Views on Healthcare: The Hispanic Migrant Worker Study in Rural Appalachia

Global migration is rapidly increasing with an estimated 200 million people living outside their country of birth [1]. Undocumented migrant workers are estimated to be 30 to 40million world-wide [2]. Many challenges to adequate healthcare for this population exist. Health disparities for migrant workers has been recognized globally and addressed by the World Health Organization [3] calling for States to develop strategies to improve migrants’ health. These strategies require consideration and action at every level of healthcare delivery including global, national, state, and local communities.

States in the United States, such as North Carolina, have a strong agricultural economy. Migrant farm workers are essential to the farming and economic infrastructure of rural Appalachia, which is located within the southeastern United States. Migrant farm workers assist in the growing, planting, and harvesting of fruits and vegetables, as well as the planting, tending and harvesting of Christmas trees. Solely in North Carolina, there are an estimated 150,000 documented migrant farm workers during every growing and harvesting season [4]. The United States Department of Labor estimates that over 53% of current migrant workers are undocumented [5].

Many of the migrant workers in North Carolina originate from rural Mexico and Guatemala [3]. The influx of these migrant workers incurs a unique set of cultural characteristics, which may set them apart from the native population and impact access to health care. The distinguishing cultural characteristics of the migrant workers may include a different language, herbal medicine use, and lack of financial and transportation resources [4,5] Other factors that may hinder Hispanic migrant workers’ access to health care in the United States may include: work schedule and fear of deportation [5,6]. Migrant workers want to avoid any loss of work hours, which can mean that they will not be hired for the next season. Migrant workers are performance-focused and desire to be viewed as hardworking and dependable individuals [5]. The verification process for eligibility of care and sliding scale payment often causes fear in potential patients, especially those who are undocumented [7,8].

Kim Godwin & Bechtel [9] discovered that migrant farm workers were at greater risk for experiencing psychological difficulties related to more socioeconomic and environmental stressors as compared to seasonal farmworkers. The investigators reported that the migrant workers reported higher levels of perceived stress and difficulty adjusting to their mobile life styles, legal/job security and long working hours which resulted in an unstable life style. This rural Hispanic migrant worker population may often be unseen, underserved, and forgotten by mainstream health initiatives in part related to the perceived barriers to health care.

People have many experiences to share. They rely on these experiences to teach, to discipline, to provide examples, to focus on their lives, and to help others. Van Manen [10] describes these human lived experiences as “getting to the essence of the experience to further understanding and ‘turning over’ the phenomenon in which we find ourselves” (p. 37). The Hispanic migrant workers in this study provided their lived experiences of their views of healthcare to the researchers. We, the researchers, as well as the nursing students and clinical staff provide meaning to these lived experiences in the context of what it is like to be here in rural Appalachia seeking care with specific barriers.

The purpose of this qualitative study was to highlight the lived experiences of Hispanic migrant workers seeking healthcare at a community care clinic in rural Appalachia with participation from student nurses learning about qualitative research methods. Structured qualitative interviews were conducted by nursing students under the direct supervision of community care clinic personnel, a Hispanic interpreter, and three experienced, doctoral level faculty. The institution review board at the local university reviewed and approved the proposed study. All interviews were conducted in English and then translated into Spanish by the interpreter. Information regarding the purpose of the study, confidentiality, and consent were explained to each participant in Spanish. Twenty-three Hispanic migrant workers of a rural health care clinic in North Carolina provided informed consent to be interviewed.

All interviews were conducted within a four-month time period. The transcribed interviews, researcher observations and student feedback were combined to represent the raw data triangulation. Each interview was attended by a nursing student, nursing faculty, interpreter, and community care clinic personnel. The student led interviews consisted of a list of 5 questions. The students asked each question to the migrant worker participant then the interpreter followed with the same question, but in Spanish. Adequate time was given for a response while often the interpreter had to repeat the question for clarification.

The interviews were audio-recorded, and then transcribed verbatim in English by the nursing students. The specific faculty member who attended the specific interview edited the written transcription with confirmation from the audio-recording. All three faculty members were given copies of each written transcription for individual interpretation of common themes. The written transcribed interviews were coded for like themes by each nursing faculty. Collaboration followed with all three faculty members confirming common themes. These research actions helped to minimize bias within the research methodology.

Trustworthiness

Trustworthiness of this research was accomplished by several processes. These processes all contributed to the established audit trail. Creswell [11] posits that the development of an audit trail establishes credibility. The processes utilized in this research included constant comparison, prolonged engagement, thick, rich descriptions, and peer debriefing.

Constant comparison

Strauss & Corbin (1998) report that the constant comparison analysis is important for establishing credibility of qualitative research. DiCicco & Bloom [12] provided the steps as to how to structurally form the interview. For instance, in this study, three separate faculty researchers took turns supervising the interviews at the rural community health clinic. Each interview was attended by a nursing student, one of the three nursing faculty researchers, interpreter, and community care clinic personnel to establish consistency. The same questions were asked of all participants at each interview. These interviews were conducted on different dates and at different times to establish validity and sameness. Once the interviews were transcribed, each individual faculty researcher coded the information by interpreting common themes of the views on healthcare. Group collaboration occurred among the faculty researchers to code the identified themes, again, establishing the final step in constant comparison for similar understanding and interpretation.

Prolonged engagement

Creswell [11] insists that as researchers engage in prolonged and persistent observation and analysis of data, in turn, allows the building of trust, while learning the culture and checking for misinformation. Immersion was accomplished over the study’s fourmonth allotment of time, while more interviews were taking place. Researchers and nursing students provided expert interpretation while being engaged with the participants. Researchers were accountable and observant of the interactions between the clinical staff, nursing students, and Hispanic migrant workers at the clinic. In addition, the researchers were familiar with the classroom discussions and perceptions being shared regarding the topics of culturally competent care of minority populations. Researchers were able to provide constant comparisons and like observations and participation establishing credibility.

Thick, rich descriptions

Charmaz [13] reported that rich data must be detailed, focused, and full. The rich data from this study is supported by the fact that the lived experiences offered during the interviews came directly from the Hispanic migrant workers themselves. This research offered structured and specific questions asked with rich detailed responses. Detailed specific written transcripts were created from the audio-recordings [14].

Peer debriefing

This qualitative research was in part an opportunity for nursing students to participate in structured interviews as well as observe how culture-competent care was given by a local rural clinic. Nursing students were given time for reflection and writing of their experiences after the interviews. Scheduled class time was also afforded following all interviews for discussion and perspective. Researchers were available for follow-up with students and each other to establish constant collaboration withstanding any researcher bias [15].

There were some barriers to care identified by the Hispanic migrant workers which included transportation, financial resources, and language. The clear majority of the Hispanic migrant worker responses were surprisingly positive. This paper will focus on the findings of the qualitative study that relate to positive aspects of the American health care system as identified by the Hispanic migrant workers and cultural observations from the study. Three themes were identified that related to perceived positive aspects of the American health care system: resources, quality care, and trust [16-19].

All the participants discussed some positive aspects of the healthcare system. One of the identified themes was “they will work with me [20].” An important positive area identified by the Hispanic workers was the willingness of the clinic to allow them to make payments for services. The cost of healthcare services was mentioned in all 23 interviews. This finding is consistent with other studies with Hispanic migrant workers. Investigators discovered that migrant worker access to health care in the United States may be hindered by several barriers such as work schedule, transportation to and from services, ability to pay for services and fear of deportation [2,4].

Although some participants in this qualitative study identified cost as a barrier to care, a majority of participants also expressed appreciation for payment options. “There are definitely more doctors. There are definitely more programs that could help you, as far as like, making payments and stuff, so you can get medicine or whatever we need.” Another participant stated that he has been able to get many of his health problems resolved in America. He stated that he would have never been able to afford the same level of medical care in Mexico. Many of the Hispanic migrant workers described past experiences within their country of origin in which they could not afford to receive medical care. These past experiences of lack of access to medical care might have influenced the current level of appreciation expressed by these workers [21].

Another consistent theme identified was “high quality of medical care.” Several participants commented about liking the health care services that they received at the rural North Carolina clinic. One participant commented that he liked the attention that he received and the fact that there was always a solution to whatever problem he was having. Several participants commented about the importance of having translators to ensure that their health care needs were understood.

The participants seemed very pleased that the clinic was open during the evening. The workers were able to attend their appointments without leaving work early. These findings are consistent with those of McCullagh [22] in the qualitative study of the cultural health practices of Hispanic migrant workers. According to McCullah [22], Hispanic migrant workers tended to use health care treatments that were low cost, accessible and did not interfere with their ability to work. Successful treatments were measured by the worker’s relief of pain and ability to return to work. “Interviewees conceptualized good health as the ability to work [4]. The same values of low cost, accessible services and hours of operation that did not interfere with work were common findings across all study interviews.

Trust

The lived experience of ‘trust’ was a surprising theme from this research. This theme was represented in the interviews from the relationship established between the migrant workers and the community clinic health care workers. A participant commented, “Even though they come from other places they are still able to get help, like any type of help that they need.” Another participant stated, “No matter who you are or where you’re from, they will treat you the same and give good care. It is also better all around.”

Observations of the interactions between the Hispanic migrant workers and the clinic reception staff revealed warm and friendly interactions. The clinic staff consistently smiled and cheerfully greeted the patients as they arrived. For the patients who did not speak any English, the clinical staff elicited the aid of a Spanish interpreter. The receptionist behaviors observed by the researchers were courteous and helpful toward the patients. This initial interaction with the receptionist sets the positive tone for the clinic visit. One Hispanic migrant worker stated that he appreciated how the nurses, doctors, and clinic workers liked their job. He noticed how the staff took pride in promoting the greater good. Another participant stated, “It doesn’t matter like what race or what culture you’re from, that people are always willing to help.” One participant even reported that the clinic arranged transportation for him when he had no other options available.

Highlighting the views on healthcare from the lived experiences of Hispanic migrant workers creates a unique perspective. This perspective of access and service from American healthcare parallels some of the unique culture aspects found among the people of rural Appalachia. The characteristics of the people from the rural areas of the Appalachians are described as self-reliant, independent, hardworking, stable and having strong ties to family [14]. Appalachians tend to be kind, friendly and helpful to one another and take care of others. Appalachians tend to have a strong sense of right and wrong and to mistrust anyone who is new. Appalachians also tend to resist change. Most Appalachians place great importance on the extended family and on family taking care of family. Historically, Appalachians have been separated from each other by steep valleys, especially during harsh winters. The geographic separations that isolated Appalachians from extended family members have forged a deep sense of self-reliance and independence [15]. The mountaineers live in an area where everyone knows them and their family history. Establishing and maintaining relationships is vital to the Appalachians. Very similar characteristics have been used to describe the Hispanic migrant workers.

“Many farm workers arrive with solid agricultural skills firmly grounded in practical experience and working knowledge of agriculture. This expertise is complemented by a strong work ethic, deeply rooted in their commitment to provide for their families or make it on their own. This is reflected in their willingness to make considerable sacrifices in order to guarantee a more prosperous future for their extended families, their children and/or their siblings” [16].

It is clear, in the interview transcripts from this study, that the Hispanic migrant workers seeking healthcare trusted that the clinic staff would not turn them away. It is also clear that the Hispanic migrant workers saw the option of having payment plans as a way for them to obtain healthcare for themselves and their families using their own resources. The health services payment options fit well with the idea of the “making it on their own” value system of both the Appalachian healthcare workers and the Hispanic migrant workers. This similar value system of the Hispanic migrant workers and the Appalachian health care workers contributes to the establishment of the trusting interconnected relationship.

The impact of a therapeutic trusting relationship also rests within the mental health literature. For instance, Hawamdeh & Fakhry [17] identify four main themes of a trusting relationship by providing physical care, conveying safety and security, protection, and companionship. In the Hispanic Migrant Study, the workers express their confidence in the rural clinic personnel by trusting that their physical health needs would be met [18]. Berry & Greenwood [8], present that a positive therapeutic relationship in combination with positive professional expectations predict social inclusion, vocational activity and hopefulness. In our study, Hispanic migrant workers communicate feelings of acceptance, regardless of their race. In addition, Sun MH et al. [19] rely on the mediating effect of the therapeutic relationship in the establishment of hope and recovery for patients. This research identifies that a caring and trusting relationship between the Hispanic migrant workers and the rural Appalachian community clinic personnel is one of the contributing factors that helps the migrant worker overcome barriers to health care. Consequently, the establishment of a trusting relationship was not easily found in a similar study conducted in Idaho. Chavez et al. [14] found that only 5% of the 555 Hispanic migrant worker participants trusted Mexican Americans or white Americans. In fact, these Hispanic migrant workers had lower levels of generalized trust for Americans than other Hispanics nationally. However, researchers noticed that when participants were more fluent in English, the more likely the Hispanic migrant worker was to trust both Mexican Americans and Caucasians.

The nursing students who participated in the Hispanic Migrant Worker Study report that this experience helped to “open their eyes” to the barriers of healthcare. Many of the nursing students were unaware of the large number of Hispanic migrant workers within the surrounding community and their inability to find adequate healthcare. The experience of interviewing the Hispanic workers provided an opportunity to explore the cultural aspect of providing health care using qualitative research strategies. Students commented on their unique experiences of personally observing the cultural care lessons learned during this study. Not only did they have unique structured exposure to the care needed by hidden minority populations, but they learned how to identify common concepts of care and identified themes shared by the migrant workers. This opportunity provided considerations of community care and resources from future practicing nurses as these nursing students prepare to enter the nursing workforce.

The interconnected relationship of ‘trust’ is a major theme identified from the Hispanic Migrant Worker Study. Participants identified common themes of trust highlighting the very ‘essence’ of what it is like for the Hispanic migrant worker to live in a foreign country with barriers for obtaining healthcare. This research assists the healthcare member to not assume how the seasonal migrant worker attends to personal health while in this country, but instead to understand some of the barriers they view while highlighting the unique positivity of human caring. Let our understanding of the moral dilemma start with revealing the personal experiences of those we are concerned, situated in the common phenomena of which they are found [10].

Hispanic migrant workers identified three favorable themes from this research. These included the availability of healthcare, the quality of care, and a trusting relationship. High importance was placed on being able to make payments to purchase healthcare services. The high quality of care, such as being able to obtain top medications for illnesses, was a common theme. Although, there were several barriers identified in obtaining health care, it was clear that the migrant workers had established a strong trusting relationship with the health care personnel at the rural Appalachian clinic. Similar values discovered between the Hispanic migrant worker culture and the Appalachian cultures included; a strong work ethic, the importance of “paying my way,” the value of being able to financially support family, treating each other with respect, and social warmth and receptiveness when greeting visitors or customers. Highlighting these lived experiences [10] offers great insight into how this population attends to personal care needs and helps the healthcare member do develop strategies in caring for them. Examining the impact of similar values across cultures in the context of developing a trusting therapeutic relationship is an area recommended for future research.

The American Association of Colleges of Nursing [1] recognizes the growing ethnic and socio-cultural diversity within the United States, resulting in the publication of a position statement describing the importance of preparing culturally competent nurses. Patient centered care that identifies differences in patient values, preferences and needs is a step toward the elimination of health disparities. The need to provide culturally competent care transcends the United States boarders throughout the globe. Cultural competency is an essential component of holistic care [22- 25]. Providing culturally competent care begins with understanding health and health care services from the patient’s perspective. Focusing on cultural similarities may help build bridges instead of barriers.

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