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Melissa Anne Elafros

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A MICHIGAN STATE UNIVERSITY EXTENSION STUDY OF THE
HEALTH UTILIZATION PATTERNS AND HEALTH CONCERNS OF
MICHIGAN LATINOS
By

Melissa Anne Elafros

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS
Bioethics, Humanities, and Society

2008

ABSTRACT
A MICHIGAN STATE UNIVERSITY EXTENSION STUDY OF THE HEALTH
UTILIZATION PATTERNS AND HEALTH CONCERNS OF MICHIGAN
LATINOS
By
Melissa Anne Elafros
Every region of the United States has experienced significant growth in the Latino
population in recent years. Between 2000 and 2006, the number of US. Latinos grew to
comprise nearly 15% of the nation’s population (US Census Bureau 2006:n.p.). Latinos
are the largest minority group, yet have the worst health outcomes of any group despite
the health benefits purportedly Offered by the “Latino Paradox”. U.S. Latinos also
experience substantial inequities in health care services. Previous research has examined
the health utilization patterns of Latinos nationwide or in select areas of the United
States. Only two published studies have asked Latinos to report their health concerns.
The purpose of this pilot study was to examine the health utilization patterns and
health concerns of Michigan Latinos compared to Latinos from other studies. Data was
collected using a written questionnaire and focus group interviews. The results of this
study were unclear about how the health utilization patterns of Michigan Latinos
compared to the same patterns of Latinos in previous studies. This was largely due to the
small sample size of this study. The health concerns of Michigan Latinos somewhat
resembled the concerns of other US. Latinos. Michigan Latinos were often more
concerned about social problems (drugs, alcohol, etc.) than about specific illnesses.
This study highlighted some of the challenges of working with the Latino

population in Michigan. It also reinforced the need for more research to design effective,

culturally-appropriate holistic health programs for Latinos in the future.

ACKNOWLEDGMENTS

Many people deserve credit for the completion of this thesis. I will be the first to
admit that it would not have occurred without them.

First, I would like to thank my Michigan State University Extension research
team. Thank you for finding a place for me and for showing me what a group of
passionate people can accomplish. I would especially like to thank Kimbirly Bodfish for
the long nights and weekends she spent coding data with me.

I am very thankful for my thesis committee. Dr. Aaron McCright, thank you for
challenging me throughout this project, for demanding that I create something worth
reading and for sticking with me. Thank you for making this a positive learning
experience. Libby Bodgan-Lovis, thank you for being a supportive and honest role
model since I started at MSU. Dr. Patricia Obando, thank you for all of your
encouragement and flexibility during this process.

I am indebted to many people for their support throughout my time at MSU thus
far. Thank you to the faculty who pushed me to do better and become more. Thank you
to the advisors and administrators who listened to my dreams and moved mountains so I
could chase them. I am also grateful for the phenomenal friendships I have made during
the past four years. Thank you for making me smile and for taking care of me.

Lastly, I would like to thank my family as well as those that have become part of
it over time. Dad, thank you for teaching me to dream. Mom, thank you for teaching me
how to be a good person. Ali, thank you for guiding me by going first. Kels and Jen, I

cannot put into words how glad I am that I have you in my life.

iii

TABLE OF CONTENTS

LIST OF TABLES .................................. vi
CHAPTER
I. INTRODUCTION
Statement of the Problem ............................ 1
Purpose of the Study .............................. 2
Importance .................................. 3
Overview of Subsequent Chapters ....................... 4
II. A REVIEW OF THE LITERATURE

III.

IV.

Growth of the Latino Population ........................ 5
Latino Health Disparities ............................ 8
Latino Health Care Access and Utilization ................... 10
Factors Influencing Health Care Access and Utilization ............ 13
Health Insurance ............................. 14
Country of Origin ............................. 15
English Fluency .............................. 16
Legal Status ................................ 18
Income .................................. 19
Health Concerns ................................ 20
Obtaining Health Information ......................... 22
Hypotheses Examined in This Study ...................... 23

STUDY DESIGN AND PROCEDURES

Sampling Procedures ............................. 29
Quantitative Data Gathering Instrument — Written Questionnaire ...... 32
Administration — Written Questionnaire .................... 33
Quantitative Data Gathering Instrument - Focus Group Interviews ...... 33
Administration — Focus Group Interviews ................... 34
Confidentiality Safeguards ........................... 37
Potential Limitations .............................. 38

ANALYSIS OF QUESTIONNAIRE DATA

Demographics .................................. 40
Hypothesis 1: Latino Health Utilization Patterns ................ 42
Hla: Income and Visits to the County Health Department or
Community Clinic ............................... 43
Hlb: Income and Visits to a Private Doctor’s Office ............. 43

iv

ch: Income and Health Insurance Status ................... 43
Hld: Language and Visits to the County Health Department

or Community Clinic ............................. 44
Hle: Language and Visits to a Private Doctor’s Office ............ 44
Hlf: Language and Health Insurance Status .................. 44
Other Quantitative Findings ........................... 45
Notable Findings ................................ 46

V. ANALYSIS OF FOCUS GROUP DATA

Analysis ................................... 48
H2: Latino Health Concerns .......................... 49
Health Concerns for the Latino Community ............... 50
Health Concerns for Latino Youth ..................... 51
Other Qualitative Findings ........................... 53
Sources for Health Information ....................... 53
Help-Seeking Behavior of Michigan Latinos by County .......... 54
Barriers to Health Care ........................... 55

VI. DISCUSSION

Hypothesis 1: Latino Health Utilization Patterns ............... 58

The Effects of Income on Health Utilization ............... 58

The Effects of Language on Health Utilization .............. 59
Hypothesis 2: Latino Health Concerns ..................... 60

Health Concerns for the Community .................... 60

Health Concerns for Youth ........................ 60
Limitations ................................... 61
Recommendations for Future Research ..................... 61
Conclusions .................................. 62

APPENDIX

A. Self-Administered Survey, English Version ................ 65

B. Self-Administered Survey, Spanish Version ................ 69

C. Focus Group Questions, English Version .................. 73

D. Focus Group Questions, Spanish Version .................. 75

E. Focus Group Moderator Guide ....................... 77

F. Focus Group Consent Form, English Version ............... 88

G. Focus Group Consent Form, Spanish Version ............... 91

LIST OF REFERENCES ................................ 110

Table 1

Table 2

Table 3

Table 4

Table 5

Table 6

Table 7

Table 8

Table 9

Table 10

Table l 1

Table 12

Table 13

LIST OF TABLES

Top Health Concerns of Latinos in Baltimore, Maryland ......... 21
The Latino Population in Selected Michigan Counties ........ 29
Quantitative and Qualitative Data Collected in Each County ....... 40
Demographic Data of Study Participants ............... 41

Percentage of Total Health Care Visits to Each Location By County. 42

Health Insurance Status of Participants by County ......... 42
Response to Other Questions on Written Questionnaire ....... 45
Categories Used to Classify Latino Health Concerns ......... 49
Latino Community Health Concerns by County ........... 50
Latino Health Concerns for Community Youth by County ...... 51
Michigan Latinos’ Sources for Health Information by County. . . . 53
Help-Seeking Behaviors of Michigan Latinos by County ...... 54

Barriers to Accessing Health Care by County ............. 55

vi

CHAPTER I

INTRODUCTION

Statement of Problem

Every region of the United States has experienced significant growth in the Latino
population in recent years. Between 2000 and 2006, the number of U.S. Latinos grew to
comprise nearly 15% of the nation’s population (US Census Bureau 2006:n.p.) At 44.2
million, Latinos are now the largest ethnic minority group within the United States (US
Census Bureau 2006:n.p.). Because of high immigration and fertility rates, the U.S.
Latino population is projected to continue to grow. By the year 2050, Latinos are
expected to constitute 25% of the U.S. population (Amaro and de la Torre 2002:525).

Latinos are now the largest ethnic minority group; yet, they also have the worst
health outcomes of any subgroup of the U.S. population. This is despite the health
benefits purportedly offered by the “Latino Paradox”. The substantial disparities in
health status between Latinos and non-Latinos in the United States are well documented.
The rates of disease diagnosis for cervical cancer, stomach cancer and sexually
transmitted diseases are substantially higher among Latinos than among non-Latino
whites (Center for Disease Control 2007:262; Howe et a1. 2006: 1719; Parker et a1.
1998:39). Latinos also have higher death rates for conditions such as chronic liver
disease, diabetes mellitus and HIV (Center for Disease Control 2004bz2330; Center for
Disease Control 2007: 196; Burke and Schur 1999:1452; Obiri et al. 1998:843).

U.S. Latinos experience substantial inequities in access to health care services.

Latinos more often lack a regular source of care than do non-Latino whites (Angel, Angel

and Markides 2005: 1268; Documét and Shanna 2004:8; Durden and Hummer
2006:1326; Center for Disease Control 2004az2332; Callahan, Hickson and Cooper
2006:63 1; Fiscella et a1. 2002:55; Guendelman and Wagner 2000: 185; Kaiser Family
Foundation 2004a:4; 2004b:3; Weinick, Zuvekas and Cohen 2000:42). Latinos are also
less likely to access preventive care than are non-Latino whites (Center for Disease
Control 2004az2331). They are significantly less likely than are non-Latino whites to
visit a doctor’s office and are more likely to visit a community clinic (Durden and
Hummer 2006:1326; Kaiser Family Foundation 2004a:4; 2004bz3). Latinos are also
more likely than are non-Latinos to report not being able to Obtain medical care when
they need it (Center for Disease Control 2004az2332).

Previous research examined the health utilization patterns of Latinos nationwide
and in certain areas of the United States. Those studies revealed some of the barriers
preventing Latinos from accessing adequate health services. Health professionals have
used those studies, along with disease diagnosis rates, to predict the health concerns for
the Latino population. Only two published studies have actually asked Latinos what their

health concerns are. No study has specifically focused on Michigan’s Latino population.

Purpose of the Study

This research was part of a pilot study conducted by Michigan State University
Extension (MSUE) as a follow-up to MSUE’s Healthy Hispanic Project (HHP). HHP
began in 2003 as an educational outreach program targeting breast and cervical cancer
screening rates in Michigan Latinas. HHP was a “promatora” outreach program; MSUE

provided training and educational materials to one female member of the Latino

community in four Michigan counties. These trained community members then educated
others in their community about breast and cervical cancer and provided social support to
encourage more Latinas to undergo screening for these types of cancer. MSUE-trained
women quickly became a valuable resource to Michigan Latinos. Once community
members trusted these women, they were approached with numerous other health
concerns. Through the HHP, MSUE identified some of the unmet health needs in Latino
communities around the state.

Tthis pilot study is the first step required to officially characterize the needs of
Michigan’s Latino population. The goal of this pilot study is to start to examine the
health utilization patterns and health concerns of Michigan’s Latino population. The
long-term goal of this research is to provide MSUE with the knowledge necessary to

design culturally-appropriate, holistic health promotion programs in the future.

Importance

This study is the first known work to determine the needs of Michigan’s Latino
communities from their own perspectives. It will focus on the permanent Latino
population that is often ignored during policy development and health program design.
This study attempts to challenge the popular stereotypes of Latinos in the United States
that depict them as socially unimportant migrant workers and undocumented immigrants.
This project also attempts to use scientific neutrality to address the challenges presented
when addressing health care concerns in a diverse cultural group.

Furthermore, this study is beneficial to MSUE. With offices in every Michigan

County, MSUE is proud of its ability to work with local residents to improve

communities around the state. By working with MSUE County Staff, this study
strengthens the trust between MSUE and Michigan’s Latino communities. By
highlighting the needs of an underserved population, this study will help further the

development of MSUE’s culturally-appropriate educational programs in the future.

Overview of Subsequent Chapters

Chapter 11 contains a summary of the demographics of the Latino population in
the United States and Michigan. It also contains a review of the literatures on the
disparities between the health status of Latinos and non-Latinos, Latino health care
access and utilization patterns, and key determinants of health care access and utilization
among Latinos. Chapter 11 includes studies regarding known Latino health concerns as
well as the methods preferred by Latinos for obtaining health information. Chapter II
concludes with hypotheses derived from the literature for analysis in this study. Chapter
III presents the methodological design and procedures for the pilot study. Chapters IV
and V contain a presentation of the results obtained during administration of the written
questionnaire and focus group interviews, respectively. Chapter VI discusses the
findings from this study’s hypothesis tests. This final chapter also includes the

limitations of this pilot study’s findings as well as recommendations for future research.

CHAPTER H

A REVIEW OF THE LITERATURE

The review of literature for this study is divided into seven sections. First, I
describe demographic trends in the growth of the Latino population over the past ten
years in the United States and, more specifically, in Michigan. Second, I review existing
findings on the health disparities between Latinos and non-Latino whites in the United
States and Michigan. Third, I highlight trends in Latinos’ health care access and
utilization. Fourth, I review studies that examine key determinants of health care access
and utilization among Latinos. Fifth, I examine what the existing literature says about the
health concerns of the Latino population. Sixth, I review current findings regarding the
Latinos’ preferred methods for obtaining health information. Finally, I present

hypotheses derived from this literature for analysis in this study.

Growth of the Latino Population

Between 2000 and 2006, the number of Latinos in the United States grew to
comprise nearly 15% of the nation’s population (US Census Bureau 2006:n.p.). At 44.2
million, Latinos are now the largest ethnic minority group in the United States (US
Census Bureau 2006:n.p.). 58.5% of this population has Mexican ancestry (Kayitsinga et
al. 2007:n.p.). Puerto Ricans are second largest subgroup of this population, accounting
for 9.6% of the Latino population (Kayitsinga and Post 2007:n.p.).

Latinos reside in all 50 states, wim different subgroups of the population
inhabiting different regions. 55.3% of the Mexican population lives in the West, while

another 31.7% resides in the South (Guzman 2007:2). In comparison, 60.9% of Puerto

Ricans live in the Northeast with another 22.3% in the South (Guzman 2007:2). 10.7%
and 9.6% of the Mexican and Puerto Rican populations, respectively, inhabit the Midwest
(Guzman 2007:2). Most Latinos reside in urban areas, with only 6.6% inhabiting rural
areas (Kayitsinga and Post 2007:n.p.). 74% of those residing rural areas around the
United States are Mexican (Kayitsinga and Post 2007:n.p.).

The U.S. Latino population is also younger on average than the overall
population. The average age for the Latino population is 27.3 years, in comparison to
36.4 years for the general population (US Census Bureau 2006:n.p., Guendelman and
Wagner 2000:182). In 2000, 33.7% of the Latino population was under the age of
eighteen, in comparison to 24.6% of the general population (US Census Bureau
2006:n.p.). In 2006, 10.6% of Latinos were under the age of five (US Census Bureau
2006:n.p.). This is 3.8% more than the general population (US Census Bureau
2006:n.p.). Because Of the higher fertility rate of U.S. Latinos (3.0 children per Latino
woman in comparison to 1.8 children per non-Latino white woman), the disproportionate
age structure of the population is anticipated to continue (De Vita 1996:14). As a result,
researchers expect the Latino population to continue to grow faster than other subgroups
of the U.S. population (De Vita 1996:14; Guzman 2001 :2; Kayitsinga and Post
2007:n.p.).

The percentage of the U.S. population that is Latino is increasing in every state
except for Hawaii (Guzman 2001 :4). Between 1990 and 2000, the U.S. Latino
population grew by 57.9%, compared with a 13.2% increase during this time period for
the entire U.S. population (Guzman 2007:2). By the year 2050, Latinos are expected to

constitute 25% of the U.S. population (Amaro and de la Torre 2002:525). Subgroups of

the Latino population have increased at different rates in recent years. From 1990 to
2000, the Mexican American population increased by 52.9%, while the Puerto Rican
population in the United States increased by only 24.9% (Guzman 2007:2).

The characteristics of Michigan’s Latino population follow national trends. In
2000, 323,877 Latinos lived in Michigan (Kayitsinga and Post 2007:n.p.). 70.4% were
Mexican and 10.4% were Puerto Rican (Kayitsinga and Post 2007:n.p.). The remaining
19.2% were Central American (2.9%), South American (2.5%), Cuban (1.4%),
Dominican (0.3%) or from some other area (12.1%) (Kayitsinga and Post 2007:n.p.).
Compared to the U.S. Latino population, a larger percentage of Michigan Latinos reside
in rural areas — 16.6% of Latinos in Michigan reside in rural areas in comparison to 6.6%
of Latinos nationwide (Kayitsinga and Post 2007:n.p.). However, like Latinos
nationwide, the majority of Michigan Latinos in rural areas are Mexican (73.9%)
(Kayitsinga and Post 2007:n.p.).

The growth of Michigan’s Latino population also parallels national trends.
Michigan’s Latino population grew by 50.3% between 1990 and 2000, a slightly smaller
increase than the national trend of 57.9% (Kayitsinga and Post 2007:n.p.). Michigan’s
Latino population is also much younger than the general population of Michigan. The
average age of Michigan’s Latino population is 23.1 years compared to 32.6 years for the
general Michigan population (Kayitsinga and Post 2007:n.p.). 36.9% of Michigan’s
Latino population is under the age of 18, in comparison to 25.9% for the general
population (Michigan Census Bureau 2005:n.p.). Furthermore, 12.3% of the Latino
population is under the age of 5, in comparison to 7.5% for the general population

(Michigan Census Bureau 2005:n.p.). Scholars expect the growth of the Latino

population in Michigan to continue (Kayitsinga and Post 2007:n.p.). To respond to the
growth of the Latino population both nationally and in Michigan, public health officials
and other scholars are working to address the health needs exhibited by the Latino

population.

Latino Health Disparities

Medical scholars and health practitioners have clearly documented the health
disparities between Latinos and non-Latinos. The following death rates are higher for
Latinos than for non-Latino whites (all death rates are out of 100,000 people): chronic
liver disease and cirrhosis (14.0 versus 9.2), diabetes mellitus (32.1 versus 22.3), and
HIV (5.3 versus 2.3) (Center for Disease Control 2004b:2330, 2007:196; Burke et a1.
1999:1452; Obiri et a1. 1998:843). Latino children also have higher death rates than non-
Latino white children. “Mexican American girls younger than 1 year (559.4 per 100,000)
and between the ages of l and 4 years (29.5) have higher death rates than their non-
Latino White counterparts (544.6 and 27.0, respectively)” (Amaro and de la Torre
2002:525).

The rates of disease diagnosis are higher for U.S. Latinos than for non-Latino
whites. Latinas have disproportionately high rates of cervical cancer - 12.6% in
comparison to 6.5% for non-Latino whites (Center for Disease Control 2007:262; Howe
et a1. 2006:1719; Parker et a1. 1998:39). Health practitioners also diagnose Latinos with
stomach cancer at more frequently (15.6% for men and 9.6% for women) than they
diagnose non-Latino whites (9.1% for men and 4.0% for women (Center for Disease
Control 2007:262; Howe et a1. 2006:1719). Sexually transmitted diseases affect the

Latino population at higher rates (Center for Disease Control 2006:n.p.). Over two times

more Latino children under the age of thirteen are diagnosed with AIDS than are non-
Latino whites in the same age group (Center for Disease Control 20072259). The
prevalence of obesity is also significantly higher within the Latino population (Flores et
a1. 2002:86; Whiteaker and Orzol 2006:580). Twice as many Mexican women over the
age of 20 are overweight or obese than are non-Latino white women (73.2% to 37.1%,
respectively) (Center for Disease Control 2007:305).

Medical scholars and health practitioners have Observed similar health disparities
within Michigan’s population. According to the Michigan Department of Community
Health (n.d.:n.p.), Latinos are disproportionately affected by cancer and diabetes. 8.5%
of the Latino population has diabetes mellitus, in comparison to 7% of non-Latino whites
(Michigan Department of Community Health n.d.:n.p). Sexually transmitted diseases are
also more prevalent among Latinos than they are among non-Latino whites in Michigan.
The rates of chlamydia and gonorrhea for 15-19 year olds are three and four times higher,
respectively, for Latinos than for non-Latino whites (Michigan Department of
Community Health 2007b:6). The rate of HIV infection for Latinos is 201 per 100,000
people, while for non-Latino whites it is only 78 per 100,000 people (Michigan
Department of Community Health 2007az98). Fourteen percent of Latino high school
students in Michigan are overweight or obese compared to ten percent of non-Latino
whites (Michigan Department of Education 2005z4). In many cases, Michigan’s Latino
population exhibits worse health indicators than do Latino populations in other states.
Similar to the national trend, the infant mortality rate for Latinos in Michigan is much
higher than it is for non-Latino whites (11.2% to 5.5%, respectively) (Michigan

Department of Community Health 20073: 101). However, this disparity is greater in

Michigan than it is nationally and, despite intervention efforts, it has increased over the

past five years (Michigan Department of Community Health 2007a: 101).

Latino Health Care Access and Utilization

In order to understand the health disparities between Latinos and non-Latino
whites, numerous scholars have examined Latinos’ interaction with the health care
system. Most researchers employ national survey data for their analysis. For example,
two studies analyze the Agency for Healthcare Research and Quality’s Medical
Expenditure Panel Survey, which collects data from noninstitutionalized U.S. civilians
regarding health care use and coverage, demographic characteristics, income, and
employment status (Weinick et a1. 2000,2004). Weinick et al.’s first paper (2000)
analyzes trends in health care utilization between Latinos and non-Latinos, while the
second (2004) analyzes trends in health care utilization between Latino subgroups. The
Center for Disease Control and Prevention (CDC) employs the Behavioral Risk Factor
Surveillance System surveys from 2000-2002 for their analysis (2004a, 2004b). Two
studies draw from National Health Interview Surveys from 1999-2001 and 1999-2002,
respectively (Durden and Hummer 2006; Callahan et a1. 2006). One study employs the
1994 Commonwealth Fund Survey of Minority Health (Guendelman and Wagner 2000)
while three others design and conduct their own surveys (Documét and Sharma 2004;
Kaiser Family Foundation; 2004a 2004b). Most of these surveys are cross-sectional and
draw sampling frames using a multistage area probability design (Callahan et a1. 2006;
Durden and Hummer 2006; Weinick et a1. 2000, 2004). Despite differences in source

data, the studies generally agree on a few points.

10

 

Many scholars find that Latinos lack a regular source of care more often than do
non-Latino whites (Angel, Angel, and Markides 2005:1268; Documét and Shanna
2004:8; Durden and Hummer 2006:1326; Center for Disease Control 2004a:2332;
Callahan 2006:631; Fiscella et a1. 2002:55; Guendelman and Wagner 2000:185; Kaiser
Family Foundation 2004a:4; 2004bz3; Weinick et a1. 2000:42). In 1994, only 58.6% of
Latinos had a regular doctor, compared to 79.9% of non-Latino whites (Guendelman and
Wagner 2000: 185). This disparity increased until the late 19808 and has remained fairly
constant since then. Weinick et al. found that in 1979, 19.9% of Latinos lacked a usual
source of care (W einick et a1. 2000:41). This percent grew to 28.0% in 1987 and to
29.5% in 1996. Weinick et a1. Offer no explanation for this initial increase and
subsequent leveling off.

Latinos typically access different types of health care services than do non-Latino
whites. Possible causes for these differences are discussed in the next section. Latinos
are significantly less likely to access preventive care than are non-Latino whites (Center
for Disease Control 2004a:2331). Guendelman and Wagner (2006: 186) found that only
50.5% of Latinos report using preventive care compared to 65.6% of non-Latino whites.
Latinos are significantly more likely than are non-Latino whites to not have had the
following preventive care tests: blood cholesterol (49% versus 40%), blood pressure
(22% versus 8%) and clinical/physical breast exam (32% versus 20%) (Kaiser Family
Foundation 2004az5). Scholars attribute these disparities to the strong positive
correlation between a regular source of care and the use of preventive services

(Guendelman and Wagner 2006: 186; Kaiser Family Foundation 2004a:4; Weinick et al.

11

2000:40). Researchers have also associated health care insurance with increased
preventive care use (Guendelman and Wagner 2006: 189).

When health care is obtained, Latinos access different services than do non-Latino
whites. Latinos are much less likely than are non-Latino whites to receive outpatient-
based services (Weinick et a1. 2000:41; 2004:317). All subgroups of the Latino
population are significantly less likely than are non-Latino whites to visit a doctor’s
office or an HMO for their immediate health care needs (Durden and Hummer

2006:1326; Kaiser Family Foundation 2004a:4, 2004b:3). Instead, Latinos are more

 

likely to visit community clinics than are non-Latino whites (Durden and Hummer

2006: 1326; Kaiser Family Foundation 2004a:4; 2004b:3). Studies report conflicting
findings about whether Latinos visit emergency rooms more often than do non-Latino
whites (Durden and Hummer 2006:1326; Kaiser Family Foundation 2004b:3). Studies
have attributed the differences in sources of health care to cost. I will explain this further
in the next section of this literature review.

Latinos are more likely than are non-Latino whites to report not having any
medical visits in a calendar year (38% versus 10%, respectively) (Kaiser Family
Foundation 2004b:3). This suggests that Latinos are meeting their health needs through
other means. Studies have shown that Latinos are more likely than non-Latino whites to
use herbal medicine (23.6% to 12.3%) (Garcés, Scarinci, and Harrison 2006:383;
Guendelman and Wagner 2006:185; Harrison and Scarinci 2007:37). Members of the
Latino population also employ home remedies, although not significantly more often than
non-Latino whites (Guendelman and Wagner 2006:185; Harrison and Scarinci 2007:37).

Latinos will also seek health care in their native country, where it is Often less expensive.

12

One study from Alabama notes that parents will take their sick children to Mexico for
health care instead of obtaining it in the United States (Harrison and Scarinci 2007:37).
Physicians and researchers have examined Latinos’ perceptions of the availability
and quality of health care in their area. Latinos are more likely than are non-Latinos to
report not being able to obtain medical care when it is needed (32% versus 25%) (Center
for Disease Control 2004a:2332). They also have more difficulty than do non—Latino
whites obtaining care from specialists when they need it: 22% versus 12% (Kaiser Family
Foundation 2004b:3). Latinos are more likely than non-Latino whites to report a lack of
health care choices (Guendelman and Wagner 2006:185). Possible explanations for these
perceptions are in the following section. When Latinos obtain health care, studies report
conflicting findings regarding patient satisfaction. Two studies state that a greater
percentage of Latinos than non-Latino whites report being dissatisfied with the quality of
treatment they received (Documét and Sharma 2004:8; Kaiser Family Foundation
2004a:5), while one study reports that 95% of Latinos report being “satisfied” or “very

satisfied” with the care received (Saint-Germain, Bassford and Montano 1993:353).

Factors Influencing Health Care Access and Utilization

Studies have repeatedly cited the following five factors as influencing Latino
health care access and utilization patterns: health insurance, country of origin, English
fluency, legal status, and income. These factors contribute to each of the health care
patterns reported in the previous section. Therefore, researchers and Latinos often cite

them as barriers to obtaining care.

13

Health Insurance

The presence of and type of health care insurance influences the availability of
health care. Scholars find that Latinos are more likely than any other ethnic group to be
uninsured (Callahan et a1. 2006:629; Keiser Family Foundation 2004a:2; 2004b:2; Flores
et al. 2002:88). Nationally, 42% of Latino adults are uninsured (Keiser Family
Foundation 2004b22), and 27% of Latino children lack health insurance (Flores et a1.
2002:88). In Michigan, 26.6% of the Latino population lacks health care insurance, a
statistic which is more than double that of the non-Latino white population in the state
(Michigan Department of Community Health 2007az93). Additionally, a greater
percentage of Latinos than non-Latino whites have Medicaid as their only option for
insurance (Callahan et a1. 2006:63 1; Fiscella et a1. 2002:55; Kaiser Family Foundation
2004a:2; 2004bz2). 12% of Latinos use Medicaid compared to 6% of non-Latino whites
(Kaiser Family Foundation 2004a22).

Scholars have repeatedly stated that Latinos who lack health insurance are more
likely to also lack a usual source of health care (Callahan et a1. 2006:629; Documét and
Sharma 2004:9; Garcés et a1. 2006:381; Weinick et a1. 2000:49; 20042318). Through
statistical modeling, Guendelman and Wagner (2000:186) find that the possession of
health insurance is the variable that most significantly enables health care utilization by
Latinos. Latinos are more likely than are non-Latino whites to delay seeking care
because they lack health care insurance (30% versus 19%, respectively) (Kaiser Family
Foundation 2004az3). Another study examines Latinos’ perceptions regarding quality of
care in terms of health insurance. Latinos perceive that lacking health insurance leads to

poor quality health care (Martinez and Carter Pokras 2007:904). This could be based on

14

the limited number of clinics that accept patients without health insurance and even
patients with Medicaid.
Country of Origin

The second factor influencing health care utilization for the Latino population is
country of origin. Country of origin has been repeatedly tied to insurance status, regular
patterns of healthcare utilization and types of care used (Callahan et al. 2006:629; Durden
and Hummer 2006:1330; Weinick et a1. 2004:316).

Most studies find that a greater percentage of Mexican Americans are uninsured
than Puerto Ricans, Cuban Americans, or non-Latino whites (26.8%, 12.9%, 20.9%, and
8.9%, respectively) (Durden and Hummer 2006:1328; Callahan et al. 2006:629). Durden
and Hummer (2006:1330) speculate that a greater percentage of Mexican Americans
could lack health insurance because of the higher rates of unemployment, lower levels of
income, and lower levels of education that exist in the population when compared to
other Latino subgroups. Interestingly, Mexican Americans are less likely to obtain
government-sponsored insurance than are Puerto Ricans (22.0% versus 28.6%), yet both
groups are significantly more likely to receive government aid than are non-Latino whites
(8.8%) (Durden and Hummer 2006:1328). I will discuss possible causes of this disparity
later.

Access to health care and the type of care Obtained also differs by nativity.
Mexican Americans are more likely than are Puerto Ricans and non-Latino whites to lack
a usual source of care (32.3% versus 27.4% and 23.4%, respectively) (Callahan et a1.
2006:631; Durden and Hummer 2006:1326). Researchers similarly attribute this

disparity to a lack of health insurance (Durden and Hummer 2006:1334). According to

15

Durden and HUmmer (2006:1326), Mexican Americans are less likely to visit a private
doctor’s office than are Puerto Ricans and non-Latino whites (67.1% versus 70.1% and
81.8%, respectively). On the other hand, Mexican Americans are more likely to visit
community clinics than any other Latino subgroup or non-Latino whites (Durden and
Hummer 2006:1326). Using statistical modeling, Durden and Hummer (2006:1338)
suggest that socioeconomic-status variables (education, family income, employment
status, and insurance status) and immigration status are largely responsible for such
differences.
English Fluency

Numerous studies discuss a third factor that influences health care access and
utilization: language. English fluency for the Latino population varies with generation as
well as country of origin. According to a recent report by the Pew Hispanic Center, the
percent of Latinos who speak English very well grows by generation. Only 23% of first
generation Latino immigrants speak English well, in comparison to 88% of second
generation and 94% of third generation Latinos (Pew Hispanic Center 2007:2). The Pew
Hispanic Center (2007:5) also found that English reading skills almost always lag behind
speaking ability. Latinos’ country of origin is also correlated with English fluency. More
immigrants from Puerto Rico and Cuba than from Mexico say they speak English well
(52% and 31% versus 16%, respectively) (Pew Hispanic Center 2007:11). More
Mexican immigrants than Cuban and Puerto Rican immigrants report speaking little to no
English (71% versus 57% and 35%, respectively (Pew Hispanic Center 2007:11).

Researchers have correlated fluency in English with the ability to obtain care, the

presence of a regular source of care, the use of preventive services, health insurance

16

 

status, as well as patient satisfaction with health services. Inability to speak English has
been repeatedly cited as a barrier to receiving any type of health care (Fiscella et al.
2002256; Flores et a1. 2002:88; Garcés et al. 20062381; Harrison and Scarinci 2007:39;
Kaiser Family Foundation 2004a25; 2004b:3; Martinez and Carter-Pokras 20062905;
Saint-Germain et a1. 1993:353). Spanish-speaking Latinos are less likely to have a usual
source of care when compared to English-speakin g Latinos and non-Latino whites
(18.2%, 12.9% and 9.8%, respectively) (Fiscella et al. 2002:55). They are also
significantly less likely to have undergone preventive care treatments, such as
mammograms in the past year, when compared to English-speaking Latinos (27.0%
versus 45.0%) (Fiscella et al. 2002256). Research shows that health education materials
in health care settings are rarely available in Spanish, or, if available, they are often
poorly translated (Flores et a1. 2002:88; Martinez and Carter-Pokras 2007:905). Because
most Latinos have weaker abilities in reading English than related speaking abilities,
most cannot understand the written information being presented (Pew Hispanic Center
2007:5).

Language has also been shown to affect health insurance status. Spanish-
speaking Latinos are more likely than English-speaking Latinos to have insurance
through Medicaid (19.5 % versus 8.7 %) (Fiscella et a1. 2002:55). However, this number
is deceiving. Flores et a1. (2002:88) finds that information about Medicaid is only
distributed to 26% of Spanish-speaking Latinos that are eligible for the program. For this
reason, Spanish-speaking Latinos are more likely to lack insurance than are English-
speaking Latinos. English fluency also influences patients’ satisfaction with care. Latino

patients often struggle to communicate their needs and feel as though doctors do not

17

understand them. Latino patients and physicians have repeatedly cited a lack of
translators as a significant barrier to health care (Kaiser Family Foundation 2004a23;
2004b:5; Martinez and Carter-Pokras 2007:905). Furthermore, Latinos report that they
are more likely to experience discrimination because of their language status (Pew
Hispanic Center 200722) and often receive lower quality service as a result (Amaro and
de la Torre 2002:527; Flores et al. 2007:88; Kaiser Family Foundation 2004b25).

Legal Status

The fourth factor influencing health care access and utilization is immigration
status. Studies that include legal status and U.S. citizenship have shown that those
variables considerably affect access to a usual source of health care. Patients who lack
proper legal documentation are often hesitant to visit physicians (Durden and Hummer
2002: 1333; Garcés et al. 2006:381; Martinez and Carter-Pokras 2007:905). Berk and
Schur (2001) attribute this hesitation to a fear that they will be denied access to necessary
medical care. Similar disparities are also present between Latinos who possess visas
versus those who obtain U.S. citizenship. Latinos who do not have U.S. citizenship are
more likely than those who do have citizenship to lack health insurance as well as usual
source of health care (Callahan et a1. 20062631).

The challenges presented by English fluency, as previously discussed, intensify
the effect of immigration status on obtaining health care services. Latinos who are
foreign-born but obtain U.S. citizenship are more likely than non-U.S. citizens to report
speaking English very well or pretty well (52% versus 25 %) (Pew Hispanic Center
2007: 15). Therefore, those that do not have U.S. citizenship and do not speak English

fluently are the most likely to struggle obtaining health care.

18

Income

The fifth barrier tO health care access and utilization by Latinos is income. A
greater percentage of Latinos than non-Latinos have a household income of less than
$20,000 a year (Callahan et a1. 2004:630; Durden and Hummer 2006:1327; Guendelman
and Wagner 2000: 183). 22.8% of Latinos in the United States live below the poverty
line, compared to 7.7% of the entire population (Da Vita 1996:37; U.S. Census Bureau
2000:n.p.). Differences in income are also apparent between subgroups of the Latino
population. Puerto Ricans are more likely to be live in poverty than any other subgroup
of the Latino population. 25.8% of those with Puerto Rican heritage earn less than
$20,000 a year compared to 24.1% of those with Mexican heritage(Callahan et a1.
20062630; U.S. Census Bureau 2000:n.p.). Differences in income are also apparent in
terms of English fluency. Fiscella et a1. (2002:55) find that a greater percentage of
Spanish-speaking Latinos live in poverty (41.9%) compared to English-speaking Latinos
(19.8%) and non-Latino whites (12.0%).

Lower income levels have been associated with a decreased use of the health care
system and preventive care, as well as with lacking health insurance. The cost of
doctors’ appointments, regardless of insurance status, is frequently mentioned by Latinos
as hindering access to the health care system (Garcés et a1. 2006:381; Gundelman and
Wagner 20002187; Harrison and Scarinci 2007:38; Kaiser Family Foundation 2004a23;
Martinez and Carter-Pokras 2006:905; Saint-Germain et al. 20062353). Through
statistical modeling, Weinick et al. (2000249) find that having a lower income level
accounted for 23% of the disparity between Latinos and non-Latino whites in the

presence of a usual source of health care. Lower income levels also contribute to the

19

disparity seen in health insurance status between Latinos and non-Latino whites (Durden

and Hummer 2006:1333; Documét and Sharma 20049).

Health Concerns

Four published articles examine the health concerns of U.S. Latinos. To create a
targeted research agenda, public health officials wrote two articles focusing on health
priorities for those working with Latinos (Amaro and de la Torre 2002; Flores et a1.
2002). These two articles derive health priorities for segments of the Latino population
based on previously published health disparities between Latinos and non-Latino whites.
Amaro and de la Torre (2002) discuss the national public health needs for Latinas, while
Flores et al. (2002) discuss physicians’ health priorities for Latino children according to
the Latino Consortium of the American Academy of Pediatrics Center for Child Health
Research. Neither of these articles consults members of the Latino population.

The remaining two published articles present studies that sought U.S. Latinos’
health concerns from the perspective of members of the Latino population (Harrison and
Scarinci 2007; Martinez and Carter-Pokras 2007); both use focus groups to rank health
priorities held by the Latino population in Alabama (Harrison and Scarinci 2007) and in
Baltimore, Maryland (Martinez and Carter-Pokras 2007). Harrison and Scarinci (2007)
examine Latino parents’ health concerns for their children. The most commonly
mentioned health problems for Latino children in Alabama are upper respiratory
infections, fevers, ear infections, asthma and gastrointestinal problems (Harrison and
Scarinci 2007:37). Parents also mention concerns about headaches, dental problems and

developmental problems for their children. Martinez and Carter-Pokras (2007) identify

20

health concerns for four different segments of the Latino population in Baltimore,

Maryland. The findings for each of these groups are in Table 1 below.

Table 1: Top Health Concerns of Latinos in Baltimore, Maryland

(Martinez and Carter-Pokras 20072903)

 

Older
Women

“Bone-related disease” (arthritis/osteoporosis)

Heart (hypertension/cholesterol)

Stress/mental health (nervios)

Respiratory problems (allergies/asthma), diabetes (glucosa),
influenza, AIDS

 

Women

Diabetes

Hypertension (presio’n)

Eye problems (la vista)

AIDS, cancers (breast and uterine), influenza (virus de la
gripe), gastritis, hearing/dental, stress/mental health

 

Men

Alcohol and drug abuse

Mental health

STDs

Violence and domestic issues, respiratory problems
(allergies/asthma), nutrition (hypertension/cholesterol)

 

Parents
(for
children)

Ear infections

Asthma

Lead poisoning

Stomach viruses, fevers, coughs

 

Martinez and Carter-Pokras (2007) also conduct focus groups with health

providers serving Latinos to determine provider health concerns for the entire population.

Providers rank the following four areas, in order of importance, as the top priorities for

improving Latino health: (1) neonatal and pediatric care, (2) preventive care for chronic

disease, (3) diabetes and heart disease, and (4) dental, alcohol/substance abuse, and

anxiety/mental health (Martinez and Carter-Pokras 20072903). Provider perspectives on

Latino health priorities are similar to the health priority ranking of Latinos themselves.

However, such health care provider assessment misses the acute needs of the population.

21

For example, health care providers did not mention Latino parents’ concern about lead

poisoning for their children.

Obtaining Health Information

Public Health professionals use various modes of communication to provide health
information to the public. Researchers note that Latinos find different sources of health
information to be useful when compared to non-Latino whites and blacks. For this
reason, health messages distributed through certain communication channels are not as
effective with Latinos as they are with other racial/ethnic groups. Two studies look
specifically at the U.S. Latino population’s opinions regarding sources of health
information. Williams et al. (2007) examine the preferences of Latino residents in
Durham County, North Carolina, while O’Malley, Kerner and Johnson (1999) examine
Latinos’ most frequently used sources of health information in New York City. Both use
random-digit dial telephone surveys.

Like non-Latino whites and blacks, members of the U.S. Latino population find
physicians to be the most useful and most frequently used source of medical information
(Williams et a1. 20072395; O’Malley et a1. 19992200). However, Latinos find health
departments to be a significantly more useful source for obtaining health information than
do non-Latino whites and blacks (88.8% versus 43.6% and 68.0%, respectively)
(Williams et al. 2007:395). More Latinos find churches and community centers to be
relevant sources for health information than do non-Latino whites and blacks (churches:
70.1% versus 23.2% and 63.4%, respectively; community centers: 86.4% versus 26.8%

and 60.5%, respectively) (Williams et al. 20072395). Latinos are also more likely to use

22

the radio and television to obtain health information (74.8% and 81.5%, respectively)
than are non-Latino whites (34.9% and 52.3%, respectively) and blacks (62.7% and
81.4%, respectively) (Williams 2007:395). Latinos are slightly less likely to use the
intemet for health information than are either non-Latino whites or blacks (59.5% versus
66.1% and 63.8%, respectively) (Williams 2007:395). Some of these preferences may be
due to the language in which the health information is available. Latinos may also prefer
certain forms of media, like radio and television, to others, such as those available on the
intemet, because they are already integrated into their daily lives and their use does not
incur additional costs. Interestingly, Latinos are also more likely than other ethnic groups
to report not being able to obtain any health information (O’Malley et a1. 19992200).
Health messages specifically designed to target the Latino population may, in fact, not be

reaching them at all.

Hypotheses Examined in This Study

At 44.2 million, the Latino population is currently the United States’ largest
ethnic minority group. Yet, scholars find that they have some of the worst health
outcomes and most limited access to healthcare of all ethnic groups, despite the existence
of the purported “Latino Paradox” (Documét and Sharma 200425). Latinos are
disproportionately affected by preventable diseases, injury, and death in comparison to
non-Latino whites (Center for Disease Control 2004b22330). Latinos also represent the
largest percentage of individuals in the United States without health insurance and a
regular source of health care (Documét and Sharma 2004:5). Scholars have begun to

understand these disparities by using national survey data to analyze U.S. Latinos’ health

23

care utilization patterns and the factors that affect these patterns. A few researchers have
also identified the health concerns of Latinos in specific regions of the United States.
Public health officials have then worked to improve the health status of Latinos in these
regions using this information. Unfortunately, no published studies analyze the health
concerns and health care utilization of Latinos residing in Michigan. Therefore, this
study examines the general health care utilization patterns and health concerns of
Michigan Latinos compared to Latinos from existing studies. In the process, I

examine two general hypotheses.

H1: The health utilization patterns of Michigan Latinos are similar to those of other
U.S. Latinos from existing studies. Within the first general hypothesis, I test six

more specific hypotheses related to family income and bilingualism.

Hla: Income and visits to the county health department or community clinic
U.S. Latinos are disproportionately affected by poverty. 22.8% of Latinos in

the United States are living in poverty, compared to 7.7% of the general population
(Da Vita 1996237; U.S. Census Bureau 2000:n.p.). Previous studies have associated
lower income levels with a decreased use of the health care system (W einick et a1.
2000:49). Latinos with lower income levels often cite the cost of private doctors’
appointments as justification for visiting a county health department or community
health clinic to receive care (Garcés et al. 2006:381; Gundelman and Wagner
2000: 187; Harrison and Scarinci 2007:38; Kaiser Family Foundation 2004a23;

Martinez and Carter-Pokras 20062905; Saint-Germain et a1. 2006:353). Therefore, I

24

hypothesize that increased family income decreases the percentage of health care

visits to the county health department or community health clinic.

Hlb: Income and visits to a private doctor’s offices
Lower income levels have also been associated with a decreased use of

preventive care from private doctors’ offices (Garcés et a1. 2006:381; Gundelman
and Wagner 2000:187; Harrison and Scarinci 2007:38; Kaiser Family Foundation
2004az3; Martinez and Carter-Pokras 20062905; Saint-Germain et a1. 2006:353).
Due in part to income levels, Latinos are significantly less likely than are non-Latino
whites to visit a doctor’s office or an HMO for their immediate health care needs
(Kaiser Family Foundation 2004a:4; 2004b:3; Durden and Hummer 2006:1326).
Therefore, I hypothesize that increased family income increases the percentage of

health care visits to a private doctor’s office.

ch: Income and health insurance status
I also hypothesize that family income is positively related to the possession

of insurance.

Hld: Language and visits to the county health department or community clinic
The U.S. Latino population is characterized by varying degrees of English
fluency (Pew Hispanic Center 2007:2). Fluency in English has been associated with
the ability to obtain health care as well as the type of care obtained (Fiscella et a1.

2002:56; Flores et a1. 2002:88; Garcés et al. 2006:381; Harrison and Scarinci

25

2007:39; Kaiser Family Foundation 2004a:5; 2004b:3; Martinez and Carter-Pokras
20062905; Saint-Germain et a1. 1993:353). Language is frequently cited as a barrier
to care, forcing Latinos to obtain services at county health departments and
community clinics where translators may be available (Kaiser Family Foundation
2004a23; 2004bz5; Martinez and Carter-Pokras 2007:905). Therefore, I hypothesize
that Spanish-only families have a higher percentage of health care visits to the

county health department or clinic than do bilingual families.

Hle: Language and visits to a private doctor’s office
Spanish—only Latinos are less likely to have a usual source of care in

comparison to English-speaking Latinos and non-Latino whites (18.2%, 12.9% and
9.8%, respectively) (Fiscella et al. 2002255). They are also significantly less likely
to have undergone preventive care treatments, such as mammograms in the past
year, compared to English-speaking Latinos (27.0% versus 45.0%) (Fiscella et al.
2002256). Therefore, I hypothesize that Spanish-only families have a lower
percentage of health care visits to a private doctor’s office than do bilingual

families.

Hlf: Language and health insurance status
Scholars have shown that information about obtaining insurance through
Medicaid is only distributed to 26% of eligible Spanish-only Latinos (Flores et a1.
2002:88). For this reason, Spanish-only Latinos are more likely than are English-

speaking Latinos to lack health care insurance. Therefore, I hypothesize that

26

bilingual families are more likely to have medical insurance than Spanish-only

families

H2: The health concerns of Michigan Latinos are similar to those reported in
existing studies.

Two published studies describe the health concerns of Latinos in the United States
(Martinez and Carter-Pokras 2007; Harrison and Scarinci 2007). This study will expand
on both by determining the health concerns of members of Michigan’s Latino population
in four Michigan counties through focus groups and written questionnaires. Focus group
questions ask about the health concerns of the Latino community as well as parents’
concerns for the health of their children. I hypothesize that the health concerns of

Michigan Latinos will be similar to those provided by Latinos in previous studies.

27

CHAPTER III

STUDY DESIGN AND PROCEDURES

This chapter describes the methodological procedures for this investigation of
Michigan Latinos’ health concerns and patterns of utilization of health resources. This
study specifically explores the health needs of Michigan Latinos and the related extent
that the current health care system addresses those needs. It is a joint project between the
graduate student Primary Investigator (me) and Michigan State University Extension
(MSUE). The research team consisted of two MSUE employees, the focus group
moderator, and me. Data was gathered for this study via written questionnaires and focus
group interviews. The sections below describe the sampling procedures, quantitative data
and qualitative data gathering instruments, the administration procedures for both
instruments, confidentiality safeguards, and potential limitations. This study earned
exemption status from Michigan State University’s Human Research Protection
Programs on December 17, 2007.

This is a cross-sectional research study Of the health concerns and health
utilization patterns of Michigan’s Latino population. Individual Latinos are the unit of
analysis. This study employs both individual written questionnaires and in-depth focus
groups interviews to examine the health concerns and experiences of Michigan’s Latino
population. The written questionnaires ask about individual health concerns and
individuals’ utilization of the health care system. The focus group interviews serve
multiple purposes. The data gathered during focus groups describes the health needs of

the Latino community; therefore, this data should closely correlate with the individuals’

28

needs reported on the written questionnaires. Focus group interviews also help elicit the

attitudes and beliefs of the Latino community regarding available health care resources.

Sampling Procedures

This study’s target population is the adult Latino population currently residing in

Michigan. The research team selected the five following counties for participation in this

study: Lenawee, Ingham, Saginaw, St. Joseph, and Van Buren. Table 2 shows the size of

the Latino population in each of these counties in comparison to each county’s overall

population.

Table 2: The Latino Population in Selected Michigan Counties (Kayitsinga 2007:n.p.)

 

County Ingham

Lenawee Saginaw St. Joseph Van Buren

Michigan

 

Total
Population
(2000)
Rural/Urban

279,320

Urban

98,890

Urban

210,039

Urban

62,422

Rural

76,263

Urban

9,938,444

 

Total Latino
Population
(2000)

16,190

6,884

14,075

2,488

5,634

323,877

 

Percent of
Population
that is Latino

5.8%

7.0%

6.7%

4.0%

7.4%

3.3%

 

Percent
Population
Change
(1990-2000)

-0.93%

7.50%

-0.91%

5.62%

8.13%

6.47%

 

Percent
Latino
Population
Change
(1990-2000)

16.75%

19.89%

6.32%

29

78.05%

59.99%

37.76%

These counties reflect the varying presence of Michigan’s Latino population. The
research team included Ingham County in this study because of the size of its Latino
population and its status as a national refugee resettlement location for Cubans. We
included St. Joseph and Van Buren County because of the large percent change in the
Latino population between 1990 and 2000 in both counties. We selected Saginaw
County because, although the size of the general population decreased slightly over the
past ten years, the size of the Latino population has increased significantly. All but one
of these counties is urban, which reflects the proportion of Michigan Latinos residing in
urban areas.

The research team also selected these counties because of the relationships that
exist between MSUE and the Latino populations in each county. Lenawee and St. Joseph
Counties both participated in MSUE’s Healthy Hispanic Project. The MSUE County
Offices in Saginaw and Van Buren have also worked closely with the Latino population
in the past. However, during the study, we noticed that Saginaw County no longer had a
working relationship with its Latino population. For this reason, we conducted only one
focus group in Saginaw. The research team then added Ingham County to the study to
collect more quantitative data because of its proximity to MSU and the personal
connections the research team had with members of the local Latino population.

Once the research team had selected the five counties, one of the MSUE
employees on the research team contacted the MSUE County Office in each county to
identify an MSUE employee who had worked with the Latino population. This employee

served as the main contact for that county. Contact employees helped identify a date and

30

location for each focus group. In St. Joseph and Van Buren Counties, our employee
contacts deferred to a Latino community leader for recruitment.

We utilized a nonprobability sampling design to enlist participants into this
research study. The use of probability sampling techniques in this study was impractical
because Latinos in Michigan have come to distrust most efforts to collect data about their
communities. This distrust has grown due to recent discussions and legislation regarding
illegal immigration. Therefore, recruitment for the study occurred through referral
sampling. MSUE employees or Latino community leaders (as was the case in St. Joseph
and Van Buren Counties) contacted members of the Latino community whom they
believed would participate in the research study. The MSUE employee or community
leader then asked those individuals for the contact information of other Latinos they
believed might participate. This snowball recruitment process continued until eight to ten
men and eight to ten women in each county agreed to participate. The goal was to have
five to eight participants in each focus group session. This number of participants has
been listed as the ideal size for conducting focus groups, although focus groups may
include up to fifteen participants (Morgan 1998277).

Referral sampling identified Latinos in four different Michigan communities who
would willingly share their personal health concerns and health care experiences with the
research team. The research team asked the MSUE employees and community leaders
doing recruitment for this study to identify a larger number of individuals with families in
order to have a more thorough discussion about family and community health needs.
This sampling method, however, is limited since it does not representatively sample

members of Latino communities. In Lenawee and St. Joseph Counties, recruitment for

31

this study occurred primarily at Spanish-speaking Catholic churches. Therefore,

individuals at those locations who do not attend masses were not informed of the study.
Also, by limiting the sample size to a number conducive for focus group interviews, the
response rate for the written questionnaire is less than ideal. Therefore, qualitative data

must be interpreted with caution.

Quantitative Data Gathering Instrument - Written Questionnaire

The research team gathered quantitative data via a written questionnaire of
individual Latinos. I designed the questionnaire to gather data from respondents about
their health needs and those of their families, as well as their access to and utilization of
health care services. The questions asked about personal opinions regarding the health
system, family dynamics regarding health care decisions and discussions about health,
insurance status, and stressful life events that may affect health. I also asked a range of
socio-demographic and economic questions. Most questions were closed-ended,
although two questions, regarding health concerns of the participant’s family and any
general comments the participant wanted to add, were open-ended. I translated the
questionnaires into Spanish and then translated responses back into English. A graduate
Student from MSU’s Spanish department checked the accuracy of each questionnaire
question and the responses. To improve the reliability and accuracy of questions, during
pretesting, I also administered the questionnaire to native Spanish speakers. Appendices
A and B contain the English and Spanish versions of the written questionnaire,

respectively.

32

Administration — Written Questionnaire

All quantitative data was collected during February and March 2008. The first
round of written questionnaires was collected in conjunction with the focus group
interviews. Focus group participants completed the questionnaires before beginning
discussion on the focus group questions. The second round of written questionnaires was
completed March 17-31, 2008. The research team distributed questionnaires to the
MSUE employee who recruited study participants in Lenawee County. We selected
Lenawee County because of its large turnout during initial data collection. We also
distributed questionnaires to a popular Mexican store in Ingham County. We selected
Ingham County because of its proximity to MSU. Unfortunately, written questionnaires

distributed in Ingham County were returned incomplete.

Qualitative Data Gathering Instrument - Focus Group Interviews

The research team gathered qualitative data via focus group interviews with
Latino community members. The MSUE members of the research team and I designed
these questions. Focus group questions asked participants about their health concerns,
the health care system’s ability to address those concerns, and their behaviors related to
seeking health information. More specifically, we asked participants how they obtain
health information and their preferred sources of information. Questions asked
participants about the general health concerns in their community and their concerns
related to the health of their children and other adults in their household. The research
team asked where members of the Latino community could go to get health issues

addressed as well as where they get help for their own health concerns and concerns for

33

their children and others. By asking where Latinos could go and where they actually do
go to address their health needs, area health services are revealed as well as the barriers to
these services. I translated focus group questions from English to Spanish and had a
native speaker translate them back to English to ensure accuracy. To improve validity, I
also gave the focus group questions to native Spanish speakers who would not be
participating in the study. Appendices C and D contain the English and Spanish versions

of the focus group questions, respectively.

Administration - Focus Group Interviews

All qualitative data collection also occurred in February and March 2008. I
conducted a male and a female focus group interview in Lenawee County, St. Joseph
County and Van Buren County and one female focus group in Saginaw County for a total
of seven focus groups. Focus groups occurred on weeknights in Lenawee and Saginaw
Counties. Focus groups in St. Joseph and Van Buren Counties occurred on a Saturday;
the male focus groups took place in the morning, while the female focus groups took
place in the afternoon. I arranged backup dates for all focus groups in case of inclement
weather. Those dates had to be used for St. Joseph and Lenawee Counties. A native
Spanish speaker conducted all focus groups in the language preferred by focus group
participants. According to those preferences, all focus groups were conducted in
Spanish, except for Saginaw County which was conducted in English. At each focus
group, copies of the consent form and written questionnaire were available in both
languages for participants.

Three members of the research team attended each focus group: the focus group

moderator, one of the MSUE employees, and the graduate student Primary Investigator

34

(me). An MSUE State Leader proficient in focus group moderating trained all members
of the research team using a moderator guide adapted from a similar study performed by
Iveris L. Martinez and Olivia Carter-Pokras of Latinos in Baltimore, Maryland (Martinez
2007). A single moderator, a visiting professor from Cuba in the MSU Spanish
Department, conducted each of the focus groups. The remaining members of the
research team took notes throughout the focus groups.

The research team audio—taped all focus group interviews. A native speaker, who
is a certified Spanish translator for the Ingham County Circuit Court, transcribed and
translated these data files into English. The Primary Investigator checked each document
for validity after it was complete. I identified very few errors in the transcripts.

At the beginning of each focus group session, the research team distributed food
from a local restaurant to participants as they arrived. Twenty to thirty minutes were
allotted for participants to eat, during which they also talked among themselves. The
research team allowed participants to select their own seats around a table and placed a
placard with an alphanumeric code in front of each participant. The research team used
this alphanumeric code — a combination of a letter representing the county (either “L”,
“S”, “J” or “V”) and a number — to refer to specific participants throughout the focus
group interview.

The remainder of the focus group sessions followed a predesigned moderator
guide, which can be found in Appendix E. After eating, the research team thanked
participants for coming. We provided information about MSUE and the project to
participants before administering the consent form. This form, available to participants in

both English and Spanish, was approved by MSU’s Human Research Protection

35

Program. The consent form was not required by the Human Research Protection
Program; however, we chose to include it to reassure participants that we were not hiding
anything from them. The focus group moderator read the consent form aloud to
participants and gave them an opportunity to ask questions before signing it. Appendices
F and G contain the English and Spanish versions of the consent form. The research
team did not associate the consent forms to assigned alphanumeric codes in any way.

The focus group moderator then verbally administered the written questionnaire
to participants to account for any literacy issues. English and Spanish versions of the
questionnaire were available. All focus group participants in Lenawee, St. Joseph and
Van Buren Counties selected the Spanish version of the written questionnaire, while
participants at the Saginaw County selected the English version. The questionnaire
required twenty to thirty minutes to complete. The Primary Investigator then collected
the questionnaires and wrote the participants’ alphanumeric codes on their questionnaire.
This was done so that the responses to focus group questions would be connected to the
collected questionnaire data.

After the questionnaire was administered, the focus group moderator conducted a
discussion covering the focus group questions. Participants were asked about their health
concerns, where they obtain health information, and finally, about the health care system
and its ability to meet their needs. Discussions on individual focus group questions
ranged from ten to twenty minutes each, for a total time spent of fifty minutes to an hour
and ten minutes. The moderator guide provided prompts for the moderator to use for
each question as a last resort if participants did not readily have responses to the

questions. The moderator used these prompts more frequently during focus groups with

36

men than during focus groups with women; this could be a result of cultural norms.
Typically Latino men do not discuss health, especially with non-family members.

When discussion on the focus group questions was complete, the focus group
moderator offered participants the opportunity to share any additional information
regarding health and health care with the research team. This typically lasted from five to
twenty minutes. Female participants generally had more to share with the research team
than did male participants. I then thanked the participants for their time and offered them
a small gift from MSUE. The gift consisted of materials currently used by MSUE in
other educational programs: a Spanish calendar about healthy eating for children, a
Spanish cookbook, a liquid measuring cup, a sponge, and a magnet listing important
health-related phone numbers in their area. I designed the magnet specifically for this

study.

Confidentiality Safeguards

The research team took steps throughout the entire study to ensure participants’
confidentiality. The research team was unaware of who would be participating in the
study prior to the initiation of each focus group interview. Initial contact and reminder
phone calls were done by the MSUE staff member or alternatively by the community
leader doing recruitment. During the second round of data collection for the written
questionnaire, the research team distributed the questionnaires to the MSUE employee in
Lenawee County and to the owner of a Mexican store in Ingham County. We never met
those that completed the questionnaires during this stage. Furthermore, the research team
never collected any contact information from participants. Participants’ names only

appeared on the consent forms for this study; they were never tied to any data collected.

37

The research team gave each focus group participant a placard with an
alphanumeric code at the initiation of each focus group interview. The research team
used this code to identify study participants throughout all data collection and analysis.
This code appeared on the top of participants’ questionnaires and was associated with
their responses to focus group questions on written transcriptions. I elected not to assign
alphanumeric codes to the Lenawee County study participants who completed the written
questionnaire, but did not participate in focus groups.

At the beginning of each focus group interview, the focus group moderator asked
study participants to share a bit of information about themselves or their families with the
rest of the group. To ensure participant confidentiality, any names mentioned during the
interview were permanently deleted from audio files before transcription using an
Olympus Digital Wave Player. Therefore, the names of participants never appear in any

collected data.

Potential Limitations

The study used a small sample size drawn via referral sampling of adult Latinos
in Michigan. The research team administered the written questionnaire to 61 participants
and asked 45 participants the focus group questions. Study participants were drawn from
only four counties in Michigan. As such, we may consider this a pilot study. It may later
provide the foundation for a larger MSUE study about the health concerns and health
utilization patterns of Latinos in Michigan.

The data collected during this study is also limited in that it depends on study

participants to be forthcoming with their needs and habits regarding health care.

38

Participants may not trust the research process, so their responses may not have been

completely forthcoming.

39

CHAPTER IV

ANALYSIS OF QUESTIONNAIRE DATA

This chapter presents an analysis of the data collected from the written
questionnaires. Data was analyzed using SPSS 16.0. An alpha value of 0.1 was assigned
for these statistical analyses. Because this is a pilot study to examine the extent to which
trends in Michigan Latinos are similar to those for other U.S. Latinos, 0.1 is a sufficient

compromise between statistical significance and statistical power.

Demographics
Table 3 below depicts the number of written questionnaires and focus group
interviews completed in each county.

Table 3: Qualitative and Quantitative Data Collection in Each County

 

 

 

 

 

 

N Percent of Number of Percent of Total
umber of
Questionnaires Total . Focus Group Focus Group
Questionnaires Participants Partrcrpants
Lenawee 33* 55.0% 18 40.0%
Saginaw 6 10.0% 6 13.3%
St. Joseph 13 21.7% 13 28.9%
Van Buren 8 13.3% 8 17.8%
Total Study 60 100.0% 45 100.0%

 

* In Lenawee County, 18 questionnaires were collected during the first round of data collection
and the remaining 15 were collected during the second round of data collection.

Table 4 on the following page provides basic demographic data about study
participants drawn from the written questionnaire. Questions 8 through 16 on the
questionnaire asked study participants about the following: gender, age, country of origin,
language, education, how long they have lived in the United States, family structure, and

income.

40

Table 4: Demographic Data of Study Participants

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of Percent of
Participants Participants
Male 20 33.33%
Gender Female 40 66.67%
A e Average: 20-29 yrs. 22 36.67%
g Youngest: under 20 yrs. 2 3.33%
Oldest: 60-69 yrs. 4 6.67%
Mexico 42 70.00%
C f Puerto Rico 10 16.67%
outrtry 0 United States 6 10.00%
Ongn
Honduras 2 3.33%
Guatemala 1 1 .67%
Average: 8-12 yrs. - -
Education Least: never attended 2 3.33%
Most: college or more 10 16.67%
Spanish-only 35 58.33%
Language English-only 3 5.00%
Bilinlgual 23 38.33%
T' . Average: 18.8 yrs. - -
'31; In Shortest: 6 mo. 1 1.67%
° ° Longest: 64 yrs. 1 1.67%
Average: $20,000-$29,000 13 21.67%
Income Minimum: < $20,000 26 43.33%
Maximum: > $50,000 3 5.00%
. Average: 4.35 people - -
FEES)! Least: live alone 1 1.67%
Most: 10 people 1 1.67 %
N h f Average: 1.66 - -
um er 0 Least: no children 20 33.33%
Children
Most: 6 children 1 1.67 %

 

 

 

41

Hypothesis 1: Latino Health Utilization Patterns

The first hypothesis tested in this study states that the health utilization patterns of
Michigan Latinos are similar to those of other U.S. Latinos from existing studies. Within
this general hypothesis, six more specific hypotheses regarding the effect of family
income and language fluency on types of health care utilized and health insurance status
are tested. Table 5 below shows the type of health services obtained by participants in

2007 (question 5 on the written questionnaire).

Table 5: Percentage of Total Health Care Visits to Each Location by County

 

 

 

 

 

County Emergency County Health Community Private
Room Department Clrnrc Doctor 3 Office

Lenawee 8.97% 29.11% 17.84% 44.07%

Saginaw 19.14% 20.35% 30.68% 29.82%

St. Joseph 7.14% 29.82% 27.69% 36.44%

Van Buren 32.14% 24.11% 41.15% 15.33%

All Counties 11.57% 27.70% 24.21% 36.51%

 

Table 6 below shows the health insurance status of study participants (question 6

on the questionnaire). Participants often selected more than one type of insurance to

describe the health coverage for their family; therefore, percents do not equal 100.

Table 6: Health Insurance Status of Participants by County

 

 

 

 

 

 

County Employer Pugsalses P333!“ Medicaid Medicare Insfiral’nce
Lenawee 18.2% 15.2% 18.2% 24.2% 15.2% 51.5%
Saginaw 66.7% 16.7% 16.7% 83.3% 16.7% 83.3%
St. Joseph 23.1% 15.4% 23.1% 30.8% 30.8% 69.2%
Van Buren 0.0% 0.0% 0.0% 25.0% 0.0% 25.0%
All Counties 21.7% 13.3% 13.3% 31.7% 16.7% 55.0%

 

42

The number of uninsured in this study is higher than both the national average for Latinos
(42%, (Keiser Family Foundation 2004b:2)) and the Michigan average for Latinos
(26.6%, (Michigan Department of Community Health 2007a:93)). The number of
participants receiving Medicaid is also higher than the national average (12% (Kaiser

Family Foundation 2004a22).

H] a: Income and Visits to the County Health Department or Community Clinic

There was not a statistically significant relationship between income level and the
number of visits to county health departments or community clinics (r=-.118, a=.369). I
anticipate that with a larger sample size, this correlation may become statistically

significant. However, this study does not support Hypothesis 1a.

H 1 b: Income and Visits to a Private Doctor’s Office

Data from this study show that questionnaire respondents with higher income
levels are significantly more likely to visit a private doctor’s office (1:314, (1:015).
This is in accordance to what previous studies have shown. Thus, this study supports

Hypothesis 1b.

H1c: Income and Health Insurance Status
There is also no statistically significant relationship between family income level
and health insurance status (r--.207, (1:1 12). This is also likely due to the sample size of

this study. Therefore, this hypothesis is not supported.

43

Hld: Language and Visits to the County Health Department or Community Clinic

Study participants who spoke only Spanish at home are not significantly more
likely to visit to visit county health departments and community clinics (r=.162, (1:.216).
Similarly, there is no significant relationship between being bilingual and the number of
visits to county health departments or community clinics (r=—.202, (1:. 122). Therefore,
this hypothesis is not supported by this study. This may also be due to the small sample

size of this pilot study

H] e: Language and Visits to a Private Doctor ’s Office

Participants who spoke only Spanish are significantly less likely to visit a private
doctor’s office to receive health care (r=-.260, a=.045). There is also a statistically
significant relationship between speaking both Spanish and English and visiting private
doctors’ offices. Bilingual participants in this study are significantly more likely to have
visited a private doctor’s office in 2007 (r=.292, (1:.024). Therefore, this study supports

this hypothesis.

H I f: Language and Health Insurance Status

There is no statistically significant relationship between language and health
insurance status. Spanish-speaking respondents are not less likely to have health care
insurance (r=-. 153, a=.244). Furthermore, bilingual respondents are not more likely to
have health care insurance (r=.152, (1:.248). This is contrary to the findings of previous
studies. A larger sample size may elucidate a relationship between language fluency and

health insurance status for Michigan Latinos.

Other Quantitative Findings
Table 7 below contains a summary of other quantitative findings from this study.

Table 7: Responses to Other Questions on the Written Questionnaire

How well does the current health care system meet
your needs and the needs of your family?

 

Average Response "It meets some of our needs"
Standard Deviation 0.847

 

How often do you and your family talk about

 

 

health and health care?
"Sometimes (3 to 4 times a
Average Response ..
year)
Standard Deviation 1.240

 

 

In 2007, did you or your family worry about any of
the following?
Unemployment or
change in 35 participants 58.3%
employment status
Housing access or

housing conditions 17 p altlcrpants 283%

 

 

 

 

 

 

Food availability 19 participants 31.7%
Health insurance 26 participants 43.3%
Quality of health 13 participants 21.7%
care servrces

Discrimination 11 participants 18.3%
Availability of . .

transportation 15 partrcrpants 25.0%
Income 35 participants 60.0%

 

 

Total number of health worries (0-2)
Average Response 0.77
Standard Deviation 0.871

 

Total number of non-health worries (0-6)
Average Response 2.05
Standard Deviation 1.692

45

Notable Findings

This study illustrated previous findings regarding factors that influence Latinos’
health care utilization patterns. In accordance to previous research, study participants’
country of origin influences the type of health care services they receive. Mexican
respondents are less likely to have visited a private doctor’s Office in 2007 to receive
health care (r=-.223, (1:087). Puerto Rican respondents, on the other hand, are more
likely to have visited private doctors’ offices in 2007 (r=.320, a=.013) and less likely to
have visited county health departments and community clinics (r=-.223, a=.086). This is
consistent with previous findings about Latino health care utilization patterns (Durden
and Hummer 2006:1326).

This study also noted that Latinos’ country of origin influences their health
insurance status. Although a significant difference was not observed in the percent of
Mexicans and Puerto Ricans with health insurance as noted in previous studies, largely
due to small sample size, this study did reveal a difference in the type of insurance
possessed. Puerto Ricans were more likely than any other subgroup of the Latino
population in this study to obtain health care insurance through a state or county-
sponsored program (r=.219, a=.092). This is consistent with previous findings (Durden
and Hummer 200621328).

Finally, this study reaffirms previous findings regarding the importance of health
insurance in relation to satisfaction with health services. Latinos with any type of health
care insurance are more likely to report that the health care system meets a greater

number of their and their family’s health care needs (r=.339, (1:008). This is consistent

46

with Martinez and Carter-Pokras finding (2007:904) that the possession of health care

insurance leads to greater satisfaction with the health care system.

47

CHAPTER V

ANALYSIS OF FOCUS GROUP DATA

This chapter presents an analysis of qualitative data collected in seven focus
groups in four different Michigan counties. The research team asked focus group
participants about four topics in the following order: (1) where members of their
community obtain information about health and health care; (2) community health
concerns; (3) their health concerns for community youth; and (4) where the community
obtains health care. Discussions regarding where Latinos obtain health care also revealed
barriers to care in their community.

Forty-five Latinos participated in the focus group interviews. This is a portion of
the same population that completed written questionnaires in the previous chapter.
Therefore, demographic data for this sample is very similar to that provided in the

Chapter IV.

Analysis

The responses for each question were coded into categories for analysis. I coded
the individual responses to focus group question 2, regarding participants’ health
concerns for the Latino community and Latino youth, into four broad categories: chronic,
contagious, social, and mental-psychological. I designed these categories to coincide
with popular perceptions about each health concern.

Table 8 on the following page depicts the illnesses that I included in each of the

four categories. The health concern “cultural norms” describes the belief that Latino men

48

feel that they cannot discuss their health with others or seek health care without appearing
weak. The health concern “health systems barriers” describes a common concern

regarding the inability to obtain health care when it is needed.

Table 8: Categories Used to Classify Latino Health Concerns
Category Included Health Concerns

 

Asthma, blood pressure, cholesterol, diabetes, epilepsy,
Chronic migraines, arthritis, kidney failure, skin problems, Parkinson’s
disease, dental, vision

 

Common illnesses, STDs, AIDS, respiratory infections,

 

Contagious vaginal and urinary tract infections
Behavioral problems, cultural norms, health systems barriers,
Social preventive care, obesity/nutrition, misuse of over the counter

medication, teen pregnancy, preterm delivery, drugs, alcohol,
smoking, health education.

 

Mental health concerns, stress/depression, developmental

Mental-Psychological disabilities

 

Participants often provided more than one response to each question. Therefore,
in some instances, the percentage that a topic was mentioned exceeded 100. I analyzed
the responses to each focus group question by county to determine if health concerns and
available resources differ around the state. I analyzed the barriers to obtaining health

care services by county for the same reason.

H2: Latino Health Concerns

The second hypothesis examined in this study states that the health concerns held
by Michigan Latinos are similar to those held by U.S. Latinos in previous studies. Data
for this hypothesis was provided by the second focus group topic. The first question

under this topic asked about community health concerns — “What do you think people in

49

this Hispanic/Latino community are worried about in terms of health?” — while the
second question asked about health concerns for community youth — “For those of you
who have kids under the age of 18, what are you worried about when it comes to their
health?”.
Health Concerns for the Latino Community

Table 9 below shows the health concerns for Latino communities by county.

Table 9: Latino Community Health Concerns by County
Lenawee Saginaw St. Joseph Van Buren All Counties

 

 

 

 

 

Social 27.8% 100.0% 61.5% 37.5% 48.9%
Chronic 44.4% 33.3% 46.2% 50.0% 44.4%
Contagious 50.0% 33.3% 7.7% 0.0% 22.2%
Cancer 27.8% 16.7% 7.7% 25.0% 20.0%
Mental-Psychological l 1.1% 16.7% 30.8% 0.0% 15.6%

 

The top three types of concerns for Latinos in Michigan are social, chronic, and
contagious illnesses. Saginaw and St. Joseph Counties consider the illnesses coded as
social concerns to be the most significant. Specifically, Latinos .in Saginaw County are
most concerned about Obtaining preventive care (50.0%), followed by obesity/nutrition
(33.3%), and health system barriers (33.3%). St. Joseph County Latinos, on the other
hand, are most concerned about health system barriers (23.1%), and preterm delivery
(23.1%) in their community. Van Buren County Latinos place more emphasis on chronic
conditions, like asthma (50.0%) and diabetes (50.0%). Lastly, Lenawee County
considers contagious illnesses, such as AIDS and STDS (38.9%), to be the largest
community health concern followed by chronic illnesses, such as blood pressure, heart
problems, and diabetes.

The health concerns mentioned by Michigan Latinos in this study are similar to

those mentioned by Maryland Latinos (Martinez and Carter Pokras study 2007).

50

Therefore, this data supports Hypotheses 2. Although Latinos in this study do not
directly mention domestic issues as a community health concern, community violence,
which is coded with domestic issues in Martinez and Carter-Pokras’ study (20072903),
was mentioned by focus group participants. It is coded here as a behavioral issue
(13.3%).

This study, however, deviates slightly from previous findings. Michigan Latinos
place more emphasis on social health concerns than do Latinos in previous studies.
Michigan Latinos mention concerns regarding social issues such as: obesity/nutrition
(24.4%), health system barriers (13.3%), and access to preventive care (13.3%).
Nutrition is mentioned as a minor concern for Latino men in Martinez and Carter-Pokras’

study (2007); the remaining concerns are not mentioned.

Health Concerns for Latino Youth
Table 10 below shows the health concerns held by parents for Latino youth.

Table 10: Latino Health Concerns for Community Youth by County
Lenawee Saginaw St. Joseph Van Buren All Counties

 

 

 

 

 

Social 44.4% 33.3% 107.7% 50.0% 62.2%
Contagigus 44.4% 0.0% 38.5% 0.0% 28.9%
Chronic 5.6% 66.7% 38.5% 0.0% 22.2%
Mental-Psychological l 1.1% 0.0% 23. 1% 12.5% 13.3%
Cancer 1 1.1% 0.0% 0.0% 0.0% 4.4%

 

Once again, participants in St. Joseph County consider social health concerns the
most pressing issue for their community. Every member of the St. Joseph focus groups
mentioned a social health concern at least once. Latino parents in St. Joseph express the
most concern about the following: providing health education to community youth

(30.8%), the use of drugs, smoking and alcohol (23.1%), and youth behavioral issues

51

(23.1%). Van Buren County parents also express the most concern about social health
issues for community youth. They are most concerned about drug use, smoking, and
alcohol in their community (25.0%).

Latino parents in Lenawee County express equal concern about social and
contagious health issues for youth. They are most concerned about social issues such as
drug use, smoking, and alcohol (16.7%), as well as the misuse of over-the-counter
medications (11.1%). Yet, Lenawee parents also express marked concern about
contagious illnesses such as AIDS/STDS (5.6%), common illnesses (cough, flu fever,
throat and ear infections) (5.6%), and respiratory infections (5.6%).

Lastly, Latino parents in Saginaw County are most concerned about dental
(33.3%) and vision (33.3%) services, which are classified as chronic conditions. They
also express concern about obesity in Latino youth (33.3 %). Interestingly, parents in
Saginaw County do not express concern for their children regarding contagious or
mental—psychological health concerns or cancer.

The health concerns of Latino parents in Michigan for their children mirror the
concerns held by Latino parents in previous studies. This adds further support to
Hypothesis 2. Latino parents in Michigan mention nearly all of the concerns held by
Latino parents in Alabama (Harrison and Scarinci 2007237). Unlike Alabama Latinos,
study participants did not express concern regarding childhood gastrointestinal illnesses.
Michigan Latinos also hold most of the same concerns held by Maryland Latinos
(Martinez and Carter-Pokras 20071903).

However, the focus of Latino parents in Michigan differs slightly from other

Latinos. Parents in previous studies place more emphasis on contagious and chronic

52

health issues, while parents in this study express more concern regarding social issues.
This may be a result of the personal characteristics of study participants. We may have

interviewed more parents with older children instead of parents with younger children.

Other Qualitative Findings

Remaining focus group questions ask about behaviors related to seeking health
information and the health care system’s ability to meet participants’ health care needs.
Discussion regarding the health care system reveals the Latinos’ help-seeking behaviors
in each county as well as the barriers preventing access to health resources resources. I

coded these data and examined them by county.

Sources for Health Information
Table 11 below presents the sources that Michigan Latinos most frequently use
obtain health information.

Table 11: Michigan Latinos’ Sources for Health Information by County
Lenawee Saginaw St. Joseph Van Buren All Counties

 

 

 

 

 

 

 

 

 

 

TV/News & Radio 44.4% 50.0% 69.2% 37.5% 51.1%
Doctors 16.7% 50.0% 61.5% 12.5% 33.3%
Friends & Coworkers 27 .8% 16.7% 38.5% 12.5% 26.7%
Relatives 22.2% 33.3% 15.4% 12.5% 20.0%
Pm“ Med” (””9" 16.7% 16.7% 7.7% 25.0% 17.8%
Magzmes, Books)

Work & School 16.7% 16.7% 15.4% 12.5% 15.6%
Internet 11.1% 33.3% 7.7% 12.5% 13.3%
Health Locations

(Clinics, Hospital & 5.6% 50.0% 7.7% 12.5% 13.3%
Health Departments)

Pamph'e‘s 8‘ 11.1% 0.0% 23.1% 12.5% 13.3%
Brochures

Church 1 1.1% 0.0% 7 .7% 0.0% 6.7%

 

53

The sources for health information used by Michigan Latinos are consistent with
those used by Latinos in previous studies. Most participants say they use television/news
and radio as their primary source of health information because it is convenient and easily
accessible (51.1%). Although it is a primary source of health information, they explain
that often it is not very useful. Most Latino communities receive only one Spanish
channel — Telemundo, a Miami-based station — so if an illness is not a national problem,
they do not hear about it. Doctors are the second most popular source for health
information (33.3%), followed by friends and coworkers (26.7%). Previous studies fail
to mention the importance of “word of mouth” in Latino communities as exhibited in this

study.

Help-Seeking Behaviors
Table 12 below displays the help-seeking behaviors of Michigan Latinos in
regards to health and health care by county.

Table 12: Help-Seeking Behavior of Michigan Latinos by County

 

Lenawee Saginaw St. Joseph Van Buren All Counties

 

 

 

 

 

self'lzm’ D" 50.0% 100.0% 46.2% 50.0% 55.6%
Nothing

Community Clinic,

Health Department, 33.3% 66.7% 38.5% 25.0% 37.8%
After Hours Clinic

Pmat" Doc” 5 16.7% 33.3% 53.8% 37.5% 33.3%
Office

Mexico 38.9% 0.0% 38.5% 25.0% 31.1%
Hospital 16.7% 16.7% 23.1% 37.5% 22.2%

 

The help-seeking behaviors of Michigan Latinos are similar to those reported in

previous studies. The most popular method for obtaining care in this study is self-care

54

(55.6%). Traditional home remedies mentioned by focus group participants include:
cinnamon tea or tequila for cough and alcohol baths for chills. The second most popular
method for obtaining health care is visiting a community clinic, the health department, or
an after-hours clinic (37.8%). This is consistent with the findings from previous studies
(Durden and Hummer 2006:1326; Kaiser Family Foundation 2004a:4; 2004b:3).
Michigan Latinos also said that they frequently travel to Mexico for medical care or
obtain help from relatives in Mexico (31.1%). One woman in St. Joseph County
explained that because she often suffers from bronchitis, she will ask anyone traveling to
Mexico to bring back penicillin for her. This behavior is consistent with past research

findings (Harrison and Scarinci 2007:37).

Barriers to Health Care
Table 13 below displays the barriers encountered by Michigan Latinos when
accessing health care.

Table 13: Barriers to Accessing Health Care by County
Lenawee Saginaw St. Joseph Van Buren All Counties

 

 

 

 

 

 

Insurance Status/Cost 88.9% 66.7% 92.3% 50.0% 80.0%
Language 38.9% 16.7% 69.2% 87.5% 53.3%
Discrimination 22.2% 33.3% 84.6% 50.0% 46.7%
Time 27.8% 50.0% 46.2% 37.5% 37.8%
Fear 16.7% 66.7% 23. 1% 12.5% 24.4%
Transportation 16.7% 16.7% 46.2% 12.5% 24.4%

 

The barriers to obtaining health care for Michigan Latinos are identical to those in
previous studies. The most commonly cited barrier to care in Lenawee and St. Joseph
County is health insurance status/cost (80.0%). Participants find that even with health

insurance, the cost of health care is too expensive. Latinos say that they will either forgo

55

care or drive as far as Detroit or Toledo to obtain less expensive care. This is consistent
with previous findings (Kaiser Family Foundation 2004a23).

Latinos in Van Buren County had the most problems with language (87.5%).
Spanish-only participants expressed their frustration regarding their inability to
communicate their health care needs and comprehend prescribed treatments:

“My English is not so good... I know that... so, you try to explain to them

and they say: “I don’t understand you... I don’t understand you ”... and

you are in a lot of pain and they keep saying, “No. I don ’t understand

you.” (Male in St. Joseph County).

This is also consistent with previous findings (Fiscella et al. 2002:56; Flores et a1.
2002:88; Garce’s et al. 2006:381; Harrison and Scarinci 2007239; Kaiser Family
Foundation 2004a25; 2004b:3; Martinez and Carter-Pokras 20062905; Saint-Germain et
a1. 1993:353). Focus group participants stressed the need for bilingual physicians and
staff at local hospitals and clinics.

Latinos in Lenawee and St. Joseph County are the only ones who mentioned
immigration status as a barrier to care. The research team chose not to direct the
conversation towards immigration in order to preserve the trusting relationship that exists
between MSUE and the Latino communities. Latinos in Lenawee and St. Joseph
Counties said that many members of their communities are undocumented and are
working under false names in order to protect their family. These people rarely seek out
or receive health care in fear that it may jeopardize their families:

“The existing problems with the undocumented are preventing the people

from receiving the necessary health services...without this, they wouldn ’t

56

fear to go and ask the teacher: “Where can I get assistance because I

don’t know how to feed my children? ” But you don ’t do it because what if

they come to your house? 012 God! ” (Woman in St. Joseph County).
Numerous focus group participants matter-of-factly stated that, because of recent
legislation regarding illegal immigration, there is no safe place for Latinos, legal or

illegal, to obtain health care in their area.

57

CHAPTER VI

DISCUSSION

The previous two chapters provided the major findings for this study. The present
chapter will focus on discussing these findings in terms of the original hypotheses, the
study’s limitations, and suggestions for future research.

Two hypotheses were tested in this study. The first hypothesis, consisting of six
more specific hypotheses, states that the health utilization patterns of Michigan Latinos
are similar to those of other U.S. Latinos from existing studies. In this hypothesis, the
effects of income and language on utilization patterns were examined. The second
hypothesis suggested that the health concerns of Michigan Latinos are similar to those

reported in existing studies.

Hypothesis 1: Latino Health Utilization Patterns

The Efi‘ects of Income on Health Utilization

The first three specific hypotheses of Hypothesis 1 (Hla, Hlb, and H10) examine
the effects of income on Latino health utilization patterns. I correlated responses to
questions 5, 6, and 16 from the written questionnaire to test these hypotheses. Family
income level is not significantly correlated to the percentage of all health care visits that
are to county health departments or community clinics (m-.118, (1:369), therefore
Hypothesis 1a is not supported. However, Latinos with higher family income levels are

more likely to visit a private doctor’s Office to receive health care (r=.3 l4, (1:.015). This

58

is in accordance to what previous studies have shown. Thus, this study supports
Hypothesis lb. Finally, data shows that a positive correlation exists between family
income level and insurance status, but this relationship is not statistically significant
(r=.207, o=.l 12). Hypothesis 1c is not supported by this study. This could primarily be

due to the small sample size.

The Effects of Language on Health Utilization

The remaining three specific hypotheses of Hypothesis 1 (Hld, Hle, and H10
examine the effects of language fluency on Latino health utilization patterns. I analyzed
responses to questions 5, 6, and 11 on the written questionnaire to test this hypothesis.
This study shows that Michigan Latinos who speak only Spanish are not significantly
more likely to visit county health departments and community clinics to receive health
care (r=. 162, (r=.216). Similarly, there a significant relationship does not exist between
being bilingual and the number of visits to county health departments or community
clinics (r=-.202, a=.122). Therefore, Hypothesis 1d is not supported by this study.
Interestingly, Spanish-speaking Latinos are significantly less likely to visit a private
doctor’s office to receive health care (r=-.260, (1:.045). On the other hand, bilingual
participants in this study are significantly more likely to have visited a private doctor’s
office in 2007 (r=.292, a=.024). Thus, Hypothesis 1c is supported by this study. Lastly,
there is no significant relationship between English fluency and health care insurance
status (r=.152, a=.248). Hypothesis If is not supported by these findings. A larger
sample size may elucidate a relationship between language fluency and health insurance

status for Michigan Latinos.

59

Hypothesis 2: Latino Health Concerns

The second hypothesis examines the health concerns of Michigan Latinos. I
analyzed data drawn from the second topic discussed during the focus group interviews
for this hypothesis. This topic specifically asked about health concerns for the Latino
community and for Latino youth. I coded this data into four broad categories —chronic,

contagious, mental-psychological, and social - and analyzed it by county.

Health Concerns for the Community

The top three categories of health concems for Michigan Latinos are social,
chronic, and contagious illnesses. These categories include nearly all of the health
concerns mentioned by Latinos in previous studies. Therefore, this data supports
Hypothesis 2. However, Michigan Latinos express more concern regarding social health
issues than do Latinos in other areas. They state concerns regarding obesity, health

system barriers, and preventive care that are not mentioned in previous studies.

Health Concerns for Youth

Latino parents in Michigan express the most concern about illnesses that are
classified as social problems or contagious illnesses. These concerns mirror those held
by Latino parents in other areas. Latino parents in Michigan mention nearly all of the
concerns held by Latino parents in Alabama and Maryland (Martinez and Carter-Pokras
2007:903; Harrison and Scarinci 2007237). This adds further support to Hypothesis 2.
However, Michigan Latinos also place more emphasis on social issues than parents in

previous studies. This may be a result of the family structure of focus group participants.

60

We may have interviewed more parents with older children, who normally have more
socially-based health problems than parents with younger children, who are more at risk

for contagious illnesses.

Limitations

Because this research is intended to be a pilot study, the small sample size limits
the ability to generalize the results of the gathered data for the entire Michigan Latino
Population. Also, because of the small sample size, certain health care trends that exist in
Michigan’s Latino population may not have been detected that are apparent in previous
studies. Relationships between income, health insurance status, and language may
become apparent with a larger sample size. A larger sample size may also increase the
significance of reported correlations.

The data gathered during this study relies on the trusting relationships between
MSU Extension County Staff and each county’s Latino population. In Lenawee County,
where MSU Extension staff work very closely with the Latino population, we had a very
high turnout for both the survey and focus group interviews. In other counties, such as
Saginaw County, we learned that MSU Extension’s relationship with the Latino
population, especially Spanish-only members of the population, was nearly nonexistent.
This hampered the data collection process as well as the extent to which study results can

be generalized to the county’s Latino population.

Recommendations for Future Research
The primary limitation to this study is its small sample size. Therefore, this

research should be replicated on a larger scale in order to truly characterize the habits of

61

Michigan’s Latino population. In addition, more Michigan counties should be included
to provide a more in depth sample of the state’s Latino population. Also, the sampling
methodology should be altered to provide a more representative sample of Michigan
Latinos. If possible, probability sampling should be employed.

Future research with Michigan Latinos should include a more in-depth written
questionnaire to better characterize the socioeconomic status of Michigan’s Latino
population. This will permit researchers to better determine which variables have the
most impact on Latino health utilization patterns. Furthermore, future researchers should
employ multivariable analysis to better characterize the role of these variables. This was
not done in this study because of time and my limited statistics background.

Finally, attention should be given to given to individual questions on the written
questionnaire. For example, in question 5, participants should be provided with a better
description of the different health care locations. Because health resources vary in each
county, participants may have been unsure what the research team meant by a community
clinic. In question 16 on the self-administered survey, researchers should include a
category for an income level of less than $20,000 dollars a year in order to further stratify

results.

Conclusions

This pilot study serves as a promising first step towards determining the health
care utilization patterns and health concerns of Michigan Latinos. It helps to illuminate
numerous unmet needs in a population that is often overlooked by health professionals

and policy makers alike. Michigan State University Extension will be able to use this

62

data as a starting point so that they may begin to design more culturally appropriate
health promotion programs for Michigan’s Latino population. This study also provided
the Latino community an opportunity to voice their needs and their concerns. This was
the first step MSUE needed to take in order to begin improving the health status of

Latinos in Michigan.

“We would like to thank you more than anything, because you gave us the

opportunity to unite our requests and listen to what the community needs...Thank you

very much! ” (Male in St. Joseph County)

63

APPENDIX

64

APPENDIX A

SELF-ADMINISTERED SURVEY, ENGLISH VERSION

65

Hispanic Health Project

To help improve the health of Latinos in Michigan, Michigan State University
Extension is working with members of Latino communities like yours to
understand your healthcare concerns, needs and experiences. Your
participation in this project will help Michigan State University Extension and
Latino community leaders develop programs to meet these needs. The following
questions on this Short survey ask about your health, your family’s health and
how often you use the healthcare system. Your answers to these questions are
completely confidential.

For Questions 1-4, select the ONE answer that best describes your situation.

1. In your opinion, how well does the current healthcare system meet your needs and the needs
of your family?

It does not meet our needs at all.

DC]

It meets some of our needs.
It meets many of our needs.
It meets all of our needs.

DD

2. What are your family’s current healthcare needs? Please be as detailed as possible.

3. How Often do you and your family talk about health and healthcare?
Never

Rarely (Once or twice a year)

Sometimes (3 to 4 times a year)

Frequently (Once a month)

A lot (Every other week or so)

DECIDE]

4. In some families, the person who decides whether or not to go see a doctor or get medical
help for their family is not the person who actually goes to the doctor. For example, in some
families, the father will decide that his child needs to go to the doctor’s office, but the mother
will be the one to take the child. Which of the following BEST describes your family?

[1 I make the decisions, and I also carry them out.

3 Someone else makes the decisions, but I carry them out.

i: I make the decisions, but someone else carries them out.

[3 Someone else makes the decisions, and someone else carries them out.

Please continue on the next page.

66

Question number 5 asks about the healthcare experience of everyone in your home. For
each question part, please give the number of times each item happened this year.
Estimates are okay.

5. In the year 2007, how many times did you or your family...

Visit the emergency room?

Visit the county health department?

Visit a community healthcare clinic?

Visit a private doctor’s office?

6. Which statement or statements below describes your family’s type of healthcare insurance?
Please check all that apply.

LIECJL—J

f “l

[T]

3

My family does not have insurance.

I don’t know what type of insurance my family has.

My family receives insurance benefits through my or my spouse’s job.

My family purchases our own insurance from a private company.

My family receives insurance through an insurance program from the state or county.
(examples include My Child and the Ingham County Health Plan.)

My family receives Medicaid.

My family receives Medicare.

7. Various social circumstances can have an impact on our lives. Changes in these
circumstances can also affect our health, both in good or bad ways.

In 2007, did you or your family worry about any of the following? Please check all that

m
CliJUlIUDUDE‘

8. How long have you lived in the United States?

Unemployment or a change in employment status
Housing access or housing conditions

Food availability

Health insurance

Quality of healthcare services

Discrimination

Availability of transportation

Income

 

9. Including yourself, how many people live with you at home?

10. How many people living at your home are under the age of 18?

Please continue on the next page.

67

11. What language do you regularly speak at home?

1:

Clllm

Spanish
English
Spanish and English equally
Neither Spanish nor English

12. What is the highest level of schooling you have completed?

D C] Li Cl

1:]

13. What country is your family originally from?

Completed up to eighth grade

Completed some high school (9 — 12 grades)
Graduated from high school, or have GED
Completed some college

College graduate or more

 

14. What is your gender?

1] Male
[3 Female

15. How old are you?

DDUUDFJD

Under 20 years old
20 — 29 years old
30 — 39 years old
40 — 49 years old
50 — 59 years old
60 -— 69 years old
70 years or older

16. How much money does your family make every year?

DEBUG

17. Is there anything else you would like to share about your healthcare concerns, needs and

Less than $20,000 a year
$20,000 - $29,999 a year
$30,000 - $39,999 a year
$40,000 - $49,999 a year
More than $50,000 a year

experiences that has not been asked?

THANK YOU FOR YOUR PARTICIPATION!

68

APPENDIX B

SELF-ADMINISTERED SURVEY, SPANISH VERSION

69

Proyecto de Salud del Servicio de ExtensiOn de MSU

Para mejorar la salud de la comunidad Latina de Michigan, el programa de
salud del servicio de Extensién de Michigan State University esta trabajando con
miembros de su comunidad para asi poder entender sus preocupaciones sobre la
salud, necesidades y experiencias. Su participacién en este proyecto ayudara a
Michigan State University y su programa de Extensir’m, y también a los lideres
de su comunidad a desarrollar programas que puedan prestar atencién a todas
sus preocupaciones. Esta encuesta tiene preguntas que trataran temas tales como
su salud, la de su familia y ver cada cuanto Ud. hace uso del sistema de salud. Su
respuesta es totalmente confidencial.

Para las preguntas 1-4, escoja UNA respuesta que describa por completo su situaciOn.

1. En su opinién, califique la calidad del sistema de salud para su tratamiento y el de su familia:

a.
b.
c.
(1.

El sistema no atiende nuestras necesidades.

El sistema atiende algunas de nuestras necesidades.
El sistema atiende muchas de nuestras necesidades.
El sistema atiende todas nuestras necesidades.

2. gCuales son las necesidades de la salud de su familia? De todo tipo de detalles.

3. gCada cuanto 0 con que frecuencia usted y su familia hablan acerca de su salud y del cuidado

de la salud?
a.

rap-9.6

Nunca

Raras veces (Una o dos veces a1 afio)
A veces (Tres o cuatro veces a1 afio)
Con frecuencia (Una vez a1 mes)
Bastante (Dos veces al mes)

4. En algunas familias, la persona que decide Si se va a visitar al doctor 0 recurre por ayuda
médica es precisamente la persona que no va a visitar al doctor. Por ejemplo, en algunas
familias, el padre decide si e1 nifio/a necesita visitar a] doctor, pero la madre es la persona que
lleva a su hijo/a al consultorio. De todas estas frases, gCual describe por completo a su

familia?

1:1

[3 F] 1:)

Yo hago la decisiOn médica y también la ejecuto o cumplo.
Otra persona hace la decisiOn, pero yo la ejecuto o cumplo.
Yo hago la decisiOn, pero otra persona la ejecuta o cumple.
Otra persona hace la decisiOn y otra persona la ejecuta o cumple.

Por favor continue con la encuesta en la siguiente pagina.

70

Estas preguntas tratan las experiencias que su familia haya experimentado. Para cada
pregunta, mencione el nr’rmero de veces para cada Situaci6n (en este afio). También puede
estimar sino recuerda exactamente.

5. En el 2007, cuantas veces usted y su familia. ..

gVisitaron la unidad de cuidado intensivo?

LVisitaron e1 departamento de salud del condado?

LVisitaron una clinica comunitaria?

LVisitaron el consultorio de un doctor por cuenta propia?

6. [Que afirmaciOn/es describen por completo e1 seguro medico de su familia? Rellene todas
casillas que califiquen.

a.

{DP-99'

:‘h

g.

Mi familia no tiene seguro medico.

No sé que tipo de seguro medico tiene mi familia.

Mi familia recibe beneficios médicos por medio propio 0 de mi conyugue.

Mi familia paga y recibe un seguro medico por medio de una compafiia privada.
Mi familia recibe beneficios me’dicos por medio de un programa estatal 0 del
condado. Por ejemplo: “My Child” y “the Ingham County Health Plan.”

Mi familia recibe Medicaid.

Mi familia recibe Medicare.

7. Varias circunstancias sociales pueden impactar nuestras vidas. Los cambios de estas
circunstancias pueden afectar nuestra salud ya sea de forma positiva o negativa.

En el 2007, LUsted o su familia se preocupo por lo siguiente? Rellene todas las casillas que

califiguen.

8. gPor cuanto tiempo ha vivido en los Estados Unidos?

arrange-9.0".»

Desempleo o cambio de su trabajo

Acceso a la vivienda o condiciones de vivienda
Acceso a alimentos

Seguro medico

Calidad del servicio medico

DiscriminaciOn

Disponibilidad de los medios de transporte
Ingresos, salario

 

9. LCuantas personas viven en casa? (Inclt’ryase usted mismo)

10. gCuantas personas son menores de 18 afios? (Que viven bajo su techo)

Por favor continue con la encuesta en la siguiente pagina.

71

11. LQue idiomas se hablan regularmente en casa?
a. Espafiol
b. Ingles
c. Espar‘iol e Ingles
d. Ninguno de los dos

12. gCual es el nivel mas alto de educaciOn que usted tiene?

He finalizado algunos estudios.

Terminé hasta el octavo grado.

Terminé parcialmente la preparatoria 0 “high school” (grados del 9 a1 12).
Me gradué de la preparatoria 0 “high school”, 0 tengo un diploma de GED.
Estudie’ en la universidad.

Terminé un post-grado, maestrr’a o doctorado .

serve-99's»

13. [De qué pais es su familia originaria?

 

l4. gCual es su sexo o género?
Cl Masculino
Cl Femenino

15. gCuantos afros tiene usted?
a. Menos de 20

b. Entre 20 y 29
c. Entre 30 y 39
d. Entre 40 y 49
e. Entre 50 y 59
f. Entre 60 y 69
g. Mas de 70

16. gCuanto dinero gana su familia anualmente?

a. Menos de $20,000 a] afio

b. Entre $20,000 y $29,999 a1 afio
c. Entre $30,000 y $39,999 a1 afio
d. Entre $40,000 y $49,999 al afio
e. Mas (16 $50,000 a] afio

17. gUsted tiene alguna inquietud o pregunta acerca de sus preocupaciones, necesidades y
experiencias médicas 0 de al go que no se haya mencionado?

zMUCHAS GRACIAS POR SU PARTICIPACION!

72

APPENDIX C

FOCUS GROUP QUESTIONS, ENGLISH VERSION

73

Focus Group Questions

1. Topic: Sources of Health Education
a. How do you get information about health?
i. Probing/prompting. . ..Family? Friends? Internet? Word of mouth?
Media - TV, Radio, Magazines? Doctors?
b. How do you prefer to get information about health (health concerns,
general health issues, and being healthy)?

2. Topic: Health concerns
a. What health concerns do people (Hispanic/Latino) you know have?
b. What are your health concerns for your children?
0. What are your health concerns for other family members in your home?
(1. Are there any other health concerns you can think of that have not been
mentioned?

3. Topic: Accessing Health Care System (HCS)
a. Do you feel you have places to go or people to see who can help you with
health concerns/issues? (resources)
b. What do you do about the health concerns just mentioned? For yourself?
For your children? For your family?
c. Do you know what others use?

74

APPENDIX D

FOCUS GROUP QUESTIONS, SPANISH VERSION

75

Preguntas Para Entrevistas En Grupo

4. Primer Tema: Fuentes para la educaciOn sanitaria

a.

b.

5Como se inforrna usted acerca de la salud?
i. LUsted le pregunta a un familiar, amigo, el intemet, o por medio de
los consejos que le da gente?
[,Medios de comunicaciOn, la radio, las revistas 0 un medico?

gUsted como prefiere obtener informacién acerca de la salud, de sus
preocupaciones/inquietudes sanitarias, problemas mas generales y también
para estar sano y fuerte?

5. Segundo Tema: Preocupaciones/inquietudes sanitarias

a.
b.
c.

(,Que tipo de preocupaciones sanitarias tienen los Hispanos/Latinos?
gCuales son las preocupaciones sanitarias de sus hijos?

gCuales son las preocupaciones sanitarias para otras personas que viven en
su casa?

LUsted tiene algrin tipo de inquietud o preocupaciOn que no se haya
mencionado?

6. Tercer Tema: EvaluaciOn del sistema de salud 0 “Health Care System (HCS)”

a.

b.

LUsted conoce lugares o personas que puedan ayudarle con el fin de
resolver sus inquietudes o preocupaciones sanitarias? (Recursos)

LQue hace usted para usted mismo, sus hijos y su familia cuando hay que
prestar atenciOn alas inquietudes que se han mencionado?

LUsted sabe lo que hacen otras personas a1 respecto?

76

APPENDIX E

FOCUS GROUP MODERATOR GUIDE

77

Hispanic Health Project - Moderator Guide for Each Focus Group

1) Please help yourself to food. This is our way of thanking you for coming today.
1) llucnas nochcs. Nos (laria mucho gusto que pascn }' SC sirvan dc comer. por

favor.

I. INTRODUCTION (2-4): 5 min

1) People:
a)Dora —professor at Michigan State. Working with MSU Extension on this project. I
am excited to be talking with you today about healthcare.
b)Melissa - a student at Michigan State and Kimbirly — who works for Extension helping
to design programs to meet the needs of communities in Michigan; will be taking notes in
the back of the room and helping out, but they will not be part of the conversation

tonight.

2) Purpose of study/ proposito de este estudio:
a) *This study is Conducted by Michigan State University Extension, which is a
department at Michigan State University that assists communities and families around
Michigan through educational programs.
Eslc es un csludio contlucitlo por MSL' Extension que es un departamento dc MSU

que ayuda a las comunidatlcs y familias de h‘lichigan con programas criucativos.

78

b). *This study that you are participating in today is to help MSU Extension understand
how to help improve health for Hispanic families in Michigan. We have 90 minutes to
talk today. To ensure we stay on time let’s try and keep our short, and let everyone have
a turn.

c)Once again thank you so much for coming. Your opinions are very important to us
today. You will be able to tell us how to best help families like yours. That is important
to us.

d)We will be tape recording our conversation today. This is so we can make sure we get
everything you say because all of it is important to us. Please ignore the tape recorder

over there.

3. Consent Form/ Formulario de permiso

a) Important form required by Michigan State University that shows you have been told
about the focus group and you are willing to participate.

b) Talks about why we need your help with this study and what exactly we will be doing
today.

c) Copies are in English and Spanish.

d) Run through each paragraph:
c )Why we’re here -— already talked about but to cover one more time. . .(you can read)
1) Risks and benefits to participating — talking about health to some people can be

personal. Please don’t feel that you have to answer every question if you don’t want to.

79

You can leave at any time. But it is important to us that you are here. After tonight, we
will be able to better understand how we can work with and help Hispanic communities
in Michigan.

g) As we stated before, we will be recording our conversation today, by signing this form,
you are giving us permission to do this. If you decide you do not want to be recorded,
you can leave at any time.

h) Everything is confidential — we will not use your names in anything. You will be
given a number to put in front of you and that is how we will always refer to you. No one
else will know what you say today besides us.

i) Please ask us any questions that you have throughout our conversation today.

j) If you take a few moments to read this paper and sign it at the bottom, we can move

onto the survey.

H. SHORT SURVEY / ENCUESTA (10 minutos)

a) Just a few pages.

b) To help us better understand who is here with us tonight.

c) Not asking for your name - referred to by the number in front of you.

d) Giving you a survey will get all of those basic routine questions out of the way so we
can have more time to talk.

e) Please ask us any questions that you have. If you get stuck on a question let us know.

We are happy to help clarify.

80

m, GUIDELINES (ON NEWSPRINT IN ENGLISH AND SPANISH) / LAS
REGLAS O NORMAS PA RA HACER MAS I’Ricrrm. FACIL \' (ir’mom

NI’IiSTRA CONVERSACION ( 2 minutos)

a. Want to set a few guidelines for our talk today. That way everything runs smoothly
and hopefully everyone will feel comfortable enough to Share their experiences. Is

that okay? (nods...)

b. Please talk one at a time so we can get everyone’s opinion.

c. Please be polite — everyone’s opinion is very important to us. We would like to be

able to provide programs that can help everyone.

d. There is no right or wrong answer to the questions we are going to be talking about
today — if your opinion is different than the person next to you. That’s great! Please

tell us what you think.

e. Please speak slowly and clearly so we and everyone else here can understand your
Opinion. It’s also important for the tape recorder and for the people taking notes —

they are a little slow - Ha! Ha!

f. Again, please ask questions about anything you don’t understand.

81

1B ICEBREAKER/ PARA ROMPER EL HIELO (3 MINUTOS)

1. Thank you for conring again. I’m really excited to get talking.
2. I know you just filled out a survey, but let’s tell each other a bit about ourselves a
second. Just so we all know who is here. We’ll just go around the room and if you could

tell the group something about you or your family that would be great.

V. GROUP QUESTIONS/ TEMAS PARA CONVERSAR ( total : 60 minutos)

TEMA 1. ( 20 minutos) Everybody ready! ©

i We are going to begin our discussion talking about where you get information
about health and health issues.
fVamos a comerrzar nuestra conversacién hablanrlo sobrc C 0310/ DE QUE

MANERA ustedes se informan sobre lOS asuntos generales de la salud.

1. Let’s say you heard that some type of sickness is going around. Where would you go
to get more information about that?

l. g,Generalmente COmO usted se entcra SOhre las enl‘ermedades nuevas que hay en
su comunidad?

Probing/prompting. . ..

a) )Who would you talk to? No-one? Family? Friends? Doctors? Co-workers?
C ompaneros de trabajo

b) Where else would you go to get information? Internet? TV, Radio, Magazines?

82

2. If you had a person health concern; where would you go to get more information about
that?

2. Si usted esta interesada en eonoeer sobre algunos asuntos de salud. crime 0 (ltlnrle
husca informacién?

Probing/prompting. . ..

a) Who would you talk to? No-one? Family? Friends? Doctors? Co-workers?

b) Where else would you go to get information? Internet? TV, Radio, Magazines?
3.Where would you go to get more information about how you can keep from getting sick

in the future?
3. Pero Si necesitara mas inl'ormacirin porque usted piensa que usted esta enferma,
gentonces (lr'mde O COmO busca irrl'ormacién mas precisa‘.’

Probing/prompting. . ..
A )Who would you talk to? No-one? Family? Friends? Doctors? Co-workers?
B )Where else would you go to get information? Internet? TV, Radio, Magazines?

4. Now that we have talked about all of the people and places you go to get health
information (like. . ..examples they used) let’s talk about which ones are your favorites.
a) If given a choice, where would you prefer to get information?

a) Finalmente. (,cual de estés formas es usted favorita? LCual de usted prefiere?

b ) How would you feel about having someone from your community come to your home
to answer questions or talk about your concerns.

1)) (,Cr'mro se sentiria usted si purliera tener todo de esta informacitin por medio de
l'orma (le personal (le su comunidad que pueda ir a su casa para responder a sus
preguntas? (Seria bueno para usted tener alguien de su comunidad que vaya a su

casa para contestar totlos de sus preguntas y ayudarle?

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c) Thank you so much for all of your answers. We really appreciate them. Let’s keep

going.

TEMA 2 (20 minutosk

*MSU Extension wants to learn about the health concerns of Hispanic/Latino
communities in Michigan.
*Extension de MSU Quiere conocer acerca de las preocupacirmcs sobre la salud que

tienen las comunirlades hispanas/ Latinas tle Michigan

1.What do you think people in this Hispanic/Latino community are worried about in
terms of health?

([,Qué asuntos de la salud le preocupa a la gente en esta comunidad hispana/
Latina?)

a)Prompting: Your friends? People at your church? People in your neighborhood?
b )Prompting: heart disease, diabetes, obesity, cancer...

2. For those of you who have kids under the age of 18, what are you worried about when
it comes to their health?

( g,Qué les preocupa sohre la salud de sus hijos menores de 18 aims?)

a)Prompt: Do you worry about them getting sick? If so, how ?/ Les preocupa que se
vayan a enfermar? ?C6mo 0 de qué podrian enfermarse?

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3.What are you wonied about when it comes to the health of other family members in
your home?
( (,Que leS preocupa Sobre la salutl de otros miembros de su familia?)

a)Prompt.° Your husband or wife, your sisters, brothers, mother, aunt, etc.

4. Are there any other health concerns you can think of that have not been mentioned.

( ;,l.es preocupa algr’rn otro asunto de la salud del que no hemos lrrrlrlado?)

That was great. Thank you for all of your comments. They’re very helpful. Let’s keep

going. Vamos a continuar.

T EMA 3. (20 min)

*Now we are going to talk about what you do when you get sick, when you feel sick, or
when you are worried about getting sick.
"‘ Ahora vamos a halrlar sobre Lo que hacen ustetles cuando se enl'erman, creen que

estan enfermos 0 se preocupan (1e poder enfermarse.

1. IS there a place that you feel comfortable going to when you are worried about your
health, your kid’s health or someone else’s health?
( {Hay algr’rn Iugar (lonrle va y se siente lrien alentlido cuando cree que esta

enfermo usted o algt’rn otro miemhro de su familia?)

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If yes — where do you go? Si = gCuales son esos lugares?
a)Prompts: Do you go to the doctor? A clinic? Do you use home remedies/take care of it
yourself? Usas remedies, medicina de la casa Do you get help from friends or family?
Recibe ud. Ayuda de su famlia?

If no - why not?

2. What are some reasons that would keep you from going to get help from one of
these places?

((1 Tiene ud. Algunas razones para no ir a esos lugares? (jHay algunos rezones por
las que usted u otro miembro de su familia no purliera ir a esos lugares para ser
atendido?)
a)Prompts: Time of day they are open? Horario. It costs too much? They don’t speak

your language? You don ’t have insurance? Seguro medieo/seguranza

3. If you can’t go to these places, what do you do?

( Si usted u otro miembro de su familia se enfermara y no purliera ir a alguno de
eSOS lugares, entonces Que haria?)
a)Prompts: Do you go to the emergency room? Van a la sala de emergencia? Do you

use home remedies/take care of it yourself? Do you get help from friends or family?

4.Are there other options besides these?

( Ademas de esas posihilitlades . (,Tienc usted otras opciones‘.’)

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5.What do you think other Hispanics/Latinos in your community do when they’re
sick or worried that someone else may be sick?
( {Que piensa usted que hacen otrOS miembros de su comunidad Latina cuando

ellos u otros miembros (le sus familias se enferman?)

XL. CLOSING / CIERRE (10 minutos)

1. Do you have anything else you would like to Share with us? Do you have any other
health concerns we did not talk about?

1. (jTiene usted algo mas que quiera deeirnos‘.’ (JAlguno otro asunto (lel qtre usted

quiera lrablar? gOtros inquietudes sobre la salurl‘.’

2. Do you have any questions for us?

3. Thank you very much for all of your help. We learned a lot. We really appreciate it.
4. We will be finishing things up here — you can stay for a bit, or feel free to leave.

5. Thank you again for all of your help. We really enjoyed talking to you tonight and we

are excited to work with you in the future.

87

APPENDIX F

FOCUS GROUP CONSENT FORM, ENGLISH VERSION

88

Hispanic Health Project

Pumse and Procedures

We would like to invite you to take part in a research study to help improve the health of
Latinos in Michigan. Michigan State University Extension is working with Latino
communities like yours to understand your healthcare worries, needs and experiences.
You have been asked to join this study because of your close ties and connection with the
local Latino community. From this study, we hope to learn what is important about
health for Latino families in Michigan and figure out the best way to offer information
and help families. You will be asked to complete a 10-minute survey, and then you will
join a group of 5 people who will talk about Latino health for approximately 90 minutes.
We are asking permission to audiotape you during this group interview.

Risks and Benefits

Some of the possible risks include brief stress or embarrassment through talking about
your healthcare worries, needs and experiences. Your input could help improve health
services within your community.

Voluntagy Participation

The information in this consent form is provided so that you can decide whether you wish
to participate in this study. Your participation in this study is voluntary. This means that
you may choose not to participate at all. If you do chose to participate, you may refuse to
answer certain questions and are free to withdraw from this study at any time without
penalty. If you withdraw from this study, we will destroy your survey and will not utilize
what you say in the group interviews.

Confidentiality

The information you share will be confidential. The surveys and audiotapes will be kept
in a locked area in the project office at Michigan State University for no more than 3
years. A backup copy of this information will be kept in a secure area at the principal
investigators residence. When the project is over, all audio files, notes taken during the
interviews, and surveys will be destroyed. Only the project staff and Institutional Review
Board (IRB) will be able to see this information. We are not asking for your name and
will only identify you by the number on the top of the survey. By request, you may
receive a copy of our research findings. Any information about you will be kept
confidential to the maximum extent allowable by law.

89

 

Contacts

If you have any questions about your role and rights as a research participant, or would
like to register a complaint about this study, you may contact, anonymously if you wish,
the Director of MSU’S Human Research Protection Programs, Dr. Peter Vasilenko, at
517-355-2180, FAX 517-432-4503, or e-mail irb@msu.edu, or regular mail at: 202 Olds
Hall, MSU, East Lansing, MI 48824. If you have any questions about this study, please
contact Marvin Cato, Principle Investigator, by phone at 517-432-7686 or by e-mail
catomarvin@anr.msu.edu .

CONSENT STATEMENT

I voluntarily agree to participate in this study.

 

 

Participant Signature Date

90

APPENDIX G

FOCUS GROUP CONSENT FORM, SPANISH VERSION

91

Proyecto para la Salud de los Hispanos

Propésito y Procedinrientos
Nos gustarr’a invitarle para que sea parte de una investigacién, esta tiene como propo’sito

mejorar la salud de los latinos en Michigan. El Programa de ExtensiOn esta trabajando
con su comunidad para poder entender sus necesidades y experiencias de la salud. A Ud.
se le ha pedido que participe en este estudio ya que tiene lazos y conexiones muy fuertes
con la comunidad latina. Nosotros esperamos que por medio de este estudio podamos
aprender mas acerca de la salud de los latinos en Michigan y asi, poder ofrecer
informaciOn y ayuda a varias familias. Se le pedira que haga una encuesta en breve (de
diez minutos) y que discuta por noventa minutos la salud de los latinos en grupos de
cinco personas. Nos gustarr’a pedirle permiso para que podamos grabarle en audio.

Riesgos y Beneficios

Algunos riesgos que Ud. podria experimentar durante este proyecto posiblemente incluir
estrés o vergiienza cuando se trata de compartir algunas de sus preocupaciones,
necesidades y experiencias de la salud. Su opiniOn podrr’a mejorar los programas de salud
en su comunidad.

Participacién Voluntaria

La informacién de este forrnulario es dada para que usted decida si quiere participar en
este proyecto o no. Su participacién en este estudio es voluntaria. Es asr’ como Ud. puede
rechazar la participaciOn. Si Ud. participa, Ud. puede rechazar a1 guna pregunta y retirarse
en cualquier momento sin ningrin tipo de consecuencia. Si Ud. se retira del estudio,
nosotros no usaremos su encuesta, ni sus comentos durante la discusiOn en grupo.

Confidencialidad

La informacién que Ud. de sera confidencial. Las materiales del proyecto - las encuestas
y cintas - se guardaran en un area muy segura (de Michigan State University) por un
periodo de tres afios. Una copia extra de estés cosas sera guardada en un lugar seguro de
la residencia del director. Cuando este proyecto llegue a su fin, todos los materiales seran
eliminados. Las personas que estén involucradas en este proyecto y el Institutional
Review Board (el grupo interno de Michigan State University que asegura la seguridad
de investigaciones) seran las finicas que tendran acceso a esta inforrnaciOn. A Ud. no se
le va a preguntar su nombre; por lo tanto sera identificado por medio del nt’rmero que esta
a1 principio de la encuesta. Si Ud. lo desea, Ud. podrr’a pedir por una copia de los
resultados de este estudio. Toda su informacién se guardara de forma confidencial y por
medio de lo establecido por la ley.

92

Contactos

Si Ud. tiene algt’rn tipo de pregunta acerca de su papel y derechos como participante, o Si
le gustarr’a poner una queja acerca de este proyecto, Ud. puede contactar de forma
anOnima a1 director del Institutional Review Board, Ser‘ior Peter Vasilenko, al 517-355-
2180, FAX 517-432-4503, 0 por e-mail irb@msu.edu, o correo: 202 Olds Hall, MSU,
East Lansing, MI 48824. Si Ud. tiene alguna pregunta acerca de este estudio por favor
pOngase en contacto con Marvin Cato, Investigador Principal, por tele’fono a] 517-432-
7686 O por e-mail catomarvin@anr.msu.edu

FORMULARIO DE PERMISO

Yo acepto participar de forma voluntaria en esta investigacio’n/estudio.

 

 

Firma del participante Fecha

93

LIST OF REFERENCES

94

REFERENCES

Angel, Ronald J ., J acquelin L. Angel, and Kyriakos S. Markides. “Stability and Change
in Health Insurance Among Older Mexican Americans: Longitudinal Evidence
from the Hispanic Established Populations for Epidenriologic Study of the
Elderly.” American Journal of Public Health 92(8): 1264-1271.

Berk, Marc L. and Claudia L. Schur. 2001. "The Effect of Fear on Access to Care among
Undocumented Latino Immigrants." Journal of Immigrant Health 3(3): 151-156.

Burke, James P., Ken Williams, Sharon P. Gaskill, Helen P. Hazuda, Steven M. Haffner
and Michael P. Stern. 1999. “Rapid Rise in the Incidence of Type 2 Diabetes from
1987 to 1996: Results from the San Antonio Heart Study.” Archives of Internal
Medicine._(159) 1450-1456.

Callahan, 8. Todd, Gerald B. Hickson, and William 0. Cooper. 2006. "Health Care
Access of Hispanic Young Adults in the United States." Journal of Adolescent
Health 39(5): 627-633.

Center for Disease Control. 2004a. "Access to Health-Care and Preventive Services
Among Hispanics and Non-Hispanics--United States, 2001-2002." Journal of the
American Medical Association 292(19): 2331-2333.

Center for Disease Control. 2004b. "Health Disparities Experienced by Hispanics—-United
States." Journal of the American Medical Association 292(19): 2330-2331.

Center for Disease Control. 2006. STD Surveillance 2006: Trends in Reportable Sexually
Transmitted Diseases in the United States, 2006. Atlanta, GA: CDC. Retrieved
February 10, 2008 (http://www.cdc.gov/std/stats/trends2006.htm).

Center for Disease Control. 2007. Health, United States, 2007. Washington, DC:
National Center for Health Statistics. Retrieved February 24, 2008.
(http://www.cdc.gov/nchS/data/huS/hu807.pdf#summary).

De Vita, Carol J. 1996. “The U.S. at Mid-Decade.” Population Bulletin 50(4):2-48.

Documét, Patricia 1. and Ravi K. Sharma. 2004. "Latinos' Health Care Access: Financial
and Cultural Barriers." Journal of Immigrant Health 6(1): 5-13.

Durden, T. Elizabeth and Robert A Hummer. 2006. "Access to Healthcare Among
Working-Aged Hispanic Adults in the United States." Social Science Quarterly
87(5): 1319-1343.

Fiscella, Kevin, Peter Franks, Mark P. Doescher, and Barry G. Saver. 2002. "Disparities

in Health Care by Race, Ethnicity, and Language among the Insured: Findings
from a National Sample." Medical Care 40(1): 52-9.

95

Flores, Glenn, Elena Fuentes-Afflick, Oxiris Barbot, Olivia Carter-Pokras, Luz Claudio,
Marielena Lara, Jennie A. McLaurin, Lee Pachter, Franciso Ramos Gomez,
Fernando Mendoza, R. Burciaga Valdez, Antonia M. Villarruel, Ruth E.
Zambrana, Robert Greenberg and Michael Weitzman. 1998. "The Health of
Latino Children: Urgent Priorities, Unanswered Questions, and a Research
Agenda. " Journal of the American Medical Association 288(1): 82-90.

Garcés, Isabel C., Isabel C. Scarinci, and Lynda Harrison. 2006. “An Examination of
Sociocultural Factors Associated with Health and Health Care Seeking among
Latina Immigrants.” Journal of Immigrant Health (8)377-385.

Guendelman, Sylvia and Todd H. Wagner. 2000. "Health Services Utilization Among
Latinos and White Non-Latinos: Results from a National Survey." Journal of
Health Care for the Poor and Underserved 11(2): 179-194.

Guzman, Betsey. 2001. The Hispanic Population: Census 2000 Brief. Washington, DC:
U.S. Census Bureau. Retrieved February 10, 2008
(http://www.census. gov/prod/2001pubS/c2kbr0l-3.pdf).

Harrison, Lynda and Isabel Scarinci. 2007. "Child health needs of rural Alabama Latino
families." Journal of Community Health Nursing 24(1): 3147.

Henry J. Kaiser Family Foundation. 2004a. Racial and Ethnic Disparities in Women ’s
Health Coverage and Access to Care: Findings from the 2001 Kaiser Women ’s
Health Survey. Washington, DC: Henry J. Kaiser Family Foundation. Retrieved
February 10, 2008 (http2//www.kff.org/womenshealth/upload/Racial-and-Ethnic-
Disparities-in-Women-s-Health-Coverage-and-Access-to-Care.pdf).

Henry J. Kaiser Family Foundation. 2004b. Uninsured and Underserved: The Health
Care Experiences of Latinos in the Nation ’3 Capital. Washington, DC: Henry J.
Kaiser Family Foundation. Retrieved February 10, 2008
(http://www.kff.org/minorityhealth/upload/PDF-Uninsured-and-Underserved-
The-Health-Care-Experiences-of-Latinos-in-the-Nation-S-Capital.pdf).

Howe, Holly L., Xiaochen Wu, Lynn A.G. Ries, Vilma Cokkinides, Faruque Ahmed,
Ahmedin J emal, Barry Miller, Melanie Williams, Elizabeth Ward, Phyllis A.
Wingo, Amelie Ramirez, and Brenda K. Edwards. 2006. "Annual report to the
Nation on the Status of Cancer, 1975-2003: Featuring Cancer Among U.S.
Hispanic/Latino Populations." Cancer 107(8): 1711-42.

Kayitsinga, Jean and Lori Post. 2007. “Working Paper Series: Latino Population Trends
& Projections.” East Lansing, MI: Julian Samora Research Institute. Retrieved
February 6, 2008 (http://www.jsri.msu.edu/RandS/research/drS/dr01.htrnl).

96

Martinez, Iveris L. 2007. E-mail Correspondance. East Lansing, MI. November 8.

Martinez, Iveris L. and Olivia Carter-Pokras. 2006. "Assessing Health Concerns and
Barriers in a Heterogeneous Latino Community." Journal of Health Care for the

Poor and Underserved 17(4): 899-909.

Michigan Department of Community Health. n.d. “Hispanic/Latino American Fact
Sheet.” Lansing, MI: MDCH. Retrieved February 6, 2008
(http://www.michigan.gov/mdch/O,1607,7-132-2940_2955_2985-109439--
,00.html).

Michigan Census Bureau. 2005. “Single Year of Age, Race, Sex, and Hispanic Origin:
Six race Categories Retrieved February 24, 2008
(http://www.michigan.gov/documents/hal_lm_census_arsh0005_167097_7.xls).

Michigan Department of Community Health. 2007a. “Critical Health Indicators Topic:
Health Disparities.” Lansing, MI: MDCH. Retrieved February 10, 2008
(http://www.michigan.gov/documents/mdch/44_HlthDispar_198947_7.pdt).

Michigan Department of Community Health. 2007b. “State of Adolescent Sexual Health
in Michigan White Paper.” Retrieved on February 24, 2008.
(http://www.michigan.gov/documents/mde/FINAL-SAASH1-25-
08_224834_7.pdf).

Michigan Department of Education. 2005. Michigan Youth Risk Behavior Survey: Weight
and Nutrition Fact Sheet. Lansing, MI: MDE. Retrieved February 10, 2008
(http2//www.michigan.gov/documents/mde/_NEW_2005_YRBS_Fact_WN_1760

55_7.pdf).

Obiri, Godwin U., E. James Fordyce, Tejinder P. Singh and Susan Forlenza. 1998.
“Effect of HIV /AIDS Versus Other Causes of Death on Premature Mortality in
New York City, 1983-1994.” American Journal of Epidemiology 147(9) 840-845.

O’Malley, Ann 8., Jon F. Kemer, Lenora Johnson. 1999. “Are We Getting the Message
Out to All? Health Information Sources and Ethnicity.” American Journal of
Preventive Medicine 17(3) 198-202.

Parker, Sheryl L., Kourtney Johnston Davis, Phyllis A. Wingo Lynn A.G. Ries, and Clar
W. Heath. 1998. “Cancer statistics by race and ethnicity.” CA A Cancer Journal
For Clinicians (48):31-48.

Pew Hispanic Center. 2007. English Usage Among Hispanics in the United States.

Washington, DC: Hakimzadeh, Shirin and Cohn, D’Vera. Retrieved April 2, 2008
(http://pewhispanic.org/files/reports/82.pdf).

97

Saint-Germain, Michelle A., Tamsen L. Bassford and Gail Montano. 1993. "Surveys and
Focus Groups in Health Research with Older Hispanic Women." Qualitative
Health Research 3(3): 341-367.

US Census Bureau. 2000. Poverty Status of the Population in 1999 by Sex, Age, Hispanic
Origin, and Race: March2000. Retrieved March 28, 2008
(httpz/lwww.census.gov/population/socdemo/hispanic/p20-535/tab14- l .txt).

US Census Bureau. 2006. “S0201: Selected Population Profile in the United States:
Hispanic or Latino (of any race). Retrieved February 10, 2008
(http://factfinder.census.gov/servlet/lPTable?_bm=y&-geo_id=01000US&-
qr_name=ACS_2006_EST_G00_S0201 &-
qr_name=ACS_2006_EST_G00_S0201PR&-
qr_name=ACS_2006_ES T_G00_SO20 1T&-
qr_name=ACS_2006_EST_G00_8020 l TPR&-
re g=ACS_2006_EST_G00_S0201 :400;ACS_2006_EST_G00_S020 1 PR:400;AC
S_2006_EST_G00_S0201T:400;ACS_2006_EST_G00_S0201TPR:400&-
ds_name=ACS_2006_EST_G00_&-_lang=en&-forrnat=).

Weinick, Robin M., Elizabeth A. Jacobs, Lisa Cacari Stone, Alexander N. Ortega and
Helen Burstin. 2004. "Hispanic Healthcare Disparities: Challenging the Myth of a
Monolithic Hispanic Population." Medical Care 42(4): 313-320.

Weinick, Robin M., Samuel H. Zuvekas, and Joel W. Cohen. 2000. "Racial and Ethnic
Differences in Access to and Use of Health Care Services, 1977 to 1996."
Medical Care Research and Review 57 Suppl 1: 36-54.

Whitaker, Robert C. and Sean M. Orzol. 2000. “Obesity among US Urban Preschool
Children: Relationships to Race, Ethnicity and Socioeconomic Status.” Archives
of Pediatrics & Adolescents Medicine 160(6) 578-584.

Williams, Jason E., Kevin J. Anstrom, J oelle Y. Friedman, and Kevin A Schulman. 2007.
“Racial/Ethnic Variation in Perceptions of Medical Information Sources in
Durham County, North Carolina.” North Carolina Medical Journal 68(6) 391 —
398.

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