An intercultural model for providing care to migrant families. Susan Dollar. Missouri State University, US Visiting Professor at Buryat State University

Although a vital sector of the U.S. farm economy, migrant farmworkers suffer from persistent poverty and low social support [1; 20]. Most migrant farmworkers have only a fifth-or sixth grade education [18], and many do not speak English as their first language [16]. These factors, along with structural vulnerabilities (i.e. community discrimination; lack of access to basic health, education, and welfare services) and legal status issues [2; 5; 6], predispose most to chronic poverty.  These factors make it difficult for the worker to recognize and be able to communicate the details of health problems to caregivers when they manage to reach a health care facility [11].  Due to fears of being deported, many migrants will not seek health care services [3].  Others, even though working, lack health insurance and experience cultural barriers of language and belief systems when seeking care [8]. Consequently, workers and their families face delays in treatment and serious complications once they receive health services [3; 6; 17; 20].

The same issues which affect migrant farmworkers as individuals impact them as families as well.  Often because of poor living conditions, the family is separated while the breadwinner is working.  However, 66 percent of farmworker parents have their children with them.  This provides an important source of social support, but compounds the need for basic services for the entire family [7].

I propose a model to help the practitioner to understand the migrant farmworker family in context with the family health approach to practice [9]. Following a cross-cultural perspective, the model gives information about the migrant families’ cultural and health practices, integrating those beliefs with traditional Western medical and social work practice methods.  The holistic nature of the family health approach will help to meet the families’ multiple needs, by emphasizing primary family health care. The approach also highlights the importance of service integration of migrants who often lack the money, time off from work, and transportation to reach traditional health and social services agencies for care [18].  A “one stop” service system would contribute to the overall well-being of the family unit by providing access to basic services; healthcare, food assistance, housing assistance, educational and employment services, and legal aid. These migrant health intervention strategies are described below:

Family Health Principle One:  Multiple Level Health and Family Assessment

What this principle suggests is that health professionals should be aware of their patients’ cultural, migratory, and family health histories when assessing service needs.  Many migrants come from areas where civil war, poverty, and natural disaster have influenced their decisions to migrate and bring family members along.  A background history, which indicates their past experiences and motivations for migrating, can be useful for determining levels of family stress likely to affect health status and motivation to comply with the treatment plan.  In addition, there needs to be a firm commitment at the agency and community levels to utilizing bilingual/bicultural workers and to developing family information forms, which aid in the assessment and intervention process.  From a community needs assessment standpoint, it is important to earn confidence and trust, in a targeted community.  Find out who is respected in the community. Question your patients, your staff, business owners, clergy, members of the media, teachers who are the respected leaders, and agencies.  And remember the value of building personal relationships in the community.  Go to the local leaders, and ask for their opinions about what people in the community need the most.

Family Health Principle Two: Brokering Services from a Holistic and Family Perspective

The use of bilingual/bicultural lay educators in assessment, prevention education, outreach activities, and social supports is an important link to developing trust and good relationships, which can lead to treatment compliance and better health outcomes.  Techniques for those with low reading levels, such as story telling, role-playing, games, and the use of pictures to illustrate ideas, are critical to communicate health educational information [4; 19].

Family Health Principle Three: Calls for Practice Expertise in Family and Health Interventions

Adapting the therapeutic style through linguistic and cultural competencies is essential to assisting migrant families.  Target whole families with understanding and respect.  Formality is a sign of respect but should not be confused with emotional distance.  Programs are most successful when emphasizing the connections among the individual, the family, and the community.  A practitioner must establish a relationship of trust with community leaders and institutions. While men are viewed as the primary decision makers to be granted formal respect in all family matters, the women have traditionally served a central role in making most of the health-related decisions for the family [11].

Modifying serves systems to meet migrant needs is another component to culturally sensitive policies.  More inclined to use home remedies for illnesses, the Hispanic family tends to delay seeking treatment [1; 5].  Allowing the patient to take his or her home remedy in conjunction with prescribe medication can be a culturally relevant strategy to improve adherence to a therapeutic regimen [1; 10].  In addition, agency policies should be flexible enough to permit bringing in traditional healers, such a curanderos, or herbalists, to work as partners with practitioners of modern medicine.  The traditional healers must be credible, respected members of their communities who understand both cultures and health belief systems [14].

Family Health Principle Four:  Calls for Advocacy Skills Concerning Social Justice Issues Related to Health and Family

Combating poverty, reducing hazardous working conditions, and addressing barriers to health care are a few of the major social justice issues related to migrant families.  Intervention strategies to address these concerns can be aided by recruiting and training migrant advocates lobbying for changes in larger societal systems.  The potential audience is quite wide:  legal services, consumer education/protection agencies, local as well as national ethnic immigrant organizations, and other non-profit organizations that address health care issues [7].  Migrant advocates also can be useful in information the families about their legal and civil rights concerning immigration laws, health statutes, safety regulations, and accessible as well as appropriate health care services [7].

Family Health Practice Principle Five: Calls for Expertise in Management of Service Systems Serving Health and Family Issues

Case- or service-level strategies to foster service integration involve a culturally sensitive practice that improves access to a range of social and health services for migrant families with multiple needs.  Extending the service delivery systems, though home visits and mobile clinics, to the places where migrant families work and live is and excellent strategy for early health screenings, intake and assessment, and follow-up with clients.  Service-level adaptations include collocation of health and social services, portable medical records, walk-in clinics with extended hours, and the provision of transportation as well as translation services.  Service integration at the community level to enhance “one-stop shopping” of migrant families includes interagency coalitions, regionalization of organizations, participation on boards of other community organizations, and joint fundraising activities  [7; 13; 15].

Family Heath Principle Six:  Calls for policy analysis and practice in family health context

Several strategies at the agency and government levels are called for to deal effectively with the current state of migrant families.  One strategy addresses the improvement of traditional public health services. This includes providing portable water, assuring sanitation services in the fields, guarding against pesticide exposure, and addressing substandard housing conditions.  All of the measures strengthen primary care for migrant [7].

Another strategy involves educators; cultural and linguistic competence can be incorporated into their curricula in order to raise awareness of the impact of society and language on health care delivery.  The audience for such as intervention includes health care professionals, educators, training institutions, and legal as well as social service education [7; 15].

Finally, program evaluation at all systems levels should be conducted regularly to keep up with the current and emergent demographic trends.  The evaluation is needed to follow migrant families and culturally y appropriate responses to their needs [12].

In closing, I believe the Family Health Model is designed to support and strengthen the migrant family through cultural relevant health interventions.  The model understands that the needs of migrant families go beyond health interventions and address the multiple needs for food, clothing, and housing.

Chart One- Migrant Health Intervention Model

Multiple level Health & Family Assessment Awareness of past experiences, family histories, and traditional health beliefs/practices.  Identifying barriers: language, perception of illness, reluctance to seek Western medical care, community prejudice Utilizing bilingual workers; developing bilingual intake/consent/assessment family information forms; adapting Western medical procedures to family’s health beliefs and practices (i.e. use of family in decision-making, use of home remedies in conjunction with Western medical regimen)
Brokering services from a holistic and family perspective Use of bilingual/bicultural lay-educators and social support; culturally relevant techniques, such as story-telling, role-playing, games, use of pictures to illustrate ideas Prioritizing primary health and prevention education and outreach and directing resources to improve access to care for families
Practice expertise in family and health interventions Adapting therapeutic style to meet needs by: Assisting in culture transition by teaching families about the Western medical system; taking more time to develop interpersonal rapport and trust; understanding family hierarchy and respecting traditional family roles; understanding folk and home remedies and its compatibility with Western medicine. Culturally sensitive policies such as:  Individual- and Agency-level linguistic and cultural competencies; modifications of service systems
 Advocacy skills concerning social justice issues related to health and family Recruiting and training advocates; and informing families about their legal and civil rights Advocating for families through: Program evaluation and research on health risks/trends/best practices; lobbying efforts at local, state, and federal level to combat poverty, hazardous work conditions, lack of access to health and social services
Expertise in management of service systems serving health and family issues  Improving access to care through:  Home visits; mobile clinics; extended hours; transportation; translation services; portable records Service integration through: interagency coalitions; regionalization/umbrella organizations; participation on boards of other community organizations; joint fundraising activities
Policy analysis and practice in family health context Evaluation of the quality and appropriateness of services using family consumer input Advocate for comprehensive family & immigration policy at state and federal levels



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