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dissertation entitled

REPRODUCTIVE HEALTH CARE SERVICES UTILIZATION
AMONG LATINA MIGRANT AND SEASONAL
FARMWORKERS IN A MIDWESTERN STATE

presented by

OMARA RIVERA-VAZQUEZ

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REPRODUCTIVE HEALTH CARE SERVICES UTILIZATION AMONG LATINA
MIGRANT AND SEASONAL FARMWORKERS IN A MIDWESTERN STATE
BY

Omara Rivera-Va’zquez

A DISSERTATION
Submitted to
Michigan State University
In partial fulfillment of the requirements
for the degree of
DOCTOR OF PHILOSOPHY
Department of Family and Child Ecology

2006

ABSTRACT

REPRODUCTIVE HEALTH CARE SERVICES UTILIZATION AMONG LATINA
MIGRANT AND SEASONAL FARMWORKERS IN A MIDWESTERN STATE

By
Omara Rivera-Vézquez

Latina reproductive health has rarely been studied in female migrant
and/or seasonal farrnworkers. The present study investigated the utilization of
reproductive health care services by female migrant and seasonal farrnworkers
using an ecological framework and more specifically adopting the behavioral
model of health services utilization (Andersen, 1968, 1995).

Data were originally collected by the Oceana Farmworker Health Needs
Assessment (Rosenbaum et. al., 2006). The sample size for this study is 183
Latina fannworkers. Predisposing variables included in the analyses were
respondents’ agricultural work status (migrant vs. seasonal), primary language,
marital status, and highest educational level. The study includes health
insurance, family income, current work status, number of years working in MI,
and available community resources (use of local migrant clinic) as important
enabling factors for utilization of reproductive health services. Health need
factors include respondent’s perceived health status, reports of any unmet
treatment, diagnosed pregnancy diabetes, and physical exam results
(normal/abnormal). Reproductive health care utilization measures considered in
this study include ever having a PAP smear, ever having a mammogram, ever
having a clinical breast exam, seeking early prenatal care, using sexual disease

protection, and practicing pregnancy prevention. In addition, composite

measures indicating scores for predisposing, enabling, need, and reproductive
health care utilization were created.

The analyses demonstrated that migrant and seasonal farrnworker women
in the sample have low to moderate use of the reproductive health care services
included in the analyses. Latina migrant and seasonal farmworkers are likely to
report not using any methods to protect themselves from sexually transmitted
diseases or pregnancy prevention. In addition, both migrant and seasonal
farrnworker women have low rates of mammogram screenings.

Seasonal farmworkers in the sample were more likely to use prenatal care
and pregnancy prevention at higher rates than migrant women. The analysis
demonstrated a relationship between ever having a mammogram and migrant
status. Migrant farrnworker women access mammogram screenings at higher
rates than seasonal farrnworker women. The predisposing variables age and
migrant status are predictors of ever having a mammogram. The number of
years working in the state is an enabling factor predictive of ever having a
mammogram. In addition, higher income levels predict use of prevention
methods for sexually transmitted diseases. The need factors models were not
statistically significant. These results contradict prior findings of studies utilizing
the Andersen model indicating that need is one of the most pressing indicators of
health care utilization (Andersen, 1968; 1995). It seems that considered together
both predisposing and enabling factors may, in fact be stronger predictors of
reproductive health care utilization than the need for care in this specific

subpopulation.

DEDICATION
This dissertation is dedicated to my baby girl Mara Nicole Criollo-Herrera,
the driving force in my life; and to the memory of my father, Nicolas A. Rivera-

Negron who instilled in me the importance of education.

ACKNOWLEDGEMENTS

My thanks and appreciation to Dr. Lillian Phenice and Dr. Robert Griffore
for persevering with me as my advisors through out the time it took me to
complete this research and write the dissertation. Their motivation and critical
feedback were key components to help me complete my doctoral program. I am
grateful as well to Dr. Karen Patricia Williams who mentored me on issues
beyond the dissertation and always had the right words inspiring me to reach my
goals. Two additional members of my dissertation committee, Dr. Renee Perez
Rosenbaum and Dr. Esther Onaga have generously given their time and

expertise to better my work. I thank them for their contribution and support.

I am grateful to many persons who shared their memories, experiences,
and advise especially Dr. Yvonne Smith at the Graduate School and Ms. Nettavia
Curry, Coordinator for the Ronald E. McNair Post Baccalaureatte Achievement
Program at Michigan State University. Dr. Heman A. Vera, Dean of Graduate
Studies in the Pontifical Catholic University of Puerto Rico was the first person

that believed in me and encouraged me to apply for the doctoral program.

I must acknowledge my mother and sister who always supported and
guided me through challenges both personal and academic. I am grateful too for
my baby girl and her father who “patiently” sat by me many times while I was

working on the dissertation.

TABLE OF CONTENTS

LIST OF TABLES ................................................................................ viii
LIST OF FIGURES .............................................................................. .ix
CHAPTER 1
INTRODUCTION
Statement of the Problem ............................................................... 1
Purpose of the Study ..................................................................... 4
Research Questions ...................................................................... 4
Study Definitions ........................................................................... 5
Overview of Subsequent Chapters .................................................... 6
CHAPTER 2
LITERATURE REVIEW
Introduction ................................................................................. 7
Scope of the Problem .................................................................... 7
Human Ecology Theory and the Behavioral Model of Health Services
Utilization
Human Ecology Theory ........................................................ 8
The Behavioral Model of Health Services Utilization .................. 1O
Conceptual Model of Utilization of Reproductive Health Services .......... 14
Reproductive Health of Latinas and Health Care ............................... 15
Latinas and Prenatal Care ................................................... 18
Pregnancy Prevention Among Latinas ................................... 19
Breast Cancer in Latinas ..................................................... 20
Cervical Cancer in Latinas ................................................... 22
Sexually Transmitted Diseases and Latinas ............................. 24
Migrant Fannoworker Health ......................................................... 24
Migrant Health Programs .............................................................. 27
Migrant Farrnworkers and Health Services Utilization ......................... 28
Michigan Latinos Utilization of Health Services .................................. 31
Conclusion ................................................................................ 32
CHAPTER 3
METHODOLOGY
Introduction ............................................................................... 34
Research Design of the Oceana Farmworker Health Study ............... .34
Research Setting ............................................................. 35
Study Sample .................................................................. 37
Procedures ...................................................................... 38
Instruments ..................................................................... 39
Research Questions ................................................................... 4O
Hypotheses .............................................................................. 40
Measures ................................................................................. 41
Sample Characteristics ............................................................... 44

vi

Data Analysis ............................................................................ 49

Conclusion ............................................................................... 50
CHAPTER 4
RESULTS
Introduction ............................................................................... 51
Research Question 1 ................................................................... 51
Hypothesis 1 .............................................................................. 53
Hypothesis 2 ............................................................................. 56
Hypothesis 3 ............................................................................. 58
Hypotheses 4-6 .......................................................................... 62
Conclusion ................................................................................ 64
CHAPTER 5
DISCUSSION
Introduction ................................................................................ 65
Summary of Findings ................................................................... 65
Policy Implications ....................................................................... 71
Limitations ................................................................................. 76
Future Research ......................................................................... 78
Conclusions ............................................................................... 80
APPENDIX A
Detailed Binary Logistic Outcomes Tables ....................................... 83
APPENDIX B
Comparing Reproductive Health Care Utilization
Rates for Latina Migrant and Seasonal Farrnworkers ......................... 89
APPENDIX C
UCRIHS Approval Letter .............................................................. 91
REFERENCES ................................................................................... 92

vii

LIST OF TABLES

Table 1. Distribution of Predisposing Factors ............................................ 45
Table 2. Distribution of Enabling Characteristics ........................................ 46
Table 3. Distribution of Health Need Factors ............................................. 47
Table 4. Descriptives of Predisposing, Enabling, Health Need

and Reproductive Health Care Utilization Scores .......................... 48
Table 5. Distribution of Reproductive Health Care Outcomes ....................... 52

Table 6.1 Chi- Square Results for Predisposing Variables
Association with Utilization of Reproductive Care Services ............. 54

Table 6.2 Chi- Square Results for Enabling Variables Association
with Utilization of Reproductive Care Services ............................. 55

Table 6.3 Chi- Square Results for Health Need Variables Association
with Utilization of Reproductive Care Services ............................ 56

Table 7. Chi Square Results for Migrant and Seasonal Farmworker Utilization of
Reproductive Health Services .................................................... 57

Table 8. Binary Logistic Regression Outcomes for Predisposing, Enabling, and
Health Need Predictors of Utilization of Reproductive Care Services..61

Table 9. Regression Outcomes for Predisposing, Enabling, and Health Need
Variables as Predictors of Utilization of Reproductive Care Scores......64

viii

LIST OF FIGURES

Figure 1. Conceptual Model of Utilization of Reproductive Health Services ...... 14

CHAPTER 1
Statement of the Problem
The United States has witnessed remarkable growth in the Latino
population across the nation. There are approximately 37 million Latinos residing
in the US. (US Census, 2001). Between the years 1990 and 2000, there was a
58 percent increase in the Latino population, and it is predicted that by the year
2050, Latinos will account for approximately 25 percent of the population. It is
further estimated that by the year 2050, one out of every four women in the

United States will be a Latina (US Census, 2000).

Despite growing in numbers, Latinas continue to face serious health care
access barriers and consequently higher incidences of disease and poorer health
outcomes, especially in areas associated with reproductive health (National
Latina Institute for Reproductive Health, 2005). Overall, Latinas are faring far
worse than other ethnic groups in areas of reproductive health. Studies have
shown that more than 25 percent of Latinas do not receive prenatal care during
the first trimester (Scott Collins, Hall & Neuhaus, 1999). Furthermore, Latinas
account for more than 20 percent of the AIDS cases among women, and the HIV
infection rate among Latinas is 7 times higher than for white women (Giachello,
2001). Among Mexican-American and Puerto Rican women, the cervical cancer
incidence rate is two to three times higher than for White women (Intercultural
Cancer Council, 2000). The unintended pregnancy rate for Latinas is nearty two

times the rate for white women (Naral Foundation, 2000).

The rate of maternal mortality among Latinas is 1.7 times higher than for
White women, the Latina teen pregnancy rate is more than twice the rate of white
women and the rate of Chlamydia among Latinas is more than 3.5 times higher
than for White women (Naral, 2000). In addition to having the highest uninsured
rate, Latinas able to access healthcare are often dissatisfied with the care
received. For example a study by Forest and Frost, 1996 found that only 51.5
percent of Latinas reported feeling “comfortable” at the family planning clinic they
last visited, and only 47.4 percent of Latinas reported that the family planning

staff “made an effort to find out their needs.”

Poverty, lack of insurance, inadequate access to health care, language
barriers, discriminatory treatment and limited awareness of health risks contribute
to poorer health outcomes for Latinas. Lack of health insurance is reportedly the
primary barrier for access to reproductive health care by Latinas (National Latina
Health Network, 2005). Latinas have the highest uninsured rate among women
(42 percent) as the number of uninsured continues to rise and shows no signs of
reduction. For example, in 1994, 46 percent of low-income Latinas reported
having no health insurance; by 1998, the number of Latinas without health
insurance had risen to 51 percent (Henry J. Kaiser Family Foundation, 2001).
Without the benefit of health insurance, many Latinas delay or miss out on
necessary reproductive and general health care services. Only 38 percent of
Latinas ages 40 and older have regular mammograms that could detect cancer
at its earliest stages before clinical symptoms develop (ICC, 2000). One out of

every three Latinas reported that they failed to get a Pap test in the preceding

three years compared with one-quarter of all American women (College of

American Pathologists, 2001 ).

Reports on the health status of Latinas in the US. generally miss out on
approximately 4.2 million migrant and seasonal farmworkers and their families
who work in the United States (Poss & Pierce, 2003). Migrant farmworkers are
known to have more health problems than the general Latino population in the
US. Moreover, they lack reliable access to health care services. Migrant
farmworkers confront many illnesses that are caused by poor nutrition, lack of
resources to seek care early in the disease process, and infectious diseases
from overcrowding and poor sanitation. Consequently, farm labor exposes
migrant and seasonal farrnworker women, to prolonged standing and bending,
dehydration, poor nutrition, pesticide and chemical exposures that contribute to
an increased risk of spontaneous abortions, premature delivery, and fetal
abnormalities (Hansen & Donohoe, 2003). The general health problems as well
as the specific reproductive health challenges suffered by migrant and seasonal
farmworkers women are exacerbated by their low-income status, unfamiliarity
with the culture, a migratory lifestyle, and the inherent dangers and health risks

involved in farm work.

Purpose of the Study
Although Latina reproductive health is a growing area of research interest,
it has rarely been studied in female migrant and/or seasonal farmworkers. The
present study investigated the utilization of reproductive health care services by
female migrant and seasonal farmworkers using the behavioral model of health
services utilization (Andersen, 1968, 1995). Several culture-specific variables will

be included in the model of Latina reproductive health care utilization.

Research Questions

The following research questions were developed to accomplish the
identified objectives and to achieve the purpose of the study. The study was
modeled using the Andersen behavioral model of health care utilization (1968,
1995). This model describes access to health care as “actual use of personal
health services and everything that facilitates or impedes the use of personal
health services” (Andersen, 1969). The Andersen model incorporates
predisposing, enabling and need factors that impact access to health care. Using
this model as a framework, the present study addresses the following questions
for a sample of migrant and seasonal farmworkers in Oceana County, Michigan.

0 What is the overall self-reported reproductive health services utilization of
female migrant and seasonal famworkers?

o Are predisposing, enabling, and need factors associated with reproductive
health care utilization?

a Do migrant and seasonal farrnworker women differ in their reproductive
health care utilization?

Study Definitions
It is important to understand that this study refers to Latinas as those
included in the sample, the majority being Mexican American migrant and
seasonal farmworker women. The term migrant farmworker refers to “individuals
who stay away from home overnight to do temporary farmwork” (Rosenbaum,
2003). They can be either hired or contract workers. Seasonal farmworkers are
“workers who are permanent residents of the communities where they do

agricultural work” (Rosenbaum, 2003).

Since the study uses Andersen (1968, 1995) model of health services
utilization as a framework, it is also important to understand the definitions of
predisposing, enabling, and need factors. Predisposing characteristics exist prior
to the perception of illness, the presence of enabling resources facilitates the use
of health services, and their absence impedes utilization. Health need related
variables pertain to physical illness as perceived by people and evaluated by

professionals.

For the purposes of the present study, predisposing factors are
operationalized by respondents’ agricultural work status (migrant vs. seasonal),
marital status, primary language, and highest education level. The study
includes health insurance, family income, current work status, number of years
working in MI, and available community resources (use of local migrant clinic) as
important enabling factors for utilization of reproductive health services. Lastly,

need factors reflecting physical health status are measured by respondent’s

perceived health status, reports of any unmet treatment, diagnosed pregnancy

diabetes, and physical exam results (normal/abnormal).

Reproductive health care utilization measures considered in this study
include ever having a PAP smear, ever having a mammogram, ever having a
clinical breast exam, seeking early prenatal care, using sexually transmitted
disease protection, and practicing pregnancy prevention. A detailed discussion
of all variables included in the analysis and their respective levels of

measurements will be discussed in the methods chapter.

Overview of Subsequent Chapters

Chapter 1 provides specific information on the relevance, purpose and
research questions for this study. Chapter 2 provides a review of the relevant
literature on Latina reproductive health outcomes. Additionally, the Andersen
model of health services utilization will be discussed in more detail in its
relationship to reproductive health outcomes. Human ecology theory also
provides a framework to understanding how the factors outlined in Andersen’s
model impact the reproductive health outcomes of female migrant and seasonal
farmworkers in the sample. Thus, a discussion on human ecology theory will
also be included in this chapter. Chapter 3 delineates the specific methodology
to be used to achieve the objectives previously identified. Chapter 4 describes
the major findings for each research question. A discussion of the findings,
limitations of the research, and implications for future research is presented in

Chapter 5.

CHAPTER 2
Literature Review

Introduction
The present chapter provides a delineation of the theoretical frameworks
of human ecology theory and the Andersen model, namely the behavioral model
of health services utilization is discussed. Moreover, this chapter discusses
relevant literature outlining the existing body of research on the status of Latina
reproductive health, migrant farmworker health, and health services utilization by

migrant and seasonal farmworkers.

Scope of the Problem
Latinas account for approximately one in every seven US. women of
reproductive age (US. Census, 2000). Significant gaps exist in the breadth and
depth of information available on Latina sexual and reproductive health. Analyses
from national and small-scale studies usually compare Latinas with other groups

on only one or two sexual and reproductive health indicators.

There is also limited research on the specific disparities facing migrant
and seasonal farmworker women. Many of the studies about this subpopulation
do not focus on female farmworkers, much less on their utilization of reproductive
health services. The evident lack of research and interest in migrant and
seasonal farm worker women is representative of the marginalization that these
women experience as immigrant women. Their invisibility is partly due to their

legal status in the United States. The present study thus responds to this void in

the literature by analyzing the reproductive health status of migrant and seasonal

farmworkers in a midwestem state.

Human Ecology Theory and the Behavioral Model of Service Utilization

Human Ecology Theorv

Human ecology theory is a way of looking at the interactions of humans
with their environments and considering this relationship as a system
(Griffore & Phenice, 2001). The ecological perspective calls for an
interdependent, multidimensional, multilevel, interactional view of the
etiology of individual or community health. Grzywacz & Fugua (2000)
defined the ecological perspective of health as characterized by the
following principles:

1. Different dimensions of well-being are reciprocally related and
linked to diverse conditions in the sociophysical environment;

2. Individual and community well-being are contingent upon multiple
aspects of the person/population, as well as multiple dimensions of
the environment;

3. Health is an outcome of the quality of the person-environment fit;

4. Certain individual or environmental conditions exert a
disproportionate amount of influence on health and well-being;

5. The physical and social environments are interdependent;

6. A comprehensive understanding of health results from
multidisciplinary approaches.

The Human ecological approach is fundamentally concerned with

specifying the individual and environmental conditions necessary for better health

outcomes, such as care-seeking behavior or utilization of services as is the
concern of the present study. Both individual and environmental conditions are
of great importance. As a result, human ecological theory views an individual
woman and her health and development in the context of physical, psychological,
social, and cultural environments (Williams, 2005). Interactions with
environments thus affect the potential for health and positive growth and
development. Human ecologists call attention to the relationships between
individuals, their families, and communities, and examine the transactions
amongst them. These transactions are dynamic and develop and change over
time. Thus, based on this theoretical framework, access to reproductive health
care services by Latina migrant and seasonal farmworkers must be analyzed in
light of the individual, family, and community factors that influence cultural and
lifestyle practices that relate to utilization of reproductive health services.
Consequently, an ecological approach to examining migrant farmworker women
supports attention to predisposing, enabling, and need factors related to health
service utilization as portrayed in the Andersen Behavioral Model of Health

Services Utilization.

Ecological factors such as income inequality, education, working and living
arrangements markedly affect physical health outcomes of migrant fannworkerS.
Research has shown that poverty and inequality are better predictors of health

outcomes than risk behaviors.

In the case of migrant farmworker families who live in extreme poverty,
this leads to suffering major inequalities in health, and more specifically related to

this project, inequalities in reproductive health care.

Although the ecological perspective provides a comprehensive view on
the perspective of health, it does not provide a parsimonious set of explanations
that can be used to predict and ultimately change health care utilization. Several
ecological models of health promotion have incorporated concepts from different
theoretical perspectives (Green & Potvin, 1996; McLeroy, et. al., 1988). The
present study uses the Andersen Behavioral Model of Health Services Utilization
to guide the study on factors that influence reproductive health service utilization
and/or outcomes by female migrant farmworkers. Using this model, migrant
fan'nworkers’ demand for health services can be characterized and analyzed.
Thus, while human ecology theory provides the general orientation, the Andersen

model will provide a more specific model for analysis.

The Behavioral Model of Health Services Utilization
The behavioral model proposed by Andersen et al. (Andersen & Newman,
1973; Aday & Andersen, 1978; Andersen, 1995) suggests that there are three
main types of variables predicting utilization of health care services. These
variables include predisposing, enabling and need factors. Predisposing
variables describe the inclination of individuals to utilize services. These
variables exist prior to the onset of illness. They include sociodemographic

variables such as age and sex.

10

Enabling variables provide the means to utilize health care services for
individuals. Structural factors such as income, health insurance, and health care
facilities are considered enabling variables. Need factors are typically considered
the stronger predictors of health care utilization and include such variables as
symptoms experienced, disability, and/or chronic diseases (Andersen, 1968,

1995).

Andersen’s behavioral model has been described as a framework for
analysis rather than a mathematical model, and therefore it does not dictate the
precise variables and methods that must be used (Phillips, 1998). Most research
studies adopting full or revised versions of this model have demonstrated the
importance of illness on health services utilization (Bice et al. 1972; Hershey et
al. 1975; Berki & Kobashigawa, 1976; Wolinsky, 1976; Andersen & Aday, 1978;
Kronenfeld, 1978; Vazquez- Barquero et al. 1992; Adler et al. 1993; Feinstein,
1993; Goldberg, 1995, Himmelstein 8. Woolhandler 1995). Positive associations
between medical visits and income have also been highlighted (Wolinsky, 1976;
Andersen & Adey, 1978; Hennelley & Boxerrnan, 1979), while increased patient
cost sharing has resulted in a reported reduction in use of services (Lefcowitz,
1973). Having health insurance either through private or public means (Rabin et
al. 1974; Hershey et al. 1975; Ferguson et al.1976; Aday & Andersen, 1978;
Andersen & Aday, 1978; Weissman & Epstein, 1993) and income and insurance
coverage (Brown, 1990; Freeman et al. 1990; Saver & Peterfreund, 1993;
Weissman & Epstein, 1993; Bashsur et al. 1994; Hahn, 1994; Monheit, 1994) are

also known to influence health services utilization.

11

Additional research using the health services utilization model has
examined the impact of social factors. Social factors explain utilization of health
services (Link & Phelan, 1995, 1996; Andersen, 1963). Specifically, gender in
that women have higher rates of health services utilization than males (Hershey
et al. 1975; Andersen & Aday, 1978). Individuals with more education (Wolinsky,
1976; Andersen, 1963) have higher rates of medical care utilization. In some
other studies, age has also been considered an important variable in health
services utilization in that utilization increases with age (Roos & Shapiro, 1981;
Jeffries, 1996). Andersen's analyses have also demonstrated higher use of
services at extreme ends of the life cycle (Andersen, 1963) even after controlling

for need.

Various studies have reported a positive association between need for
medical care and health services utilization (Berki, 1979; Starfield, et. al., 1985;
Diaz, et. al., 1986; Leaf, et. al., 1988; Connelly, et. al., 1989; Weinreb, et. al.,
1998; Ryan, et. al., 2001). Repeated applications of the Andersen Behavioral
Model of Health Services (Andersen, 1968, 1995) have shown that need for care
accounts for most of the explained variability in utilization, almost all of the
variability in usage of hospital services, and approximately two thirds of the

variability in use of physician services (Aday & Awe, 1997; Wolinsky, 1978).

12

Over time, the behavioral model of health services utilization has
undergone revisions and updates by including measures of health services use
specific to particular conditions and episodes of illness and consumer satisfaction

(Aday & Awe, 1997; Andersen, 1995).

The model has also been expanded by recognizing its dynamic nature and
that changes in personal practices and the maintenance and improvement of
health status are explicit outcomes and goals of health services delivery.
Furthermore, a revised and expanded model specific to vulnerable populations
has been adapted (Gelberg, et. al., 2000). As in the original behavioral model,
predisposing, enabling, and need factors predict personal health practices,
including the use of health services. A major addition was the examination at the

impact of utilization on health status outcomes.

This recently revised model for vulnerable populations has been applied to
homeless populations (Gelberg, et. al., 2000), underserved populations
(Bazargan et. al, 2004), and veterans (Dessai, et. al., 2003). There are gaps,
however, in our knowledge of the association of predisposing, enabling and need
for care with health services utilization for certain vulnerable populations such as

migrant and seasonal farmworker women.

It is important to note that the model proposed in this study assumes that
cultural factors impact the usage of reproductive health services, thus, culture-
specific variables such as primary language, agricultural work status, and

number of years working in Michigan are incorporated into the framework as

13

enabling and predisposing factors for migrant and seasonal farmworker women.
Figure 1 portrays the conceptual model of utilization of reproductive health

services for a sample of Latina migrant and seasonal farmworkers.

EgretmmidwbdeldljlizfimthmddieHedthSmices

 

 

 

 

 

 

 

 

 

14

Reproductive Health of Latinas and Health Care

The Department of Health and Human Services recognizes in its Healthy
People 2010 objectives the elimination of health disparities among different
segments of the US. population as one of the country's most significant goals.
While the high rate of pregnancy and births among Latina teenagers has
received attention, a relatively limited amount of research has examined
unintended pregnancy and contraceptive use among Latinas in their adult lives.
By and large, research on sexually transmitted diseases (STDs) in the Latina
population has been narrow; however, some attention has been paid to HIV

transmission, in particular.

Latinas are more likely than the general population to be low-income
(Census, 2000) and are consequently more likely to be eligible for publicly
funded prenatal, family planning, abortion and STD services. Although they may
be eligible for public services, low-income Latinas are in general less likely than
low-income Whites or Blacks to have health insurance; 43 percent of low-income
Latinos were uninsured in 2002, in contrast with 25 percent of low-income Whites
and 26 percent of low-income Blacks (Mills & Bhandari, 2003). Many Latinas
without health insurance mainly depend on publicly funded clinics for their sexual
and reproductive health care needs. Conversely, public funding has not kept
pace with increases in the costs of many reproductive care services such as
contraceptives. Thus, these clinics have an increasingly difficult time offering
uninsured women the most effective contraceptive methods (Dailard, 2001). In

addition, 40 percent of Latinos are immigrants who may not understand their right

15

to free or low-cost services or may fear that their immigration status could be

endangered if they seek any type of health care (Ramirez & De la Cruz, 2003).

Welfare laws that have been attached to immigration status also have an
effect on the reproductive health of immigrant Latinas by restraining access to
health care programs. Under federal law, legal immigrants who have arrived after
1996 do not have access to federal public health care programs for their first five
years in the United States. Undocumented immigrants only have access to
emergency care, which excludes prenatal care. Language barriers also create a
major problem in accessing reproductive health care services for the many
immigrant and non-immigrant Latinas with limited English proficiency (Hooton,

2004)

Moreover, Latinas are more likely than Black and White women to delay
health care appointments because of transportation or child care difficulties or an
inability to pay for health care services (Kaiser Family Foundation, 2004). Even if
Latinas can access sexual and reproductive health care services, they must
contend with a lack of culturally and linguistically competent services. Only 5
percent of US. physicians (Pasko & Smart, 2003) and 2 percent of nurses
(Smedley et al., 2003) are Latino; yet Latinos comprise almost 14 percent of the
US. population (Census, 2004). Many health care providers do not speak
Spanish and do not have trained, on-site interpreters; as a result, mothers must

often use their children as translators.

16

This situation may compromise the quality of information women receive,
the services they use, and the extent to which they feel their concerns are
adequately and/or sensitively addressed. These reasons may explain why
Latinas often report being dissatisfied with their visits to sexual and reproductive

health care providers (Forrest & Frost, 1996).

Although nearly half of adult Latinas (46 percent) have not completed high
school and may therefore lack basic health education (Census, 2000) there is a
shortage of community health education programs designed to improve Latinas'
understanding of the health care system and help them play a more active role in
their own health care. Such programs are crucial because some Latinas may not
use available services as a result of concerns about the medical examination, the

gender of their potential clinician or distrust of medical providers.

Factors such as fatalism and sexual silence also impact the reproductive
health of Latinas. Fatalism can be described as the general outlook on life that is
associated with the belief that destiny is out of our hands and that events are
inevitable (Chavez et al, 1997). Sexual silence is a cultural characteristic that
affects the behavior of the individuals in Latino families. Sexuality is perceived to
be personal and is not to be talked about openly. Sexual silence leads to a lack
of communication among family members and between sexual partners.

(Chavez, 1997).

17

A study of the sexual and reproductive health of Latinas in the state of
North Carolina (Talmi, 2005) found that women’s shyness and the existence of
cultural taboos limit discussion about sexuality. When Latina women were asked
to discuss unusual beliefs regarding reproductive health held by Latinas, most
respondents referred to misconceptions about contraceptive use and pregnancy
prevention. Respondents also mentioned the fear of consequences of using
contraceptives, in terms of risks to both physical and spiritual well-being. (Talmi,

2005).

Religious beliefs, social customs, and the lack of accurate and
comprehensive sexual education at home and in school affect how well Latinas
are able to utilize reproductive health care services and access the services and

information they need to make healthy decisions.

Latinas and Prenatal Care

Latinas have the highest fertility rate of any group and account for 18
percent of all births yet 50 percent of all pregnancies are unintended and of these
unintended pregnancies, one half result in an abortion (Naral Foundation, 2003).
The 1995 National Survey of Growth indicated that only 32 percent of Latinas
aged 15-44 reported visiting a family planning provider within the last 12-month
period. More than 25 percent of Latinas do not receive prenatal care during the

first trimester (National Latina Institute for Reproductive Health, 2002).

18

Early prenatal care can encourage healthy behaviors during pregnancy,
help discover potential medical problems, and facilitate involvement with support,
and other educational resources. The Naral ProChoice America Foundation
(2002) reported that African American women and Latinas were over twice as
likely as White women to obtain delayed or no prenatal care. The majority of
women with late or no prenatal care wanted to enter care earlier; however, they
cited various factors that prevented them from doing so, including: they did not
know they were pregnant; they lacked the money or insurance to pay for their

visits; and were unable to obtain an appointment.

Preqnancv Prevention Among Latinas

The rate of unintended pregnancies for Latinas at the national level (69
per 1000 women) is close to twice the rate of non-Hispanic White women (36 per
1000 women) (Naral, 2000). Female sterilization remains the most popular
method of birth control for Latinas, an estimated 37 percent use this method.
Only 59 percent of Latinas between the ages of 22 and 44 reported using some
form of contraception as compared to 66 percent of White women and 62 percent

of African American women (National Survey of Growth, 1995).

Various factors affect the use of contraception by Latinas. Latinas are less
likely than blacks or whites to report feeling comfortable talking with their partners
about sex or condom use, though they were more likely to report that use of birth

control was a joint decision.

19

A number of studies have reported on barriers to contraceptive use among
Latinas. These barriers include those related to personal and relationship
characteristics (Kems, et al. 2003); barriers related to women’s experiences with
side effects from methods or their perceptions of method safety; and structural
barriers such as cost, lack of insurance, service unavailability and language
difficulties (Guendelman, 2000). These studies have generally found that access
to services is diminished among Latinas. On one hand, Latinas may face barriers
due to lack of information and education about services that might actually be
available to them. For example, Latinas were much more likely than blacks or
whites to report that a reason for non—contraceptive use prior to an accidental
pregnancy was due to not knowing about contraception or where to get it (Frost

& Driscoll, 2006).

Breast Cancer in Latinas

Although legislation has been passed that increases the availability of
cancer detection services for low-income, monolingual women, this does not
mean that women will routinely access the services available to them. Latinas
have consistently lower breast and cervical cancer screening rates compared
with non-Hispanic white women, regardless of risk status (Ramirez et al., 2002).
The incidence of breast cancer among Latinas is lower than for white females;
however, Latinas are more likely to be diagnosed at later stages when the cancer

is harder to fight (Washington, 1993).

20

Studies conducted by Borrayo (2000) indicated that in the past decade
many Latinas were not aware of breast cancer risks, symptoms, screening
methods, and mammography financing options. Valdez (2002) also observed
that Latina women believed that mammograms were harmful and painful to their
health and might detect cancer, a fear-provoking aspect. Moreover, the
participants of this study believed that receiving a mammogram was not as
important as other priorities in life, and they believed breast cancer could only be

cured if detected early.

Although the American Cancer Society (2002) indicates that there is an
increase in breast cancer screening among women in general, there are still
women within the Latino community who do not get regular mammograms,
particularly those women with lower education and income levels. This trend
continues despite that in recent years there has been an increase in available
information sources for underserved women about mammography information
and resources (Ackerson et al., 2001). In Frazier’s (1996) study, the reasons for
underutilization of breast cancer screening procedures included factors such as
lack of access to preventive health care services, an inaccurate perception of the
risk of breast cancer, and the belief that breast cancer screening examinations

are essential only if a lump has been detected.

21

Cervical Cancer in Latinas

Cervical cancer is the third most common cancer amongst Latinas
(Ramirez et al., 2002). Moreover, According to the National Cancer Institute
(1999) the incidence rate of cervical cancer among Latinas is 15.8 per 100,000
compared to 7.1 per 100,000 among white women and the mortality rate of
cervical cancer is 40 percent higher than among white women. Latinas of
reproductive age have been found to have lower rates of Pap smear and pelvic
examination than white and African American women (Elder et. al., 1991;
Jennings-Dozier & Lawrence, 2000). Although the percentage of women who
have received cervical cancer screening has increased from 91.1 percent in 1991
to 93.1 percent in 1997, the disparities between Latinas and non-Latinas
prevailed (Blackman, 1999). Blackman (1999) reported that in 1991, 84 percent
of Latinas reported participating in cervical cancer screening compared to 91.9
percent of non-Latinas. These percentages were 86.7 and 93.8 percent,
respectively in 1997 (Blackman, 1999). When comparing these rates Latina
immigrants (68%) have even lower rates compared to U.S.-bom Latinas (94%)
and whites (98%) (Hubbell, et. al.,1996). As a result, there is a considerable need
to increase the percentage of Latinas who engage in cervical cancer screening,

particularly Latina immigrants (Scarinci, et.al., 2003).

Several studies have explored the factors associated with cervical cancer
screening among Latinas. Some of these variables include income (Skaer, et. al.,
1999), education (Skaer, et. al., Chavez, et. al., 1995), health insurance (Chavez,

et. al., 1995), regular source of health care (Zambrana, et. al., 1999), prior cancer

22

prevention screening (Zambrana, et. al., 1999), social networks (Suarez, et. al.

2000), and acculturation (Suarez, et. al., Perez-Stable, et.al., 1992).

Research has also evidenced that Latinas tend to be less aware about
cancer signs, causes, and treatment effectiveness when compared to white
women (Elder, et. al., 1991). Latinas are also more likely to display fatalistic
beliefs regarding cancer than white women (Chavez, et. al., 1995). When
comparing the knowledge and attitudes regarding cervical cancer among Latina
immigrants, U.S.-bom Latinas, and whites; Latina immigrants were less likely to
identify family history as a contributing factor for cervical cancer than U.S.-bom
Latinas and whites(Hubbell, et. al., 1996). On the other hand, they were more
likely to identify early sexual intercourse and having multiple partners as
contributors to cervical cancer than U.S.-bom Latinas and whites. With regard to
cancer related beliefs, Latinas were more likely to believe that factors such as
poor hygiene, abortion, vaginal trauma, antibiotics, and having sexual intercourse
during their menses contributed to development of cervical cancer than the other
two comparison groups. In addition, Latina immigrants were more likely than
U.S.-bom Latinas and whites to believe that fate played a role in the
development of cervical cancer and preferred to not know if they had cervical
cancer. Latinas were also more likely than their counterparts to believe that they
had good chances of developing cervical cancer in their lifetime (Hubbell, et. al.,

1996)

23

Sexually Transmitted Infections (STDs) and Latinas

According to the National Latina Institute for Reproductive Health (2005),
Latina women report the second highest number of cases of gonorrhea. Latinas
have the highest rate of cervical cancer caused by human papilloma virus. The
rate of recently reported cases of young Latinas - between the ages of 10-19 —
with Chlamydia is more than double that of young white females (National Latina
Institute for Reproductive Health, 2005). Latinas have higher rates of syphilis
than non-Hispanic white women. HIV/AIDS is the leading cause of death among
Latinos aged 25-44. For Latinas, the HIV rate was 12.9 per 100,000 contrasted to
2.4 for White women. Nationally, Latinas have been disproportionately affected
by HIV/AIDS, compared with non-Hispanic white women, and they are making up
an increasingly greater share of all AIDS cases reported among Latinos. Among
Latinas with AIDS, the majority of cases are due to heterosexual contact with an
infected male (63 percent). This is slightly higher than the percentage of cases
among white women due to heterosexual contact (56 percent). The bulk of the
remaining AIDS cases are due to exposure through injection drug use (35
percent for Latinas and 41 percent for white women) (National Latina Institute for

Reproductive Health, 2005).

Migrant Farmworker Health
Migrant farmworkers are known to have more health problems than the
general Latino population, and they lack access to health care services. Early
research on the impact of health needs, enabling and predisposing variables on

health care utilization considered Latino health care behavior to be a

24

consequence of cultural beliefs and demographic traits (Abril, 1977, & Adelman,
1983). More recently, an emphasis has been placed on variables such as low
socioeconomic status, lack of or insufficient health insurance and barriers to care

placed by the health delivery system (Guendelman & Wagner, 2000).

Other studies have focused exclusively on the determinants of farmworker
health. Sakala (1987) considered the multitude of health problems suffered by
hired migrant and seasonal agricultural workers a consequence of primary and
secondary occupational hazards of farm labor, coupled with extreme poverty and
migrancy status. Primary occupational hazards included pesticide exposure, sun
exposure, injuries, and poor field sanitation. Secondary occupational hazards
resulted from structural and institutional barriers such as difficulties in accessing
health care services, exclusion from traditional worker health benefits, lack of
enforcement of health and safety standards, lack of adequate housing, the lack

of access to clean water, and other social determinants of health such education.

Studies on the social determinants of health (Ward, 2002, 2003) have
concluded that famworker health issues are complex and extend beyond the
delivery of health services to farmworker populations. According to Ward, the
farmworker population lags behind other disadvantaged groups in securing
access to essential health care services, in part because migrant health must
include social determinants of health, such as housing, work conditions,
transportation, sanitation, water supply, and education (Ward, 2003). This study

further concluded that male gender, following the crops, poor working conditions,

25

higher native language literacy levels, and more access barriers decreased the
likelihood that farmworkers would receive US. medical care. On the other hand,
use of Medicaid, WIC, or government clinics increased the likelihood that

farmworkers would receive such care (Ward, 2002).

There is a difference between migrant farmworkers who are in the
community for only a few weeks and those who stay in the area longer (Chapa,
1999). Farrnworkers that stay in the community for a short time are less likely to
be involved in community events because they spend most of their time working.
Workers that remain longer frequently have children in school and use other
community and health resources more often. Reasonable access to community
services, such as doctors' offices, social and health related services, are

important to the migrant farmworkers.

Access to services such as health care should be considered as an
extension of migrant and seasonal farmworkers’ investment in labor. However,
studies have reported that community members sometimes express a different
opinion with a documented perception of the migrant farmworker population as
“using” the system in order to benefit from the social services offered (Chapa,
1999). Furthermore, many farming communities have fragile economies and fear

that an influx of farmworkers can strain resources.

26

Migrant Health Programs
The recognition that there is indeed a migrant farmworker health problem
has prompted federal initiatives to address it. The decade of the 1960’s saw the
Bracero program come to an end with documentation of migrant hardships,
including working in the fields without drinking water or toilets, exposure to
harmful pesticides, and limited access to child care facilities and healthcare.
These conditions became national concerns, prompting some protection under

various federal laws, regulations, and programs (Martin & Martin, 1994).

Due to these circumstances the federal government enacted numerous
programs to specifically assist migrant workers and their families. The result was
the institutionalization within various Federal departments of several programs
specifically committed to serving migrant farmworker and their families. The first
of these programs was the Migrant Health Act enacted in 1962, which provided
for the Migrant Health Program through grants to states, local governments, and
nonprofits agencies for clinics and visiting health services for migrant families.
The Migrant Education and Migrant Head Start programs were formed as part of
the Economic Opportunity Act two years later. During the 19703 and 19805 the
number of Federal programs for migrant farmworkers increased. Today, many of
these programs have expanded their target population to include seasonal

farmworkers, however this is not always the case (Martin & Martin, 1994).

27

In spite the introduction of ameliorating measures to address migrant
health concerns, challenges impacting farmworker health status have continued
to exist. More recent assessments of migrant health status report major health
concerns such as infectious diseases, chemical-and pesticide relate illnesses,
dermatitis, heat stress respiratory conditions, musculoskeletal disorders and
traumatic injuries, reproductive health problems, dental diseases, cancer, poor
child health, obesity, inadequate preventive care, and social and mental health

problems (Hansen & Donohoe, 2003; Villarejo & Lighthall, 2000).

Migrant Farrnworkers and Health Services Utilization

Nearly three million workers earn their living through migrant or seasonal
farm labor. Migrant and seasonal farmworkers and their families confront health
challenges stemming from the nature of their work, their extreme poverty and
mobility, and living and working arrangements that impede access to health
coverage and care. Reports of poor health status among migratory agricultural
workers and their families are widely recognized (Leone & Johnston, 1954;
Goldsmith, 1989; Dever, 1991). Despite this, there is little health services usage

research directed to this population (Council on Migrant Health, 1993).

According to the most recent reports by the National Agricultural Workers
Survey (NAWS, 2005). Almost all migrant and seasonal farmworkers are
foreign-bom; only 6 percent reported being born in the United States. The

majority (70 percent) permanently reside in the United States.

28

Although concentrated in certain areas of the country, migrant and
seasonal farmworkers reside in all states. They travel frequently between
“migrant streams” for their employment. As a group, migrant and seasonal
farmworkers face significant language barriers—about 9 in 10 say they read and
speak little or no English. They are predominantly male (88 percent), over half
are married (52 percent), and over four in ten have children (44 percent). Even
though migrant and seasonal farmworkers report working five to six days a week,
they live in extreme poverty. In year 2000, the median income for migrant and
seasonal farmworkers was $6,250, compared to $42,000 for US. workers

overall.

The great majority of migrant and seasonal farmworkers and their families
are uninsured. The Keiser Commission on Medicaid and the Uninsured reported
that in year 2000, 85 percent of the migrant and seasonal farmworkers were
uninsured as compared to 37 percent of low-income adults nationally. Migrant
and seasonal farmworkers thus have very low rates on health care compared to
other low-income groups. In 2000, only 20 percent of the migrant and seasonal

farmworkers reported using any healthcare services in the preceding two years.

Studies demonstrating the reproductive health status and utilization of
reproductive health services amongst Latina migrant and seasonal farmworkers
are scarce. The National Latina Institute for Reproductive Health (2005) has
been an advocate on behalf of this specific subpopulation because of their limited

access to preventive screenings, family planning, and prenatal care among other

29

services. There are many challenges to addressing the reproductive health
concerns of Latina migrant and seasonal famworkers. One of the main issues is
the high mobility of this population, which makes it difficult to reach them to
provide essential care as well as educational information. Most studies focusing
on migrant and seasonal farmworkers do not focus on female farmworkers much

less on their utilization of reproductive health services.

One study found that only 42 percent of women in farmworker families
reported seeking early prenatal care compared to 76 percent nationally
(Rosenbaum, et al, 2006). A review of maternal health care services to migrant
farmworker women conducted by WIC and the Pregnancy Prevention System,
examined prenatal care, weight gain during pregnancy, and birth outcomes, they
concluded that the national goals for the year 2000 were not being met (CDC,

1997)

To further complicate this situation, it has been reported that most
farmworkers appear to access health care services “only when absolutely
necessary” (Villarejo & Lighthall, 2000). Thus, many farmworkers only seek care
when it is absolutely essential, visiting hospital emergency rooms or community
clinics. The most common form of payment for health care visits being out-of-
pocket. Lack of insurance and fear of deportation discourages many farmworkers
from utilizing the health care system (Villarejo & Lighthall, 2000; Hansen &

Donohoe, 2003).

30

Summarizing, migrant and seasonal farmworkers are considered to be
one of the most underprivileged groups in the United States. The majority live in
extreme poverty, most are uninsured, monolingual individuals who endure
significant health disparities. In fact, the health status of farm workers in the
United States is among the worst when compared to any other Latino sub-
populations as well as US population in general (National Latina Institute for

Reproductive Health, 2005).

Michigan Latinos Utilization of Health Services

Similar to the nation-wide trend, under-utilization of health services is a
significant problem for Latinos in Michigan (Coupe, et al, 1999). Reportedly,
since 1991, Michigan is one of the thirteen states where health insurance
coverage rates have significantly decreased over time (US Census, 1993).
According to the 1989 Health Insurance Survey of Michigan, 5 percent of Latinos
did not have health insurance and 4 percent were underinsured as compared to
less than 9 percent of Whites who were uninsured during that same time period

(Johnson,1994)

Data indicating the exact numbers of migrant and seasonal farmworkers in
the state of Michigan is not currently available. Best estimates provided by
Rosenbaum (2002) placed migrant agricultural labor force at 45,000 in 1997. It is
estimated that with a workforce of 45,000 and an average family size of 3.4 the
migrant population in Michigan ranges around 153,000-160,000 (Rosenbaum,

2002)

31

Michigan is fourth in the nation in migrant labor utilization with 95 percent
of farmworkers being of Mexican descent. The majority of these workers come
from Texas, and the remaining typically come from Florida and other southern
states. Michigan migrant farmworkers average annual income falling below the
federal poverty line; average is $7,200 for a family of four (Coupe, et al., 1999).
Michigan migrant famworkers’ educational levels also fall below national and
state averages, with the average grade completed being 6th grade (Coupe, et al.,
1999)

Conclusion

Chapter two has reviewed the theories guiding the research,
demonstrating that reproductive health services utilization amongst Latina
migrant and seasonal farmworkers can be analyzed within an ecological
framework and more specifically adopting the behavioral model of health
services utilization.

In addition, this chapter discussed relevant literature regarding Latinas’
reproductive health care status and utilization of services; migrant farmworker
health; migrant farmworker health services utilization; migrant programs put in
place to alleviate the health hazards among this population; and challenges

impacting migrant farmworkers utilization of health services.

Studies on migrant and seasonal farmworker women and their utilization
of reproductive health care services are scant. Reviewing the literature on US
Latinas demonstrates that as a whole Latinas in the United States share poor

reproductive health status when compared to other ethnic groups.

32

This is important to know when studying migrant and seasonal farmworker
women as a Latina subgroup. Being Latina places women at risk for more
reproductive health care problems as well as less utilization of these services.
Being a migrant and/or seasonal farmworker further complicates this relationship
as issues attached to the migratory lifestyle limit women’s access to preventive
screenings and reproductive health care overall. Thus, being both Latina and
migrant or seasonal farmworker compounds the issue and places women at even
lower likelihood to utilize the reproductive health care services they need. This
study addresses deficits in the literature concerning migrant and seasonal
farmworkers and contributes to research on predisposing, enabling, and need
factors associated with their reproductive health services utilization. The following

chapter will delineate the research methodology specific to this study.

33

CHAPTER3

Methodology

Introduction
The study used data originally collected by the Oceana Farmworker
Health Study (OFHS, 2006). Thus, this chapter highlights the specific
methodology employed by the original OFHS study. This discussion is followed
by information regarding specific variables, their respective levels of

measurement and suggested analysis for the purposes of the present study.

Research Design of the Oceana Farmworker Health Study

The OFHS study (Rosenbaum, Lahousse, Babladelis, & Rivera-Vazquez,
2006) adopted the research design and survey methodology employed in the
California Agricultural Worker Health Survey (CAWHS), which was developed by
the California Institute for Rural Studies (CIRS) in 1990, to conduct a health
needs assessment of the agricultural worker population in that state. The
assessment procedures included a household-based cross-sectional health and
risk behavior survey of migrant and seasonal farmworkers in the area. Moreover,
the assessment included a free physical examination for those who agreed to
participate in the survey. The survey instrument was developed following both
the CAWHS survey framework and the Behavioral Risk Factor Surveillance
System (BRFSS), an annual health risk survey of the Nation developed by the
Centers for Disease Control and Prevention. In addition, Andersen’s (1968)
model of health services utilization was used to examine the factors that

influence access and utilization of health services among this population.

34

A thirty-five dollar incentive and a ten-dollar gas stipend were provided to each
participant after completion of the interview and physical exam phases of the
project.

The study was guided by a multidisciplinary, participatory research
approach. lnformants of services available to the farmworker population were
involved at all stages of the research, including developing instrumentation,
collecting data, processing and analyzing data, and disseminating the results.
The project design and planning was steered by the project’s advisory panel.
This advisory panel met monthly to advice and assist on the design and
implementation of the project. Panel members represented seasonal farmworker
health service providers and representatives from the local Extension office,
human services agency, mental health clinic, migrant Head Start, and farm labor
specialists.

Research Setting

Data were collected in Oceana County, from summer 2002 to summer
2004. Oceana County, in northwest Michigan is an “upstream” community in the
Midwest that relies on migrant workers to meet its farm labor needs. Over the
course of nearly a century of serving as a seasonal agricultural labor market area
to the migrant population, some migrants have become permanent residents of
the area, and many continue to work in seasonal agriculture (Rosenbaum, et al.,
2006). The century old migration pattern has produced a large resident Hispanic

population in the area that still works in agriculture.

35

In year 2000, 11.6 percent of the County’s population was Hispanic. By
contrast, the percentage of Hispanics in the state was 3.3 percent (US. Census
Bureau, 2005). Oceana county represents an important fruit and vegetable
agricultural area in the state with a large demand for migrant and seasonal labor.
Oceana County ranks number one in the nation for its production of asparagus
and has over 15,000 acres in vegetable production, 15,000 acres in fruit
production and 6,000 acres in Christmas tree production. This acreage helps to
make Oceana Michigan’s largest vegetable growing county in the state. It is also
the state’s 4th largest fruit producing county, and its third largest Christmas tree

producer (Myers, 2003).

Migrant numbers peak in Oceana County in July after asparagus season
is over due to a jump in jobs available at food processing plants during the cherry
season. In the post cherry harvest season in August, workers are employed in
the harvest of summer squashes and peaches, pruning of Christmas trees or
weeding of carrots. In September, the summer squash and peach harvests
come to an end. Some families return to Texas or Florida, but others stay to
harvest apples during the late September period. Apple harvest continues
through October and some workers move into harvesting Christmas trees. The
harvest season finishes up with the end of the Christmas tree harvest around
Thanksgiving, after which many of the migrants return to their home base
community in Texas and Florida (Myers, 2003). It is estimated that 2500 workers

are used during the asparagus harvest in May and June. (Martinez, 2003).

36

Thus, in a typical year, an estimated 5,000 (Rosenbaum, et. al., 2006) migrant
farmworkers and their dependents leave their homes in Texas, Mexico or Florida

to come to the area for an average of six months to perform agricultural work.

As far as health services available to migrant and seasonal farmworker
women in Oceana County, even though migrant camps are scattered throughout
the County, a single health care provider offers bilingual services from reception
to examination. Thus, migrant and seasonal famworker women are largely
constrained to the use of this specific health care provider in the County. A clinic
outreach program was in place in prior years but was eliminated due to lack of

funding (Rosenbaum, et. al., 2006).

Study Sample
The original sample included a total of 300 adult (18 years old and older)
migrant and seasonal farmworkers comprising 180 migrant and 120 seasonal
agricultural workers. A total of 183 (61 percent) of the survey participants were
women and the rest, (39 percent), were men. The mean ages were 35 and 34
years old for migrant and seasonal farmworkers respectively. Additional data on
work and gender status were collected on 1,231 household members living with

the primary respondents at the time of the interview.

For the purposes of the present study, only female farmworker (primary
respondent) data were used. Thus, the sample size for this study is 183

participants. Female migrant farmworkers comprised 56 percent of the sample,

37

while the remaining 42 percent were female seasonal farmworkers. Further

sample descriptives are discussed later on this chapter.

Procedures

In order to identify migrant farmworkers, a list of randomly selected
licensed migrant housing units was created from the 2002—licensed migrant labor
housing sites (camps) report produced by the Michigan Department of
Agriculture. Postcards with prepaid postage and information about the project
and soliciting volunteers were used to identify seasonal farmworker participants
for the study. The postcard asked for work and residential status, name, and
contact information. They were distributed at the local migrant clinic, the local
social service agency, churches, laundry mats, and other public places often

visited by the farmworker community.

Community migrant service and migrant health workers were hired and
trained to select predetermined housing units and to conduct a structured
interview in the participants’ preferred language, mostly Spanish, which required

approximately 2-2.5 hours to complete.

A description of the study’s research procedures and copies of the
research instrument were approved by the University Committee on Research
Involving Human Subjects at Michigan State University (MSU UCRIHS). As part
of these procedures, participants were informed about the project and their rights
as participants. Once the individual agreed to participate, a consent form was

presented and signed before proceeding with the interview. Numeric identifiers

38

were used instead of participants’ names. Additional approval from MSU
UCRIHS was obtained for the purposes of the secondary data analyses involved

in the present study (see Appendix C).

Instruments
A main survey instrument and a clinical exam served as the two principal
components of the study. The survey was administered in a structured interview
format to be able to account for any participants’ literacy issues. English and
“Spanish and male and female specific versions of the questionnaire were
developed. Male and female field interviewers were all Hispanic and proficient in
both Spanish and English. In some cases, interviewers themselves were

farmworkers in the past. The survey required about 2-2.5 hours to complete.

The survey instrument inquired about household composition and
household member access and utilization to health care services. Other
variables included demographics, health services utilization data, self-reported
health conditions, doctor-reported health conditions, work history, income and
living conditions, workplace health conditions, field sanitation, work related
industries, and behavior risk assessment. After the survey was administered, the
interviewer arranged for the participant to have a physical exam at the local
migrant health clinic. The clinical exam included biometrics (height, weigh, blood
pressure, temperature, pulse rate, respiratory rate, lab tests (urine dip,
hemoglobin, high serum cholesterol, fasting blood sugar, and diagnostic and

therapeutic procedures (Pap smear, STDs, PPD/Tuberculosis Skin Test). The

39

clinic performing the physical examinations had a contract with the federal
government for services to the migrant farmworker population in the area and

adhered to all matters of client confidentiality.

Research Questions
The following research questions provided a guiding framework for the

analysis.

. What is the overall self-reported reproductive health care utilization of
female migrant and seasonal famworkers?

. Are predisposing, enabling, and need factors associated with reproductive
health care utilization?

0 Do migrant and seasonal farmworker women differ in their reproductive
health care utilization?
Hypotheses
The following hypotheses were tested in this study:

H1. Predisposing, enabling and need factors are directly associated with
reproductive health care utilization for both migrant and seasonal farmworkers.

H2. Migrant and seasonal farmworkers will differ in their reproductive health care
utilization.

H3. Predisposing, enabling and need factors increase the odds of reproductive
health care utilization as measured by prenatal care, ever having a PAP Smear,
ever having a mammogram, pregnancy prevention, and sexually transmitted
disease protection.

H4. Migrant and seasonal farmworker women with lower rates of predisposing
factors will be less likely to utilize reproductive health care services.

H5. Migrant and seasonal farmworker women with lower rates of enabling factors
will be less likely to utilize reproductive health care services.

H6. Migrant and seasonal farmworker women with lower rates of need factors will
be less likely to utilize reproductive health care services.

40

Measures
Reproductive Health Care Utilization

Reproductive health care has been defined as “the constellation of
methods, techniques, and services that contribute to reproductive health and
well-being by preventing and solving reproductive health problems” (WHO,
1998). Reproductive health implies a state of complete physical, mental and
social well-being, and not merely the absence of disease or infirmity.
Reproductive health, therefore, implies that people are able to have a
responsible, satisfying and safe sex life and they have the capability to reproduce
and the freedom to decide if, when and how often to do so. Implicit in this
definition, is the right for women to be informed of and have access to
appropriate health care that will enable women to go safely through pregnancy

and childbirth and having a best chance of having a healthy baby (WHO, 1994).

For the purposes of the present study, the dependent variable-
reproductive health care utilization has been operationalized using data obtained
from the self-reported answers to the survey instrument. Specifically, the
following questions were used as dependent measures of reproductive health

care USGI

a. The last time you were expecting a baby, how soon did you go see a
doctor or midwife? This variable was originally measured using an
ordinal scale where 1=within the first three months, 2=between the first
3-6 months, 3=in the last three months of pregnancy, and 4=at the

baby’s birth: no prenatal care.

41

b. Have you ever had a mammogram? This is a dichotomous variable
where 1=yes and 2=no.

c. Have you ever had a PAP smear? This is a dichotomous variable
where 1=yes and 2=no.

d. When you have sexual relations, do you use anything to protect
yourself from diseases? This is a dichotomous variable where 1=yes
and 2=no.

e. When you have sexual relations, do you use anything to prevent
pregnancy?

Composite Measure of Health Care Utilization

A composite measure of reproductive health care utilization was created

by summing all dichotomous variables (including early prenatal care
dichotomized as yes/no). This composite measure allowed for a multidimensional

analysis examining the impact of the independent measures included in the

model on rates of reproductive health care utilization by Latina farmworkers.

Predisposing. Enablinq and Need Variables

Predisposing variables are conceptually defined as inclination to utilize
services. Predisposing variables are measured as self-reported age, educational
level, respondents’ agricultural work status (migrant vs. seasonal), and primary

language.

Enabling variables are conceptually defined as those influencing the ability
to obtain services. Enabling measures included in this study are health
insurance, work status, family income, number of years working in MI, and use of

local migrant clinic.

42

Need variables are conceptually defined as medical need and are
operationalized as respondent’s perceived health status, diagnosed pregnancy
diabetes, having an abnormal physical exam, and reports of unmet treatment
need. Perceived health status is measured by using a Likert scale where
respondents rated their health in general as excellent, good, fair, or poor. Unmet
need for medical care is a binary variable based on the woman's perceptions of
her need for health services. Having an abnormal physical exam is a clinical
variable obtained where a physician has indicated any kind of abnormally events
when the participants’ exam was conducted. This was a binary variable. Having
been diagnosed pregnancy diabetes was a binary variable where participants
self-reported if they have been diagnosed with diabetes while pregnant. A
woman had perceived unmet need if she answered yes to: ”During the last 12
months, have there been times when you wanted to go to a clinic or doctor and
couldn’t?” Table 2 outlines the distribution of the outcome and independent

measures in the study.

Predisposingénabling. and Need Factors Composite Measures

Composite measures of predisposing, enabling, and need factors were
used in the analyses. These composite measures were created by summing the
number of each factor category. Thus, for the predisposing score, a value of one
was given to each of the predisposing factors. Each of these categories was
coded as one and then added to create a total predisposing score. For example,

if a person was a seasonal farmworker, with more than 7th grade education, age

43

40 or less, married, and able to speak English or both Spanish and English, this

participant would have scored 5. The predisposing score ranged from 0- 5.

The same sum technique was used to create the enabling score. Values
of 1 were assigned to having health insurance, having a higher income rate
(more than $15,000), having a job/being employed at the time, having resided in
Michigan for more than 3 years, and having visited the local migrant clinic in the

last twelve months. This score ranged from 0-5.

Lastly, the need factors score was created using the sum technique
coding at a value of one for the following categories: having unmet treatment
needs, perceiving that the health status was poor, having been diagnosed
pregnancy diabetes, and having an abnormal physical exam. This score ranged

from 0-4.

Sample Characteristics

Predisposing Characteristics

The mean age for female farmworkers in the sample is 34.98. Seventy
percent of the female subsample was composed by migrant farmworkers ages
under 40 years old, the other thirty percent were females over 40 years old. In
regards to agricultural work status, fifty nine percent were migrant workers and
the remaining forty one percent were seasonal workers. The average educational
level was 7th grade and most participants indicated that Spanish was their
primary language, as well as the language that they prefer to speak and write in

general. Most respondents were married and the number of people in the family

44

ranged from 1-11 and averaged 4.49 family members. Table 1 displays

predisposing characteristics of the sample.

Table 1. Distribution of Predisposing Factors

 

 

 

 

 

Independent Measures Frequency Percent
Age
Under 40 years old 123 70
40 years old and over 53 30
Migrant Status
Migrant 107 59
Seasonal 76 41
Marital Status
Married 130 80
Other 50 20
Primary Language
Spanish 1 19 67
English/Both 59 33

 

 

 

 

 

Enabling Characteristics

The majority of the female farmworkers had no medical insurance and
reported a family income of less than $14,999/year. Most participants were
employed in farrnwork at the time of the interview and more than half of the
female sample reported having worked in Michigan for 5 or more years. When
inquired about their use of the local migrant clinic, an ovenivhelming majority
indicated that they have ever been to the clinic. Table 2 portrays enabling

characteristics for the sample.

45

Table 2. Distribution of Enabling Characteristics

 

 

 

 

 

 

 

 

Independent Measures Frequency Percent
Insurance
Yes 76 43
No 102 57
Income
Less than $14,999 118 67
Over $15,000 57 33
Work Status
Farrnwork 130 72
NonFarmwork/Not 49 28
Working
Years Employed in MI
1 year or less- 3 years 49 30
3-5 or more years 114 70
Migrant Clinic
Yes 160 90
No 18 10

 

 

 

Need Characteristics

The majority of the female farmworkers perceived their health status to be
good and 25 percent reported that their perceived health status was fair/poor.
When asked “Have there been times when you wanted to go to a clinic/doctor
and couldn’t?”, thirty one percent of the respondents said yes while sixty nine
percent reported no unmet treatment needs. Approximately half of the migrant

and seasonal farmworker women in the sample had an abnormal physical exam

46

and another 14 percent indicated having been diagnosed with diabetes while

pregnant. Table 3 portrays the distribution of health need variables in the study.

Table 3. Distribution of Need Factors

 

 

 

 

 

Independent Measures Frequency Percent
Perceived Health Status 24 14
Excellent 107 61
Good 45 25
Fair/Poor
Unmet Treatment
Yes 52 31
No 1 17 69
Pregnancy Diabetes
Yes 22 1 4
No 1 39 86
Abnormal Physical
Exam
69 51
Yes
67 49
No

 

 

 

 

 

General Reproductive Health Care Characteristics

Seventy percent of the women reported having had a physical exam at
some point in their lives. The majority of the women (92 percent) in the sample
reported that they have been pregnant. The average age for first pregnancy was
20.34 years old. The range for age at first pregnancy was 13-35 years old. The

average number of pregnancies was 3.85 and average live births was 3.35.

47

Fourteen percent of the women reported being diagnosed with diabetes while

pregnant.

Composite Measures Descriptives

Composite measures of reproductive health care utilization, predisposing,
enabling, and need variables were created. Table 4 highlights the descriptives of
all scores created for analyses. On average, Latina migrant and seasonal
famrworkers in the sample had low reproductive services utilization as well as

low-moderate enabling, predisposing and need scores.

Table 4: Descriptives of Predisposing, Enabling, Need and Reproductive Scores

 

 

 

 

 

 

 

Score St. Deviation Mean
Predisposing Score 1.06 2.80
(Range 0-5)

Enabling Score 1.08 2.43
(Range 0—5)
Need Score .80 .94
(Range 0-4)
Reproductive Score .84 2.12
(Range 0-5)

 

 

 

48

Data Analysis

Univariate analysis was performed to characterize the sample and to
describe the reproductive health care utilization by migrant and seasonal
farmworker women. Bivariate analyses were performed to determine the
relationship between the independent predisposing, enabling, and health need
variables, with utilization of reproductive health care services. Logistic regression
models and multiple regression models analyzed the predictive power of
predisposing, enabling and health need factors on the dependent variables-

reproductive health care utilization.

Thus, hypotheses 1 and 2 examining the relationship between
predisposing, enabling, health need, and reproductive health care services were
analyzed using Chi-Square analysis. Given the binary nature of the reproductive
health care outcomes, the third hypothesis was analyzed using binary logistic
regression. Lastly, since a continuous composite measure of reproductive health
care utilization as well as continuous predisposing, enabling and health need
rates were created, hypotheses 4-6 were analyzed using multivariate regression

analyses.

49

Conclusion
This chapter outlined the specific research methods used in the study.
This chapter has included the purpose of the research and related hypotheses,
design of the study as well as methods used. The sample was described, data
collection techniques and data analysis procedures necessary for completion of

the study. The next chapter will delineate the results.

50

CHAPTER4
Results
Introduction
The main objective of this study was to investigate Latina migrant and
seasonal farmworker utilization of reproductive health services. This chapter
includes relevant information on data patterns and major findings for each

hypothesis.

Research Question 1. What is the overall self-reported reproductive health

care utilization of female migrant and seasonal farmworkers?

To answer this research question, univariate analysis was performed to
describe the general use of reproductive health care services of migrant and
seasonal women in the sample. The outcome measures of reproductive health
care included ever having a mammogram, ever having a Pap smear, early
prenatal care, STD prevention, and pregnancy prevention. When asked “Have
you ever had a mammogram?” and “When you have sexual relations, do you use
anything to protect yourself from diseases?”, the majority of the female
farmworkers in the sample responded “No”. In regards to ever having a PAP
smear most respondents reported that they have had a PAP Smear. When
asked “When you have sexual relations, do you use anything to prevent
pregnancy?”, fifty seven percent of the respondents said “Yes” and 43 percent
said “No”. In regards to early prenatal care, the majority of the respondents

reported having sought prenatal care during the first three months of pregnancy

51

the last time they were pregnant. Table 4 highlights specific distributions for all

reproductive health care outcomes included in the analysis.

Table 5. Distribution of Reproductive Health Care Outcomes

 

 

 

 

 

 

 

Reproductive Health Frequency Percent
Care Outcomes
Ever had a
mammogram
56 32
Yes
1 19 68
No
Ever had a PAP Smear
Yes 159 90
No 17 10
Use protection for STD
Yes 37 22
No 131 78
Pregnancy Prevention
Yes 73 43
No 95 57
Early Prenatal Care
Yes 140 89
No 17 11

 

 

 

 

52

Research Question 2. Are predisposing, enabling, and health need factors

associated with reproductive health care utilization.

Hypothesis 1. Predisposing, enabling, and health need factors are
associated with reproductive care utilization outcomes for both migrant and

seasonal farmworkers.

This first hypothesis was tested using Chi-Square analysis. The analysis
demonstrated that certain predisposing, enabling, and health need variables are
associated with reproductive health services utilization outcomes for both migrant
and seasonal farmworkers in the sample. Specifically, the predisposing variable
age is associated with mammogram screening and pregnancy prevention.
Women who are over 40 years old seem to be getting their mammograms as
recommended at age 40. Women less than 40 years old are less likely to use
methods for preventing pregnancy. Marital status is associated with STD
prevention, migrant and seasonal farmworkers who are married are less likely to
utilize STD protection. Lastly, women with more than 7th grade education are
more likely to get mammograms. The enabling variables, years employed in the
state and having visited the local migrant clinic are associated with increased
mammogram screenings. Also, having an income level over the $15,000
increases the likelihood of utilization of PAP smears and STD prevention

methods for women in the sample.

53

In regards to health need variables association with reproductive health
care utilization, having no unmet treatment health need is associated with a
greater likelihood to obtain PAP smears screenings. Tables 6.1-6.3 portray
detailed results for these analyses.

Table 6.1 Chi-Square Results for Predisposing Variables Association with
Utilization of Reproductive Care Services

 

Independent Marmogan PAP S'ID Prenatzi Pregimcy

 

 

 

 

 

Measures Prevention Cale Prevention
Predisposing fies N2 Es N_o Yfi lie Yes _Np. Y_e_s N_o
Ace * *
<40yearsold 25 92 71 62 76 67 69 60 84 60
>40yeasold 75 8 28 38 24 33 31 40 16 40
MaIiaISlatus *
Marned 77 71 74 65 56 78 74 73 71 75
Other 23 29 26 35 44 22 26 27 29 25
Pr'rnary
Lavage

69 65 67 70 56 68 71 53 62 67
Spm'sh

7 9 8 12 11 7 10 1 9 7
Ergsh

23 25 25 18 33 25 19 46 29 26
Both
EdtmlionalLevel *

Less than 7th 39 23 3O 88 25 31 30 33 25 34

7mgrade or 61 77 7o 12 75 69 7o 67 75 66
more

 

 

 

 

 

 

 

 

Note *= P<.05

54

Table 6. 2 Chi-Square Results for Enabling Variables Association with Utilization
of Reproductive Care Services

 

Independent Marmog'an PAP STD Prenatal Premmcy

 

 

 

Measures Prevention Care Prevention
Enabhg 1% N9 Lee E Yes '10 Yes N_0 1686 .N2
lnsua'tce

Yes 31 44 46 23 37 42 47 47 43 41
No 59 56 54 77 63 56 53 53 57 59
Income * *

Leesthan 39 33 37 12 21 38 36 27 34 34
$14,999

Over$15fln 61 67 63 88 79 62 64 73 66 66

 

WOIkStaIus
Farmwork 71 73 73 71 81 77 70 87 75 80

NonFaImmrk/
NotWork'ng 29 27 27 29 19 23 30 13 25 20

 

YearsEmployed *
'nM

1-3years 14 38 28 47 32 30 25 40 27 33

3yeasorntoie 86 62 72 53 68 70 75 60 73 67

 

 

 

 

 

 

 

 

 

MgatCiric *

Yes 98 87 92 82 77 85 92 80 83 84
No 2 13 8 18 23 15 8 20 17 16
Note*=P<.05

55

Table 6.3 Chi-Square Results for Health Need Variables Association with
Utilization of Reproductive Care Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Independent Mammoga'n PAP STD Prenatd Pregmmcy
Measures Prevention Care Prevention
HealfliNeed 12$. & Les m Y_es_ & Y2 _N_Q Yes &
Perceived Heelh
Emlert 18 12 13 18 16 13 15 7 14 15
Good 54 65 62 53 60 64 62 60 61 65
FaitPoor 28 23 24 29 24 23 23 33 25 20
UrrnetTreamert *
Yes 32 27 31 18 18 27 28 50 27 25
No 68 73 69 82 80 73 72 50 73 75
999%
Diabetes
Yes 18 11 14 10 19 11 13 20 17 11
No 82 89 86 90 81 89 87 80 83 89
Abnormal
Physid Exam
Yes 48 50 48 64 39 45 53 64 45 39
No 52 50 52 36 61 55 47 36 55 61
Note *= P<.05

Hypothesis 2. Migrant and seasonal farmworkers will differ in their

utilization of reproductive health care services.

In order to test the second hypothesis, Chi-Square analyses were
conducted. It was expected that migrant farmworkers would have lower of
reproductive health care utilization compared to seasonal due to the high rates of

mobility and lower rates of social networks within the receiving community.

56

Results of the Chi-Square analyses demonstrated that seasonal women

are more likely to utilize pregnancy prevention and prenatal care. This

relationship was statistically significant at P<.05. Migrant farmworkers in the

sample were less likely to utilize the same services. Other reproductive health

care services such as PAP Smears, mammogram, and STD prevention were not

statistically significant. Table 6 highlights specific Chi-Square results.

Table 7. Chi-Square Results for Migrant and Seasonal Farmworker Utilization of

Reproductive Health Services

 

Reproductive Health

Percent Migrant

Percent Seasonal

 

 

 

 

 

 

 

 

 

Services

Mammogram

Yes 57 40

No 43 60

PAP Smears

Yes 88 93

No 12 7

Prenatal Care *

Yes 86 96

No 13 4

STD Prevention

Yes 28 26

No 72 74

Pregnancy Prevention *

Yes 39 55

No 61 45
Note: *=P<.05

57

 

Hypothesis 3. Predisposing, enabling, and health need factors increase
the odds of reproductive health care utilization as measured by prenatal care,
ever having a PAP Smear, ever having a mammogram, pregnancy prevention,

and sexually transmitted disease protection.

A total of five logistic regression models were performed with all the binary
reproductive health care measures as the dependent variable. Logistic
regression is the most reasonable statistical technique given the binary nature of
the several reproductive health outcomes. Thus, logistic regression models
included both theoretically and statistically significant predisposing, enabling, and
health need predictors of reproductive health care utilization as measured by
prenatal care, ever having a PAP Smear, ever having a mammogram, pregnancy

prevention, and sexually transmitted disease protection.

Due to sample size limitations (n=183), the logistic regression models
needed to be constrained to a maximum of six predictors per model. Based on
the Anderson theoretical framework, logistic regression models were used to
analyze the predictive power of several predisposing, enabling, and health need

factors separately.

1. Predisposing Factors as Predictors of Reproductive Health Services

The predisposing factors reflect mostly sociodemographic characteristics
that increase or decrease the propensity to use reproductive health care
services. The predisposing variables assessed in this study were educational

attainment, age, migrant status, primary language, and marital status.

58

When considering the impact of predisposing factors on mammogram
screening, the logistic regression analysis demonstrated that two variables: age
and migrant status are statistically significant. In specific, women who are less
than 40 years old are less likely to get mammograms. Additionally, migrant
farmworker women are more likely to report having had a mammogram ever

(Table 8).

Based on the results, some predisposing factors were predictive of
migrant/seasonal farmworker women’s’ utilization of mammogram screening.
Predisposing factors did not reach levels of statistical significance for PAP
screening, prenatal care, and STD prevention. The specific binary logistic results
for PAP screening, prenatal care and STD prevention are outlined in Tables
A8.1-A8.5. Age 40 was predictive of pregnancy prevention. In this case,
farmworker women below age 40 are more likely to utilize pregnancy prevention

methods.

2. Enabling Factors as Predictors of Reproductive Health Care

Enabling factors are resources or circumstances that allow a person to act
on her inclination to seek reproductive health services. The enabling variables
considered were health insurance status, employment status, annual income,
number of years the person has worked in Michigan, and reported use of the

local migrant clinic.

59

The logistic regression analysis demonstrated that certain enabling factors
influence the utilization of reproductive health care services, specifically
mammogram screenings and STD prevention practices (Table 8). Particularly,
the number of years residing in Michigan predicts mammogram screening. In this
instance, women who have been working in Michigan for less than 3 years are
less likely to report having ever had a mammogram. In regards to STD
prevention, the logistic regression analysis showed that income levels are
predictive of reported use of STD prevention methods. In this case, farmworker
women in the higher income categories, reportedly having an approximate
household income for the last 12 months higher than $15,000 are more likely to

use protection for sexually transmitted diseases (Table 8).

Based on the results, enabling factors were not predictive of migrant
farmworker women’s’ utilization of PAP Smears screening nor prenatal care.
Binary logistic outcomes for PAP screening and prenatal care did not reach

statistical significance at P<.05. (Tables A8.6-A8.10).

3. Health Need Factors as Predictors of Reproductive Health Care

Based on the results, health need factors were not predictive of migrant
farmworker women’s utilization of reproductive health services. Binary logistic
outcomes for mammogram screening, PAP screening, prenatal care, STD
prevention and pregnancy prevention did not reach statistical significance at
P<.05. Detailed binary logistic results for all health need logistic regression

models are outlined in tables A8.11-A8.15.

60

Table 8. Predisposing, Enabling and Need Predictors of Utilization of
Reproductive Care Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mammogram PAP STD Prenatal Pregnancy
Prevention Care Prevention
Predictors B 39 .3_ $9 5 £9 6 $9 5 $9
Predisposing
Education .592 .162 -.039 .056 -.366
Age 40 -4.017 * .462 .084 .076 1.21 *
Migrant -1.091 * -.530 -.114 -.806 -.359
Status
Language -.241 -.241 -.142 .630 .370
Marital Status -.066 -.311 1.18 * .603 -.512
Enabfing
Insurance .090 -.977 .401 -.064 .071
Status
Employment -.178 -.637 .202 .672 .679
Status
Income -.041 - .967 * -.427 -.466
1.361

Years in MI -.600 * -.267 .093 -.162 -.067
Migant Clinic -20.09 -.675 -.969 -.951 -.786
Need
Pregnancy -.511 .121 -.283 .540 .323
Diabetes
Normal .106 1.78 .086 -.706 -.683
Physical
Exam
Perceived .038 -.351 .439 .391 .330
Health Status
Unmet .074 -18.59 -.139 .787 -.042
Treatment
Note *= P<.05

61

 

Hypotheses 4-6. Migrant and seasonal farmworkers with higher rates of
predisposing, enabling, and health need factors will be less likely to utilize

reproductive health services overall.

In order to test hypotheses 4-6 outlining the predictive power of rates of
predisposing, enabling, and health need factors, three multiple regression
models were tested using the composite measure of reproductive health
utilization as the outcome. The composite measure is a sum of predisposing,
enabling, and health need factors. These scores were tested on a multiple
regression model to analyze the extent to which having lower rates of
predisposing, enabling, and health need factors impact reproductive health

service utilization for both migrant and seasonal farmworkers.

To determine which individual predictors are significantly associated with
utilization of reproductive health care controlling for other factors, regression
models using fonivard and backward stepwise techniques were performed. The
regression model including predisposing factors of reproductive health care rates

did not produce any statistically significant results at P<.05 (see Table 9).

The second regression model included enabling factors as predictors of
reproductive health care utilization rates (Table 9). The analysis demonstrated
that enabling factors predict reproductive health care utilization rates for migrant
and seasonal farmworker women (Table A9.1). Specifically, insurance status and
having visited the local migrant clinic in the last 12 months predict higher

utilization rates of reproductive health services overall. In this case, migrant and

62

seasonal farmworker women who do not have insurance utilize reproductive
health services at a lower rate than those who are insured. On the other hand,
the migrant farmworker women who have recently visited the local migrant health
clinic are more inclined to use reproductive health services such as PAP smears,
mammograms, etc. (see Table A92). The third regression model included health
need factors as predictors of reproductive health utilization rates. None of the

health need variables were statistically significant at P<.05 (See Table A9.3).

An additional model was tested while including predisposing, enabling,
and health need factor scores (all entered at once). The model displayed on the
table below examined the predictive power of these scores on the utilization of
reproductive health services among migrant and seasonal farmworkers. The
results were not statistically significant at P<.05. Thus, enabling, predisposing,
and health need scores, do not seem to predict health care utilization scores for

migrant and seasonal fannworker in the sample (Table A94).

63

Table 9. Regression Outcomes for Predisposing, Enabling, and Need Health

Variables as Predictors of Utilization of Reproductive Care Score

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Beta P Value

Predictors of Reproductive
Health Care Scores

Predisposing
Education .349 .108
Age 40 .424 .061
Migrant Status .143 .499
Language -.041 .849
Marital Status -.257 .223

Enabfing
Insurance Status -.339 .028*
Employment Status .225 .168
Income .088 .579
Years in MI .191 .408
Migrant Clinic .568 .050“

Need
Pregnancy Diabetes .115 .654
Normal Physical Exam -.035 .836
Perceived Health Status .353 .548
Unmet Treatment -.028 .148
Predisposing Score -.028 .813
Enabling Score -.002 .984
Need Score -.044 .767

Note: *=P<.05
Conclusion

This chapter presented the findings for the research hypotheses

introduced in Chapter 3. The next chapter will present a discussion of these

findings.

64

 

CHAPTER 5

Discussion

Introduction
The previous chapter provided the major findings for this study. Taking
into consideration all of these results, the present chapter will focus on
discussing relevant issues as they pertain to the study’s limitations, implications,

and suggestions for future research.

Summary of Findings

As a group, migrant and seasonal farmworkers comprise one of the most
disadvantaged in Michigan and in the nation. Migrant and seasonal farmworkers
are overwhelmingly uninsured and monolingual (Spanish-speaking), and suffer
from significant health disparities, including reproductive health utilization.
Migrant and seasonal farmworkers women have perhaps the most limited access
to preventative screenings, family planning, and prenatal care, among other
reproductive health services. This study endeavored to describe and analyze
factors that impact utilization of reproductive health care services by this
subpopulation in a Midwestern state. The study adopted an ecological framework

as well as the Anderson model of health care utilization.

Approximately, 90 percent of the women in the sample reported having
ever had a PAP Smears and another 89 percent reported seeking early prenatal
care. While these numbers are encouraging, there is a serious gap in

percentages of women who have had appropriate reproductive health care

65

utilization as measured in this study. The analyses demonstrated that migrant
and seasonal farmworker women in the sample have low to moderate use of the
reproductive health care services included in the analyses. Latina migrant and
seasonal farmworkers are likely to report not using any methods to protect
themselves from sexually transmitted diseases or pregnancy prevention. In
addition, both migrant and seasonal farmworker women have low rates of

mammogram screenings.

It was also proposed that seasonal and migrant farmworker would differ in
their reproductive health services utilization. There is statistical evidence
indicating that being a seasonal or a migrant farmworker does impact utilization
of reproductive health services. Specifically, seasonal farmworkers in the sample
were more likely to use prenatal care and pregnancy prevention at higher rates

than migrant women; thus, this finding provides support for Hypothesis 2.

The statistical analysis demonstrated a relationship between ever having
a mammogram and migrant status. It seems that migrant farmworker women
have been able to access mammogram screenings at higher rates than seasonal
farmworker women. A plausible explanation in light of the current study might be
that migrant farmworker women have been the target of specific programs
delineated to reduce health disparities specifically addressing the low rates of
breast cancer screening among this subpopulation. While the local migrant clinic
in the nearby township serves migrant farmworkers and seasonal farmworkers

equally, the Promotoras program -health education program- has made

66

aggressive attempts to educate migrant women residing in the camps about the
importance of cancer screening. Seasonal workers can still receive services and
information at the migrant clinic, however they are more limited as far as the

information they receive on breast cancer screening.

Based on results obtained from binary logistic regression models, it was
demonstrated that age and migrant status are predisposing predictors of having
ever had a mammogram. Having worked in the state for more than 3 years is an
enabling factor predictive of having ever had a mammogram. In addition, higher
income levels predict use of prevention methods for sexually transmitted
diseases. These findings provide limited support for hypothesis 3 in that specific
predisposing and enabling factors increase the odds of reproductive health care

services utilization by migrant and seasonal famworker women.

The health need factors models were not statistically significant. These
results contradict prior findings of studies utilizing the Andersen model indicating
that health need is one of the most pressing indicators of health care utilization
(Andersen, 1968; 1995). It seems that considered together both predisposing
and enabling factors may, in fact be more important and/or stronger predictors of
reproductive health care utilization than the need for care in this specific
subpopulation. These findings further indicate that cultural and behavioral
differences better explain the use of reproductive health care use among migrant

and seasonal farmworker women. Thus, for Latina migrant and seasonal

67

farmworkers in the sample, need for care is not associated with utilization of

reproductive health care services.

Enabling factors are also predictive of a woman’s reproductive health care
utilization score. Both migrant and seasonal women who do not have health
insurance utilize reproductive health care services at a lower rate than those with
health insurance. On the other hand, women who have not recently visited the
local migrant clinic have lower reproductive health utilization scores. These
findings provide support for Hypothesis number 5 outlining that migrant and
seasonal farmworker women with lower rates of enabling factors will be less

likely to utilize reproductive health care services.

The fact that certain predisposing and enabling factors are predictive of
Latino Migrant farmworker women reproductive health care utilization rates does
suggest that structural factors play a particularly important role in determining
these women utilization of services. Predisposing and enabling factors are key in
Andersen’s behavioral model of health services utilization and should continue to
be explored in light of the current findings. Hypotheses number 4 and 6 were not
supported by the statistical analysis. See Appendix A for detailed tables
summarizing results obtained for binary logistic regression and multiple

regression analyses.

Consistent with previous findings in the literature, results in this study have
demonstrated that some predisposing (migrant agricultural status and age in the

case of mammograms) as well as various enabling variables such as income

68

level and years working in the state are predictive of utilization of specific
reproductive health care services among Latina migrant and seasonal
farmworkers. On the other hand, finding that health need variables are not
statistically significant for migrant and seasonal fan'nworker women in the
sample, shows that both migrant and seasonal farmworker women have equal
deficits when it comes to needs and utilization of reproductive health care
services. Prior research applying the Andersen model and the role of need
variables on health services utilization has indicated the strength of this
association (Andersen & Aday, 1978). Analyzing these results in scope of the
Andersen behavioral model of health services utilization it would seem that
barriers such as language and income obviously have a stronger impact on
farmworker women’s use of these services. Health need on the other hand might
be a lesser explanatory factor that can be accounted for after the structural
barriers are considered. These results further suggest that the circumstances of
utilization and relationship with objective indicators of reproductive health care
utilization are both complex and diverse and might vary for women from the

migrant and seasonal farmworker population.

The reproductive care utilization measures included in this study are
considered to be preventive screenings, based on the Andersen model, then the
non significant results could be due to utilization of these services influenced

primarily by predisposing and enabling factors (Aday & Awe, 1997).

69

If utilization of these reproductive health services were based primarily on
responses to disease and/or disorders, a statistically significant association could

have been found.

Another plausible explanation might be that the lack of association of
health need with reproductive health care utilization could be due to the low
numbers of farmworker women who reported having health needs. Further
research is needed to explore whether these findings are consistent across other
migrant and seasonal farmworkers women whose reported health need s are

higher.

Situating this discussion within the national scope of reproductive health
care utilization seems appropriate. When comparing the reproductive health care
utilization amongst US women in general, US Latino women and Michigan Latino
women, both migrant and seasonal farmworkers fair very low in areas of
mammogram screening and STD prevention. In addition, while seasonal
farmworkers in the sample are similar to US Latino women in terms of pregnancy
prevention utilization, these numbers are still lower than those of US women in
general. Both migrant and seasonal farmworkers in the sample seem to have
made great strides towards increased utilization of PAP smears screenings as
well as prenatal care utilization. These results are reported in full in table B1

located in Appendix B.

70

Policy Implications

This study has important policy implications. At a local level, this study
adds to the disparities research agenda by informing on the reproductive health
care utilization of migrant and seasonal farmworkers in a specific Midwestern
“upstream” location. It has been demonstrated that there are structural
components that impact migrant and seasonal farmworker women’s and that
these factors are still significant even when controlling for the need for care.
More importantly, this research helps to document the specific predisposing,
enabling, and health need factors that must be considered within the local health
care system so that efforts to increase utilization of reproductive health care
services among this subpopulation are adapted. The results of this study could
further serve to inform the local community so that improvements in the areas of
prevention and awareness of reproductive health services are introduced and

monitored.

The results indicate that migrant and seasonal farmworker women who
have reported health need, do not utilize reproductive health care services. This
finding is striking since women who have been diagnosed with pregnancy
diabetes, have reported unmet treatment needs, considered their health status to
be less than fair and had an abnormal physical exams, would be more prone to

seek reproductive health care services.

71

Adopting an ecological perspective helps us to understand the present
findings as well as to suggest policy innovations. There is an important ecological
principle that applies in this case, “treating the whole not the part”. Thus for
reproductive health services to be truly adaptive to the needs and hence reduce
reported health disparities of Latina migrant and seasonal farmworkers, it would
have to treat this subpopulation’s social and physical environment and its
relationships with them and thereby the larger system. Government policies
need to be put in place that promote a holistic approach to procuring effective
health services, including reproductive health services, for this marginalized

segment of the US. population.

Such policies would need to include community and family interventions
that are culturally and theoretically appropriate for Latina migrant and seasonal
farmworkers. Programs that do not talk at these women about services, but
rather reach out to them with a culturally appropriate message about behaviors
that are perceived as both unfamiliar as well as unreasonable to them. One
example highlighting the inadequacies of current approaches is that of
mainstream campaigns for breast cancer screening focusing on finding the
cancer on time and thus preventing death, it has been noted that these types of
messages scare Latino women away (Borrayo, 2000). Thus, a better way to
address Latinas is through focusing on family centered interventions that
contextualize breast cancer screening as a healthy behavior for Latinas and their

families, since their culture emphasizes family ties.

72

Recent work by Torres et. al. (2003) validates and expands on this idea
with the conclusion that, “the successful attainment of sexual and reproductive
health promotion goals in US. Latino communities depends on: the effect of the
transcultural and transnational experience in explanatory models of sexuality and
human reproduction, the reassessment and redefinition of women’s power, the
inclusion of men in sexual health programs, the integration of sexual health
education in community systems, and the development of education
interventions with economic development components.” However, these
programs should only be temporary solutions. They should play a supplemental
role to more extensive efforts to reduce racial and ethnic health disparities in
general. Only when issues such as the lack of health insurance among Latinos
are addressed, will it be possible to most effectively meet the reproductive health

needs to migrant and seasonal farmworker women.

Additional policy implications concern the area of outreach to migrant and
seasonal farmworkers. Several federal programs have been put in place to
address health problems in this population, however, these programs have in
some instances limited their services to migrant farmworkers and not seasonal
farmworkers. Reaching both migrant and seasonal farmworker women should be

a priority item, particularly in areas of reproductive health care utilization.

Another important finding for policy implementation is that having visited
the local migrant clinic is predictive of increased utilization of reproductive health

services. Thus, visiting the local migrant clinic enables farmworker women to

73

utilize reproductive health services at a higher rate. This finding warrants close
attention within the context of the migrant healthcare system composed of
approximately 400 federally authorized clinic sites that reaches only 12-15
percent of the this population annually (Gwyther & Jenkins, 1998). As few as 15
percent to 20 percent obtain assistance program benefits because of impractical
requirements and fear of deportation (Donohoe, 2004). Given these facts,
federal programs and initiatives advocating for migrant and seasonal farmworker
utilization of reproductive health services need to be furthered while considering
the context in which migrant farmworkers operate, their perceptions and
variables that impact utilization of reproductive health services including the

enabling effects of using local migrant clinics.

Further policy implications include the area of reporting systems on health
indicators data. While measuring health disparities has been approached by
considering race and ethnicity, occupational status is currently not included in
routine reporting systems for health indicators to measure specific farmworker
health disparities. Based on the results of this study, migrant and seasonal
farmworkers differ on their utilization of reproductive health services. These
differences pose a strong public policy implication for outreach based on the
agricultural work category of these women. It seems that the promotoras
(community health advisors) might be a good approach to continue reaching
migrant women because services are brought to them while in the migrant

camps.

74

This is also a culturally appropriate approach to reach underserved
seasonal farmworker women, however, based on the fact that seasonal
famrworkers settle down in a particular community and most of the times do so
with their families, a more appropriate intervention would use the family setting
as the ground for imparting education, awareness, and prevention services, thus
increasing access to reproductive health services by seasonal farmworker

women.

Regardless of the reasons that impacted the non-significance of the health
need factors for this subpopulation of migrant farmworkers, the analyses did
demonstrate through the application of the behavioral model, that migrant and
seasonal farmworker women do no have equitable access to reproductive care
services. This is based on Andersen’s definition of equitable access as occurring
when demographic and health need variables account for most of the explained
variance (Andersen, 1995). lnequitable access occurs when social structure,

health beliefs and enabling resources determine who gets medical care.

Including agricultural work status as a predisposing variable for
reproductive health services utilization is only a small step towards advancing
research applying models of health services utilization to underserved and
vulnerable groups. Further developments in this research area are needed in
order to inform policy makers specifically those in charge of Medicare, Medicaid,
and other welfare programs at both federal and state levels refocus their

attention on the health needs and utilization of services of migrant and seasonal

75

farmworker women, a group who is at higher risk for adverse reproductive health

outcomes and decreased utilization.

Limitations

This study took a particular and relatively selective focus on reproductive
health of Latina migrant and seasonal farmworker women. However, the author
recognizes that there is room for great value in also carrying out research from a
broader perspective; for example drawing out the linkages between Latina
migrant and seasonal farmworker general and reproductive health status with
their utilization of these services. In addition, while this study focuses on Latinas,
it should be acknowledged that many of the issues discussed are not unique to
Latinas, but may be relevant to other medically underserved women. Additional
research that compares different racial and ethnic groups is important, because
such studies are useful for assessing the degree to which disparities in utilization

of reproductive health services are being reduced or continue to exist.

In addition, since data were originally collected as a general health needs
assessment of migrant and seasonal farmworkers in the state, the researcher
was limited as far as the utilization measures included as well as those measures
of predisposing, enabling, and health need factors. Moreover, while the original
behavioral model of health services utilization has been specifically revised for
vulnerable populations (Gelberg, et. al., 2000), important variables such as
acculturation, available community resources, health services resources, and

satisfaction with care, were not available for analyses.

76

Future studies examining these variables while adopting the revised
behavioral model for vulnerable populations among migrant and seasonal
farmworker women are needed. For instance, studies examining the impact of
acculturation and the use of health services have been consistent in that low
levels of acculturation for Latinos are associated with the underutilization of
preventive health services (Suarez, 1994; Kirkman-Liff 81 Mondragon, 1991; &
Wells, et. al, 1989). A study found that after controlling for demographic,
socioeconomic and access to health care variables, Latina women of Caribbean
origin who were more acculturated had higher odds of receiving a mammogram
than less acculturated women (O’Malley et. al., 1999). More research looking at
acculturation and reproductive health services utilization among migrant and

seasonal farmworkers is needed.

Although the conceptual model used in this study is considered a non-
recursive model, sample size limited the ability of conducting a higher order
statistical analyses such as structural equation modeling. Using structural
equation modeling would provide more powerful analyses by taking into account
the modeling of interactions, nonlinearities, correlated independents,
measurement error, correlated error terms, multiple latent independents each
measured by multiple indicators, and one or more latent dependents also each

with multiple indicators (Kline, 1998).

77

Future Research

There is room to continue this line of research in many different realms.
One particularly interesting idea is to target mammogram-screening behaviors of
migrant and seasonal farmworkers in the state and factors that promote or hinder
this utilization rate. Future research could then look into the impact of community
health worker approaches on increasing mammogram screening for migrant and
seasonal farmworker women. Also, it would be interesting to find out if the health
literacy of these women impacts their utilization of reproductive health services

such as mammograms and PAP smears.

Health literacy has been defined as “the degree to which individuals have
the capacity to obtain, process, and understand basic information and services
needed to make appropriate decisions regarding their health” (Ratzan & Parker,
2000). At some point, most individuals will encounter health information they
cannot understand. Even well educated people with strong reading and writing
skills may have trouble comprehending a medical form or doctor's instructions

regarding a drug or procedure.

Research on health literacy has demonstrated that is an important barrier
that must be addressed. Given that migrant and seasonal farmworker already
confront literacy barriers, the researcher would like to analyze the issue of health
literacy in the migrant and seasonal farmworker subpopulation and its impact on

reproductive health care utilization.

78

A study examining functional health literacy in Spanish on cancer
screening among Latinas in New York City found that almost half of their sample
had difficulty interpreting written materials, even in Spanish (Garbers & Chiasson,
2004). Thus, the authors concluded that programs and service providers need to
be aware that the women most in need about information on screening may be
more likely to be unable to read any written materials provided to them,
regardless of the language or level of simplicity of the materials. Programs and
strategies need to be implemented that increase screening prevalence and to

minimize the gaps in regular screenings for Latinas with low health literacy.

Another issue for future investigation is the issue of mistrust in health care
providers. Medical mistrust has been documented as impacting utilization of
health services. More specifically, it has been noted that Latino women tend to
report having had numerous negative experiences with health care providers. A
study examining breast cancer screening barriers among Latinas found that most
women across several Latino subgroups did not perceive doctors as trustworthy
gatekeepers of health information (Buki, Borrayo, Feigal, & Carrillo, 2004).
Impact of distrust needs to be addressed in relationship to utilization of health

care services among migrant and seasonal farmworkers.

The inclusion of the above mentioned variables as predisposing and
enabling factors to reproductive health care utilization among migrant and
seasonal farmworker women would allow for the use and adaptation of the

revised behavioral model of health services utilization for vulnerable populations.

79

In addition, future research with this specific dataset could look into the impact of
reproductive health status (i.e. clinical variables such as having been diagnosed
with Chlamydia) on each of the reproductive health care services analyzed. For
example, it could be hypothesized that women who have been diagnosed with
Chlamydia will use STD prevention at higher rates. Using the Oceana
Farmworker Health Needs Assessment for this purpose would enhance the

research in this area.

Conclusions
This chapter has provided a discussion of the findings relevant for this
study. Overall, this study has significant implications for practice and
demonstrates the importance for addressing barriers to reproductive health care

utilization by migrant and seasonal farmworker women.

The limited sample size made it impossible to fully test the Andersen
model, however, the use of the binary logistic and multiple regression techniques
facilitated the analysis of the data. Demonstrating that there are still gaps in
reproductive health care utilization by migrant and seasonal farmworkers and in
some instances it would make sense to address the specific reproductive health
care utilization factors that impact each group separately. Migrant and seasonal
famnivorkers do have several differentiating factors when it comes to their
utilization of reproductive health services. As outlined in this study, these
differences might be due to the less availability of social connections for migrant

farmworkers who often travel from sending to receiving states and have less

80

opportunity to get to know what resources are available in each community.
These differences pose a strong public policy implication for outreach based on

the working/employment category of these women.

This study was too narrow to account for the complexities in the
relationship between environmental factors that contribute to utilization of
reproductive health services amongst this subpopulation. Despite this, it is an
important contribution to the small body of literature on reproductive health
services utilization by Latino migrant and seasonal farmworker women because it
provides baseline information that is potentially useful when examining factors
associated with health disparities in this medically underserved and

underprivileged group.

Improving our understanding of Latina migrant and seasonal farmworker
utilization of reproductive health services is critical for the development of
strategies that will reduce health disparities in this area. Additional research is
needed that looks at understanding how protective aspects of the culture can be
used to help others. Identification of positive perceptions, facilitators, and
behaviors that foster increased utilization of reproductive health care services are

crucial in this population.

81

APPENDIX A

82

Table A 8.1 Binary Logistic Outcomes of Mammogram Screening

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Predisposing Factors Beta P Value
Educational Level .592 .053
Age 40 -4.017 .000“
Migrant Status -1.091 .043*
Language a241 .404
Marital Status —.066 .909
*P<.05; -2 Log likelihood= 116. 702; R Square= .5 79
Table A 8.2 Binary Logistic Outcomes of PAP Screening
PredisposinLFactors Beta P Value
Educational Level .1 62 .596
Age 40 .462 .409
Migrant Status -.530 .363
Language a241 .480
Marital Status -.31 1 .593
-2 Log Likelihood= 102.859; R Square= .031
Table A 8.3 Binary Logistic Outcomes of Prenatal Care
Predisposing Factors Beta P Value
Educational Level .056 .866
Age 40 .076 .908
Migrant Status -.806 .249
Language .630 .054
Marital Status .603 .460
-2 Log likelihood: 80.446; R Square= .107
Table A 8.4 Binary Logistic Outcomes of STD Prevention
Predisposing Factors Beta P Value
Educational Level -.039 .862
Age 40 .084 .854
Migrant Status -.1 14 .784
Language -.142 .547
Marital Status 1 .186 .005

 

 

 

 

-2 Log likelihood= 158.904; R Square= .082

83

 

 

 

 

Table A 8.5 Binary Logistic Outcomes of Pregnancy Prevention

 

Predisposing Factors

Beta

P Value

 

 

 

 

 

 

 

 

Educational Level -.366 .053
Age 40 1.211 .004“
Migrant Status -.359 .311
Language .370 .078
Marital Status -.512 .220

 

-2 Log likelihood: 198.558; R Square= .155

Table A 8.6 Binary Logistic Outcomes of Mammogram Screening

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enabling Factors Beta P Value
Insurance Status .090 .807
Employment Status -.1 78 .688
Income -.041 .914
Years in MI -.600 .004*

Migrant Clinic -20.089 .998
*P<.05; -2 Log likelihood: 1 73.631; R Square= .188
Table A 8.7 Binary Logistic Outcomes of PAP Screening

Enabling Factors Beta P Value
Insurance Status -.977 .1 10
Employment Status -.637 .302
Income -1.361 .085
Years in MI -.267 .215
Migrant Clinic -.675 .371

-2 Log likelihood= 96.713; R Square= .143
Table A 8.8 Binary Logistic Outcomes of Prenatal Care

Enabliry Factors Beta P Value
Insurance Status -.064 .908
Employment Status .672 .405
Income -.427 .494
Years in MI -.162 .489
Migrant Clinic -.951 .207

 

 

 

 

-2 Log likelihood: 91.752; R Square= .054

84

 

 

 

 

Table A 8.9 Binary Logistic Outcomes of STD Prevention

 

Enabling Factors

Beta

P Value

 

 

 

 

 

 

 

 

Insurance Status .401 .314
Employment Status .202 .677
Income .967 .040“
Years in MI .093 .589
Migrant Clinic -.969 .238

 

*=P<.05; -2 Log likelihood= 161.230; R Square= .077

Table A 8.10 Binary Logistic Outcomes of Pregnancy Prevention

 

Enabling Factors

Beta

P Value

 

 

 

 

 

 

 

 

Insurance Status .071 .833
Employment Status .679 .099
Income -.466 .189
Years in MI -.067 .656
Migrant Clinic -.786 .216

 

-2 Log likelihood= 203.978; R Square= .063

Table A 8.11 Binary Logistic Outcomes of Mammogram Screening

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Need Factors Beta P Value
Pregnancy Diabetes -.511 .392
Normal Physical Exam .106 .800
Perceived Health Status .038 .909
Unmet Treatment .074 .878
-2 Log likelihood= 136. 726; R Square= .010
Table A 8.12 Binary Logistic Outcomes of PAP Screening
Health Need Factors Beta P Value
Pregnancy Diabetes .121 .919
Normal Physical Exam 1.787 .122
Perceived Health Status -.351 .637
Unmet Treatment -18.592 .998

 

 

 

 

-2 Log likelihood= 38.891; R Square= .191

85

 

 

 

 

Table A 8.13 Binary Logistic Outcomes of Prenatal Care

 

 

 

 

 

 

 

 

 

 

Health Need Factors Beta P Value
Pregnancy Diabetes .540 .543
Normal Physical Exam -.706 .315
Perceived Health Status .391 .459
Unmet Treatment .787 .279
-2 Log likelihood= 61. 731; R Square= .079
Table A 8.14 Binary Logistic Outcomes of STD Prevention
Health Need Factors Beta P Value

 

 

 

 

 

 

 

Pregnancy Diabetes -.283 .699
Normal Physical Exam .086 .861
Perceived Health Status .439 .266
Unmet Treatment -.139 .808

 

-2 Log likelihood= 107.932; R Square= .022

Table A 8.15 Binary Logistic Outcomes of Pregnancy Prevention

 

 

 

 

 

 

 

 

Health Need Factors Beta P Value
Pregnancy Diabetes .323 .607
Normal Physical Exam -.683 .099
Perceived Health Status .330 .320
Unmet Treatment -.042 .928

 

-2 Log likelihood: 137.471; R Square= .047

Table A 9.1 Regression Model 1. Predisposing factors as predictors of
Reproductive Health Care Utilization Rates

 

 

 

 

 

 

 

 

 

Predictors Beta P Value
Educational Level .349 .108
Age 40 .424 .061
Migrant Status .143 .499
Language a041 .849
Marital Status -.257 .223

 

R Square= . 100

86

 

 

 

 

Table A 9.2 Regression Model 2. Enabling factors as predictors of
Reproductive Health Care Utilization Rates

 

 

 

 

 

 

Predictors Beta P Value
Insurance Status -.339 .028"
Employment Status .225 .168
Income .088 .579
Years in MI .191 .408
Migrant Clinic .568 .050“

 

 

 

 

 

 

Note *=P<.05; R Square= .006

Table A 9.3 Regression Model 3. Health Need Factors as predictors of
Reproductive Health Care Utilization Rates

 

Health Need Factors

Beta

P Value

 

 

 

 

Pregnancy Diabetes .1 15 .654
Normal Physical Exam -.035 .836
Perceived Health Status .353 .548
Unmet Treatment -.028 .148

 

 

 

 

 

 

R Square= .031

Table A 9.4 Regression Model 4. Predisposing, enabling and health need factors
scores as predictors of Reproductive Health Care Utilization Rates

 

 

 

 

Predictors Beta P Value
Predisposing Score -.028 .813
Enabling Score -.002 .984
Health Need Score -.044 .767

 

 

 

 

 

 

R Square= .032

87

APPENDIX B

88

Table BI. Comparing Reproductive Health Care Utilization Rates for Latina
Migrant and Seasonal Fannworkers

 

 

 

 

 

 

 

 

 

 

 

 

Reproductive US US Michigan MI FW Ml FW
Health Care Women Hispanic] Hispanic] Migrant Seasonal
Utilization Total Latino Latino Women Women
Measures Women Women

Mammogram 70% 66% 97% 31% 33%

PAP 92% 85% DNC/DSU 88% 93%

STD 71% 53% DNC 28% 26%
Prevention"

Pregnancy 71% 53% DNC 39% 55%
Prevention“

Prenatal Care 83% 74% 77% 86% 96%

 

 

Notes: US women total and Hispanic Latino women percentages obtained from
Data2010-The Healthy People 2010 Database- June, 2006 Edition
( www. wonder. cdc. gov). ** STD and Pregnancy Prevention were reported as a
single category in Data2010. DNC/DSU=Data Not Collected/Data does not meet
criteria for statistical reliability or data quality. Mammogram Screening Ml data
obtained from the 2004 Cancer Behavioral Risk Factor Survey. Ml migrant and
seasonal farmworker data obtained from OFHS survey.

89

APPENDIX C

90

 

OFFICE or
RESEARCH
ETHICS AND
STANDARDS

University Committee on
Research involving
Human Subjects

Michigan State University
202 Olds Hall

East Lansing, MI

48824

517/355-2180

FAX; 517/432-4503

Web:
wwwhumanresearchmsuedu
E-Mail. ucrihs©msuedu

MS U 15 an allirmativwctim.
equal-opportunity institution,

Revision
Application
Approval

MICHIGAN STATE

UNIVERSITY

October 31, 2005

To: Rene ROSENBAUM
131 Natural Resources Building

Category: EXPEDITED 2-7
October 31, 2005
April 4, 2006

Re: IRB # 01-706
Revision Approval Date:
Project Expiration Date:

Title: STUDYING MIGRANT AND SEASONAL FARM WORKERS

The University Committee on Research Involving Human Subjects (UCRIHS) has completed their review of
your project. I am pleased to advise you that the revision has been approved.

This letter notes Omara Rivera-Vazquez as an additional investigator.

The review by the committee has found that your revision ls consistent with the continued protection of the
rights and welfare of human subjects, and meets the requirements of MSU's Federal Wide Assurance and the
Federal Guidelines (45 CFR 46 and 21 CFR Part 50). The protection of human subjects In research Is a
partnership between the IRS and the Investigators. We look forward to working with you as we both fulfill our

responsibilities.

Renewals: UCRIHS approval is valid until the expiration date listed above. If you are continuing your project,
you must submit an Application for Renewal application at least one month before expiration. If the project Is
completed, please submit an Application for Permanent Closure.

Revisions: UCRIHS must review any changes in the project, prior to initiation of the change. Please submit an
Application for Revision to have your changes reviewed. If changes are made at the time of renewal, please

Include an Application for Revision with the renewal application.

Problems: If Issues should arise during the conduct of the research. such as unanticipated problems. adverse
events, or any problem that may increase the risk to the human subjects, notify UCRIHS promptly. Forms are

available to report these Issues. -

Please use the IRB number listed above on any forms submltted which relate to this project. or on any
conespondence with UCRIHS.

Good luck In your research. If we can be of further assistance, please contact us at 517-355-2180 or via email
at UCRIHSQmsgedu. Thank you for your cooperation.

2W-

Peter Vasilenko. Ph.D.
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0: Israel CUELLAR
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91

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