Journal of Community Health Vol. 3, No. 1, Fall 1977

H E A L T H CARE C H A R A C T E R I S T I C S OF M I G R A N T A G R I C U L T U R A L WORKERS IN T H R E E N O R T H

FLORIDA C O U N T I E S

Phyllis R. Bleiweis, M.A., Richard C. Reynolds, M.D., Louis D. Cohen, Ph.D., and Neil A. Butler, M.N.

ABSTRACT: Farm workers, representing 65% of the migrant work force in the St. Johns River basin agricultural area of north Florida, were questioned in 1973-1974 about their own and their families' health status and about their use of professional health care services and facilities. The facilities available for use by this population included 22 physicians in private practice, two hospitals, three public health clinics, and two health clinics operated for migrants. Most contacts made by the migrant farm workers were with the health care professionals in the public facilities, primarily those in the migrant health clinics. The average number of visits made by migrant farm worker heads of households to a physician each year was 3.5 visits. In 1971, the National Health Survey reported an average of 4.9 physician visit~ for all U.S. citizens. The major factors that affected utilization were the presence of an acute medical condition and the perception of being in poor health. The factors that generally have been thought of as impediments to seeking health care, such as transpor- tation, the presence of children in the household, and a lack o f education, were found to be of little import. The acute disease conditions that were most frequently reported by these migrant workers as the reason for their contacts included respiratory illnesses, digestive system problems, injuries, and musculoskeletal problems. The chronic conditions included heart disease and hypertension, musculoskeletal disorders, digestive sys- tem problems, and genitourinary problems. Little use was made of dental services, except for tooth extractions.

The plight of the migrant farm worker has been examined for decades. They are a poor, marginally educated people, who are em- ployed at tasks requiring rigorous manual labor. They differ from most other labor groups because they move from one work site to another and are seldom members of any established community. Social services of any kind are less readily available to them than to other people.

Other reports have described the health care problems of migrant workers.l-12 Because of the special considerations migrancy brings to the

The authors are with the J. Hillis Miller Health Center, University of Florida, Box J-222, Gainesville, Florida 32610. Mrs. Bleiweis is an Assistant in the Department of Community Health and Family Medicine, Dr. Reynolds is Professor and Chairman, and Mr. Butler is an Associate in that department. Dr. Cohen is Professor and Chairman of Clinical Psychology in the Health Center's College of Health Related Professions. This study was supported by Contract PHS-NSA-105-74-42 with the Migrant Health Division, Bureau of Community Health Service, Health Services Adminis- tration, of the Public Health Service. The authors gratefully acknowledge the help of Sara Kenaston and Marilyn Uelsmann of the Florida State Division of Family Services and Dr. Ronald Marks of the University of Florida Division of Biostatistics.

32

Migrant Health Care 33

provision of personal health services, no uniformly acceptable program of health care delivery for these workers has been suggested.

To define better the health care problems of migrant farm work- ers, the Departments of Community Health and Family Medicine, Clini- cal Psychology, and Community Dentistry of the University of Florida studied the health status and health care behavior of migrant workers in three north Florida counties during 1973-1974.

The three counties, which make up the St. Johns River basin ag- ricultural area, are Putnam, St. Johns, and Flagler; the major crops grown are cabbages and potatoes, in a growing season that extends from October to May. During that time the migrant farm workers live in the small towns of Hastings, Bunnell, Palatka, and Crescent City and in nearby migrant camps; migrant workers with families usually live in the towns, while the single workers live in the camps. During the summer most of the workers from this area migrate to Virginia and the Carolinas, and then return to the area.

The health care resources available to these migrant workers in- clude two hospitals of 117 and 58 beds in Palatka and Bunnell, public health clinics in Palatka, Bunnell, and Crescent City, and migrant health clinics in Hastings and Bunnell. Twenty-two physicians in private prac- tice, mostly general physicians, serve the 86,500 people residing in the 1,870 square miles of these three counties. Only the migrant health clinics, however, solicit the approximately 850 transient workers and their families as patients.

M E T H O D S

Locating and counting the actual number of people in the migrant farm worker population was the first problem we encountered. Three separate counts were made over a six-month period. Although the total size of the population did not vary, the individuals themselves changed by 35% to 40% in each census; this fact made it difficult to select an appro- priate sample. Finally, all heads of household who could be located within the study period, which was to last for two months, were interviewed-- 291 migrant heads of household, who represented a total of 552 people. This number of interviews represented 65% of the total number of mi- grants within the growing area at any one time during the survey. Table 1 describes the population surveyed, according to their area and place of residence.

The field staff coordinator supplied the names of the migrants who were to be interviewed, made changes in the lists when necessary, and collected the completed interview forms weekly. All interviews were conducted in the migrant workers' homes.

34 J O U R N A L OF C O M M U N I T Y H E A L T H

TABLE 1 Migrant Population Surveyed, According to Locality and Place of Residence

Total Total % Interviewed of Locality Camp* Non-camp Interviewed Availablet Total Available

Crescent City 38 48 86 151 57 East Palatka 58 41 99 117 85 Hastings 37 47 84 126 67 Bunnel l 21 1 22 50 44

154 137 291 444 65

*A camp, according to Florida statutes, is: "One or more buildings or structures, tents, trailers or vehicles, or any part thereof together with the land appertaining thereto, established, operated or used as living quarters for 5 or more seasonal, temporary or migrant workers whether or not rent is paid or reserved in connection with the use of occupancy of such premises." ?Available includes the names of all migrant farm workers who became known to the project staff dur- ing interview period.

Six former migrant workers who had settled permanently in the four survey locations were hired as interviewers. They were trained by the field staff coordinator in the recording, abstracting, and coding of answers, proper interview techniques, and the need to return as many times as necessary to the respondent's home to complete the interview. The interviewers were personally familiar with the locations of the resi- dences in the towns and the locations of the migrant camps. They were also personally acquainted with the crew leaders and were able to obtain their cooperation, to the extent that they were permitted into the camps and were not hampered during their visits.

The survey instrument contained 37 items, covering the worker and his family's health history, their health needs and health status (as perceived by the worker), their use of the various health facilities, and possible impediments to their use of health care facilities; 84% of the items were selected from seven questionnaires that had been tested pre- viously.11.13-1s The questionnaire also reflected material that had been obtained during contacts made in the field with health personnel, grow- ers, contractors, and federal employment service personnel. In designing the form, an attempt was made to remain within the language limitations set by this population, who had only a minimal formal education. The interviewers, who were former migrants, helped to word the questions in the vernacular of the migrant. Just before the scheduled interview period a preliminary test of this questionnaire was made in two migrant camps in an adjacent county; appropriate revisions were then made.

The data were prepared for computer analysis with the help of the Statistical Package for the Social Sciences. a9 Statistical analysis included frequency histograms and chi-square comparisons.

Migrant Heal th Care 35

RESULTS

Most farm workers in the St. Johns River basin area, as shown in Table 2, are black men who have less than a ninth-grade education; they are primarily migrant rather than seasonal agricultural workers. One half of the respondents were over 40 years of age; 48% had completed 9-12 years of schooling, while another 48% had completed only 8 years or less. Over half of these farm workers were single, and when those who were divorced, separated, or widowed were included, over 80% were classified as living without a legally recognized spouse. The data showed that only 28% of the households contained children.

When the camp and non-camp residents are compared, the greater number of one-person households was found among the camp residents. Many of these farm workers, however, claimed to have been married before, or to be married currently, and to have left their families behind when they migrated to work. The average annual income of those knowledgeable enough to report their earnings in such terms was $2,150; 35% of the farm workers reported earnings of less than $2,000, while only 15% earned more than $3,000.

TABLE 2 Selected Characteristics of Migrant Heads o f Household,

St. Johns River Basin, 1973

Characteristic Number %

Sex Male 222 Female 69

Race Black 266 Other 25

A g e t U n d e r 20 21-30 31-40 41-50 51-60 O v e r 6 0

76.3 23.7

100.0

91.4 8.6

100.0

18 6.2 67 23.0 66 22.7 81 27.9 42 14.5 17 5.9

100.2

*Sums may differ from 100%, due to rounding. tMean age of the head of house is 39.45 years.

continued overleaf

36 JOURNAL OF COMMUNITY H E A L T H

TABLE 2 continued

Characteristic Number %

Marital status* Single 153 52.6 Married 56 19.2 Divorced 14 4.8 Separated 52 17~9 Widow(er) 13 4.5 No answer 3 1.0

100.0 Education§

0 years completed 12 4.1 1--4 years 34 11.7 5-8 years 92 31.6 9-12 years 140 48.1 More than 12 years 7 2.4 No answer 6 2. I

100.0 Occupation =®

Migrants 256 87.9 Seasonal agricultural workers 33 11.3 No answer 2 .7

99.9 Residence

Camp 137 47.1 Non-camp 154 52.9

100.0 Income**

0-$1,000 58 19.9 $1,001-2,000 44 15.1 $2,001-3,000 80 27.4 Over $3,000 45 15.4 Don't know 64 22.3

100.1

*Sums may differ from 100%, due to rounding. :~Total number of people covered by the survey is 552--247 children and 305 adults. Only 28% of the 291 households contain children. Approximately 7% of the households with children are headed by an adult who is classified as a single person. Mean size of the house- hold is 2.0, and those households with three persons or less comprise 82.5% of the sample. Mean number of children in a household is 0.85. §Mean grade in school completed is 8. =®According to the Florida Migrant Labor Program office, a seasonal agricultural worker lives and works in the same area. He does agri- cultural work only in planting or harvesting season and may do non- agricultural work at other times of the year. A migrant worker travels a distance outside his residential area to work. $:~Mean income of those who were able to report it is $2,150.

Use of Health Care Facil it ies and Personne l

T h e migran t workers were asked to give in fo rmat ion about their use of professional heal th care services and facilities, bo th for themselves and their families. These f indings were t hen c o m p a r e d with those that were der ived f rom a study of a "normal" popula t ion that lived in ano the r

Migrant Health Care 37

TABLE 3 Comparison of the Percentage of St. Johns River Basin Migrants and Alachua County Residents Who Used Medical Care Facilities and Personnel Over a One-Year Period

Agency Contacted

St. Johns River Basin Farm Workers and

Their Families (1972-1973) (N = 552)

Alachua County Residents

(1973) (N=1,645)

Medical doctor Public health nurse Public health clinic Hospital inpatient Community mental health center Faith healer or spiritualist Psychiatrist or psychologist Social worker

47.4 80.3* 28.2 3.7 39.8 12.6 10.3t 30.0 0.003 0.8 0.003 1.6 0.003 5.1 4.1 5.9

*National Health Survey reports national average of 85.4% (Vital and Health Statistics. Series 10, Data from the National Health Survey, No. 95, 1973.) tNational Health Survey reports national average is also 10.3%. (Vital and Health Statistics. Series 10, Data from the National Health Survey, No. 95, 1973.)

north-central Florida county (Alachua). is Table 3 reports the number of health care contacts made during a one-year period for both groups. The public health fadlities and personnel, the public health nurse, and the health clinic were used more frequently by the farm workers in the St. Johns River basin area than by the residents of Alachua County. The percentage of the migrant population that reported at least one visit to a physician is only one half that of the Alachua County residents.

Of the migrant farm workers who did report seeing a physidan, they averaged 3.5 and 2.8 visits per heads of household and members of households respectively (Table 4). According to the National Survey

TABLE 4 Number of Physician Visits per Person per Year

for Selected Population Samples

Number of Visits per Population Sample Person per Year

St. Johns River Basin Migrant farm worker heads of house (1973)

St. Johns River Basin Migrant farm worker household members (1973)

National Health Survey Sample (1971)* National Sample: Non-white (1971) National Sample: Under $3,000 income

per year (1971) National Sample: South (1971) National Sample: Outside a standard metro-

politan statistical area--farm (1971) National Sample: 5-8 years of education (1971)

3.5

2.8 4.9 4.4

6.2 4.8

3.8 4.6

* National Health Survey Sample data taken from Vital and Health Statistics. Series 10, Data from the National Health Survey, No. 97, 1971.

38 JOURNAL OF COMMUNITY HEALTH

TABLE 5 Disease Conditions Reported by Migrant Farm Workers:

Incidence During One Year of Selected Conditions (Subjects May Have More Than One Condition)

Condition

% Distribution

St. Johns Sample National (Based on Self-Report) Sample Distribution*

(1973) (1973) t

Acute Respiratory 23.0 53.3 Digestive system 13.5 4.8 Injuries 26.0 16.4 Genitourinary 7.0 2.9 Headaches 2.0 0.7 Musculoskeletal I0.0 1.5

Chronic:~ Heart conditions,

including hypertension 18.7 16.3 Musculoskeletal 15.5 16.2 Conditions of

digestive system 5.1 4.0 Genitourinary 3.4 1.7

*Does not total 100%. tVital and Health Statistics. Series 10, Data from the National Health Survey, No. 98, 1972. z~Includes persons with any degree of physical limitation. Vital and Health Statistics. Series 10, Data from the National Health Survey, No. 96, 1972.

Sample (1971), the national average for physician visits per individual in the United States is 4.9, close to the average reported for the farm worker head of household. 2° Table 4 also gives more specific demographic data for comparison with the St. Johns River basin migrant farm workers. Those who lived outside the standard metropolitan statistical areas made about the same number of visits to a physician as did the migrant farm workers. The remaining groups from the national sample, with the ex- ception of those whose annual income is below $3,000, averaged four to five visits per year, or approximately one visit per year more than did our farm workers. Low-income individuals averaged more than six visits per year.

Table 5 lists the selected disease conditions that brought the St. Johns River basin migrant farm workers to seek care within the one-year period and compares the incidences of these diseases with those recorded in the National Survey sample. Of the acute conditions, only respiratory illness precipitated a physician visit more often in the national sample than in the migrant farm worker sample. The percentage of migrant farm workers with digestive problems is almost three times higher than the national sample; there are more than one and a half times as many

Migrant Health Care 39

TABLE 6 Percentage of Population Seeking Dental Care in a One-Year Period

Item

% Distribution

St. Johns Sample National Sample (Based on Self-Report) Income Less than

(1973) $3,000

Visited dentist in past year % of Those seeing a dentist

who had tooth extracted

13.3 35.8* (1969)

74.1 15.0t (1964)

*Vital and Health Statistics. Series 10, Data from the National Health Survey, No. 76, 1969. tVital and Health Statistics. Series 10, Data from the National Health Survey, No. 23, 1964.

injuries, more than twice as many repor ted geni tourinary illnesses and headaches, and seven times as many musculoskeletal problems.

A comparison of the c o m m o n chronic conditions reveals that the national sample and the farm worker sample percentages are similar.

T h e use of dental facilities by migrant farm workers was almost limited to those dental conditions that required tooth extraction. Table 6 compares our data with a sample f rom the national Heal th Survey popu- lation whose income was less than $3,000. These data revealed that mi- grant fa rm workers saw a dentist much less often and tended to have more tooth extractions that did o ther low-income people.

Factors Influencing the Seeking of Health Care

In Table 7, several factors that are known to affect health facility usage are listed. T h e presence of an acute medical condition and a per-

TABLE 7 Factors Influencing the Seeking of Health Care

Factor

Health Care Source

Physician Clinic Dentist

Chi-square level of significance

Presence of acute medical condition

Presence of chronic medical condition

Perceived poor health past year

Inability to pay for treatment

Positive Positive Positive (0.005) (0.003) (0.003) No correlation Positive No correlation

(0.001) Positive No correlation No correlation (0.05) No correlation Positive Negative

(0.001) (0.0O3)

40 JOURNAL OF COMMUNITY HEALTH

son's percept ion of being in poor health (unspecified in nature) were the factors that most inf luenced the migrants to seek health care. T h e re- spondent 's repor t about his own health status was de te rmined by asking if he had been to a doctor or had used any of the other medical services in the past year, who he had seen (by name), how often he had gone, where he had been seen, and the date of his last visit.

T h e respondent was also asked again about his hospital experi- ences, whether he needed regular medical care, and whether he thought he had any present medical problems. How the respondent viewed his own health status was de te rmined by asking if, in the past year, he thought his health had been good, fair, or poor, and, in ano ther par t of the questionnaire, he was asked, "Do you think you are healthy?"

T h e data also indicated that a decreased ability to pay for medical care was associated with an increased use of the public heal th clinic. Al though the ability to pay for care was not a significant factor in the farm worker's use of a physician's services, it was significant in his use of dentists' services; the ability to pay for dental care and the visits to a dentist were positively l inked.

Other factors did not appear to act as impediments to seeking health care. These included the presence of chi ldren in a household , lack of transportat ion, camp residence, lack of a p e r m a n e n t home, or the lack of education. Because it was expected that some of these factors would be significant in the seeking of health care by migrant workers, direct ques- tions were asked, such as, "Is it too hard for you to go to where the doctor or the clinic is located?", "Have you ever been t reated badly by a doctor or at a clinic?", "Do you have the money to pay for medical care?" T h e data reflecting their answers were then analyzed by chi-square comparisons with visits to medical facilities. In no instance were any of these factors found to be significant.

D I S C U S S I O N

Comparisons were made between selected samples of the national populat ion and migrant fa rm workers in north-central Florida in their use of health care facilities. These data showed that only two thirds as many farm workers as those in the national sample saw a physician dur- ing a one-year period. A m o n g those who did see a physician there was no marked difference in the actual number of visits made dur ing this time period. One of the keys to bringing better heal th care to this populat ion may lie, then, in fostering the initial meeting with health care profession- als. This problem was set out in a discussion of health care and the disadvantaged by Banks when he described them as socially disadvan- taged people who have difficulty seeing themselves as the initiators or as

Migrant Health Care 41

colleagues in the delivery of heal th care; on the contrary, they usually saw themselves as objects to be worked upon31 In another study, H e r m a n notes:

There are also a number of indications that the poor may less generally believe in the patient's responsibility to seek and follow profes- sional advice, a widely held assumption among laymen of higher eco- nomic status and health professionals. However, only among the very poor and disorganized would these tendendes toward passivity and living in the present reach a state which could be called apathy or anomie. 2~

The data listed the most f requent acute and chronic illnesses found among the nor th Florida migrants. The acute conditions, particu- larly the high incidence of injuries and musculoskeletal problems, were probably related to their work. Poor diet, as repor ted by the fa rm work- ers, and the of ten-ment ioned high incidence of alcohol use could explain the large n u m b e r of digestive illnesses reported. Twice as much acute respiratory illness was repor ted in the national sample as among the fa rm workers. Acute respiratory disease, such as colds or flu, may be consid- ered by the fa rm workers as illnesses of too little significance to be treated or even reported.

Chronic illness as r epor ted by the St. Johns farm workers approx- imated its incidence among the national population. Such chronic illnes- ses as hypertension do not interfere with work and were not often con- sidered reason enough for visiting a doctor or clinic. Similarly, the need to treat an asymptomatic illness over a long per iod is not usually under - stood by the fa rm workers because of their limited educational back- grounds.

This study indicates that the factor that most inf luenced the mi- grant farm worker to seek health care was the presence of, or his percep- tion of the presence of, a medical condition. Items such as a lack of transportation, residence in a migrant camp, f requent moves f rom one communi ty to another , and the social-psychological factors that are characteristic of a poverty-stricken populat ion-- lack of aspiration, chronic frustration, despair, and isolation--certainly do not encourage anyone to seek health care, but we were unable to find any significant correlation with these factors.

A large propor t ion of the farm workers in the St. Johns River basin area live in rent-free quarters that are controlled by the crew lead- ers. These fa rm workers pay board to the crew chiefs, upon whom they are dependen t for food and transportation. This study found that the average distance a farm worker had to travel to see a doctor was 7.9 miles and to a public health clinic, 8.5 miles. Harrison, in his study on "The Crew Leader as a Broker with Implications for Heal th Service Delivery", concludes, "Attempts to reach migrants and change their illness behavior and health seeking behavior may require a subversion of the broker role

42 J O U R N A L OF C O M M U N I T Y H E A L T H

of the crew leader or the creation of a new broker role for a migrant health specialist in camp or en route, with the grower's sanction. ''~ Harri- son does not, however, suggest how this change can be accomplished.

Any plan initiated to better the health care of migrants must take into account the resources and needs of the local community and region. Although the resources for health care in this agricultural area are sub- stantial, these respondents were not encouraged to share the same health facilities or health personnel used by the rest of the community. On the other hand, a major health care scheme that would be directed only toward the medical needs of the migrant farm workers in regions com- parable to this three-county area in northeastern Florida does not seem warranted or wise. Because the number of migrants has dwindled over the past few years and because of the variations in numbers throughout a year, any stable form of health care system that would be responsive only to migrant workers would be precluded. The problem of staffing public health clinics with professionals dedicated primarily to migrant health care has never really been solved.

Moreover, virtually all the concentrations of migrant workers occur in rural areas where there is already a scarcity of health services. What is really needed is a workable program of rural health services, with a particular emphasis on those geographic sections that include migrants. These programs should include the encouragement of small group prac- tices in rural areas by family physicians, an expansion of the National Health Service Corp (NHSC) in rural, medically underserved regions, and an increased use of the new health professionals, the nurse prac- titioner and the physician's assistant.

REFERENCES

1. Koos EL: They Follow the Sun. Jacksonville, Florida State Board of Health Monographs No 2, 1957.

2. Migrant Project: A Report of the Observations and Activities of a Public Health Team Working Directly with A~ricultural Migrant Laborers in Palm Beach Count~, Florida. Jacksonville, Florida State Board of Health, Bureau of Maternal and Child Care, Palm Beach County Health Department,1959.

3. Browning RH, Northcutt TJ, Jr: On the Season. Jacksonville, Florida State Board of Health Monographs No 2, 1961.

4. Comprehensive Health Planning Council of South Florida, Inc, Status Report: Development of a coordinated program of health services for the poor and near poor in South Dade, July 20, 1960.

5. Florida Migrant Health Project: Fourth Annual Progress Report 1966-67. Florida State Board of Health in Cooperation with U.S. Public Health Service.

6. Florida Migrant Health Project: Sixth Annual Progress Report 1968-69. Florida State Board of Health in cooperation with U.S. Public Health Service.

7. Harrison IE: The crew leader as a broker with implications for health service delivery. Presented at the 30th Annual Meeting of the Society for Applied Anthropology, Miami, Florida, 1971. P 6.

8. Schoonover RA: Health of the migrant farm worker. Florida Health Notes 63:61, 1971. 9. State of Florida Department of Health and Rehabilitative Services, Bureau of Comprehensive

Health Planning, Division of Planning and Evaluation: Physicians" Services to Migratory Farm Workers. Appendix B, 1971.

Migrant Health Care 43

10. Friedland WH, Nelkin D: Migrant: Agricultural Workers in America's Northeast. New York, Holt, Rinehart and Winston, 1971.

11. Caffery CV, Maycock TR, McGovern E, et al: The East Coast Migrant Health Project Mobile Team Report. Washington, D.C.: East Coast Migrant Health Project, 1971, Pp 6-7.

12. Northeast Agricultural Experiment Stations in Cooperation, Worker Questionnaire of the Farm Labor Survey. Institute of Food and Agricultural Services, GainesviUe, University of Florida, 1970.

13. Florida Health Study Program: Survey Questionnaire. Gainesville, College of Medicine, University of Florida, 1969-1970.

14. National Opinion Research Center: Health Opinions Questionnaire 4106. Chicago, University of Chicago, 1971.

15. Public Health Service: U.S. Public Health Interview Survey, Form HIS-1. Washington, DC, 1971. 16. Health Services and Mental Health Administration, Public Health Service: The Health and Nutri-

tion Examination Survey. Rockville, Md, 1971. 17. Health Se:vices and Mental Health Administration, Public Health Service: Community Health

Service St. ! ouis Survey Questionnaire (OMB No 68-$69050). Rockville, Md, 1971. 18. Schwab JJ, Warheit GJ: unpublished data from A Survey of Southern Mental Health Needs and

Services, privileged communication. 19. Nie NH, Bent DH, Hull CH: Statistical Package for the Social Sciences. New York, McGraw-Hill,

1970. 20. Data from the National Health Survey. Vital Health Stat No 97, 1971. 21. Banks SA: The meaning of deprivation: Health care attitudes of disadvantaged groups. In R

Reynolds (ed): The Health of a Rural County. Galnesville, University Presses of Florida, 1976. 22. Herman MW: The poor: Their Medical needs and health services. Ann Am Acad Pol Soc Sci

399:20, 1972.