nursing. The existing federal traineeship program in nursing currently addresses master’s and doctoral preparation.
The paradox of the shortage of bilingual registered nurses in the US, compounded by the current and projected shortage of RNs for the US, in the face of an oversupply of registered nurses in Mexico, was discussed. Mexican-trained nurses who migrate to the US, a potential source of culturally congruent health professionals to meet the shortage of bilingual registered nurses, have difficulty achieving recognition to practice as registered nurses in the US because of differences in preparation and language barriers.
Emphasis on Skills of Communication and Collaboration
Participants called for a list serve from the conference to provide a mechanism for communication among conference colleagues. In addition, the group felt that a clearinghouse of ideas, information, and best practices is needed to facilitate collaboration across state and national boundaries. For example, faculty at the University of Alabama School of Nursing are developing a resource book for migrant workers which will include information on educational, health, and local social service resources. A mechanism is needed to share exemplars such as this one.
Provision of Culturally Appropriate Educational Materials and Resources
Literacy level is a fundamental issue in use of written materials to educate immigrant Hispanics. Strategies to overcome reading deficiencies include reliance on use of pictorial icons or comics or other visual modes of learning. Participants recognized the sizable number of already translated health education materials available through Mexico’s Communities Abroad Programs. A critical need is to test for appropriateness of the materials across the US border. Based on conversations with Conference representatives from the Mexican government, there is interest in testing the validity of their translated materials with migrant populations residing in the US.
Building on Knowledge and Expectations of Health and Health Care within the Hispanic Population
The importance of health programming for Hispanics that recognizes the existing knowledge base about a particular health issue and developing initiatives that build on that knowledge was seen as culturally sensitive and effective. For example, National Vaccination Week in Mexico is the third week in May. Community efforts in the US could build on this existing appreciation and expectation of immigrants by calling vaccination efforts the same name and scheduling during the same period.
Development of Inter-Organizational Linkages
Participants noted that many health agencies have developed inter-organizational linkages at the local level as a mechanism to increase access to care for immigrant populations. Church-based programs have demonstrated effectiveness as trust is naturally established through this linkage. However, the group noted the need to expand linkages to the national and international levels. The recently established United States-Mexico Border Health Commission will be an additional resource as each of the ten border states between Mexico and the US will have membership on the Commission. These individuals will be able to provide information on the kinds of support available through the Commission. Other linkages suggested include the National Association of Hispanic Nurses and the National Parish Nurses (see Table 3).
Administrators of health programs are challenged to articulate a vision of health care for all population groups and to develop resources to enable the organization to implement the vision of care. Increasing access to health care for immigrant Hispanic populations requires consideration of a number of issues including the development and maintenance of funding streams to support innovation programming, methods to develop linguistically and culturally competent health care professionals and the use of educationally appropriate teaching methods and materials. Administrators are in a critical position to develop collaborative relationships and linkages at the local, national and international levels that will facilitate culturally competent care and assure access to health care for immigrant Mexican populations.
Instituto National de Salud Publica. Encuesta National de Nutrition (1999). Tomo I. Ninos menores de 5 anos. Cuernavaca, Morelos, INSP, 2000. (in Cuademos de Nutrition 24,(2), marzo-abril, 2001, 69-76.)
Ross, H. (2001). Office of Minority Health publishes final standards for cultural and linguistic competence. Closing the Gaps. US Dept of Health and Human Services, Office of Minority Health, Washington, DC, February/March, pp 1-10.
Carolyn Cason, RN, PhD
Mary Elaine Jones, RN, PhD
Delia Solis, MS, RD
Ferne Kyba, RN, PhD
Mary Lou Bond, RN, PhD
Facilitators: Dr. Carolyn Cason is Professor, Associate Dean for Research and Director, Center for Nursing Research at the University of Texas at Arlington. Dr. Mary Elaine Jones is Samuel T. Hughes Jr. Professor of Nursing and Co-Director, Center for Hispanic Studies in Nursing and Health at the University of Texas at Arlington. Ms. Delia Solis is a registered dietician and is Manager of Dietetic Services for the Community Oriented Primary Care Program for Parkland Health & Hospital System, Dallas, Texas. Dr. Ferne Kyba is Director of the RN to BSN Program and Clinical Professor at the University of Texas at Arlington; Dr. Mary Lou Bond is George W & Hazel M. Jay Professor in Nursing and CoDirector, Center for Hispanic Studies in Nursing & Health at the University of Texas at Arlington.
Copyright Riley Publications, Inc. Center for the Study of Multiculturalism and Health Summer 2002
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