Migrant farmworkers focus of new research
Hidden population doesn’t get regular care
During a decade of providing health services to migrant farmworkers in eastern North Carolina, pediatrician Andrea Weathers, MD, DrPH, made some careful observations. In the clinic, she saw the same patients over and over again for health problems. But when she visited the camps and places where the workers lived, there were always other sick people needing treatment who did not come in for care.
In her role as a researcher and assistant professor in the department of maternal and child health at the University of North Carolina (UNC) School of Public Health, she wanted to find out why.
"I wanted to know whether the people who come in are the ones who really need care and find a way to come in, or whether — as I suspected — there was a large trove of unmet need in the community that is not able to access care for various reasons," Weathers tells Medical Ethics Advisor.
"When I would go out into the camps, there were always people who wanted care, but had not come in. You would go to a house to see one child, and there would be a mom in the same house behind a curtain with a 3-month-old baby with a fever. It happened all the time. I would be there for one reason, and then all of these people would show up, saying, Come look at my baby.’"
When she later became a public health researcher, she wanted to know if her experience was unique or represented a larger problem among migrant farmworkers. And if access problems exist, what causes them? But when she went looking for studies about factors influencing health care access among migrant farmworkers, she came up empty.
There was no systematic research into what factors influenced use of health services by the children of migrant workers. Are language barriers an issue? Does lack of insurance lead to nonuse of available services? What about access to financial aid and social service programs?
Weathers didn’t know. And she found out, the public health community and health care providers didn’t know either.
"If you look at the literature, there is a lot of anecdotal information — people with experiences similar to what I had seen," she explains. "But really, I wanted to know if there was a systematic way to look at this as a population problem. When I looked, there was nothing available where anyone had looked for associations between different factors and use of health services, and then done a multivariable control to make sure there weren’t other things leading to an association."
In the May issue of the journal Pediatrics, Weathers and colleagues at the UNC School of Public Health published the initial results of a systematic survey of health services use by children of migrant farmworkers in eastern North Carolina.1
The paper is only the fourth article about the health of migrant farmworker children published by the journal since 1948 and the only one to examine the population’s access to basic care services, fellow pediatrician Steve Berman, MD, notes in a commentary accompanying the study.2 Berman is a professor in the department of pediatrics at the University of Colorado School of Medicine in Denver.
According to federal estimates, there are approximately 3 to 5 million migrant farmworkers in the United States, and health professionals treating these workers report a high prevalence of many acute and chronic medical conditions.3 In addition, farmworkers and their children continue to report exposures to high levels of toxins from pesticides and other chemicals used on the crops.4,5
Researchers must overcome three challenges when attempting to study migrant farmworker children, he explains. One, establishing methods for defining and enrolling the eligible population is difficult when the population is mobile; 2) researchers must determine relevant measurable outcome measures; and 3) they must get community participation in the design and implementation of the study.
Weathers and colleagues’ research is important not only for the information obtained, but also because it demonstrates that this population can be studied accurately, which may remove an obstacle to further research into ways to help these children, he wrote.
Sick kids getting care
To study the population, Weathers and the other researchers used a database from the North Carolina Migrant Education Program, a federally funded program to help states ensure education for children of migrant farmworkers.
Although funding for this program has been cut significantly in many states, it has remained well supported in North Carolina, Weathers notes. The program has been in place for more than 20 years, and program staffers have good relationships with both the farmworkers and the farmers who employ them.
The program also routinely performs extensive canvases to locate migrant families and gather data on all children ages 3 years and older.
The database allowed Weathers and colleagues to look for both people accessing care in migrant clinics and to reach families not seen by the counties’ health system.
Using their database, the UNC researchers performed a cross-sectional household survey using a multistage, partially random sampling approach to evaluate health services use by migrant farmworkers in the eastern part of the state.
They were able to gather data for 300 children about whether the children had used health services in the past three months, if their caretakers had access to financial aid available to families and to the services of an interpreter, if the children had health insurance, and other factors.
The results were somewhat surprising, Weathers says.
"I expected the only differences between those migrants using health services and those not using health services to be these sociodemographic factors — insurance coverage, access to an interpreter, whether the family was stable residentially — had a home for a stable period of time — those kinds of things," she recalls. "That was my original guess. I thought we had the same population, otherwise. But what we found was that factors differed across all three areas — there were different levels of need, differences in access to resources, and different sociodemographic factors, which was interesting."
What she found, however, was that the parents obtaining health services for their children reported the children as being in "less than good health" on the survey, while the children not accessing care were largely reported to be in "good health" by their parents or caretakers.
Weathers and colleagues held focus groups with parents and caretakers prior to the survey to explain the terms used and to lessen communication barriers during the survey, she says.
"I explained to them what we meant by a well check’ or a health check’ and what we meant by good health and poor health, etc.," Weathers notes. "So, it is not as if they had a different standard for judging what was good health and less than good health."
However, it would be incorrect to interpret her findings to indicate no migrant children are lacking access to needed health services, she says.
Large reporting of unmet need for care
Unusually, both groups — both the users and nonusers of health services — reported a high, unmet need for care in their communities, she adds. More than half of the survey respondents reported that they experienced an unmet need for health care.
"We are still [figuring] out what the results of the survey mean in different areas — but that may be a tip-off that things are not quite as well as they seem," Weathers notes.
Another difference between users and nonusers, which will be examined in depth in an upcoming paper, is that nonusers were more likely to have never accessed health care services.
"Part of this may be that they are an unexamined population. I used to see children in the clinic all the time from Mexico who never had seen a doctor before at 12 years of age," she says. "They are saying that they are healthy, but they really haven’t been assessed."
Other factors that still need more study are an association between age and gender among children getting care.
In this study, younger children were more likely to receive care than older ones, and girls more likely to receive care than boys.
"Some of that may be natural; younger children tend to have more needs than older children," she says. "But we were surprised about the difference in gender. That may have something to do with the demand for older children — particularly older boys — as workers in the fields."
The large number of families reporting an unmet need for care, coupled with the association of less-than-optimal health for those children accessing health services, indicates to Weathers that families may seek care only in dire circumstances.
"This seems to be a population whose use of health services is illness-driven," she says. "All they can make time for is coming in when they are very sick, and that is what the system is supporting. It may be that our system will only allow the emergency access when you really, really need it."
An area not covered by the recent survey is delayed care, she adds. In her experience, many farmworkers delayed seeking care for health needs that would send many people to a regular physician without hesitation, Weathers says.
"With this study, we did not assess delayed care, so it doesn’t tell us about the timeliness of care, either," she notes.
Why the lack of research?
The paucity of funding for research studies in this area may indicate some disturbing biases on behalf of the American public and our health care system, adds Berman.
Governmental attempts to restrict access to Medicaid and the State Children’s Health Insurance Program further marginalize and endanger the lives of people who harvest the food that feeds our country, he emphasizes. Unwillingness to examine the needs of such a large group of children indicates our society has turned a blind eye to the exploitation of migrant workers, he says.
"Why have government agencies and private foundations not supported more studies of these vulnerable, disadvantaged children? Funding research in this area should have been given a high priority," Berman states. "I suspect the explanation has to do with our fears about being overrun by immigrants and our dependence on their cheap labor, especially in agriculture. Whatever the reason, now is the time for research funders and pediatric researches to close this glaring and significant gap in the scientific literature. We must all accept responsibility for its existence and work to close it."
• Andrea C. Weathers, MD, DrPH, Assistant Professor, Department of Maternal and Child Health, UNC School of Public Health, 402A Rosenau Hall, CB# 7445, Chapel Hill, NC 27599-7445.
1. Weathers A, Minkowitz C, O’Campo P, et al. Health services use by children of migratory agricultural workers: Exploring the role of need for care. Pediatrics 2003; 111:956-963.
2. Berman S. Health care research on migrant farm worker children: Why has it not had a higher priority? Pediatrics 2003; 111:1,106-1,107.
3. Rust GS. Health status of migrant farmworkers: A literature review and commentary. Aust J Polit Hist 1990; 80:1,213-1,217.
4. Chase HP, Kumar V, Dodds JM, et al. Nutritional status of preschool Mexican-American migrant farm children. Am J Dis Child 1971; 122:316-324.
5. U.S. Department of Labor. Table 48. Occupational injury and illness incidence rates by industry. Monthly Labor Rev 1988; 118-119.