Promoting Health among Hispanic Residents

Promoting whole health wellness for preventing Nutrition-related illnesses and diseases among Hispanic residents of Silver Spring in Montgomery County MD

Background

Montgomery County is located adjacent to the nation's capital, Washington, D.C., and includes 497 square miles of land area. It is Maryland's most populous jurisdiction and its most affluent. cities in this county are: Aspen Hill, Glenmont, Wheaton, Layhill, Olney, Leisure World, Silver Spring, and Cloverly.

As of July 1st, 2018, the U.S Census Bureau estimated the population base to be 71, 452. “The median age is 34.3, median household income is 72,887, the poverty rate is 11.7%, and the number of people employed is 44,796. Of this total population, 76.3% are citizens. The racial groups in Silver Spring are 26,997 Whites which is 34.9% of the total population, 22,318 are Hispanics which is 28.8%, 19,491 are blacks which is 25.1%, 6,160 Asian that is 7.95%, and 2,140 are two or more races that is 2.76%.”1 The most common foreign languages spoken in Silver Spring are Spanish which is spoken by 17,803 residents, African languages spoken by 5,335 residents, and French spoken by 2,475 residents.

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“30.2% of the population in Silver Spring are native-born and 38.3% are foreign-born. The birthplace for the foreign-born residents in Silver Spring are El Salvador, followed by Ethiopians, and then Guatemala. 11.7% of the population in Silver Spring live below the poverty line which is a number lower than the national average of 14.7%. The highest demographic of people living in poverty are females aged 25-34 followed by males 18-24, and then females 18-24.”1

The individuals from this populace are faced with chief socio-economic challenges; and, many are challenged with life-changing health disparities. Research indicated that many of these individuals are of Hispanic/Latino ethnicity. In Montgomery County, the largest race or ethnicity living in poverty is Hispanic or Latino, followed by unknown races, and then whites. Between “2014 and 2015, the employment in Silver Spring grew from 44,139 to 44,795 which is at a rate of 1.49%.”1

The focus group for this project is located at Sargent Shriver Elementary School in Silver Spring, Montgomery County Maryland. “There are 755 students currently enrolled in a diversified culture consisting of Whites, Hispanics, Blacks, American Indians, Pacific Islanders, and two or more races.”3 Of this total number of students, 563 or 74.6% are Hispanics with the largest segment of enrolled students. This school has a drastically diversified ethnic distribution. There are 49% males and 51% females enrolled in this school.

The majority of students at this school receive free lunches, as 81.6% of students participate in the National School Lunch Program. In order to qualify for lunch, a student’s family income needs to be below $15,171; which, is below the poverty line. 64.5% of students at this school receive free lunch indicating the parent’s low-income levels.

Within this focus group, Diabetes and Heart Disease are the two main illnesses affecting these Hispanic residents of Silver Spring MD. They are also affected by: Obesity, Malnutrition, High blood pressure, Asthma, flu, and Depression. This population is not privy to immediate medical attention due to a lack of insurance and low income. To suffice, they use customs, that they believe will help cure their illnesses and or diseases. They use alternative therapies and their beliefs in traditional folk cures. Many Latinos are accustomed to self-treating because most pharmaceutical products are available without prescription in their home countries.

Patients may seek out the care of brujos or brujas (wizards or witches) for the treatment of some diseases or conditions. Other healing specialties include gerberas (herbalists), hueseros (bone setters), parteras (midwives), and sobadores (similar to physical therapists). Various symptoms are often interpreted differently based on cultural presuppositions. For example, abdominal pain may be attributed to empacho, or food stuck in the intestine. A child’s failure to thrive may be attributed to mal de ojo (“evil eye”) or, a hex that is conveyed by an envious glance. Therapies for these conditions are usually odd but most are harmless.

Herbal therapies play a major role in Latino folk medicine; as such, knowing the Hispanic/Latino names of common herbs can be helpful. It is often possible to safely accommodate conventional and alternative treatments if potential conflicts or interactions are identified in advance. Physicians and health professionals may use web-based resources as well as patient interviews to assist them in understanding Hispanic/Latino health beliefs; in order to promote whole health wellness and encourage a life free from nutrition-related illnesses and diseases.

Healthy People 2020 seeks to have a society in which all people live long, healthy lives. “The overarching goals of Healthy People 2020 are to: attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; achieve health equity, eliminate disparities, and improve the health of all groups; create social and physical environments that promote good health for all; and promote quality of life, healthy development, and healthy behaviors across all life stages.”2

The Community Health Needs Assessment (CHNA) Report of 2016, identified 63 strategies to address the existing Healthy Montgomery priority issues of obesity, behavioral health, diabetes, cardiovascular disease, cancers, and maternal and infant health. These strategies are derived from the key findings of the qualitative data, quantitative data, community resources, and evidence-based strategies. In addition, “the strategies were considered within the framework of Healthy Montgomery’s goals of achieving health equity for all residents; improving access to health and social services; and enhancing the physical and social environment to support optimal health and well-being and reduce unhealthful behaviors.”2 When paired with proper education, nutrition programs can help citizens in under-resourced areas make better choices about the food they eat, helping to contribute to a healthier lifestyle and an enhanced quality of life. Hence, the main intended purposes of my internship.

During my internship, I intend to identify and evaluate the social, cultural/religious, and environmental inhibitors that contribute to nutrition-related illnesses and diseases among Hispanic residents of Silver Spring in Montgomery County Maryland. I intend to create a curriculum for preventing nutrition-related diseases/illnesses and promote whole health wellness within this populace.

Objectives

1. By March 2019, conduct a community-based assessment via archival data and personal surveys on the main contributing factors of nutrition-related illnesses and diseases among Hispanic residents of Montgomery County.
2. By the end of April 2019, identify and compile resource packets for low-income, unemployed and under-insured residents to promote nutritional whole health wellness and decrease nutrition-related illnesses and diseases among Hispanic residents of Montgomery County, as measured by a PowerPoint Presentation.
3. By the end of the practicum, develop and deliver instruction via a health fair with International HELP, develop cultural and religious sensitive learning material (pamphlet) for promoting nutritional whole health wellness among Hispanic residents of Montgomery County.

Within this setting, the support and guidance for the framework of this study will aid in molding and developing my skill as a Public Health Professional. This is based on the core foundational competencies for Public Health. The Public Health Foundation identifies the competencies as “The set of skills used in the broad practice of public health by healthcare professionals that were developed by the Council of Linkages.”4 They are categorized into three tiers and eight domains. The competencies that will be utilized in supporting the approach taken by this study are from the first domain - The Analytical/Assessment Skills and the Cultural Competency Skills that focus on understanding and responding to diverse needs, assessing organizational cultural diversity and competence, assessing effects of policies and programs on different populations, and taking action to support a diverse public health workforce.

The underlying approach for this project is therefore meant to skillfully analyze and assess the nutritional inhibitors of the focus group and provide culturally sensitive and relevant healthful information for promoting and possibly achieving optimal health.

Methods

Objective 1: Community-Based Assessment.

Hispanics are the second largest minority group in Maryland, accounting for 9.5% of the state’s population. Approximately 35% of the state’s Latino population resides in Montgomery County, significantly exceeding all other jurisdictions. This population is also largely affected by Nutrition- related illnesses and diseases because of the social, environmental, psychological, and economic implications surrounding where they reside. Objective one aims to use archival data and personal surveys to identify the main contributing factors of nutrition-related illnesses and diseases among Hispanic residents of Montgomery County. As such, members of the research team of International HELP entered into a partnership with the Sergeant Shriver Elementary school based on the fact that data suggested that “The leading causes of death in the County were cancer (24%), heart disease (22%), cerebrovascular disease (5%), accidents (4%), and chronic lower respiratory disease (3%).”4

A focus group was chosen as a representation of Montgomery County’s population, to conduct the research and to respond to questionnaires based on their health practices. Consequently, it was determined that the research would focus on: Diabetes, Hypertension (High Blood Pressure), Childhood Nutrition (Obesity), Maternal Health, Mental Health, Accessing Community Resources (such as Medicaid and health/dental care); as well as, the implications surrounding having little or no health literacy skills.

To gain an understanding of the statistical background of the county and its residents, relevant archival studies were identified. Guided by the framework, literature on comprehensive Hispanic health review were searched, and documents in electronic databases, government websites and agencies, and civil society organizations addressing Hispanic health were also searched. Information considered to be of significance was chosen and used for the purposes of this research.

“For this research, a design based on complementary assistance of research methods was used. Complementary assistance uses mixed methods to integrate the strengths of each, as one method can enhance the other and allows for greater creativity and adaptability in studies in real-world conditions.”5, 6 According to Morgan, “Complementarity is a likely strategy for health researchers because the strengths of different methods help address the complexity of health research topics which often have dual goals—pure research as well as applications for practitioners.”4

Qualitative data gathered from the exploratory focus group and individual interviews were used to determine and explain the factors that influence food-related choices, behaviors, inaccessibility to resources, lack of access to community resources as well as limited nutrition education for the residents of Montgomery County MD. This information was supplemented and expanded with data from personal surveys. This provided the opportunity for gathering data on the frequency of these factors in a more representative cross-section of the focus group/ target population. These results guided the design and development of the intervention materials; which, were then confirmed with additional qualitative research.

Objective 2: Compiling Resource Packets.

The information researched and compiled from archival data as well as interviews and contributing surveys; were used to assemble the resource packets as per objective 2. The focus of objective 2 was to: identify and compile resource packets for low-income, unemployed, and under-insured residents to promote nutritional whole health wellness; and, decrease nutrition-related illnesses and diseases among Hispanic residents of Montgomery County, as measured by a PowerPoint Presentation.

The first step for creating the lessons, handouts, and PowerPoint presentations integrated one of the chief foundational competencies of public health. This included the assessment of the social, cultural/religious, and environmental inhibitors that contribute to nutrition-related illnesses and diseases among residents of Montgomery County. It was imperative in order to ensure the content was relevant to the needs and setting of the community.

The second step included having a discussion with the practicum preceptor to determine what specific educational information was required in the lessons, handouts, and PowerPoint presentations. It was determined that 5 lessons were to be created. Each was to focus on a different topic as they pertained to Diabetes, Hypertension, Maternal Health, Mental health, and Childhood Nutrition. The lesson plans were to be concise with bulleted points since participants in the impending heath fair were not as proficient in English Language and were of limited educational backgrounds. See figure 2.

Figure 2.

The handouts that were to be made were to be of similar nature in terms of quality and quantity; but, with a little more added to the content. They were to be visually appealing and easy for participants to comprehend. See figure 2.2.

Figure 2.2

Information about Nutrition-related illnesses and diseases among Hispanic residents of Silver Spring in Montgomery County MD was researched using peer-reviewed sources from government databases and via other archival mediums. The research included information pertaining to Diabetes, Hypertension (High Blood Pressure), Childhood Nutrition, Maternal Health, Mental Health, Accessing Community Resources (such as Medicaid and health/dental care); and, having little or no health literacy skills as per the focus group and the populace at hand. Additionally, PowerPoints were to be created on each topic and presented at the upcoming health fair.

Each set of learning material was created and presented for evaluation to be done by the preceptor and program coordinating team members. The materials were both created and delivered online for efficiency, to save time, and monetary resources. Hence, all involved benefited from this public health practice.

Objective 3: Health Fair

Objective 3 constitutes developing and delivering instruction via a health fair with International HELP and developing cultural and religious sensitive learning material (pamphlet) for promoting nutritional whole health wellness among Hispanic residents of Montgomery County. This impending health fair is slated for Saturday, May 18 at 11: 00 am. It will be held at the Sergeant Shriver Elementary School.

At the health fair, attending residents will have access to the resource packet that was created. One of the focal goals for the resource packet was to use best practices in public health in making it cost-effective, and easy to make and distribute. The resource packet includes information on 24-hour emergency and hotline numbers, clinics for uninsured and underinsured residents, dental clinics, financial resources, maternal health services, mental health services, school-based services, and shelter services. Each set of information for the packet was created and sent in via Google drive to the preceptor and corresponding personnel. It was reviewed, needed clarifications made, and given final approval for compiling.

Additionally, residents and attendees will be privy to the lessons that were created that will be presented by residents who were trained on basic medical terms and literacy. Residents/attendees will receive the handouts that were created, have access to booths with health care professionals such as nutritionists and dietitians to clarify and answer questions they may have. They will have the opportunity to see medical doctors who will be able to check vital signs such as their blood pressure on site; as well as to have dentists and or dental hygienists perform basic oral cleanings free of charge. Since one of the areas of focus included the literacy skill levels of the target population, the materials and messages therein were carefully selected and used to reflect the age, social and cultural diversity, language, and literacy skills of the intended users. This way, individuals will always have access to the literature resources given and can use them for future referrals as needed.

Results

Of the ethnic minorities in the United States, Hispanics are the largest of group at 16.7%. This group of minorities have been disproportionately affected by the social determinants of health for example cultural values, income, occupation, health services, and education. These inherently affect individuals’ stress levels, physical activity behaviors, and dietary factors. Health inequalities particular to Hispanics are also related to their socioeconomic status, cultural background, employment, and foreign-born or undocumented statuses. “Hispanics residing in the USA are on average 15 years younger, four times more likely to not have finished high school, twice as likely to live below the poverty line, and 20 times less likely to speak proficient English than non-Hispanic Whites (NHW). Hispanic women are also a growing demographic group that endures adverse social and health conditions and lack of access to health care.”8 Figure 1. Hispanic Health in the United States. The figure below further displays the social determinants faced by Hispanics and the diseases and nutrition-related illnesses they faced.

Figure 1.

Just as is evident across the United States with the nutrition-related illnesses and diseases faced by Hispanics, such is the same in Montgomery County Maryland. According to a health assessment of Montgomery County Maryland, it was found that within this diverse population of residents, Hispanics constitute a large percentage. In fact, in “2015, Montgomery County’s overall population surpassed one million (1,040,116).”9

Figure 2.

Hispanics migrate to Montgomery County from many regions and countries around the world. The majority (54.5%) migrate from Central America, many of whom are fleeing violence in their home countries (Figure 1). The additional two countries of origin for Hispanics who have made their home in Montgomery County are from South America (22.6%) and Mexico (8.3%).10

With diversity and migration, being at the forefront of their immediate surrounding, Hispanics are faced with challenges that have to do with adapting to their new place of residence. This is in addition to barriers they had prior to migrate. According to research, Hispanics in Montgomery County face language barriers, access to healthy foods, safe neighborhoods and places for physical activity, affordable housing, problems with mobility/transportation; and, quality education. All these are factors that affect and influence the whole health and wellness of these residents.

Within the homes of Hispanic residents, it was found that “86 .1% of Hispanics/Latinos in Montgomery County spoke a language other than English at home; 85 .4% spoke Spanish, and 75% spoke another language. Approximately one-quarter (24 .3%) of the Spanish-speaking population spoke English “not well” or “not at all.”3 The remaining 75 .4%10 spoke English very well or well. This is further conveyed in the educational outcomes of residents because “in Montgomery County, approximately one-third of Hispanics 25 years and older (37 .4%) have less than a high school diploma, 23 .2% have a high school diploma or equivalent, 16 .4% have some college education or an associate’s degree, and close to one-quarter (23 .0%) have a bachelor’s degree or higher.”10 Figure 3. below highlights the graduation rates among ethnicities in Montgomery County.

• Maryland and Montgomery County Graduation Rates: % by Group
• Year Latino Black White
• MD MoCo MD MoCo MD MoCo

1. 2017 73.98 78.54 85.44 88.21 92.66 95+
2. 2016 76.55 80.37 84.06 87.69 92.41 95+
3. 2015 76.89 79.64 82.29 86.78 92.03 94.94
4. 2014 77.46 80.03 80.54 86.42 91.91 94.94

Data sources: U.S. dept. Of education and national center for education statistics

Figure 3.

Economically, Hispanic residents of Montgomery County are faced with financial hardships as 13 .1% live below the poverty level. Research also established that “The unemployment rate among Latinos in Montgomery County is 6 .4% compared with 4 .8% of the population as a whole and 3 .2% of the Caucasian/ White population in the county.”9

The evidence unequivocally suggests that the above-mentioned factors play critical roles in the lives of Hispanic residents’ health and wellness. These are then perceived and translated in the types of nutritional illnesses and diseases that affect these individuals; as well as, the percentages of those that are morbidly affected. According to the Health and Data Resources for Hispanics in Maryland, the leading causes of death among Hispanics are cancer, diabetes, heart diseases, accidents, and hypertension. Lack of health insurance continues to present a major barrier to accessing health care by Hispanics. “In Montgomery County, 21 .7% of Hispanics are uninsured. Educational challenges, poverty, inadequate transportation, the lack of health insurance, and other social determinants affect the ability of Hispanics in Montgomery County to access safe, quality, culturally competent and linguistically appropriate, timely, and affordable health care.”12 The Maryland Behavioral Risk Factor Surveillance System (2014) reports that:

• Hispanics who could not afford to see a doctor in the previous year were at 22.4%.
• Hispanics who had a routine check-up in the past year were at 64.3%.
• Hispanics who had never had a routine check-up were at 9.5%, compared with 0.1% of Caucasians/Whites.
• Hispanics who did not have a personal doctor or health care provider were at 47.1%.
• Hispanic women who received late or no prenatal care were at 11.5% compared with 9.2% of all women and 5.8% of Caucasian/White women. 10, 12 See figure 4. below.

Figure 4

• Social and economic factors also contributed to higher illness and disease prevalence in the Hispanic population:
• Hispanics are often more likely than their non-Hispanic Caucasian/White counterparts to suffer from, and die from, chronic and infectious diseases.
• In Maryland, Hispanics are 41% more likely to have diabetes than non-Hispanic Caucasians/Whites.

More than half of the Hispanic population in Montgomery County is overweight (55.4%) and 21.2% are obese.10, 12 This means that they are at higher risk for stroke, heart disease, cancer, diabetes, and other serious health conditions and diseases.

Data strongly suggests that Hispanics are particularly vulnerable to depression, anxiety, and post-traumatic stress disorder, arising from family separation, social isolation, moving to a new country, and ramifications of war in countries of origin. According to a report prepared for the Latino Health Steering Committee by one of its members: The lack of a comprehensive culturally and linguistically competent community, work, and school-based action plan aimed at promoting positive mental health and preventing problems or conditions that could require intensive and more expensive interventions poses a serious risk to Hispanic behavioral health outcomes. It was found that Hispanics are particularly vulnerable as a result of the lack of:

• Culturally and linguistically competent mental health resources, services, and residential treatment facilities
• Health Insurance
• Knowledge of Available Resources
• Sensitivity around mental health issues by emergency department personnel
• Services to treat the chronically mentally ill.13

In conjunction with the aforementioned information and statistics, the interviews conducted with the participants of the focus group, highly suggest and determine that the same factors from the archival data research and results, also affected and influenced the well-being and whole health wellness of said participants. Each participant identified the fact that their food choices for meals are based on what they are able to afford, based on what they “believe they know” about those particular food items; and, their ability to readily access the food items. Most participants identified the fact that fast foods are more accessible and affordable, they also pointed out the fact that transportation was an inhibitor for accessing fresh foods and affordability. Many were unaware of where to locate the nearest farmer’s market and the fact that they would be eligible for SNAP/EBT because of their immigration status. It was also revealed in the surveys and interviews that all of the participants did not know how or where to access information on community resources; and, with limited language skills, and the inability to properly understand medical terms and interpret medical conditions, many felt intimidated to ask questions in reference to said topics.

In preparation for the health fair, all materials were created, evaluated, printed, and compiled for distribution to attendees. Booths were set up, and health care professionals, practitioners, and personnel were contacted to confirm their presence and contribution to the residents of Montgomery County at the fair. Unfortunately, the plan for the fair did not occur as was envisioned. First of all, there attendees were low in numbers. It cannot be said with certainty as to why this occurred. Secondly, there was the need for more than one interpreter, and said resource personnel was unavailable; as such, that created a language and communication. Barrier. However, the main goal was achieved as it pertained to the resource packet being distributed to attendees. This was especially since Hispanic residents were unaware of and unable to access community resources as it pertained to health care, find educational, mental, and dental resources for preventing Nutrition-related illnesses and diseases; and, to have whole health wellness prevail.