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Bienvenido, and Stay Well


Shut out by high costs, a lack of insurance and other obstacles, many of America's 34 million immigrants lack proper health care. New culturally attuned interventions and education strategies could be the answer.

By Jackie Powder

It's late afternoon on a hot Friday in the heart of Baltimore's Latino community. On their way home from work, people begin to fill the sidewalks of South Broadway, the neighborhood's main street. Many wear work boots and paint-spattered pants or T-shirts bearing the names of chain restaurants. As Hispanic music escapes from store windows, they stop at small shops to buy a cold drink, a Spanish-language newspaper or a telephone card for a weekend phone call home.

Jermin LaViera and Marcia Gonzalez are also part of this street scene. Stationed outside the Value Express gift shop beside a makeshift kiosk, the women approach passers-by, chat briefly with them and hand out small, fluorescent-orange measuring tapes. They're not stumping for a political candidate or test-marketing a new product; LaViera and Gonzalez are here to improve the health of the Hispanic community.

Outreach workers with the Hispanic Apostolate—a community-based human services organization—the women are part of a public health education initiative developed by the Bloomberg School's Center for Communication Programs (CCP) in partnership with the Wilmer Eye Institute at Johns Hopkins Hospital. Called ProVision, the program aims to fight diabetes-related eye disease in Baltimore's Hispanic community by distributing educational materials about diabetes and spreading the word that free screening and treatment services are available to those referred to Wilmer. Hispanic-Americans are nearly twice as likely as whites to have diabetes, according to the CDC.

One immigrant recalled her first experience with U.S. health care. Told it would cost $100 to see the doctor, she said, "If this is what it is to get sick in the U.S., then I'll have to die."

With a portable kiosk and a box of token giveaways like tape measures, small flashlights or water bottles, LaViera and Gonzalez make regular appearances at Latino businesses and festivals to reach their intended audience. Funded by the National Eye Institute, the project is targeted to an immigrant population that's typically not comfortable seeking out health care for a variety of reasons, including a language barrier, lack of insurance and fear of being questioned about their resident status.

"They're afraid someone is going to ask them, 'Are you legally here? Where are your papers?'" says CCP senior faculty research associate Fannie Fonseca-Becker, DrPH '00, MPH '89, a co-investigator with ProVision and senior researcher with its health, behavior and communication campaign.

ProVision is just one example of an increasing awareness in the public health community of the need to reach out to America's growing immigrant population. In 1967, there were 9.7 million foreign-born people living in the U.S., comprising 5 percent of the population. Today, there are 34.3 million, making up 12 percent of the U.S. population. Eight U.S. metropolitan areas have immigrant populations of 1 million or more. In one gauge of their unmet health needs, a 2005 study found that immigrants' expenditures on health care averaged $1,139 per capita compared with $2,546 for those born in the U.S.

To meet the needs of the fast-growing immigrant population, new intervention and education strategies geared to specific immigrant groups are being developed. Bloomberg School researcher Hee-Soon Juon, for example, has designed a Korean language education program to increase breast and cervical cancer screening rates among Korean-American women. And the School's Johnson & Johnson Community Health Care Scholars program provided technical support to a program in Los Angeles to increase health care access for Asian and Pacific Islanders living with HIV/AIDS, a group that faces an especially strong stigma from within their own community.

"The more culturally appropriate the program, the more successful it will be," says Fonseca-Becker.

The ProVision program was designed to serve an East Baltimore neighborhood in which Hispanic immigrants make up 15 percent of the population. According to a 2005 CCP baseline household survey, 63 percent of respondents reported that it's difficult for Latinos to access health care in the U.S.

Fonseca-Becker recalls one woman who told researchers that after she had filled out forms at a medical clinic, the receptionist informed her that the clinic required a $100 payment to be seen by a doctor. "She said, 'If this is what it is to get sick in the U.S, then I'll have to die,'" says Fonseca-Becker.

ProVision seeks to make more Hispanics aware of diabetic eye disease, the most common being diabetic retinopathy, which is caused by damaged blood vessels in the retina. The disorder can lead to vision loss and blindness.

The program is predicated on removing barriers that keep medical services out of reach for many Hispanics. Six neighborhood community health clinics carry ProVision information cards, and are authorized to refer diabetic patients to Wilmer for an eye exam. The Hispanic Apostolate has a hotline that provides immediate help in scheduling an appointment. And Sheila West, PhD, professor of Ophthalmology at Hopkins Medicine and principal investigator of the ProVision project, met with security officers at the Wilmer Outpatient Center to discuss the program and let them know that Hispanic patients may need extra help when they arrive.

"Everything is set up to facilitate their participation and getting to the appointment," says Fonseca-Becker, "because sometimes there are too many obstacles to the visit."

In the past year, the Hispanic Apostolate referred 81 people for eye exams.

Central to the intervention, which began in July 2005, are the in-person contacts between outreach workers and residents. Many take place at the 12 local businesses that signed on to the "Amigos Network," to make ProVision materials available for customers. They include a grocery, a bank, a Laundromat and other places that residents frequent in their daily lives. "People tend to be very shy," says Evelyn Rosario, who serves as the ProVision liaison from the Hispanic Apostolate, a Catholic Charities program. "If we just put up the kiosk with the materials, it won't work," she says. "When they don't go to you, you have to go to them."

It's a philosophy that outreach worker LaViera takes seriously. From the kiosk at Value Express, she approaches a couple coming her way, explains the goals of ProVision and hands them measuring tapes, along with information cards that include numbers for Wilmer and area health clinics. The woman barely stops; the man mumbles, "Muchas gracias." LaViera moves on to a handful of men sitting on the sidewalk eating snowballs; she jokes a little before making her point, and one man promises to take the information home to his wife.

Next, LaViera sets her sights on a couple getting out of a white pickup truck. "It's great," the woman, Reyna Villegas, says of ProVision, after looking over the materials. "A lot of Spanish-speaking people don't know where the resources are, and they just live with problems," Villegas explains. "My mother lost all her teeth because she didn't get medical care in time. I'm going to take this home and tell my mother, my sister, my cousins, my aunt, everybody."

CCP researchers will begin to evaluate the ProVision program in December 2007 by measuring the level of change in knowledge, attitudes and health-seeking behaviors among East Baltimore's Hispanic residents with respect to diabetes and related eye problems. There are also plans to launch a media campaign in the fall, mainly on Spanish radio stations, to reinforce the ProVision message.

In the meantime, the project's outreach workers will continue the kiosk campaign, which seems to be getting the message across.

Rosario remembers giving ProVision materials to a man when she staffed the kiosk at a grocery store one afternoon. "He took his bags to his car, then came back and said, 'You know what? I have diabetes. Now what do I do?'" Rosario says. "So we really are reaching the folks we want to get."

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