Increasing Health Care Access for Mesoamerican People Living in Los Angeles

Metropolitan Service Planning Area Health Office (SPA 4)

SPA 4 CASE STUDY

INCREASING HEALTH CARE ACCESS FOR MESOAMERICAN PEOPLE LIVING IN LOS ANGELES

SPA 4 BEST PRACTICE COLLECTION RELIABLE INFORMATION FOR EFFECTIVE COMMUNITY HEALTH PLANS, PROGRAMS AND POLICIES

M. RICARDO CALDERÓN, SERIES EDITOR

September 2001 Los Angeles County Department of Health Services • Public Health

At a Glance METROPOLITAN SERVICE PLANNING AREA HEALTH OFFICE (SPA 4)

241 North Figueroa Street, Room 312 Los Angeles, California 90012 (213) 240-8049

The Best Practice Collection is a publication of the Metropolitan Service Planning Area (SPA 4). The opinions expressed herein are those of the editor and writer(s) and do not necessarily reflect the official position or views of the Los Angeles County Department of Health Services. Excerpts from this document may be freely reproduced, quoted or translated, in part or in full, acknowledging SPA 4 as the source.

Internet: http://www.lapublichealth.org/SPA 4

The SPA 4 Best Practice Collection fulfills the Los Angeles County Department of Health Services (DHS) local level goal to restructure and improve health services by “establishing and effectively disseminating to all concerned stakeholders comprehensive data and information on the health status, health risks, and health care utilization of Angelinos and definable subpopulations”.1 It is a program activity of the SPA 4 Information Dissemination Initiative created with the following goals in mind: To highlight lessons learned regarding the design, implementation, management and evaluation of public health programs To serve as a brief theoretical and practical reference for program planners and managers, community leaders, government officials, community based organizations, health care providers, policy makers and funding agencies regarding health promotion and disease prevention and control To share information and lessons learned in SPA 4 for community health planning purposes including adaptation or replication in other SPA’s, counties or states

LOS ANGELES COUNTY BOARD OF SUPERVISORS

Gloria Molina, First District Yvonne Brathwaite Burke, Second District Zev Yaroslavsky, Third District Don Knabe, Fourth District Michael D. Antonovich, Fifth District DEPARTMENT OF HEALTH SERVICES Fred Leaf, Acting Director Jonathan E. Fielding, MD, MPH, MBA. Director of Public Health and County Health Officer

James Haughton, MD, MPH. Medical Director, Public Health

BEST PRACTICE COLLECTION TEAM M. Ricardo Calderón, Series Editor Manuscript Author & SPA 4 Area Health Officer

Christopher Corniola, MPH.

Manuscript Author & Epidemiology Analyst

Angela Salazar, MPH.

Manuscript Author & Program Director, Health Education

Patricia Alexander, RN, PHN.

To advocate a holistic and multidimensional approach to effectively address gaps and disparities in order to improve the health and well-being of populations The SPA 4 Information Dissemination Initiative is an adaptation of the Joint United Nations Program on HIV/AIDS (UNAIDS) Best Practice Collection concept. Topics will normally include the following: 1. SPA 4 Viewpoint: An advocacy document aimed primarily at policy and decision-makers that outlines challenges and problems and proposes options and solutions.

2. SPA 4 Profile: A technical overview of a topic that provides information and data needed by public, private and personal health care providers for program development, implementation and evaluation.

3. SPA 4 Case Study: A detailed real-life example of policies, strategies or projects that provide important lessons learned in restructuring health care delivery systems and/or improving the health and well being of populations.

4. SPA 4 Key Materials: A range of materials designed for educational or training purposes with up-to-date authoritative thinking and knowhow on a topic or an example of a best practice.

Manuscript Author & Community Liaison Representative

Carina Lopez, MPH.

Project Manager, Information Dissemination Initiative

Photos: Courtesy of Patricia Alexander

2 Increasing Health Care Access for Mesoamerican People Living in Los Angeles : SPA 4 Case Study

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INCREASING HEALTH CARE ACCESS FOR MESOAMERICAN PEOPLE LIVING IN LOS ANGELES

Table of Contents i.

ABSTRACT

4

ii.

EXECUTIVE SUMMARY

4

SEPTEMBER 2001 SURVEY LAUNCH

I.

INTRODUCTION

5

II.

RESEARCH METHODOLOGY

7

III.

FINDINGS AND RESULTS

8

IV.

DISCUSSION

13

V.

APPENDICES

14

1. 2003 Los Angeles County Productivity and Quality Award 2. 2003 DHS Office of Diversity Programs Award 3. 2004 National Association of Counties Achievement Award

14

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ABSTRACT & EXECUTIVE SUMMARY

ABSTRACT The Los Angeles County Department of Health Services (DHS), like many other county and state health departments, has been forced over the past several years to provide more services with fewer resources and personnel. With a population larger than any other municipal health department in the country, DHS serves a 10 million population that is markedly diverse. Included in this population is a group of Mesoamerican people estimated at more than 20,000. These people speak neither English nor Spanish but Mayan and Aztec languages and dialects. Creating innovative, low cost solutions to cultural and language barriers in health care access is critical to the health status and well being of Los Angeles County residents. Diverse and culturally competent work forces are also needed to overcome existing nonfinancial barriers to health services. Consequently, DHS partnered with Clinica Monseñor Oscar Romero (CMOR) and developed a Mesoamerican Research and Intervention Project. In light of DHS’ emphasis on sustainability thinking from project inception, project activities were funded by DHS at 34% and CMOR at 66% for a total of $136,014.00 for 18 months. This project allowed the Department of Health Services to: (1) better understand and serve Mesoamerican people, (2) create low cost, sustainable health care, (3) implement the first formal, culturally-sensitive clinics in town for Mesoamericans, (4) increase the CMOR patient load by more than 1033%, (5) generate an annual return of 1177% ($547,156 .00 and growing) from DHS’ seed investment of $46,462.00 and most importantly,

(6) improve access to health care for Mesoamericans living in Los Angeles.

EXECUTIVE SUMMARY The Metropolitan Service Planning Area Health Office (SPA 4) created an innovative, low cost solution to the cultural and language barriers in health care access among the Mesoamerican people residing in Los Angeles County. Estimated at 20,000, this population speaks neither English nor Spanish but rather Mayan and Aztec languages and dialects.

SPA 4 partnered with a communitybased organization, Clínica Monseñor Oscar Romero (CMOR), to create and pilot a Mesoamerican Research and Intervention Project during the period of July 2001 through December 2002. This project sought to: (1) better understand and serve the Mesoamerican population, (2) improve their health status and well being, (3) create a low cost intervention, and (4) develop a diverse and culturally competent work force needed to overcome existing non-financial barriers to health services. In light of SPA 4’s emphasis on sustainability thinking from project inception, project activities were funded by DHS at 34% ($46,462.00) and CMOR by 66% ($89,552.00) for a total of $136,014.00 for 12 months. The project was extended at no cost for an additional six months. The DHS funding for this project was provided by the Office of Supervisor Gloria Molina, First District, Los Angeles County Board of Supervisors. Following an18month period, CMOR assumed total financial responsibility for project activities that presently continue and are expanding. Specifically, the project: (1) provided clinical services in Mesoamerican languages, (2) researched the health needs and

demographic patterns of disease of Mesoamerican people, (3) researched the social, economic, cultural, educational, and religious factors acting as barriers to health care, and (4) developed recommendations for sustainable health promotion, wellness, and disease prevention and control interventions for Mesoamerican communities.

The DHS diversity vision and mission was advanced through a public/ private partnership that improved both qualitatively and quantitatively the provision of culturally sensitive, patient/customer services for Mesoamerican populations. Creating low cost and sustainable solutions to cultural and language barriers in health care access is critical to the health status and well being of Mesoamerican people and Los Angeles County residents as a whole.

Using information gathered through research, SPA 4 and CMOR gained insight into the Mesoamerican community; particularly, their culture, values, practices and beliefs.

This allowed the development of programs and services that were tailored to meet their health care needs in a culturally and linguistically specific manner. This project: (1) created an environment that respects the culture and understands the language of Mesoamerican patients/customers incorporating them into the health care delivery system, (2) promoted diversity and enhanced cultural competency of the workforce through the hiring of indigenous Mesoamerican staff, and (3) encouraged the involvement of Mesoamerican people in their individual health care and the health of their children, families, and community.

3

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INTRODUCTION

The Mesoamerican Research and Intervention Project was recognized with local and national awards by the Los Angeles County 17th Annual Productivity and Quality Awards Program (October 2003), The DHS Office of Diversity Programs (November 2003), and The National Association of Counties 2004 Achievement Award (see Appendix page 13 and 14) for the following achievements and milestones: • CMOR programs and services targeted to a population previously overlooked and underserved were strengthened, expanded, and diversified.

• An environment where Mesoamerican patients and customers feel welcome, accepted and valued was created.

• The first formal, culturally-sensitive clinics in town for Mesoamerican people were implemented.

• The functions of CMOR became accessible to a diverse range of employees and clients.

• The pool of qualified surveyors and clinic staff with knowledge of Mesoamerican languages, dialects, and culture was increased.

• Principles of equal opportunity were integrated through the hiring of indigenous Mesoamerican surveyors and clinic staff.

• Health care access increased from 312 patients per year to more than 4,160 per year.

• The annual cost avoidance by DHS equaled $457,600.00 per year (CMOR provides care to at least 80 Mesoamerican patients per week at a cost of $110 per patient. This includes pharmaceuticals, X-rays, diagnosis, case management, treatment, and translation services).

• The project is financially sustainable without DHS funding (DHS saves approximately $136,014.00 per year in operating costs, i.e., CMOR salaries and benefits, educational materials, utilities, etc.).

In summary, the Mesoamerican Research and Intervention Project increased health care access for Mesoamericans and advanced the DHS diversity vision and mission. This was done through a public/private partnership that conceptualized and implemented strategies to build and fully utilize a representative and culturally competent workforce to increase diversity, promote cultural competence and enhance institutional credibility and effectiveness. In turn, the Mesoamerican community has been receptive and appreciative of services enhanced and non-financial barriers to public health and health care services were diminished (i.e. language and communication barriers, mistrust and fear of health care or governmental institutions, limited knowledge about how to navigate large agencies and systems).

SEPTEMBER 2001 SURVEY RESULTS: I. INTRODUCTION Guatemala recently emerged from 36 years of civil war. The peace accords mediated by the United Nations officially took effect in January 1997.

The lengthy conflict resulted in over 100,000 people dead, 40,000 people missing and/or presumed dead, and the dislocation of two million people, many of whom fled permanently to Mexico and the United States.

The actual number of Mayas who

migrated to the U.S., particularly to Los Angeles County, is unknown.

The best estimate is that 20,000 Mayas reside in Los Angeles County.

In addition, little is known about the quality of life, access to health care and the health needs of this population.

Poverty, illiteracy and poor health is common among Mayan immigrants and their children. These adverse conditions are compounded by their unfamiliarity with the U.S. legal system as well as the health, education and social services, a fear of governmental entities, transportation issues, a lack of health insurance coverage, and reliance upon traditional, botanical and/or folk medicine. Making matters worse is a huge linguistic and translation gap.

Both Latinos and non-Latinos assume that Mayas are fluent in Spanish, but some speak only limited Spanish and the majority do not speak Spanish or English, particularly the historically neglected Maya women.

Contrary to popular stereotypes, contemporary Maya populations do not constitute a single ethnic or language group. Twenty separate Mayan languages are spoken in Guatemala today. Other Mayan languages are spoken in southern and eastern Mexico and Belize. The official number of languages listed for Guatemala is 53, including 51 living languages and two (2) that are extinct. Consequently, culturally and linguistically appropriate information and services, including limitations on outreach into these communities are major factors that create access barriers to the Los Angeles healthcare system for the Maya population.

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INTRODUCTION

In Los Angeles, Maya populations seek healthcare primarily at Clínica Monseñor Oscar Romero (CMOR), and to some extent at Clínica para Las Américas. CMOR was founded originally to address the health needs of Central American refugees; however, their primary and specialty services today extend beyond Central American communities. CMOR estimates that 80% of the Maya people reside in the Pico-Union Area, 10% in South-Central Los Angeles, and 10% in the San Fernando Valley.

Approximately 20-25 Maya patients seek health services from CMOR each week resulting in 90-112 monthly and 1,080–1,344 patients annually. The main two Mayan languages spoken by patients are Kanjobal and Quiché.

Overcoming language barriers has been a challenge of many immigrants in Los Angeles when seeking health care. This challenge is compounded by thousands of Mesoamerican people with limited-Spanish, nonSpanish and non-English proficiency residing in Los Angeles. Linguistic, translation and cultural impediments include, but are not limited to, a health care system that relies on rudimentary skills, patients’ family members, hospital service employees, and other untrained interpreters.

Although the staff of many health facilities speaks several languages, the languages spoken by Maya and Aztec residents in Los Angeles are not easily translatable. Therefore, communication regarding their health status, diagnosis, treatment and follow-up care may be unclear or incomplete to the patients. This indicates that these populations are unlikely to understand health related messages, health education, and health warnings sent into the community. The language barriers

faced by this population places them at risk for illness and poor health in the long run. Also, missed opportunities for primary prevention are likely due to the language barriers.

Many individuals whose culture is traced to the ancient Mayas and Central America are currently living in Los Angeles County. These people speak any one of a number of languages such as Quiche, Kanjobal, and Mam as a first language rather than Spanish, as well as several others. Speakers of these languages cannot mutually understand each other although the languages are related. Very little information exists regarding the extent to which health services are available to these individuals and their health needs and concerns. According to The American Heritage Dictionary of the English Language, a “Maya” is a member of a Mesoamerican Indian people inhabiting southeast Mexico, Guatemala, and Belize, whose civilization reached its height around A.D. 300-900. They were noted for their architecture and city planning, their mathematics and calendar, and their hieroglyphic writing system.

A modern-day descendant of this people is called a Maya or Mayan.

For the purposes of this survey, “Mesoamerican” is defined as an indigenous individual whose roots are in Central America, typically Guatemala, who does not speak Spanish or English as a first language.

Clínica Monseñor Oscar Romero (CMOR) has served the Mesoamerican population for a long period of time. The clinic is located in an area that is densely populated with Mesoamericans. Its mission is to serve the underserved communities.

The SPA 4 Area Health Office worked in conjunction with CMOR to survey this population to determine major health issues, barriers in access to health care, and other health-related data. CMOR serves as a crucial link between the SPA 4 Epidemiology Team and the Mesoamerican population in Los Angeles County by providing translators and surveyors who complete surveys both in-house as well as in the field. Although the total number of people is difficult to ascertain because of counting issues including undocumented aliens, approximately 20,000 Mesoamericans live Los Angeles. However, the goal of this research and intervention project was not to quantify the number of Mesoamericans, but rather to determine the demographic characteristics of those surveyed.

The four strategic goals of the Mesoamerican Research and Intervention Project to better serve Mesoamericans in Los Angeles County comprised the following: • Address the immediate health care needs of limited-Spanish, nonSpanish and non-English speaking Maya and Aztec populations that receive services at CMOR. • Determine the health needs and demographic patterns of disease of Mesoamericans, • Research the social, economic, cultural, educational and religious factors acting as barriers to health care access, and • Develop recommendations for sustainable health promotion and disease prevention interventions for Mesoamerican communities.

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RESEARCH METHODOLOGY

II. RESEARCH METHODOLOGY Project Design: The study design was cross sectional and a survey was used to measure the dependent variables.

A convenience sample was used for this study (non-random sampling was utilized in a largely Mesoamerican immigrant community).

Project Participants: The recruitment of participants was conducted at market places and a Lutheran Church located on Burlington and Pico in Los Angeles (SPA 4). Door to door surveying also took place in the Pico neighborhood. Within the community, the 90017 zip code includes areas of high concentrations of Kanjobal-speaking people. The 90057 zip code area is home to a high concentration of Mam and

Quiche speakers. CMOR provided information directing surveyors to several specific blocks within SPA 4 with a high concentration of Mesoamericans.

Three Guatemalan indigenous surveyors were trained to survey three target linguistically defined communities: Kanjobal, Mam and Quiche. The people conducting the surveys were recruited by CMOR staff and were fluent in both Spanish and one of the target Maya-descent languages. These interviewers were trained by the SPA 4 Epidemiology Analyst in survey methods and administration. There were no consent forms for this particular study. The data is confidential and individuals are not identifiable from the information collected. The only

identifying information collected from the respondents was street name and number. A map was created from this information, but there is no identifying information such as name and or date of birth on the map that could be traced back to the individual.

Data Analysis: All primary data was extracted from the surveys and entered into X Software according to inclusion and exclusion criteria. People who were from Central America met the criteria to participate in the study and spoke one of the Mayan languages. The survey was designed to find out the health needs of people of Central American origin. Individuals who did not originate in this geographic area were excluded from the survey.

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FINDINGS AND RESULTS

III. FINDINGS AND RESULTS A total of 693 surveys were completed in August 2001. Ninetyfive surveys were completed at CMOR and the remaining 598 were completed from the non-clinic population. Ninety-five percent of the respondents reported themselves as non-Spanish speakers for their primary language. The majority of respondents were young males (~75%). The age category 19-25 was the largest and 476 = 69% selfreported as single and 197 = 28% married (Figure 1). The respondents were mostly Quiche (474 = 68%) and Kanjobal (139 = 20%) speakers (Figure 2). This is not a representative proportion of the actual distribution of the Mesoamerican people in Los Angeles County. Instead, we believe that the proportion of participants is a result of the availability of translators and surveyors who conducted the survey. The reader should bear in mind that with a very small sample size for such groups as the Mam, Zapoteko and Kaqchikel, there is a low statistical significance. of the responses from these groups.

Figure 1. Reported Marital Status of Mesoamerican Population

Figure 2. Language Distribution of Surveyed Population

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FINDINGS AND RESULTS

Figure 3 indicates the geographic distribution of the people surveyed.

As was expected, there is a large concentration of Mesoamericans in the Central Health District as this is an area known to house a colony of Mesoamericans and was the location of the survey. However, there were a number of locations to the south of SPA 4 that also reported Mesoamericans, such as the Southwest and Southeast Health Districts. In SPA 4, there is a large concentration of Mesoamericans within the area bordered by the streets of Alvarado, Beverly, Olympic and Wilshire (Figure 4).

Figure 3. Geographic Distribution of Mesoamericans in Los Angeles County byHealth District- September 2001

Figure 4. SPA 4 Distribution of Mesoamerican People

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FINDINGS AND RESULTS

Among the Kanjobal population, 66% reported needing a translator for medical services, compared with 56% of the Zapoteko speakers, 40% of Mam speakers and 37% of Q’iche speakers (Figure 5). This represents a significant number of individuals, when extrapolated to the total population, who need translation services to access health care.

More than 90% of respondents in all age groups reported having no health insurance and access to health care services, particularly 96% of the 19 – 26 age group (Figure 6), reflecting the acute need for health care access among Mesoamericans.

In addition, A gender difference in healthcare access was also noted.

Males reported a higher proportion of lack of healthcare access (98%) compared to 97% of female surveyed (Figure 7).

Figure 5. Percent of Survey Population Needing Translator for Medical Needs

Figure 6. Proportion of Mesoamericans Lacking Healthcare by Age

Figure 7. Proportion of Mesoamericans Without Healthcare Access in Los Angeles

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FINDINGS AND RESULTS

In terms of employment and health care access, individuals in all employment categories reported lack of health care access ranging from 76% in those not working to 100% among people employed in construction, food service, day workers and sewing (Figure 8).

Lack of access to healthcare varied by cultural subgroup among the Mesoamerican population and ranged from 86% in the Kanjobal cultural group to 97% Quiche and 100% among Mam and Zapotekos (Figure 9).

The literacy level varied considerably among specific cultural groups.

Respondents in the Kanjobal group reported 56% ability to read or write any language compared to 71% of Q’iche, 100% of Mam and 94% of Zapoteko. This information is important when planning for community and health education outreaches since Mesoamericans experience high degrees of isolation and written communication can be understood only by a very small percentage of them (Figure 10).

Figure 8. Proportion of Mesoamericans Without Healthcare by Employment

Figure 9. Percentage of Mesoamericans Reporting No Access to Health care, by Cultural Group

Figure 10. Percentage of Mesoamericans Able to Read or Write any Language, by Cultural Group

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FINDINGS AND RESULTS

In terms of health issues, chronic conditions such as back pain, headache, vision and hearing problems, asthma and gastrointestinal symptoms were more prevalent.

Acute illness is apparently treated at emergency rooms free of cost (Figure 11).

Responses from the survey revealed the barriers to access to healthcare experienced by Mesoamerican people (Figure 12). Lack of money was the most frequently reported barrier to health care access. This is not surprising given the typically lower incomes found among Mesoamericans and the need for free or low-cost medical care is evident. Language barriers were noted by the target population to be another obstacle.

The need for translators able to communicate to individuals using relevant languages was also indicated.

In addition, many of the participants experience difficulty navigating the health care system and those that work in manual labor have no benefits such as sick days or leave time, and time off for medical reasons during normal business hours is not an option. Consequently, individuals that need health care do not seek services and risk losing their jobs or wages if they take a day off. Transportation is another access problem reported. It is difficult for the Mesoamericans to go to health care providers because of a “perceived� public transportation system in Los Angeles that is cumbersome. Possibly, barriers to healthcare access compound one another and language barriers may result in the inability to understand bus schedules and/or follow guidance and instructions.

Figure 11. Physical Illness Condition Reported at Time of Survey

Figure 12. Most Frequently Reported Barriers to Healthcare Access

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DISCUSSION

IV. DISCUSSION In this cross sectional study, demographic variables and health indicator variables such as health care access, health insurance status, self reported chronic and acute illnesses were examined. The results obtained from this study indicate that most of the target population is in need of translation services, do not have health insurance and face barriers in accessing health care. These findings reflect an urgent need for medical, public health and social services to reach out to Mesoamericans to improve their access to health care, help them navigate the county system, and develop health promotion and disease prevention and control efforts, particularly for chronic conditions. Mesoamericans do not utilize health care services regularly and are at risk for increased morbidity and mortality including underreporting or no reporting of acute and chronic diseases.

Furthermore, the utilization of preventive services is not a likely option given the barriers faced when seeking regular or urgent health care. Consequently, findings support the need for increased health care access among Mesoamericans due to socioeconomic, educational and cultural risk factors leading to poor health outcomes among the Mesoamerican people living in Los Angeles County.

There are several limitations to this study. It is important to note that the selection method of participants was non-random and participants were recruited primary in communities with a high concentration of Mesoamerican immigrants. The sample surveyed is not representative

and cannot be generalized to the entire Mesoamerican community.

Another limitation of this study is the small sample sizes of some of the linguistic groups and, thus, the statistical accuracy is limited among those groups. In addition, this research was cross sectional and measured behaviors for only one time point; thus, limiting the ability to determine cause and effect.

In any event, the Mesoamerican Research and Intervention Project indicated that further investigation is needed to examine the health needs, priorities and concerns of Mesoamerican people. A longitudinal research is recommended to track health seeking behaviors and access to health care among the target group. Nevertheless, the following barriers to healthcare access were discovered and need attention in order to improve the health status and wellbeing of the Mesoamerican population.

• Free or low-cost health care must be available. Mesoamericans simply cannot afford to pay for expensive healthcare.

• Translation services must be available. In order to communicate effectively, there must be someone who speaks the patients’ indigenous languages.

• There must be information readily available to patients in verbal form.

Many individuals surveyed reported an inability to read or write. Written materials are of little value unless there is someone available to read the materials to the patient.

• Transportation issues must be addressed. A community clinicsponsored van to transport patients to the health care provider might be one of the strategies to address this issue. Bus tickets could also be provided. The transportation issue is simplified by the fact that the majority of the Mesoamericans live clustered within a small area of SPA 4.

Finally, the Mesoamerican Research and Intervention Project proved to be a useful tool to bring increased focus and attention to the social and health needs of Mesoamerican people that live in Los Angeles. It is our hope that Clinica Monseñor Oscar Romero (CMOR) will continue to serve this population and that there will be continued cooperation between DHS and CMOR to enhance the health status and wellbeing of this population, as well as to bring to the table additional public, private and non-profit partners and stakeholders.

• Office hours must extend beyond the normal 8:00 am to 5:00 pm schedule. For many, it is difficult to make clinic visits during regular work hours. Health centers should offer evening and possibly weekend office hours as a way to increase health care access.

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APPENDIX 1

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APPENDIX 2

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APPENDIX 3

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Metropolitan Service Planning Area (SPA 4) 241 North Figueroa Street, Room 312 Los Angeles, California 90012 Tel: (213) 240-8049 Fax: (213) 202-6096 www.lapublichealth.org Š 2001 SPA 4

Increasing Health Care Access for Mesoamerican People Living in Los Angeles: SPA 4 Case Study

September 2001