Northwest Michigan Health Services, Inc s1

Northwest Michigan Health Services, Inc. A Farmworker Health Program

Tri-County Farmworker Demographic Study and Health Needs Assessment 2006

A Report by: Elizabeth Horevitz, Public Outreach Coordinator Table of Contents

1. Executive Summary…………………………………………………………. 3

2. Introduction …………………………………………………………………. 7

3. Methodology …………………………………………………………………. 8

4. Section I: Basic Data ………………………………………………………… 10

5. Section II: Language ………………………………………………………… 13

6. Section III: Living Accommodations ………………………………………. 16

7. Section IV: Race and Ethnicity ……………………………………………… 18

8. Section V: Family Status……………………………………………………… 20

9. Section VI: Education Level…………………………………………………. 22

10. Section VII: Occupation of Respondents……………………………………. 25

11. Section VIII: Migration Patterns…………………………………………… 26

12. Section IX: Barriers to Care………………………………………………… 28

13. Section X: Services Requested………………………………………………. 29

14. Section XI: Perceived Health Problems…………………………………….. 33

15. Section XIII: Occupational Safety and Free Time Activities……………… 35

16. Conclusion…………………………………………………………………….. 36

2 Northwest Michigan Health Services, Inc. Executive Summary Judith Williams, Executive Director

Migrant and Seasonal Farmworkers in Michigan

Year after year, thousand of families make their way across state and national borders to help United States agricultural growers harvest a magnificent abundance of fresh produce. As one of the leading producers in the nation, Michigan is second only to the state of California in the variety of fresh produce grown throughout its rural terrain. In Michigan, alone, it is estimated that over 45,000 migrant and seasonal farmworkers and their families comprise the essential labor force that supports the region’s agricultural economy (Dr. Alice Larson, “Farmworker Profile Study,” 2006).

These workers contribute great skill and expertise in each community, as well as bringing new languages, philosophies, music, art, religious beliefs, health practices, and social cultures to the region. Because farmworkers often experience increased health risks, access to quality services are paramount in treating acute and chronic conditions, minimizing risks, and averting poor health outcomes.

Northwest Michigan Health Services, Inc.

In response to a growing need for health care for Michigan’s agricultural labor force, Northwest Michigan Health Services, Inc. (NMHSI) has provided culturally appropriate primary medical and dental services to Migrant and Seasonal Farmworkers and their families since 1968. Serving seven rural counties that span 3,100 square miles in Northwest Lower Michigan, NMHSI is the only health organization in the state of Michigan that serves exclusively Migrant and Seasonal Farmworkers. NMHSI’s expert staff specialize in providing all services in both English and Spanish.

In recognition of the unique needs of agricultural employees and their families, the following mission represents the core root from which NMHSI’s programs are grown:

“To provide basic medical and dental services to the migrant and seasonal farmworkers of Northwest lower Michigan in a compassionate manner which is intended to be responsive to their specific circumstances.”

NMHSI is a non-for-profit entity that operates a network of Federally Qualified Health Centers and outreach programs. Each clinic conducts extensive bi-lingual outreach programs to facilitate access to services, alleviate barriers to care, and provide health education to constituents in their home environments. Outreach activities extend into isolated and remote areas of rural Michigan. In addition, Screenings and well-child examinations are conducted throughout the service region at multiple Migrant Head Start and Migrant Education Program facilities.

3 NMHSI professionals provide the full range of primary dental and medical diagnostic and treatment services as well as preventive services, including physical examinations, immunizations, and vaccinations. Each practitioner makes referrals for specialty care as needed. Because the vast majority of farmworkers do not speak English, NMHSI provides language support services for Spanish-speaking clients, including those who have been referred to specialist providers who cannot communicate with the patient in his/her native language. NMHSI’s qualified medical interpreters help to reduce language barriers and avert poor health outcomes that may be attributable to communication failures.

NMHSI’s bilingual staff assist patients in applying for health programs, as well as social support services. Case management is a high priority to ensure continuity of care. Both clinical staff and outreach teams educate clients about health risks and prevention, empowering both adults and children to participate in their own health management.

Northwest Michigan Health Services, Inc. takes pride in promoting effective service models and partnering with other organizations to provide culturally responsive services. This project is designed to further NMHSI’s mission to provide quality medical and dental services for Migrant and Seasonal Farmworkers in appropriate ways that honor their culture and traditions.

Project Puente: “The Bridge Project”

In January 2006, Northwest Michigan Health Services, Inc. conducted a tri-county Grower’s Survey to learn more about farmworkers in their employ. NMHSI’s Public Outreach Coordinator interviewed 31 agricultural producers in Antrim, Leelanau, and Grand Traverse Counties to solicit their input regarding health issues affecting their farmworkers, as well as their suggestions for improving health services. Respondents to the Grower’s Survey provided invaluable background information for NMHSI’s “Project Puente” Farmworker Survey, which soon followed as a companion study.

“Project Puente,” meaning the “Bridge Project,” was created to help “bridge” the barriers that impede access to health care, which are often experienced by migrant and seasonal farmworkers. NMHSI first launched its Project Puente in June 2006. This unique undertaking embraces a multi-disciplinary learning program, giving college-level interns training and experience in working with migrant and seasonal farmworkers. Project Puente Team members participate in lay health education, active research, interviewing, problem resolution, and project development.

The Puente approach integrates outreach activities and health education with investigative research about the consumer. The Puente Team operates under this framework, which not only maximizes limited resources, but also enriches each visit.

The Puente Team visited the dwellings of migrant and seasonal farmworkers in Antrim, Leelanau, and Grand Traverse Counties to gain a fuller understanding of family composition, employment, migration patterns, health issues, and service needs. The Team conducted interviews in 369 households, learning about the living patterns, experiences, and insights of over 1,300 residents.

A few of the Team’s findings include the following: 4  Age: Average 34 years.  Language: 79% claim Spanish as their first language: of those, 70% speak no second language.  Gender of those surveyed: 55% male; 45% female.  Family Composition: 51% males are unaccompanied; 39% males with family; 9% males live with one extended family member. 87% females live with family; 1.2% females are unaccompanied.  Education: 53% have completed 6th grade or below; 1% completed college. 7% no education.  Agricultural Work: 93% cherries;70% apples; 37% strawberries; 33% grapes; 23% Other produce; 17% cucumbers; 6.5% Christmas Trees; 6% Melons; 5% Flowers; 1% Nuts.  Other Family Member Occupations: Construction, Landscaping, Restaurant, Hotel, Plant Nurseries, Social Services, Poultry Processing, Dairy, and Fisheries.  Workforce Composition: Migrants = 65%; Seasonal (Year-round Residents) = 35%.  Range of time in United States: 2 weeks – 62 years.  Barriers to Health Care Services: Language, Transportation, Cost, Conflicts with work schedules, Limited clinic hours, Unavailable specialty services.  Most Requested Services: Dental, Transportation, Interpretation, Men’s Health, Pediatrics, HIV Testing, Women’s Health, Diabetes Education, TB Testing, Job Safety Training, Mental Health, Prenatal Services and Education.

The following report, prepared by Lizzie Horevitz, Public Outreach Coordinator, represents the findings of the research team after completing Phase I of the Farmworker Study in Antrim, Leelanau, and Grant Traverse Counties. NMHSI is currently expanding its research initiatives to include the other four counties in its Northwest Lower Michigan service region (Benzie, Manistee, Oceana, Mason).

Special Acknowledgements

Northwest Michigan Health Services, Inc. wishes to thank the regional agricultural growers who participated in the Grower’s Survey and supported NMHSI’s efforts to learn more about the needs of our constituents. We are also deeply indebted to the many farmworkers and their families who opened their homes to NMHSI workers and shared their insights and experiences with the interviewing teams. Special thanks goes to the following NMHSI staff members for their tireless efforts in meeting and surpassing the original goals of the project:

 Lizzie Horevitz, NMHSI’s Public Outreach Coordinator, who assumed the day- to-day leadership and supervision of the 2006 Farmworker Study;  The Project Puente Team: Ryan Malosh, Andie Gonzalez, Rachel Lovis, and Emily Nykaza;  Outreach Worker, Sharon Jacker;  Lay Health Educator, Marty Fleming; and  Ann Avery, Director of Clinical Services, who provided guidance and mentorship to the entire team.

5 Finally, we extend our gratitude to the many members of community based organizations that work along side us as professional colleagues and service providers. Your support and shared commitment to improving community services helps to propel worthwhile projects forward. We trust that the information contained here may assist our continuing partnerships in promoting public awareness and enhancing services for migrant and seasonal farmworkers and their families.

6 Introduction

During the summer and fall of 2006, Northwest Michigan Health Services, Inc. (NMHSI), via its Office of Public Outreach, conducted an informal demographic study and needs assessment of 369 farmworkers in the tri-county service area of its Traverse City-based clinic (Leelanau, Grand Traverse and Antrim counties). The three main goals of the survey were: first, to approximate the number of migrant and seasonal farmworkers living in NMHSI’s tri-county service area; second, to obtain their demographic information; and third, to ask the farmworkers about their needs. NMHSI plans to use the results of this study to guide program development. The demographic information obtained was in response to questions regarding: age, gender, marital/family status, migrant vs. seasonal status, migration patterns, language ability, education level, occupation (self and family members), country of origin, and current type of living accommodations. The needs assessment addressed: perceived barriers to care, perceived health problems, and asked which services the respondents believed should be more accessible and/or available to them. Because of the magnitude and scope of this project, the initial goal for sample size was 200. However, the project team was able to exceed this initial goal, ultimately surveying 369 people, representing approximately 1314 people. The project team started the season with the hopes of reaching the 70 or so places of farmworker residence that NMHSI was aware of previously. Not only did the team succeed in reaching all 70 camps, homes, trailers, and apartments—but, through snowball methodology, were able to locate 75 new places of residence not previously known to NMHSI- more than doubling the initial listing to a total of 145 places of farmworker residence1. NMHSI believes this process helped to greatly increase the number of clinic users during the 2006 season, as approximately 30% of the people surveyed had not known about our clinic or services prior to being surveyed. The data and its analysis presented in this document are meant as a guide for NMHSI program development. NMHSI will share this information with partner organizations; however, it should be emphasized that the study conducted was informal in its nature, and has not been tested for validity and reliability. Furthermore, as this was not a longitudinal study, the data gathered represents a “snapshot” of the farmworker population between June and October of 2006. NMHSI plans to repeat this study every three years so that we may begin to track patterns and changes within the farmworker community in lower northwest Michigan to better serve NMHSI’s farmworker clients and their families.

1 Each migrant camp was counted as one place of residence (individual units within the camps were not counted as separate places of residence). 7 Methodology

The goal for this project was to reach every farmworker home. The survey was designed to be conducted via in-person interviews. The survey interviews lasted between five and twenty minutes, depending on how detailed the respondents were in their answers. The survey itself was in both Spanish and English, and designed to be understandable at a 6th grade reading level. The Public Outreach Coordinator entered each survey into a database for later analysis. In order to cover the span of area for this study, NMHSI created a specialized internship (“Project Puente”) for four bilingual college students from Michigan State University’s CAMP Program (College Assistance for Migrants Program), and the University of Michigan, Ann Arbor. Project Puente interns worked as part of the greater outreach program2, and as such underwent extensive training in cultural competence and lay health education (using a “Popular Education” model3). The Puente team worked from the Traverse City clinic and, in pairs, traveled to farmworker places of residence in Leelanau, Grand Traverse, and Antrim counties. The team had three main activities in their counties: conduct the farmworker demographic survey, provide health education presentations (designated by farmworkers), and help connect farmworkers to the clinic and other services in the community. Because the goal was to interview each head of household (1 survey per family), the team only conducted surveys in farmworker homes so as to avoid duplicate counts. The team’s progress was tracked on a large wall map where all places of farmworker residence in the tri-county service area clinic were charted, and also on a database maintained by the Public Outreach Coordinator. Because the majority of camps had numerous units, the interns diagrammed each camp so they could track which units (e.g. trailers) had been surveyed, and which units still needed to be surveyed. This, again, was to avoid duplicate counts. Before conducting the surveys, the Puente team spent several weeks getting to know farmworkers in the area, informally chatting with them and helping to connect them with local services. Besides the obvious goal of facilitating access to care, this offered an opportunity to build a sense of trust between the farmworkers and the Puente team. Despite the fact that the survey was anonymous and confidential, it was imperative to build trust between the interviewers and interviewees for reasons of accuracy, as some of the questions in the needs assessment section of the survey were of a sensitive nature. As such, a major goal for the execution of the survey was for respondents to feel comfortable and safe responding to survey questions honestly. As a general rule, NMHSI tried to pair the male intern with male respondents and female interns with female respondents. However, this was not always possible as three out of four interns were female. As such, some of the responses of males interviewed by females (and/or females interviewed by our male intern) may not represent their viewpoints as accurately as those interviews conducted by members of the same sex as the respondent. The interns completed the surveys, for the most part, in the evenings, when they were more likely to find farmworkers at home. During the height of cherry season, however, this proved challenging as workers stay in the fields from early in the morning until late at night (10pm). Despite this challenge, the project team was able to visit all 145 camps, apartment complexes, trailer parks, and homes. NMHSI estimates that the project

2 NMHSI’s Outreach Worker and the Men’s HIV Lay-Health Educator also conducted surveys in addition to the Puente team, and their efforts were part of the overall success of this project. 3 See Paolo Freire, “Education as a Practice of Freedom” (1974), and “Pedagogy of the Oppressed” (1970). 8 team missed approximately 100 families due to timing issues (work schedule and/or families leaving the area before the Puente team reached them), or, in a few cases, constituents declined to be interviewed. As an incentive for completing the survey, respondents received an NMHSI T-shirt4. In several cases people approached NMHSI requesting to be surveyed because a coworker had a T-shirt and they wanted to find out how to get one as well. In general, the team found that most respondents enjoyed the opportunity to share their experiences, concerns, and suggestions in a more formal format. In addition to conducting the survey during a visit, the project team also helped connect respondents to local support services, make appointments at the clinic, and provided health education on subjects ranging from oral health to HIV prevention5. The list of farmworker residences was originally based on outreach documentation from previous seasons, and listings of registered migrant camps from the Department of Agriculture. The enumeration study was also a follow-up study to a growers survey conducted by the Public Outreach Coordinator during the winter months, where we acquired other addresses of smaller, unlicensed camps. NMHSI ultimately doubled its original list by asking respondents if they knew of other places of farmworker residence in the area, and by checking through registered addresses in the clinic database each week to ensure that all new addresses were added to the master list from which the interns and outreach team worked. NMHSI found the process of conducting the surveys to be extremely successful. As mentioned previously, approximately 30% of farmworkers surveyed had not known about the clinic prior to being interviewed. This project provided a formal way for farmworkers to share their experiences and ideas. It will allow NMHSI to take direct action related to farmworkers’ suggestions and guide long-term development based on new demographic data and farmworker input. In addition, the four interns – one of them a former migrant worker-- who participated in Project Puente gained valuable knowledge and insight into issues facing the farmworker community in Northwest Michigan through the strong relationships they built with farmorkers throughout the internship. NMHSI believe these bonds have also resulted in more clients seeking health care at the clinic and, conceivably, better patient compliance.

4 As more and more people were surveyed, the Puente team would encounter fields of workers all in the bright blue clinic shirts. 5 For more information on the activities of the Project Puente team, visit http://www.record- eagle.com/2006/aug/21migrant.htm, or the NMHSI website: www.nmhsi.org

9 Section I: Basic Data

Surveyed Population by Number and Group

1400 1314 r

e 1200 b m

u 1000

y 800 Total b Migrant n

o 600 491 i

t Seasonal a l 400 u p

o 200 P 0 1 Population by Group

Total persons surveyed: 369 Total persons represented: 1314

Total Migrants represented: 823 (63%) Total Seasonal workers represented: 491 (37%)

Gender of those surveyed: Male: 202/369 = 55% Female: 167/369 = 45%

Age: Average age of those surveyed: 34.4 years

Country of Origin: The majority of respondents were originally from Mexico, followed by the United States, at about one quarter of the total group.

Country of Origin of Farmworker Respondents Ukraine El Salvador 0.3% Guatelmala0.3% Germany 1% Honduras 0.3% 1% Mexico USA USA 23% Honduras Guatelmala Ukraine El Salvador Mexico Germany 75%

Population Surveyed by County:

10 Grand Traverse County shows the highest ratio of migrant to seasonal workers (at about 1:1), while Leelanau shows a ratio of about 3:1, and Antrim 2:1. While it is possible that more farmworkers settle-out (become year-round residents) in Grand Traverse than the other two counties represented in this study, this data may be skewed due to the number of seasonal farmworkers the team was able to find throughout the course of this study. The team acquired more information about the whereabouts of seasonal housing in Grand Traverse than any other county. Therefore, there may be more seasonal farmworkers living in Leelanau and Antrim than represented by this study.

Population Represented by County

400 Total 300 Migrant Seasonal 200

0 Grand Traverse Leelanau Antrim

Leelanau (130 surveyed)- Total: 509 Migrant: 378 Seasonal: 131

Grand Traverse (146 surveyed)- Total: 533 Migrant: 268 Seasonal: 265

Antrim (93 surveyed)- Total: 272 Migrant: 177 Seasonal: 95

OTHER:

Range of time in USA (of foreign-born farmworkers) at time of survey: 2 weeks- 62 years - Average time in USA: 15.2 years

Clinic information:

11 71% of people surveyed knew of NMHSI’s Traverse City Farmworker clinic previously; 29% did not know about the clinic 80% of those who knew about the clinic had utilized the clinic’s services at least once in the past.

12 Section II: Language

The majority of farmworkers represented in this survey were native Spanish speakers, and of those, a large majority did not speak a second language. Those who claimed English as their first language were more likely to speak Spanish as a second language than any other language.

Data: 79% First language is Spanish Of those: 71% do not speak a second language 24% speak English as a second language 1% speak a Mayan dialect as their second language 3% speak another indigenous dialect as their second language 0.3% speak German as their second language

20% First language is English Of those: 12% do not speak a second language 84% speak Spanish as their second language 1% speak Russian as their second language 1% speak German as their second language 1% speak a Native American-Indian dialect

First Language of Total Respondents Surveyed

21% English

Spanish English

Spanish 79%

13 Second Language Data Represented by Graphs:

Second Language of Primary Spanish-Speaking Respondents

3% Other Indigenous Dialect

1% Mayan Dialect No Second Language 25% English English

71% None Other Indigenous Dialect

Second Language of Primary English-Speaking Respondents 1% 1% 1% 12% None

Spanish

German

Other (Indigenous Dialect) Russian 85%

14 Language Proficiency Not surprisingly, seasonal farmworkers (those who live in the area year-round) were slightly more likely to have some English capabilities. Migrant farmworkers were less likely to speak any English at all. In general, English proficiency is low among primary Spanish-speakers.

Limited English Proficiency of Migrant and Seasonal Farmworkers Of

u 76% 81% o 80% 74% r g

l 65% a

t 60% o t Spanish is first language

f 50% o 40%

e No English capability g

a 30% t

n 20% e c

r 10% e

P 0% Seasonal Migrant seasonal farmworkers: 76% claim Spanish as their first language, of those, 65% speak no English at all

Of migrant farmworkers: 81% claim Spanish as their first language; of those, 74% speak no English at all

15 Section III: Living Accomodations

The majority of farmworkers surveyed lived in migrant camps. However, the highest number of seasonal workers lived in homes and trailer parks. It is likely that there are many more seasonal workers in the area, but due to the lack of information about their places of residence, we do no not have a good estimate of their real numbers.

Living Accomodations for Migrant and Seasonal Farmworkes Surveyed

House 19%

Apartment 3%

Migrant Seasonal Total Trailer Park 9%

Camp 69%

0 10 20 30 40 50 60 70

Percentage of Population

Living Accommodations:

69% of total population surveyed lives in migrant camps 21% of this group is seasonal; 79% migrant

9% of total population surveyed lives in trailer parks 71% of this group is seasonal; 29% migrant

3% of total population surveyed lives in apartments 78% of this group is seasonal; 22% migrant

19% of total population surveyed lives in houses 56% of this group is seasonal; 44%, migrant

Raw Number Data for # of Persons in Various Living Accommodations:

Total number of people surveyed living in camps (as represented by survey): 857 Seasonal: 169, Migrant: 688 16 Total number of people surveyed living in trailer parks: 136 Seasonal: 107; Migrant: 29

Total number of people surveyed living in houses: 243 Seasonal: 169; Migrant: 74

Total number of people surveyed living in apartments: 39 Seasonal: 34; Migrant: 5

- 90% of respondents have hot water in their place of residence

Section IV: Race and Ethnicity

17 The majority of respondents identified as Mexican, followed by Hispanic/Latino. The team found this question to be problematic, as many people did not understand the question “With what race or ethnicity do you identify yourself?” Most respondents needed prompting with the multiple-choice answers before responding. Interestingly, several respondents from indigenous groups self-identified as “non-indigenous Central American”, despite other references to their indigenous heritage.

Race/Ethnicity as Identified by Respondents Other White Indigenous Hispanic/Latino 1% 11% 2% 0.2%

Central American Mexican 2% Native American Central American Hispanic/Latino Native American White 1% Other Indigenous

Mexican 83%

(continued)…

Race by County:

18 The racial breakdown, by county, is generally consistent throughout the three counties studied. However, white farmworkers were more prevalent in Antrim County than any other.

Race/Ethnicity by County

s 88% t 90% 83% n

e 76% d 80% n

o 70% p s

e 60% R

Grand Traverse f 50% o Leelanau e 40% g

a Antrim t 30% n e

c 20% 12% r 8%11% e 10% 4% 6% P 0 2% 1%1% 1% 1%2% 2% 0 1% 0% o n n n n a a e r a ti c c it e ic a ri ri h th x /L e e W O e c m m M i A A n l a a e p tr iv is n t H e a C N Race Leelanau Grand Antrim Traverse Mexican 88% 83% 76% Hispanic/Latino 8% 12% 11% Central 2% 0 4% American Native 1% 1% 1% American White 2% 1% 6% Other 0% 2% 1%

Section V: Family Status

19 The majority of respondents were living without family members at the time of the survey6, with a smaller bell-curve-trend peaking at respondents living with families of four. The growing trend of unaccompanied males is consistent with the current national trend7. An increasing number of men are leaving family members back “home” (mostly in Mexico) and working alone in order to support them. Not surprisingly, when divided by gender, we see that the majority of men are living alone, without their families, while most women are here with family members. The growing trend of unaccompanied male farmworkers in NMHSI’s service area is significant, as lack of familial support and isolation have been found to be contributing factors to higher rates of depression, alcoholism and risky sexual behavior amongst male farmworkers8.

Family Status:

Family Size of Survey Respondents r e p

i 120 S

y 100 l n i e

m d 80 a n F o 60 Family Size

f p o s

40 e y R c 20 n

q r s s s s s s s s rs rs

e r r r r r r r r le e e e r b e e e e e e e e g b b b b b b b b b b

F m in e m m m m m m m m m m S M e e e e e e e e e e M M M M M M M M M M ly i ly ly ly ly ly ly ly ly ly ly m i i i i i i i i i i a m m m m m m m m m m F a a a a a a a a a a F F F F F F F F F F 1 s 2 3 4 5 6 7 8 9 0 1 u s s s s s s s s 1 1 l u u u u u u u u s s P l l l l l l l l lu lu P P P P P P P P P P

Family Status by Gender

120% s t n

e 100% d n o

p 80% s e Men R

o Women

g 40% a t n e

c 20% r e P 0% Single Live with 1 family Live with family member of >3 persons same sex

*”Single” denotes unaccompanied.

6 For the purposes of this study, the terms “single” and “unaccompanied” are interchangeable. 7 NAWS 2001-2002. 8 Organista, K.C., (2001). “HIV Prevention Models with Mexican Migrant Farmworkers.” UC Berkeley Press, 2001. 20 Family Status- Raw Data by Gender: 52% of males self-reported as unaccompanied (living without any family members) 9% of males live with one other male family member (e.g. cousin, uncle) 39% of males live with families

1% of females self-reported unaccompanied (living without any family members) 1% of females live with one other female family member 98% of females live with families

NMHSI used the status of “living with 1 family member of the same sex” as a marker because several males reported living with a cousin, or brother-in-law in camps of all single males. Despite the fact that they are technically living with family, they remain a high-risk sub-group. Having one other (distant) male family member may not provide enough familial support to curtail the effects of isolation they may face.

Section VI: Education Level

The majority of farmworkers reported an education level of 6th grade level of or below, with the second highest majority reporting some high school education. These statistics are consistent with the national average.9

9 NAWS 2001-2002. 21 Education level of Survey Respondents 1% 1% 3% 7% 15% No formal education 6th grade or below Some high school Completed high school 17% Some college Completed college 56% Advanced degree

56% of those surveyed have 6th grade-level or below education (119m (59%),79f (47%)) 17% of those surveyed have some high school education (29m (14%), 33f (20%)) 15% of those surveyed completed high school (30m (15%), 26f (16%)) 7% of those surveyed have no education at all (17m (8%), 8f (5%)) 3% of those surveyed have some college (3m (1%), 9f (5%)) 1% of those surveyed completed college (2m (1%), 2f (1%)) <1% of those surveyed obtained an “advanced degree”10 (1m (0.5%), 2f (1%))

Education Level by Gender: In general, women reported an overall higher level of education. More men than women reported having an education level of 6th grade or below, while more women reported an overall higher level of education (high school and beyond).

10 The terminology “advanced degree” was problematic, as some people understood it to mean “other degree” (e.g. electrician’s license, etc.) Thus, these numbers may be unrepresentative of real numbers for persons holding advanced degrees within the farmworker community. 22 Education Level by Gender

u 60% o r

e 40% Male d

n Female

e 30% G

f 20% o 10% % 0% l l n w o o e e e io o o o g g e t l h h e e r a e c c ll ll g c b s s o o e u r c d d o h h C d e ig ig e d e th h h m e c o 6 o t n N e d S le a m te p v o le m d S p o A m C o C

Other Education Statistics: Those who reported no education were, on average, ten years older than those who reported at least some education. Those who reported completing high school were the youngest group- on average about 30 years old. This trend would suggest that younger generations may have more educational opportunities.

We also cross-referenced country of origin with education-level. Although this report lists percentages for Central American and European countries, the sample size for these is too small to accurately reflect the general education level of farmworkers from these countries.11

Average age of those with no education: 44.5 Country of origin: Mexico (8%), USA (2% of total), Guatemala (20% of total)

Average age of those with some elementary education as highest level: 36.4 Country of origin: Mexico (31% of total), USA (11% of total), El Salvador (100% of total), Honduras (50%), Guatemala (20% of total)

Average age of those who completed elementary school as highest level: 33.8 Country of origin: (30%) Mexico, (20%)USA, (40%) Guatemala

Average age of those who have some high school as highest level: 34.4 Country of origin: (13%)Mexico, (30%) USA, (50%) Honduras

Average age of those who completed high school as highest level: 30.6 Country of origin: (13%) Mexico, (30%) USA

Average age of those who have some college as highest level: 30.8 Country of origin: (1%)Mexico, (6%) USA, (100%)Germany

11 The percentages listed under “country of origin” represent the percentage of the total number of respondents from that country (not the percentage of those reporting a specific education level). 23 Average age of those who completed college as highest level: 31.75 Country of origin: (1%)Mexico, (1%)USA

Section VII: Occupation of Respondents

Current job of those surveyed: 88% agriculture 3% childcare 2% landscaping 2% homemaker 1% unemployed 24 1% “other” 1% factory work (non agriculture) 1% health care 0.5% construction 0.2% office work

Other jobs of family members or past jobs from highest to lowest frequency:

-Construction (63) -Landscaping (44) -Restaurant (36) -Hotel Services (29) -Other (28)—e.g. factory work (non agriculture), casino, painting, sales, electrician, carpentry, truck-driver -Plant nurseries (31) -Social Services (11) -Poultry processing (11) -Dairy farming (8) -Fisheries (6)

Crops worked in Northwest Lower Michigan:

93% cherries 70% apples 37% strawberries 33% grapes 23% other (beets, zucchini, pears, apricots, plums, blueberries, carrots, raspberry, tomato, peach, honey, chilis, beans, cabbage, potato) 17% cucumber 6.5% Christmas trees 6% melons 5% flowers 1% nuts

Section VIII Migration Patterns

The highest percentage of respondents reported arriving to the tri-county area in June and leaving in November, the second highest percentage reports leaving in October, and the third highest reports leaving in August. Contrary to NMHSI’s previous experience, the survey team did not encounter a large new wave of migrant workers coming after cherries for the apple harvest. However, this trend may be attributable, in part, to a 2006 spring frost that caused damage to portions of the apple crop, which may have curtailed the demand for a harvest labor force. 25 Migration Patterns of Respondents s t 120 n e

d 100 n o

p 80 s

e Arrival

f Departure o 40 r e

b 20 m u

l t r r ri y e ly s r r e ry ry h a n u u e e b e a a c p u J g b b b u u r A M J u m to m m n r a A te c e e a b M p O v c J e e o e F S N D

Destination States:

The migrants surveyed claimed 18 separate destination states, with the largest percentage going to Florida, followed by Texas. However, this data may be skewed as several respondents listed multiple states when asked, “Where will you go when you leave northern Michigan”- multiple-state destinations were entered as “multiple.” Had the destination states been counted individually, NMHSI believes Texas would be the top destination-state.

1. Florida (29%) 2. Texas (20%) 3. Multiple states (11.5%)* 4. Georgia (5%) 5. Michigan (5%) 6. Mexico (3%) 7. Alabama (1%) 8. Ohio (0.5%) 9. Arizona (0.3%) 10. California (0.3%) 11. Kentucky (0.3%) 12. Illinois (0.3%) 13. North Carolina (0.3%)

* States listed in multiple destinations: Florida, Georgia, Mexico, Texas, Wyoming, Montana, Colorado, Indiana, Ohio, Michigan, Texas, North Carolina, South Carolina, California, New York, Kansas, Connecticut, Arizona.

26 Section IX Barriers to Care

When asked, only 23% of farmworkers surveyed claimed they had experienced barriers to health care; however, when asked to name barriers to care, 90% named barriers they believed to exist for themselves or others.

Barriers to care from greatest to least: 27 1. Language barriers (211) 2. Cost (180) 3. Transportation (179) 4. Time conflicts (175) 5. Clinic hours of operation (85) 6. Unavailable services (e.g. specialty)

Barriers to Care s t n

n 180 179 o 200 175 p s

R Series1 85 f 100

e 50 b

m 0 n s e t e s n l t u o r s s g i c o b s i i N r t u o l t a a e f l e a o i i a u t C c n r r i r h a g r o v e o v n c r a i p p C a a e

B n s o n i s L e l n f U a C o m i r T T

Other commonly cited from greatest to least:

- Clinic not open year-round (nowhere to go in winter months) - Lack of insurance - Distance to clinic - No drivers license - Not enough providers - Providers in community do not accept Medicaid - Racism in community - Fear of deportation - No one available for childcare - Lack of information regarding available services - Crew leader does not allow workers to leave - Boss does not allow workers to leave

Section X: Services Requested

By far, the most commonly cited service that respondents identified as necessary (or to which they wanted better access) was dental care. Language interpretation services and transportation services followed. Interestingly, when broken down by gender, we see that more women requested interpreting services- suggesting that more women struggle with language barriers. Another (more likely) explanation is that Latina women, fulfilling their traditional role as “care taker” of the family, may be more in-tune with service gaps, as they (rather than their male counterparts) are the ones who usually accompany their 28 children to appointments, school functions, etc. Although mental health services were lower on the requested services list, mental health issues appear higher on the perceived health issues list (see section XI). We found this to be true with several items, indicating a lack of correlation between perceived health issues and requested health services.

Services Requested s t n e d

o 80 p

e 60 R

50 f Series1

g 20 a

t 10 n

e 0 n g c l n n s s o n s s r a o o e s e g ti g i e e t ti ti ic ic ic in a in in ic ic e n a a v tr v t c t a v v e t rt r a r s u s r r r P e e i e e e e e D r o d t d /T p p S S E T n S S r s h e h IV B o h l te n lt P lt H d T ti lt ta n a a a n a a a I r e e a c e n T H e u H e H r d l r 's 's a E a P n n C t e e ty n s e e M m te f M o e a W b S a b i o D J

(continued)…

29 Requested Services by Gender s t n e

d 100% n

p 80% s

Male (of 199) f 50% o

40% Female (of 165) e 30% g

a 20% t

e 0% c

r l n n g l a s o o g s in B a th e l t ic ti ti in te T t n tr a a t e in a a P t t s n e e ia r e e b ra D o r t a t re H d p p i y l e s r IV D t P ta P n te H fe n ra In a e T s M b o J

Requested Services by gender

Service Male (of 199) Female (of 165) Total Dental 84% 88% 86%

Pediatrics 66% 65% 65.5% Transportation 63% 62% 62.5% Interpretation 46% 70% 58% HIV testing 48% 47% 52.5% Men’s health 50% 55% 52.3% Diabetes 42% 62% 52% Women’s health 36% 60% 48% Job safety training 40% 53% 46.5% TB 45% 46% 45.5% Prenatal 33% 55% 44% Mental Health 37% 45% 41%

(continued)…

30 Services Requested by County:

Services Requested by County r e p

t 100% n

e 90% d 80% Leelanau (of 130) n

o 70% p y t s 60% n e Grand Traverse (of

u 50% R

o f 40% 146) C o 30% e Antrim (of 93)

g 20% a t 10% n

e 0% c

r l n n . e . l a o o 5 d r g d th a e t ti ti 9 E a in E l t n a a 1 / C t a a P e t t - g / s y e n e r s n d e t H e D r o c ti E T fe l r p p ri s a P r s t e s B ta te n ia T e T S n n a d t b e I r V e o T e I b J M P H ia D

Service Leelanau (of Grand Antrim (of Total 130) Traverse (of 93) 146) Dental- 317 87% 87% 81% 85%

Interpretation- 240 72% 69% 49% 65%

Transportation- 65% 64% 58% 62% 231 Men’s Health 60% 67% 38% 58% Services Pediatrics 195 53% 68% 29% 53%

Women’s Health 51% 62% 38% 52% Services 192 HIV testing 190 55% 61% 31% 51%

Diabetes 49% 64% 32% 51% Education/Care 188 TB testing 182 48% 62% 31% 50% Job Safety 41% 60% 30% 46% Education/Training 169 Mental Health 165 45% 58% 24% 45% Prenatal 156 39% 57% 80% 42%

31 Other service requested: English classes, eye exams (most frequent), holistic health services, education about how to get services, more social services in clinic, Initial Client Visits at night, podiatry, nutritionist, dentist in clinic all the time, speech therapist, more time with MD, more Spanish-speaking providers, male provider, physical exams in the field, more specialists, day care, more assistance with medications, X-rays in clinic, accept walk-ins, ear doctor, parenting education, orthodonture, arthritis care, vouchers to cover more than $50, dermatologist, pediatrician, urgent care services, services closer to home, food stamps, gynecologists, elder care, more provider time.

Other suggestions comments:

#1- Stay open year-round #2- Reduce waiting time/ Stay open on weekends #3- More provider time (not just nurses)

- Keep coming to the camps and talking to people about resources, focus on domestic violence and abuse, stay open 7 days a week, have ICV and provider visits on same trip, don’t turn patients away, come out to camps for TB tests, send interpreters with clients to other agencies, more flyers about available services at camps, understand where we (farmworkers) come from, bilingual mental health counselor for adults and kids, have more sites.

32 Section XI: Perceived Health Problems

Work-related health problems and chronic illness were the most commonly perceived health problems, followed by acute illness. When divided by gender, more women perceived health problems within the farmworker community than men. In particular, women seemed more aware of (or likely to report) hypertension, mental health issues and domestic violence issues than their male counterparts. We do not believe that this is because more women suffer from mental health issues, or that they are more aware of domestic violence, but rather that they are more willing to talk about it. Mental health issues, already taboo, are even more stigmatized amongst Latino males. Conversely, although the percentage of reporting STIs (Sexually Transmitted Infection) as a perceived health problem was only 5% overall, men were slightly more likely to report this as a perceived problem than women.

Perceived Health Problems 2% 3% Acute Illness 13% 17% Work-related health problems Chronic illness

Dental

33% 32% Domestic Violence

STI/HIV

Perceived Health Problems Ailment Leelanau (of Grand Traverse Antrim (of 93) Total 130) (of 146) Acute illness- 56% 56% 52% 55% Back aches 52% 53% 54% 53% Dental- 38% 34% 54% 40% Skin reactions 30% 34% 27% 31% Diabetes 26% 29% 27% 27% Physical injury- 26% 27% 23% 26% Heat Exhaustion- 20% 32% 25% 26%

Repetitive Motion 20% 29% 24% 25% injury Hypertension 22% 27% 27% 25% Emotional issues 23% 23% 24% 23% Respiratory 19% 22% 20% 21% Ailments Domestic Violence 5% 14% 6% 9%

STI 5% 8% 2% 5%

33 Perceived Health Problems by Gender s t n e

d 70% n

o 60% p

s 50% e

R Male (of 199) 40% f

o 30% Female (of 165) e

g 20% a

t 10% n e

0% l l c s l t n e y s c I e a r i n r s a a v a o i t e t i T h i e n t o e c t k e s i i t c n s o S P e t n i e s l S a e H n t A l b e r i y i e o m D a p t k h i p r e o e c m t s P D e a D u R E e p c B y R A H

Perceived Health Problem by gender:

Ailment Male (of 199) Female (of 165) Total Acute illness 51% 58% 55% Backache 48% 58% 53%

Dental 37% 44% 40% Skin Reactions 25% 39% 31% Diabetes 20% 38% 27% Heat exhaustion 23% 31% 26% Physical injury 23% 29% 26% Hypertension 14% 39% 25% Repetitive motion 21% 30% 25% injury Emotional issues 17% 30% 23% Respiratory Ailment 18% 24% 20% Domestic Violence 4% 15% 9% STI 6% 5% 5%

34 Section XIII: Occupational Safety and Free Time Activities

In addition to asking farmworkers about their needs, the survey also looked to them for their suggestions regarding occupational safety. When asked about the best way to protect oneself from injuries on the job, the most common responses were:

1. Be careful 2. Get someone to show you how to do the job properly 3. Make sure the ladder is put up correctly/don’t climb on the ladders 4. Follow your boss’s directions and talk to him/her if you get hurt 5. Have First Aid materials available

Finally, respondents were asked what they did during their free time. This qualitative information was sought in order to gain a better idea of what NMHSI’s clients do when they are not working, or at the clinic (the two most common circumstances under which NMHSI professionals interact with farmworkers). The most common responses were:

1. Go into town to shop/run errands 2. Play soccer 3. Go to the beach 4. Go to the mall 5. Go to the movies 6. Watch television 7. Do nothing- just relax 8. Talk with friends and family 9. Play other sports: volleyball, basketball 10. Go out to eat 11. See the sights around the area 12. Clean the house 13. Listen to music 14. Go to church/study the bible 15. Play games (Nintendo, cards, dominos)

35 Conclusion

This study found the number of eligible farmworkers (1314) for NMHSI’s services to be at least twice the number of users seen in the Traverse City clinic over the past several seasons. There are most likely even more eligible farmworkers that we are at present unaware of in the area. Areas of concern in this regard involve reaching seasonal and settled-out farmworkers who may be unaware of NMHSI’s health care services, or unaware that they are eligible for our services. On numerous occasions respondents assumed they were not eligible for our services, despite the fact that they or someone in their family had worked in agriculture sometime within the past two years.12 The demographic trends indicated in this study are, for the most part, consistent with national demographic trends amongst the farmworker population. This data, nonetheless, sheds light on the specific demographics and needs of the farmworker community in lower Northwest Michigan, which until now, has been unavailable. One of the more surprising results of this study was the lack of new arrivals for apple season. The largest influx of workers came for cherry season, and slowly declined throughout the late summer and fall months. Although there was a slight increase in arrivals around apple season, by in large, we found that camps that open solely for apples were filled by workers that had already been surveyed at camps (or other places of residence) during cherry season. Again, this may be attributable to the lower abundance of apple crop in the 2006 season due to an early spring frost. As a result of this study, NMHSI will be able to take direct action in program development in response to farmworker input. For example, in regards to health education, it is clear that work safety should be at the top of the list due to the high number of reported work-related injuries. In regards to direct services, our previous experiences about limited English proficiency among our clients, and the need for interpretation services has been reaffirmed by this study. Certain client needs, such as transportation and lack of insurance, are issues that cannot be immediately addressed, but will be part of more long-term planning. Certainly, one of the most common requests was for more access to dental care. This supports NMHSI’s current work to expand its dental services in a year-round capacity. NMHSI is also currently looking into options for maintaining the Traverse City clinic year-round—another top request of our clients. NMHSI believes that providing a formal format in which farmworkers were able to share their experiences, stories, knowledge, and concerns was a mutually beneficial process. The respondents who participated in the survey expressed appreciation for being valued for their opinions and experience (many of them have since become new clinic users). NMHSI is grateful to the farmworkers and their family members who took the time to work with us on this project. It is NMHSI’s goal to continue working with farmworkers to gain their input so that we may continue to improve our services to better meet their needs.

12 Basic eligibility requirement for NMHSI services. 36