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August 2015
Adreanne Waller, MPH – Washtenaw
County Public Health
Charo Ledón – Latino Community Health
Leader/Advocate
Daniel Kruger, Ph.D. – University of
Michigan, School of Public Health
LATINO HEALTH EQUITY IS ESSENTIAL FOR WASHTENAW COUNTY HEALTH, WELLBEING AND PROSPERITY: The Washtenaw County Encuesta Buenos Vecinos Collaboration
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This project was funded by the following: • U.S. Housing and Urban Development, Sustainable Communities Grant; Washtenaw
County Office of Community and Economic Development • University of Michigan Institute for Clinical Health Research • Michigan Department of Community Health • Washtenaw County Public Health
With most sincere gratitude to the Washtenaw County Latino Community and EBV survey respondents, as well as the dedicated EBV Community Leadership Team: Glenda Flores
Kate Lemler
Mikel Llanes
Mollison Morgan
Felipe Riaño
Leonardo Riaño
With additional appreciation for Sharon P. Sheldon,
Washtenaw County Public Health and Carrie Rheingans,
Interim Director, Casa Latina
Adreanne Waller, MPH – Author/Editor
Publication Date:
August 2015
Washtenaw County Public Health
De
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Table of Contents ABSTRACT .................................................................................................................................................. 4
EXECUTIVE SUMMARY .............................................................................................................................. 5
INTRODUCTION ......................................................................................................................................... 9
BACKGROUND ......................................................................................................................................... 10
ENCUESTA BUENOS VECINOS ................................................................................................................. 12
COMMUNITY ENGAGEMENT .................................................................................................................. 15
PILOT SURVEY.......................................................................................................................................... 17
IMPLEMENTATION SURVEY .................................................................................................................... 18
PILOT SURVEY – Results .......................................................................................................................... 19
IMPLEMENTATION SURVEY – Results ..................................................................................................... 20
COMMUNITY LEADERSHIP TEAM - Recommendations for Intervention................................................ 23
QUALITATIVE FINDINGS .......................................................................................................................... 23
DISSEMINATION PLANS ........................................................................................................................... 26
PROJECTS RESULTING FROM EBV ........................................................................................................... 27
LESSONS LEARNED .................................................................................................................................. 28
Appendix A. – Pre-Post Survey of EBV Community Leadership Team Members ................................... 30
Appendix B - ‘The Final Word from EBV Respondents’ ......................................................................... 33
Appendix C. – Action /Commitment Card Contacts................................................................................ 34
Appendix D. – EBV FREQUENCY TABLES – SELECTED RESULTS ............................................................... 37
Appendix E. – Scientific and Institutional/Agency Presentations – (To Date) ........................................ 40
ENDNOTES............................................................................................................................................... 42
Table of Figures
Figure 1 – Latino Contributions to Michigan Population ...................................................................... 9
Figure 2 – Births to Females With No High School Diploma: Washtenaw County 2000-2011 .......... 11
Figure 3 – Average Age of Death – Black, White, Hispanic: Washtenaw County Residents – 1970-2011
............................................................................................................................................................ 11
Figure 4 - EBV Pilot and Implementation Survey Timelines MICHR and HUD Grants ........................ 14
Figure 5 - Recruitment Flyer for EBV Survey ...................................................................................... 16
Figure 6 - Washtenaw County Distribution of Latino Residents by Census Tract - 2010 ................... 19
Figure 7 – Bonding, Bridging and Linking Framework ........................................................................ 17
Figure 8 - Final Sample Distribution - EBV Implementation Survey .................................................... 20
Figure 9 - Selected EBV Results - Health Status, Behaviors and Access to Care ................................. 21
Figure 10 - Selected EBV Implementation Survey Results - Neighborhood and Social Conditions .... 22
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Figure 11 - EBV 'Prioritizer' for Top Ten Issues ................................................................................... 26
Figure 12 – Sample Poster of ‘Top Ten Issues’ .................................................................................... 27
Figure 13 – Riano Draft Framework for Future of EBV Project ........................................................... 28
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ABSTRACT Title IV of the Affordable Care Act emphasizes the need to "... (P)rioritize strategies to reduce racial and ethnic disparities, including social, economic and geographic determinants of health..." as well as collecting "...data on race, ethnicity, sex, primary language and disability status....at the smallest geographic level..." During 2000-2010, the proportion of Washtenaw County Hispanics rose 125% and is projected to increase 233% between 1990-2035. Washtenaw Hispanics' births increased 151% between 2000-2009. This young and growing population is critical cultural and economic contributors to our local economy. The average age of death of Washtenaw Latinos (58 years) is 17 younger than for Washtenaw Whites and six years younger than Blacks. Access to healthy environments, social support and health care provides greater opportunity for mental and physical health, as well as productivity of these vital community members. To address the chronic lack of population health data on Washtenaw County Latinos, local public health, academics and Latino community collaborated on a community benefit driven assessment called Encuesta Buenos Vecinos (EBV). EBV was designed to assess and enhance the health, wellbeing, and social support of this population. Nearly 500 Washtenaw County Latinos responded to face-to-face, group and internet surveys. This report describes our unique multi-modal methodologies; the health equity and social determinant links between health behaviors, physical and mental health care access, social support, social capital and immigration and other cultural stressors in our Latino community; as well as discussion regarding our successful plan and commitment to community engagement, investment and benefit.
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EXECUTIVE SUMMARY Latino Have Become Increasingly Represented, Influential and Critical To U.S. Residents' Health, Well Being, and Prosperity. By 2060, estimates suggest that one of every three Americans will be Latino. In a much shorter horizon, estimates also suggest that by 2020, Hispanics and African Americans will comprise 30% of the U.S. labor force. Equitable opportunities for social, educational, employment, health and access to community resources increase the likelihood that the Latino population will be able to contribute fully to community prosperity and economic resilience. Washtenaw County is in the midst of a demographic shift where proportion of total County residents aged 25-44 decreased 10% between 2000 and 2010 comprise an increasingly smaller proportion of the total Washtenaw County population. This is critical given that this age group represents one of the most economically robust and income productive years in the employment lifespan. Potentially compensating for some portion of that demographic loss is the approximately 15,000 Washtenaw County Latinos, whose average age is six years younger than that for Whites. Economic Resilience is a Benefit of Health Equity - Communities that have less socioeconomic disparity have greater health and prosperity. Latinos in the United States have the lowest rates of controlled high blood pressure, highest proportion of uninsured 18-64 year olds, highest diabetes rates (age standardized) and highest occupationally related fatality rates compared to Whites, Blacks and other foreign persons working in the U.S. In Washtenaw County, Latino residents had an average age of death of 55 in 2010, which is 20 years younger than that for Washtenaw County Whites and seven years younger than for Blacks. Washtenaw County Latinos also have nearly twice the poverty and triple the high school dropout rate as Washtenaw County total population. The proportion of births to Washtenaw County Latinas with no high school diploma is 75% higher than for Black births and seven times higher than that for White births. “IF Michigan Is To Compete, We Have To Welcome The Investment, The Jobs, The Workers And The Ingenuity Of Immigrants And Refugees,” according to the Michigan Welcoming Director, Steve Tobocman, Welcoming Michigan is the foundation of a global economic growth strategy to return prosperity to our State. Clearly, Latinos, as well as other immigrant populations, will be powerful influences on success in Washtenaw County. As identified above, opportunities must be forged deliberately and equity challenges must be addressed in order to maximize the likelihood that these individuals will be able to contribute most fully to a prosperous community. Health and social determinant risk factors must be fully understood to most effectively address these issues.
Since 1995, Washtenaw County Public Health And HIP Partners Have Provided Leadership in executing a health assessment and planning process that includes a population wide survey of 2000 households called the Health Improvement Plan (HIP) survey. These data, along with hospitalization, birth and death certificate data, education, employment, etc., provide a broad picture of health needs in Washtenaw County. However, the survey sampling, which provides health related behaviors, access to care, physical and mental health status and social support metrics, consistently renders too few Latino respondents to make valid estimates about this population. As a result, community conversations and convenience sample surveys of the local Latino population were conducted. These activities, along with numerous anecdotal evidence from local clinicians and service providers identifying severe gaps in Latino health and access to community services, as well as HIP partners’ commitment to health equity and eliminating disparities, led to initiation of the Encuesta Buenos Vecinos (EBV – translated – ‘Survey of Good Neighbors’) project in 2011.
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HIP Partners Identified The Latino Population As A Priority Group In Washtenaw County as a result of the Michigan Department of Community Health Capacity Building Grant (CBG) to address health disparities,. Washtenaw County Public Health provided initial leadership and consulted with both Casa Latina (a Latino Community Based Organization) and the University of Michigan, School of Public Health for guidance on how to best proceed. The three entities forged a partnership, later called the EBV Project Leadership Team (PLT). The PLT applied for further funding (beyond the seed funding from MDCH) from the University of Michigan Institute for Clinical Health Research (MICHR) and the U.S. Department of Health and Urban Development to fund community engagement, a pilot EBV and full Implementation survey of 500 Latino Washtenaw County residents.
The Goals Of Project Included Assessing Health And Wellbeing Needs Of Latinos, As Well As Building Social Support And Social Capital In The Local Latino Population. Objectives focused on combining the research skills from the University of Michigan, School of Public Health, the epidemiologic, population health and community engagement expertise of WCPH and the knowledge, wisdom and experience of the Casa Latina leadership and staff to increase trust in the Latino community; provide valid and reliable data and information; examine health disparities and prioritize health needs; and build a foundation for future efforts to improve Latino health and wellbeing. The project was the first of its kind in Washtenaw County, as it focused its entire foundation on the engagement, guidance and participation of local Latino community members. These functions were provided by a core advisory group of local Latino community members called the EBV Community Leadership Team (CLT), professionals, volunteers, community advocates and service providers for Latinos.
In Order To Develop Culturally Sensitive Messaging, Enhance Community Trust And Build Optimism About The Benefits Of EBV, the PLT and CLT met weekly and bi-monthly. They focused their work on developing the EBV instrument; engaging community members, Latino businesses and agencies, and community partners who serve Latinos; and identifying appropriate sampling and survey administration methodologies. The groups developed text messaging list serves, hosted community meals and group gatherings to share information about the survey, as well as build trust and anticipation regarding the benefits of EBV. Survey topics included conventional public health behavior, access to care, mental and physical health status, but were also fortified with extensive item regarding social support, social capital, cultural stressors and neighborhood conditions. Items were prioritized that reflected local HIP survey items as well as national and state items providing comparable data. During June the August of 2013, CLT members administered 57 pilot surveys using individual, group and internet methods. Subsequently, survey respondents and administrators provided feedback on the EBV instrument, sampling methodology and survey administration methods. PLT members revised and translated the instrument and revised processes accordingly to prepare for the full EBV Implementation Survey (IS) that was administered to 487 Washtenaw County Latinos during September to December 2013. Sampling methods utilized the U.S. Census and American Community surveys to provide indicators of population density by zip code, and gender, age and education status distributions. CLT survey administrators provided daily and weekly reports of survey attempts and completions by zip code, education, gender and age to PLT to assure that respondent distributions reflected Census data as closely as possible.
Marketing Materials Focused On The ‘The Future Is In Our Hands!’ Messaging. The EBV took approximately 30 – 45 minutes to complete for group and individual surveys. Surprisingly, the most difficult methodology to attract respondents to was the internet. One repeating theme throughout the entire project was that many of these Latinos prefer face to face sharing, celebrating and interacting. Additionally, this is even truer when divulging sensitive information as items on the EBV. However, another surprise was how anxious many of these individuals were to discuss their health and life
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circumstances. In fact, despite anticipation that most Latinos would be wary and untrusting, they were quite enthusiastic, in most cases, to contribute to improving the Latino issues via the EBV. Marketing materials also highlighted that Casa Latina, which is familiar to many local Latinos, provided leadership and endorsement of the EBV. All materials were ipreduced in both English and Spanish and survey administrators were bilingual, group sessions were culturally sensitive regarding foods, locations, hospitality to family members, Latino neighbors shared information with other potential respondent neighbors for the door to door interviews, in addition to many Latino serving agencies and businesses were informed about the EBV. These all contributed to an effective marketing strategy and likely increased community trust.
The EBV Implementation Sample Distribution Indicated A Relatively Representative Sample Of
Washtenaw County Latinos across age, gender, education and cities, townships and villages, as a result
of the daily monitoring of target respondent categories by both CLT interviewers and PLT members,.
However, compared to the U.S. Decennial Census and American Community survey, our sample
indicated an underrepresentation of persons 65 and older, males, college educated, 18-29 year old
females, 48104 zip code (central Ann Arbor) and an overrepresentation of persons with less than high
school education, females 30-44 years, 48105 zip code (north Ann Arbor).
The EBV Survey Included Over 130 Questions Regarding Physical And Mental Health Status,
Social Support, Access To Health Care, Immigration Concerns And Neighborhood Conditions. These questions provide enormous analysis potential. Initial analyses were conducted and compared to
Washtenaw County Health Improvement Plan (HIP) 2010 survey data. Results indicate that Washtenaw
County Latinos have poorer overall health status, less access to health care, have greater overweight rates
and poorer nutritional status than Washtenaw County as a whole. Additionally, Washtenaw County
Latinos are less likely to identify that people help each other out in their neighborhoods, less likely to feel
safe walking in their neighborhoods, and are less likely to receive the emotional and social support that
they need compared to their non-Latino neighbors. The CLT reviewed the survey data and identified the
initial ‘Top Ten’ priority issues based on agreed upon criteria. Criteria included: 1) frequency, 2)
severity, 3) ability to intervene. The top ten issues that they CLT identified include six more conventional
public health issues and four specifically focused on the social determinants of health): substance abuse,
unplanned pregnancy, healthy nutrition, physical activity, depression, access to dental and vision care,
access to English language learning, access to community services, parental influence and access to
education.
In June 2014, The CLT And PLT Began Numerous Presentations To The Latino Community, Institutions And Agencies That Serve Latinos, As Well As The Scientific Community. These presentations include recommendations that the CLT identified for organizational, academic and community approaches to these issues. As of this printing, there have been approximately 30 community based, health care, governmental, academic, scientific and Latino community presentation covering various aspects of the EBV project results. Additionally, there have been numerous projects and grants submitted and funded resulting from the EBV project. Funded grant projects include those focused on key social determinants of health including high school graduation, access to healthy foods, increasing social support and social capital. Further, research projects that have been generated as a result, mostly at University of Michigan include study of frequent mental distress, immigration concerns, health care utilization and academic and community partnerships associated with Latino health.
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The EBV Project Met Its Goal Of Increasing Social Support And Social Capital For Washtenaw County Latinos. The EBV produced increases in both social support (individual connections) and social capital (access to community resources) as evidenced in EBV survey respondents, Community Leadership Team members and PLT members and partner organizations. As CLT members met with survey respondents, they described many discussions regarding the enthusiasm of the Latino community members regarding their gratitude for being asked for their input, for being given a ‘voice,’ for no longer being ‘invisible,’ and for being given the opportunity to improve life in Washtenaw County. The CLT members, in pre and post intervention evaluations described that they felt like they were an important part of the EBV process, able to make connections with other Washtenaw County Latinos, better able to understand the needs of Latino community members and helped Washtenaw County Latinos to unite. Further, CLT members developed technical, leadership and presentation skills; were invited to be members of Ypsilanti School Board advisory group, increased access to Habitat for Humanity for Latinos, and gained employment in community based organization (Growing Hope) as well as community partnership grant at Ypsilanti Community Schools. Finally, as a result of the Casa Latina leadership, the Ann Arbor Transportation Guide was translated into Spanish and a text messaging service for Washtenaw County Latinos was developed. Even beyond the grant period, the CLT continues to vision and strategize regarding future plans for this initiative. Current focus is on increasing education, employment and access to healthy food.
Lessons Learned – The EBV project was a remarkable opportunity to know, listen and understand our local Latino neighbors. This has already reaped numerous benefits and will continue to do so in the future. One key finding was that effective, genuine and mutually beneficial community engagement requires extensive time and space. Time must include beyond the typical Monday through Friday, 9-5 workday. Space must include hospitable environments such as homes, kitchen tables, room for extended family members to attend, etc. The EBV partnership was novel given the participation of government, community and academia. These partnerships have great potential for improving health, but require great sensitivity to demands and incentives for each partner organization. The EBV project was aptly aimed at increasing social support and social capital, in addition to assessing Latino health. The enormous advantage of increasing social support and capital is that the Latino community is much better positioned and empowered with relationships, data, resources, and skills to improve life in Washtenaw County FOR AND BECAUSE OF LATINOS.
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INTRODUCTION – According to the U.S. Census Bureau, the proportion of Hispanics in the United States is expected to double between 2012 and 2060, from 53.3 million to 128.8 million, respectively. In other words, one in three U.S. residents will be Latino by 2060, compared to one in six in 20121. In Michigan, the proportion of Hispanics more than doubled between 1990-20132. Further, as seen in Figure 1, as of 2004, Latinos contribution to the Michigan population exceeded those of non-Latinos. According to PEW Research Hispanic Trends Project3, 78% of Michigan Latinos were native born and 73% were of Mexican heritage in 2011. Approximately one-third of Michigan Latinos live below the poverty level and over half live in homes where languages other than English only are spoken. DISPARITIES AFFECT COMMUNITY PROSPERITY - In order for Latinos to have optimal for health and wellbeing, in addition to contributing positively to their communities and neighborhoods, it is critical to assure the opportunities and circumstances that enable such prosperity. Unfortunately, persistent national and statewide inequities exist regarding Latino health. According to the U.S. CDC4, the following health disparities exist for Hispanics compared to Black and White, non-Hispanics in the U.S.:
One-quarter of Latino U.S. workers are employed in high risk occupations (excessive unintentional and intentional injuries and illnesses), nearly double the proportion for White, non-Hispanic workers (13%).
During 2005-2009, Hispanic workers had the highest occupationally related fatality rates compared to Whites, Blacks or other foreign persons working in the U.S. The majority of these injuries occurred in mining, agriculture or construction related jobs.
Persons from Spanish speaking (only) homes have the highest proportion of living within 150 meters of a major highway (2010).
Hispanics have lowest proportion with recommended colon cancer screening for 50-75 year olds (2010),
Highest proportion of uninsured for 18-64 year old adults (2010).
Figure 1 – Latino Contributions to Michigan Population
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Lowest proportion of 18-49 year olds for recommended influenza vaccine coverage (2010-11),
Highest birthrates for 15-19 year olds (2010).
The highest age standardized prevalence rate of adults diagnosed with diabetes (2010);
Double the White rate for severe periodontitis for adults older than 29 years (2009-10);
Lowest proportion of controlled blood pressure among adults ever diagnosed with hypertension (2007-2010).
EDUCATION AND POVERTY DETERMINE HEALTH AND WELLBEING - Probably the greatest contributing factor in these inequities is the fact that Hispanics have the greatest proportion of adults 25 years and older who do NOT have a high school diploma (2011). Their rates are seven times higher than that for White adults and double that for Black adults. According to the U.S. Centers for Disease Control and Prevention5, “Health equity (is)… "the absence of systematic disparities in health between and within social groups that have different levels of underlying social advantages or disadvantages—that is, different positions in a social hierarchy.” Social determinants of health such as poverty, unequal access to health care, lack of education, stigma, and racism are underlying, contributing factors of health inequities. While the vast majority of U.S. health resources are directed toward health care, according to the CDC, less than a quarter of the determinants of population health are medical care. Over a half of these determinants are social, societal or ecological.
ECONOMIC IMPACT - By 2020, the U.S. Department of Labor projects, Hispanics and Blacks will comprise 30% of the U.S. labor force. These two groups have the lowest proportion of high school graduates6. The potential impact on our ability to have young people prepared for employment, as well as higher education is of critical consequence. Further, Latinos will not only have a huge impact on our labor force, but also, by 2018, Latinos will possess 10% of the nation’s purchasing power7. According to the Partnership for a New American Economy, 28% of all business startups in 2011 were started by immigrants8. It is critical to our national, state and local communities and economies that Latinos have access to equal opportunities for education, health and wellbeing in order to be adequately prepared for this horizon. According to Welcoming Michigan Director Steve Tobocman, “If Michigan is to compete, we have to welcome the investment, the jobs, the workers, and the ingenuity of immigrants and refugees. Welcoming Michigan is the foundation of a global economic growth strategy to return prosperity to our state9.
BACKGROUND SHIFTING DEMOGRAPHICS - Washtenaw County demographics are in the midst of a major shift. While non-Hispanic whites comprise an increasingly smaller proportion of the total population, Hispanics comprise increasing numbers and proportions. According to the 2013 American Community Survey10, approximately 16,000 Latinos live in Washtenaw County. This number includes the 1.5% undercount suggested by the Census Bureau11 For instance, according to the South East Michigan Council of Governments (SEMCOG), between 2000 and 2010, Washtenaw County Whites’ proportion decreased by 5% (75.9% to 72.1%), compared to a 125% increase for Hispanics (2.7 to 4%)12. Wayne State University, Center for Urban Studies projects that the proportion of Hispanics comprising the Washtenaw population will increase 233% between years 1990-2035. (In fact, these estimates are conservative given that they pre-dated that 2010 Census and underestimated the actual 2010 Washtenaw Hispanic population13.) In particular, during 2000-2010, the proportion of Hispanics increased over 50% in Ypsilanti City and 64% in Ypsilanti Township14.
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Besides the racial shift, the age structure for Washtenaw County is transforming. In particular, the proportion of total County residents aged 25-44 decreased 10% between 2000 and 201015. This is critical given that this age group represents one of the most economically robust and income productive years in the employment lifespan. Potentially compensating for some portion of that demographic loss, Washtenaw Hispanics have much younger average age, 29.3 years, compared to 35.3 for Whites. Fertility is also affected by this younger age structure. Birth and Death Rates - The number of Washtenaw Hispanics' births increased 68% between 2000-2011 compared to only a 10% increase for Black births and a 13% decrease for White births16. Washtenaw County schools Hispanic enrollment increased 30% from between 2009/10 and 2013/1417. The proportion of Washtenaw residents’ Hispanic births to mothers with no high school diploma was 28% in 2011 compared to 4% for Whites and 16% for Black births18 (See Figure 2 below). Further, Births to women less than twenty years who were giving birth to a child of second order or higher was 35% for Hispanic births, 20% for Black births and 11% for White births19.
Finally, according to the Michigan Department of Community Health, the average age of death for Washtenaw County Latinos was 55 years in 2010. This is 20 years younger than that for Washtenaw County Whites, 7 years younger than that for Washtenaw County Blacks (See Figure 3 below). Employment, Education and Poverty - According to the U.S. Census, American Community Survey20, although half of White males and females are in
management, professional or related occupations,
approximately a third of Latino/as are in management or professional occupations. Poverty rates are nearly twice as high for Latino/as (21%) as Whites (12%). However, only 15% of Latino/as have received food assistance in the past year. Latino adults aged 18-64 years are significantly less likely to have health insurance (9%), compared to White adults (22%). These social disparities likely have a critical impact on individuals’ and communities’ awareness and ability to access community resources necessary for health and well-being. According to the American
Community Survey, 5% of Washtenaw County
residents 25 years and older have not attained a high
school diploma compared to Latinos with triple the
rate at 16%21
.
Figure 2 – Births to Females With No High School Diploma: Washtenaw County 2000-2011
Figure 3 – Average Age of Death – Black, White, Hispanic: Washtenaw County Residents – 1970-2011
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WASHTENAW COUNTY PUBLIC HEALTH PRIORITIES - In 2006, the Washtenaw County Health Improvement Plan (HIP) project, identified ‘depression and social support’ as a key focus area for its work. This action, along with the HIP partner’s commitment to health equity and eliminating health disparities, led to MDCH Capacity Building Grant project to enhance communities’ capacity to address health disparities and inequities. The CBG grant included a partnership across health care providers, non profit agencies and lead by Washtenaw County Public Health. Consequently, the partners identified the need for enhancing health and well being information regarding the Washtenaw County Latino population. Previously, standard behavioral risk factor surveys (Washtenaw HIP Surveys) have not rendered useful responses from the Latino population. This is largely due to both community trust issues in addition to the HIP survey being conducted only in English. The ensuing Latino Health Survey, called Encuesta Buenos Vecinos (EBV) additionally entailed a long and successful partnership between the local Latino community, Washtenaw County Public Health, Casa Latina and University of Michigan, School of Public Health. Two Latino Community Conversations held during 2009-10 as part of Washtenaw County Public Health’s participation in the Michigan Department of Community Health’s (MDCH) Health Disparities Planning grant program. The Conversations were well-attended, qualitative discussions of various factors facing Latino/as and their health status that took place at trusted community locations. These Conversations revealed two primary social determinant challenges in the Washtenaw County Latino community: 1) lack of transportation access and 2) lack of community cohesion and connectedness. Particular issues that participants described regarding transportation challenges include lack of driver licenses, profiling of Latino/as drivers, lack of information about bus routes, language barriers, and incompatible and inconvenient bus routes. These issues are particularly significant given that 15% of Washtenaw Latino/as use public transportation to travel to work, compared to only 3% and 6% for Whites and African Americans, respectively. Further, these Community Conversations were instrumental in determining priorities for the Capacity Building and Implementation phases of the MDCH Health Disparities grant program.
ENCUESTA BUENOS VECINOS PARTNERSHIP - In 2011, Washtenaw County Public Health Epidemiologist, Adreanne Waller, and Charo Ledon, Executive Director of Casa Latina, proposed that one aspect of the ‘Capacity Building Grant’ partnership should include exploring the possibility of conducting a comprehensive, representative survey of Washtenaw County Latinos. Washtenaw County Public Health provided initial leadership and consulted with both Casa Latina (a Latino Community Based Organization) and the University of Michigan, School of Public Health for guidance on how to best proceed. The three entities forged a partnership, later called the EBV Project Leadership Team (PLT). The PLT discussed detailed plans for how to engage the Latino community in a culturally sensitive manner, necessary steps for creating a comprehensive instrument and the advantages and disadvantages of having the community conduct the survey or to hire a survey research firm. FUNDING - After consultation with local experts, the group decided that 500 completed surveys would be necessary to provide an adequate representation of Washtenaw County Latinos. The group further decided that the only culturally competent method to complete this project would be to have community members conduct the survey. Further, because of the cultural and language barriers, in addition to the comprehensive nature of the survey, the group decided that a pilot survey would be necessary to conduct prior to the full survey. Therefore, the organization partnership applied to the University of Michigan Institute for Clinical and Health Research – (Community University Research
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Partnership (CURES)) to fund community engagement and pilot survey. The partnership proposed to be part of the Housing and Urban Development Sustainable Communities grant application to fund the full Implementation survey. STRUCTURE - The CURES funding application was awarded in 2012. Daniel Kruger and Adreanne Waller were named as Co-Principle Investigators and Charo Ledon was named and Community Investigator. The three partners, along with Sharon Sheldon, Program Administrator for Health Promotion/Disease Prevention at Washtenaw County Public Health, established the Project Leadership Team (PLT). GOALS/AIMS - The primary goals of the CURES and HUD projects was to assess health and wellbeing, as well as build social support and social capital in Washtenaw County Latinos. The specific aims included:
Combine the research skills of University of Michigan faculty, practical expertise of Washtenaw
County Public Health staff, and the knowledge, experience, and wisdom of Casa Latina staff and other representatives from the Latino/a focus population to increase public trust and participation in projects improving local health conditions.
Provide systematic data on health and health related issues in the Washtenaw County Latino/a population. These data will include: a) health related knowledge, attitudes, beliefs, and behaviors; b) Access to health care; c) Sources of health information; d) Disease diagnoses and maintenance of chronic health conditions; e) Social and neighborhood conditions; and f) Other environmental or socio-demographic factors related to health issues and outcomes.
Examine local health disparities and factors related to local health disparities.
Build a foundation for future efforts improving Washtenaw County Latino health and wellbeing.
DEVELOPMENT - The PLT initial tasks included naming the project, drafting topics and survey items, establishing a Community Leadership Team, raising awareness throughout the community, (institutional and Latino residents), identifying methodology necessary to elicit representative survey response and identifying recruitment methods, IRB Human Subjects Review approval, as well as identifying timeline for both the Pilot and Implementation surveys.
a. PLT members initially selected the name ‘Buenos Vecinos’ (Good Neighbors) Survey (BVS) as the working title of the project. The name was selected as it reflected both Washtenaw County and Latino neighbors involved and benefitting. CONTENT - PLT members identified a list of proposed topics to include in the instrument. They considered the following criteria when selecting topics, as well as items: 1) comparable to other local data, in particular the Washtenaw County HIP survey, 2) focus on social support and social capital, 3) cultural sensitivity, 4) potential for prevention intervention, 5) reasonable survey length, 6) reflects local health priorities, 7) reflects the principles and goals of the CURES and HUD Sustainable Communities initiatives, and 8) previously tested for validity and reliability. PLT identified the following topics as relevant for the BVS instrument.
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Health-related knowledge, attitudes, beliefs Health-related behaviors (nutrition, exercise, smoking, etc.) Diagnoses and maintenance of chronic health conditions Access to health care Sources of health information Family planning Child health Social support and conflict Social cohesion, social capital, community engagement Social and neighborhood conditions Healthy food access Affordable housing availability Discrimination Economic opportunities Immigration/migration Language and acculturation
TIMELINE – PLT identified estimated timeframe for both Pilot and Implementation Surveys. These are included in Figure 4 below:
Figure 4 - EBV Pilot and Implementation Survey Timelines MICHR and HUD Grants
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COMMUNITY ENGAGEMENT COMMUNITY LEADERSHIP TEAM – The PLT members identified first the need to establish relationships with key community stakeholders and members to 1) provide leadership 2) provide input into the survey instrument, 3) work with the community to elevate trust and recruit survey respondents, 4) explore survey vendor candidates, and 5) administer surveys. Charo Ledon, as key community leader and Executive Director of Casa Latina, Community Co-Investigator on BVS, provided the primary contact between the PLT and Latino community. The PLT hosted two evening meetings to recruit CLT members. Latino community members, business owners, non-profit agency representatives, religious institution representatives, academics and those working on projects focused on serving Latinos were invited to November and December 2012 meetings. Meeting agendas included introductions, purpose of the survey, CLT roles and responsibilities, distribution of draft instrument topics items, question, answer and feedback, as well as a request to complete a commitment card identifying willingness to be involved. Both meetings had a total approximately 40 attendees. Attendees provided thoughtful and meaningful input and leadership that provided guidance for the entire project. Details included in ‘Cultural Sensitivity’ section below. CULTURALLY SENSITIVE MESSAGING - CLT members met on both bi-monthly and monthly basis during January 2012 through December 2014. Approximately ten dedicated community members, with some attrition and addition during the 2012-2014 periods, provided critical input on how to engage Latino community members as well as how to recruit survey respondents. A group of students from the University of Michigan, called the Public Health Assistance and Support Team (PHAST), participated and assisted in a specific brainstorming session to generate marketing ideas. Further PLT meetings included significant discussion of how to connect with the Latino community. The following common themes emerged from these discussions:
Necessity for Bilingual materials and communication, including survey Translated materials and survey items must not only be grammatically correct, but also
culturally comparable Appropriate literacy level for materials and survey Must establish certainty and trust regarding confidentiality Oral tradition Individual relationships Sharing typically happens at parties, sporting and gatherings in the home Focus on having involvement, optimism and determination in their future Build on community familiarity with Casa Latina Latinos are a diverse group Limit survey questions that may elevate immigration fears Work with agencies that already have community connections, i.e. WCHO, churches, Catholic
Social Services, employers Limit length of survey Younger Latinos may prefer social media or internet based survey; older Latinos will prefer face-
to-face interaction Spanish media would be optimal (radio, TV or newspaper) – very limited availability Buenos Vecinos Survey was modified to Encuesta Buenos Vecinos (EBV) to reflect fidelity to
Spanish language, rather than using a hybridized title. These principles were used in all of the written, verbal and presentation materials throughout the project. See Figure 5. This is an example flyer recruiting survey respondents for the EBV Pilot survey that integrates many of the principles identified above. The flyer was translated into Spanish as well.
16
RAISING AWARENESS IN THE INSTITUTIONAL/AGENCY COMMUNITY - In order to inform institutional community members, especially those who serve Washtenaw County Latinos, the PLT presented information about EBV to numerous organizations. Additionally, these organizations and agencies could provide critical input regarding how to access Latinos, unmet needs, potential challenges and opportunities, as well as suggestions regarding contacting other Latino serving organizations. These presentations included the University of Michigan Minority Health Research Program, the Washtenaw County Health Improvement Plan (HIP) Community Health Committee, Catholic Social Services Board, Casa Latina Fiesta, the HUD Sustainable Communities partner projects, as well as the University of Michigan Clinical and Health Research, Community Engagement Council, among others. These presentations and presence enhanced recognition and endorsement of critical agencies and associated populations. SOCIAL SUPPORT AND SOCIAL CAPITAL – Bonding, Bridging and Linking - Building social support and social capital can occur at numerous levels. Our approach for understanding and targeting these changes included the concepts of ‘Bonding, Bridging and Linking.’ ‘Bonding’ occurs when like individuals connect with like individuals, such as when a community member surveys a neighbor. ‘Bridging’ occurs when like, but distant community members connect with like, but distant community members. This occurs between community members enhancing career skills through survey training, as well as those who meet at EBV events. ‘Linking’ occurs when unlike and distant community members connect with unlike and distant community members or agencies. For instance, linking occurs when community groups like Casa Latina collaborate with community organizations like AATA (Ann Arbor Transportation Authority) to translate the ‘Ride Guide’ to increase access to public transportation for Latinos. Individual relationship bonding strengthens a united front,
Figure 5 - Recruitment Flyer for EBV Survey
17
trust and sharing. Bridging enhances group strength, diversity, job skills, community organizing, equity and adaptation. Linking fortifies community strength, access to power and resources, even beyond immediate community).
SOCIAL SUPPORT AND SOCIAL CAPITAL - Community Leadership Team - Numerous items on the EBV were included to measure survey respondent’s social support and social capital status. However, since part of the project goals was to not only measure these characteristics in the Washtenaw County Latino population, we also wanted to build social support and social capital as a result of the project. One approach to doing this was to design and administer a pre and post
survey of the CLT members to identify rationale for being involved and perceptions of social support and social capital. This survey is included in Appendix A.
PILOT SURVEY – Development - The PLT elicited and received ongoing feedback and revisions on the EBV from the CLT between January to April 2013. Concurrently, during January 2013 – March of 2013, the PLT designed and executed survey administration trainings, led by Dr. Kruger. The project also applied and was granted approval from the University of Michigan Institutional Review Board (IRB). Further, an informed consent form, in both English and Spanish were approved by the IRB. Also during that time, PLT and CLT identified three primary survey methodologies, 1) face to face (individual), 2) group sessions, and 3) internet. Locations and organizations such as churches, community centers, mobile home courts, etc. were approached, educated and informed regarding the benefits of hosting or allowing group or door to door pilot survey administration. Charo Ledon provided translation and back translations (for validation) for the pilot EBV. Finally, 60 Target gift cards were purchased to provide incentives for Pilot survey respondents.
PILOT SURVEY – Results – Fifty-three surveys were completed during June and July of 2013, approximately 1/3 for each of the three methodologies. Key data highlights from the Pilot survey included (with comparisons for Washtenaw total population – HIP 2010 Survey):
30% have been diagnosed with depression - (22% for Washtenaw)
9% have been refused health care
25% could not get medical care because of the cost (10% for Washtenaw)
33% could not get dental care b/c of cost 5. 44% have been diagnosed with high cholesterol (29% for Washtenaw)
25% rarely or never get emotional support that they need (5% for Washtenaw)
Figure 6 – Bonding, Bridging and Linking Framework
18
32% treated with less respect than others more than once a month
18% are called names or insulted more than once a month
Over half speak English fairly, poorly or not at all
Approximately 1/3 read English fairly, poorly or not at all
Almost 40% feel unable to help their children with problems sometimes, often or always
Nearly 40% feel what they say will not influence whether their child uses drugs (10% for Washtenaw)
11% of their kids have attempted suicide, 11 % are afraid to go to school PILOT SURVEY – Feedback And Revisions - CLT survey administrators provided suggestions regarding adding questions regarding mental health services and desire to see a united Latino community in Washtenaw, among others. They also recommended that in some cases, the survey, especially face-to-face, when reading the questions to a respondent, was very lengthy. However, in other cases, when more literate respondents were able to take the survey on their own, in the presence of a survey administrator, much faster. They also suggested that letting families in neighborhoods know that they will be in the neighborhood, allowed for respondents to notify other friends and family of the opportunity to complete the survey. During September 2013, the PLT presented Pilot survey findings to the CLT. CLT provided feedback on their experience administering surveys to the 57 respondents (including internet based surveys). Primarily, this included survey item related input as well as process and methodology. Regarding instrument input, survey administrators (CLT) suggested that the instrument should include enhanced social support, social capital, Latino community unity and eviction related items. Regarding process, CLT members identified that incentives ($30) gift cards were an important gesture and signified our appreciation to the community. However, many respondents were so grateful to be able to take the survey and provide their input and have a voice; they may have completed the survey without such incentives. For community members who were not interested in participating, the incentive gift card was not adequately persuasive. According to one CLT member:
“It’s something that you feel when you are in a church or other group survey setting. People are very enthusiastic and excited that their voice is being heard and that these Institutions (WCPH, UMSPH and CL) want to hear their voice and that their voice may have an impact. No one has ever asked them before.” (Translation from Spanish)
Regarding methodological issues, surprisingly, the internet based surveys were the most difficult to have completed in the Pilot survey. While we expected this avenue to be most amenable to younger Latino adults, it bore out the message that we learned early on that many Latinos in this population prefer face-to-face, individual oral communication.
IMPLEMENTATION SURVEY – Revisions & Administration– During September to December 2013, after suggestions from CLT (above) were integrated into the survey and methods, CLT survey administrators, who were not previously trained during the Pilot Phase, participated in training, and again led by Dr. Kruger. In order to assure adequate and representative sampling distribution, PLT members developed targets for survey completions by age range, gender, educational attainment and zip code of residence based on U.S. Census, American Community Survey estimates. (Figure 7 for Census Tract Map). Weekly reports guided CLT members regarding areas and demographic groups that needed
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Number Latino Population by Census Tract
Waller, A...number latino.mxd 7/23/12
Number of Hispanic/Latino/a by Census Tract - 2010 Census
WGIS.CensusTracts_Demographics
TOTAL_HISPANIC_LATINO
13.000000 - 40.000000
40.000001 - 72.000000
72.000001 - 105.000000
105.000001 - 174.000000
174.000001 - 345.000000
WGIS.Cities_Villages_point
WGIS.CntyPrimaryRds
WGIS.Census_Tracts
more or less intensive sampling. Similar to the Pilot survey, targets also included 1/3 face-to-face (individual), 1/3 group and 1/3 internet completions for 500 surveys.
PILOT SURVEY – Results - As seen below in Table 8, the final EBV Implementation Sample Distribution tables indicate a relatively representative sample of Washtenaw County Latinos, with the following exceptions:
Underrepresentation of persons 65 and older, males, college educated, 18-29 year old females, 48104 zip code (central Ann Arbor)
Overrepresentation of persons with less than high school education, females 30-44 years, 48105 zip code (north Ann Arbor)
Figure 7 - Washtenaw County Distribution of
Latino Residents by Census Tract - 2010
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Figure 8 - Final Sample Distribution - EBV Implementation Survey
For the purposes of the initial analysis, the PLT decided to not use statistical weighting to adjust the sample to the U.S. Census or American Community Survey. The sample of 487 Latinos closely reflected the Census data, with a few exceptions identified above. Further, weighting data for the initial analyses and presentations to the community might be confusing and introduce a sense of misrepresenting results. Further, weighting survey data to match ACS or Census data may be considered inaccurate since Latino populations have reputed consistently underrepresented in completing Census surveys. Our primary goal with initial analyses was to maintain as much transparency as possible. Future analyses can certainly implement weighting variables. IMPLEMENTATION SURVEY – Results - The EBV instrument included over 130 items. The frequency tables for selected results are included in Appendix D. However, some data highlights are included in Figure 9 and 10 below. Figure 9 focuses on traditional health status, access to care and health behaviors. The EBV results are compared to the Washtenaw County Health Improvement Plan (HIP) results for 2010. HIP results represent the total Washtenaw County population. As seen below, the EBV data suggest that Washtenaw County Latinos have poorer overall health status, less access to health care, have greater overweight rates and poorer nutritional status than Washtenaw County as a whole.
21
Regarding neighborhood conditions and social conditions, Figure 10 below identifies that Washtenaw County Latinos are less likely to identify that people help each other out, less likely to feel safe walking in their neighborhoods, and are less likely to receive the emotional and social support that they need compared to their non-Latino neighbors. Further, while no comparable data exist for the non-Latino Washtenaw County population, 40% of Latinos feel that their level of English makes interacting with others difficult and a quarter have difficulty finding legal services.
Figure 9 - Selected EBV Results - Health Status, Behaviors and Access to Care
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Given that the CLT planned to disseminate findings to both the institutional and Latino communities, they sought to find a way to distill enormous amounts of data from over 130 EBV survey questions and nearly 500 respondents. The EBV CLT decided to review survey data and identify the initial ‘Top Ten’ priority issues based on agreed upon criteria. Criteria included: 1) frequency, 2) severity, 3) ability to intervene. Most of the EBV CLT members had never reviewed vast amounts of data (or any data tables) in the past. PLT members provided brief training on how to review frequency tables. Results of those reviews, which included numerous meetings and discussion, resulted in identification of the following ‘Top Ten’ priority issues to initiate action:
Figure 10 - Selected EBV Implementation Survey Results - Neighborhood and Social Conditions
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Lack of physical activity Unintended pregnancy Poor nutritional habits Depression Substance abuse Poor vision and dental care Lack of community organization Low level of education Lack of parental attention, guidance and involvement Low English proficiency
COMMUNITY LEADERSHIP TEAM - Recommendations for Intervention - CLT also developed a set of recommendations for researchers, institutions and organizations to enhance connection, service and opportunity regarding the Washtenaw County Latino community. Some of these items require no new resources, some require significant resources and may require further collaboration and partnerships to achieve or share resources:
Washtenaw County Community Agencies and Government
1. Intervention partnerships – For example, Jovenes Tejedores (Young Weavers, partnership between Latino Community members, WCPH, Corner Health Center and Ypsilanti Community Schools
2. Leadership Development in Latino community – For example, the EBV project 3. EBV dissemination, community engagement, intervention planning and replication to allow
monitoring progress Academic Institutions and Partnerships
4. Partnerships to generate research from current EBV data – For example, CIRLI (Coalition of Interdisciplinary Research on Latino/a Issues) faculty at University of Michigan
5. Generate future research projects which explore Latino health and wellbeing in further depth – For example, relationships between high school graduation, optimism and birth intervals
Organizational Structure and Resources
6. Hire or partner with other organizations to support Spanish speaking or bilingual community health advocates or community health workers
7. Train and hire Spanish speaking physicians, mental health providers and dentists 8. Reduce barriers to Latinos contributing and benefiting from community resources by
requiring social security number only when completely necessary. – For example, applications to volunteer, register for youth activities or continuing education
9. Identify and train at least one person in organization to provide liaison and cultural sensitivity assurance to increase access for Spanish speaking residents.
QUALITATIVE FINDINGS – CLT Membership – As described above, in order to additionally assess effects of the EBV project and process on CLT member’s social support and social capital a Pre and Post
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Participation Process Feedback survey was administered to CLT members. Highlights of the survey include that, CLT members:
Are most likely to contact a friend, family member or neighbor when needing help (rather than institutions or agencies)
Identify that Latinos are most likely to access spiritual, employment, health services or entertainment resources for help
Identify that Latinos are least likely to use political, mental health, public safety or immigration resources for help
The reasons that CLT members are most willing to be involved in EBV: o Want to increase opportunities for a good life in Washtenaw County o Need to make connections in Latino communities for current and future work o Socializing and sharing meals with other Latinos
The greatest benefits for CLT members to be involved in EBV: o Making connections with other Latinos o Better understanding Latino needs o Meeting with other Latinos o Helping Washtenaw County Latinos unite
Overall, CLT members agreed that EBV leadership made them feel like an important part of the process
All CLT members identified that the EBV team understands the Latino community, values, culture, people and habits
QUALITATIVE FINDINGS – EBV Survey Respondents - While the majority of the EBV 135 question items were scored quantitatively, there were a number of questions that requested open-ended responses regard three questions: 1) What do you think about this survey, 2) What other issues exist in your neighborhood or community, and 3) What other issues are important that we did not ask about? Appendix B includes a consolidation of the open ended responses from these questions. The information in this document, entitled ‘The Final Word,’ may be one of the most critical findings in the entire project. While there are numerous themes throughout, a few dominant ideas emerge:
Gratitude for being asked to participate
Gratitude for being given a voice and being acknowledged
Gratitude for no longer being invisible
Being poor or uninsured is expensive, for everyone
Emergency rooms are not the optimal location for preventive care
Latinos are forced to ignore important health issues until they become dire and debilitating
Lack of Spanish speaking providers, including mental health care, severely limits Latinos ability to be healthy for work and home life
Neighborhoods where they live are often dangerous, drug trafficking, poorly lit, poorly maintained housing
Social cohesion is severely limited due to neighborhood conditions
Latinos do not access community services due to immigration concerns, language barriers and lack of awareness
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Latinos want Washtenaw County to be a better place for and because of Latinos.
QUALITATIVE FINDINGS – Social Capital Effects – A number of social capital benefits resulted from the EBV work that are likely to have lasting effects in the community. These include:
Greater understanding of culturally sensitive messaging
Enhanced connections between Washtenaw County Latinos who met as a result of EBV
Group text messaging list developed to communicate with Latino community members
Ann Arbor Transportation Authority Ride Guide translated into Spanish
CLT members’ connections and relationships with governmental leaders, community agencies and academic institutions and faculty
CLT members being asked to serve on school boards and other advisory bodies
Greater understanding of challenges and opportunities regarding community/governmental/academic partnership, including increased appreciation for demands and investment incentives for each
,
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DISSEMINATION PLANS – PLT and CLT dissemination of initial EBV results for Latino, Institutional and Academic communities. The groups planned to present the ‘Top Ten’ issues to the Latino community at a June 1 event, prior to the Institutional presentations so that Latino community feedback and response could be included at the broader institutional and academic presentations. The first community presentation, June 1, 2014 community roll out event, took place at St. Mary’s Church in downtown Ann Arbor. Longer term plans included numerous community events around the County to ensure adequate community response to survey findings and Top Ten priority issues. CLT members designed a sophisticated priority setting system so that community members could vote for their ‘Top Three’ issues based on information and discussion. (See Figure 11 for picture of the ‘Prioritizer.’ The June 1 event included dinner, a large group discussion, small group discussions and prioritizing regarding the ten issues presented by CLT members in Spanish. Additionally, PLT members created posters for each of the CLT Top Ten. The posters included the issue selected, disparities between groups, comparisons to the total
Washtenaw County population, risk factors associated with the issue, as well as evidence based interventions, all in Spanish. DISSEMINATION PLANS – Latino Community - Unfortunately, CLT targeted to have 30 or more community attendees, only approximately 15 attended. Nevertheless, discussion and input on each of the ten issues was rich and valuable. The Latino community members in attendance selected ‘Access to Education,’ ‘Healthy Nutrition,’ and ‘Parental Influence’ as the Top Three priorities. PLT and CLT plans to continue to disseminate findings to Latino community members to both raise awareness of issues, elicit feedback on Top Ten, as well as encourage further participation in future related work.
ii. DISSEMINATION PLANS – Institutional and Agency Community - The initial institutional presentation occurred on June 10, 2014 at Washtenaw Community College. The Washtenaw County Health Improvement Plan (HIP) Community Health Committee (CHC) sponsored the event. Invitees included CHC members, Washtenaw Health Initiative members, non-profit agency leaders, schools, government, business and academic leaders. The event was attended by nearly 200 community leaders. It included the Top Ten posters (in English) as described above (See Figure 12, presentations on EBV, including community engagement and comments from Community Leadership Team members. Further presentations from PLT members included background, funders, survey content, methodology, findings,
Figure 11 - EBV 'Prioritizer' for Top Ten Issues
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and requests to attendees for future participation in subsequent interventions needed in the local Latino community. Finally, the even concluded with requests for attendees to complete ‘Action/Commitment Cards’ to identify what issues they were interested and willing to work on in the future. (See Appendix C.)
Since the initial June 2014 community and institutional roll out events, numerous agencies and groups
have requested and received presentations on various aspects of EBV. In particular, health and health care organizations which are trying to address health disparities and inequities have appreciated this focused understanding of the Latino community. These agencies have included, but are not limited to: *Washtenaw Health Plan Board *Ypsilanti Human Relations Commission *University of Michigan Coalition for Interdisciplinary Research on Latino/a Issues (CIRLI) *HUD Sustainable Communities – Economic Resilience Summit *Washtenaw County West Willow Community Impact Team *Washtenaw County Barrier Busters DISSEMINATION PLANS – Academic and Scientific Community – PLT and CLT members have been invited and accepted to present at numerous conferences regarding EBV results. Additionally, research faculty has requested to collaborate on projects utilizing the EBV data to inform both investigational as well as translation science.
A complete list (to date) of these conferences and projects is included in Appendix E. However, some of these conferences include the following:
University of Michigan Clinical Health Research Community Engagement
Michigan’s Premier Health Conference
Midwestern Psychological Association
Julian Samora Institute
National Association of City and County Health Officials
PROJECTS RESULTING FROM EBV – The CLT and PLT and EBV findings have fueled both application as well as award of a number of subsequent projects. These include CLT members who initiated a project entitled ‘Jovenes Tejedores 3D,’ (JT3D) which is focused on increasing Latino teens’ hope, health
Figure 12 – Sample Poster of ‘Top Ten Issues’
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and high school graduation. This project was initiated by EBV CLT members in the Ypsilanti Community Schools (YCS), where Latino enrollment has had significant increases. The project is focused on enabling Latinos to contribute to their community, social, moral and physical development of both middle and high school students. TJ3D utilizes a framework of self, others and community as the three dimensions. Three of the CLT members have also applied for grant funding (to be awarded in January 2015) to support this collaboration between YCS, University of Michigan, Washtenaw County Public Health and the Corner Health Center.
The Michigan Department of Community Health awarded Washtenaw County Public Health, YCS and Growing Hope a grant which will increase access to healthy foods to Latino community members. This access will include healthy foods at school, as well as partnering with Washtenaw Community College to build a ‘mobile farmers market’ that will serve Latino neighborhoods in Washtenaw County. THE FUTURE OF EBV - The CLT and PLT have had numerous discussions, including two half day retreats, to vision and plan for the future of improving Washtenaw County for and because of the Latino community. While the immediate focus of the group is to disseminate the findings in EBV, the group has also generated ideas regarding how to move forward past the HUD grant period. One such idea includes a broad, four component framework that are represented by ‘The Weavers’ graphic below. These components include: 1) the importance of building trust within the Latino community and across Washtenaw County; 2) Latinos as community role models; 3) identifying effective approaches for addressing problems; and 4) identifying needs to further study and investigate other related issues (See Figure 13 below). A second approach, loosely entitled ‘Accione Buenos Vecinos,’ to moving forward includes utilizing the CLT Top Ten Issues to generate further participation and action of both the institutional and Latino community. LESSONS LEARNED – While the number of ways that the individuals and organizations engaged in this project, as well as the many recipients of the information, enthusiasm and creativity of the EBV initiative is impossible to enumerate, there are a few focal lessons learned from this project:
Figure 13 – Riano Draft Framework For Future of EBV Project
29
Partnership between academics, community and government are extremely challenging. Each entity works on different timeframes, deadlines and requirements. Each has cultural influences and investments that may often conflict. However, such partnerships have enormous potential to increase understanding, empathy, creativity, patience, and advocacy for one another that are necessary to address complex issues such as the importance of Latino health and well being. future collaboration
Community engagement is not something that can happen at a presentation, a meeting, in a newsletter, a website or a notice. Community engagement requires work beyond the hours of 9-5pm. Engagement and community change requires ability to connect with individuals and genuine willingness to develop and cultivate relationships. This requires a genuine interest and desire for one’s neighbor to have a better and good life. While this approach takes time, it is the only avenue to build genuine and lasting trust between individuals and agencies that plan to work on the long horizon of collaboration.
Social support of individuals and social capital increasing access to community resources is absolutely necessary for communities to be empowered to help themselves and contribute to a better overall community. Increasing equity and eliminating disparities benefits everyone.
The EBV connection with the many and varied Washtenaw HUD Sustainable Communities projects enabled a more informed and effective project. This included greater understanding regarding large community infrastructure that sustain communities, such as walkability, safety, public art, etc. However, it also increases understanding that many vulnerable communities have commonalities that can potentially be better addressed through shared experience, knowledge and resources.
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Appendix A. – Pre-Post Survey of EBV Community Leadership Team Members
Buenos Vecinos Survey
Pre-Participation Questionnaire
Thank you for your assistance with the Buenos Vecinos Survey Project. We are interested in learning how participation in the project affects perceptions of social support and community resources. We will also ask these same questions later in the project. Please take a few minutes to answer the following questions. Your answers will be confidential.
1. Are you Hispanic or Latino? __Yes __No __Decline to answer 2. What is your gender? _____ 3. What is your age in years _____ 4. Your initials ______
5. If I had a serious problem I would turn to the following for help:
Strongly Agree
Agree Neutral Disagree Strongly Disagree
No such person in my life
Friend
Family Member
Neighbor
Co-worker
Professional (Counselor, health professional, religious leader, social worker etc.)
6. In the past 12 months how many times have you joined together with other community members to address a common issue? 5 or more times___ 3 to 5 times___ 1 to 2 times ___ Not at all____
7. In the past 12 months how many times have you talked with a local authority or governmental agency about problems in this community? 5 or more times___ 3 to 5 times___ 1 to 2 times ___ Not at all____
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8. Please indicate how much you agree or disagree with the following statements:
Strongly Agree
Agree Neutral Disagree Strongly Disagree
In general the majority of the people in this community can be trusted.
The majority of the people in this community generally get along with each other.
I feel as though I am very much a part of this community.
The majority of people in this community would take advantage of me if they had a chance.
Latinos/as in Washtenaw county use the following resources when they need them
Strongly Agree
Agree Neutral Disagree Strongly Disagree
Health Services
Mental health Services
Religious or Spiritual
Employment
Substance abuse
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treatment or counseling
Financial assistance
Housing
Immigration
Public Safety
Recreation
Entertainment
Social Services
Legal Services
Adult education
Youth education
Political
Community organizing
Media (TV, Radio, Newspapers)
9. What are the most common reasons Latinos/as do not use resources that they might need?
Please rank the top three most common reasons.
Lack of awareness
Language barriers
Cost barriers
No time
Don't perceive as important
Don't perceive as useful
Privacy concerns
Transportation barriers
Other (describe)
10. Is there anything else that would benefit the Latino community?
33
Appendix B - ‘The Final Word from EBV Respondents’
34
Appendix C. – Action /Commitment Card Contacts Categories
My Agency Would Like To Partner On… Contact Name Phone Email
Um Student Not Quite Sure But Wanted To Leave Info
Patrick Mullen 517 648 6318
Addiction Um Addiction Treatment Services
Accessing Care For Latino/Addictions
Carol Rose Kahn, Rn 232-0465
Addiction Aging
Catholic Social Services Senior Services
Substance Abuse Issues For Latinos. Promotion And Social Services For Adults Aged 60 And Over Keven Bell 712 7226
Aging Emu Health Administration
Additional Research On Aging Issues For Latino Community Sarah Walsh 407 2364
Cancer
SJMH
Women’s Health Pap Test Screening And Mammography, Cervical And Breast Cancer Screening
Sharon Bihlmeyer 646 2419
Bihlmeys@Trinity-Health
Cancer SJMH Cancer Center Free Colon Cancer Screening Joan Schmidt 712 2335
Cancer UMHS Cancer Center
Cancer Prevention Education And Access To Care
Madeline Cronealez 998 7073
Cultural Sensitivity
Um School Of Nursing
Training For Cultural Sensitivity
Leontine Wallace
989 1000 9399
Dental
Whp/Sbg
Recruiting Bilingual Staff/Providers For New PH Dental Clinic Kelly Stupple 544-3079
General Public Policy And Candidate And County Commissioner Education/Public Health
Wilma Gold-Jones
734-484-2739
General
UMHS
Chan Implementation Plan Strategies That Address Latino Health
Maria Thomas
734-709-7289
General
UMHS Data sharing For CHNA And Implementation Plan [email protected]
35
General
Um SPH Education Community Collaboration
William Lopez
General Blue Cross Blue Shield Complete Intervention Partnerships Pat Embry 313 225 0624
General Ypsilanti Pediatrics
Academic Institution And Partnership Terry Joiner 4847288
General City Of Ypsilanti Human Relations Commission
EBV Dissemination And Community Engagement
Darlene Scott And Glen Sard 323 0634
General Um Ypsilanti Health Center Education To Um Nurses
Susan Nearing 544 3282
General
MICHR How To Identify Additional Funding Mechanisms
Tricia Piechowski 998 7632
High School Corner Health Center
Continue With Tejedores Jovenes Project Kate Guzman 714-2228
Language Corner Health Center
Recruiting And Hiring Spanish Speakers
Ellen Clement 714-2240
Language
Casa Latina
Language Service Access - Community Member Training As Interpreters
Maria Militzer 975-9214
Language Mental Health
Washtenaw Intermediate School District
Access To English Language Education And Mental Health
Holly Heaviland
994 8100 X 1250
Legal Justice For Our Neighbors Of Se Mi
Documentation And Free Legal Counsel Tori Booker 629 6271
Mental Health WCHO
Mental Health/Substance Abuse
Hazelette Robinson 780 4572
Mental Health Dental Health
Washtenaw Health Plan
Access To Mental Health, Physical Health, Dental Health Ruth Kraut 544 3068
Nutrition
Growing Hope Recommendations - 6, 8, 3
Danielle Gartner 786 8401
36
Nutrition Physical Activity
Growing Hope
Healthier Retail And Physical Activity, Especially Bilingual Materials/Outreach
Karen Spangler 786 8401
Perinatal UMHS Program For Multicultural Health
More Info Perinatal Health - Specifically Pregnancy And Postpartum Health Support
Angela Johnson
Perinatal Maternal Management LLC
Pregnancies, Family Planning, Maternal Health
November Taylor
365 1523 Or 207 0136
Perinatal Safehouse Center
Unplanned Pregnancy/Parental Influence
Margaret Gleason
973 0242 X 207
Margaretg@Safehous Center.Orge
Research UMHS Office Of Health Equity And Inclusion
Partnerships To Generate Research From Current EBV Data Esther Ayers
Research
Um Student Generate Future Research Intervention Partnerships Julia Porth
Research Um School Of Social Work Partnerships - CIRLI
Linda Leonard 846-4847
Research Um School Of Nursing Research - CIRLI
Megan Czerwinski 313 618 1959
37
Appendix D. – EBV FREQUENCY TABLES – SELECTED RESULTS
Washtenaw County Encuesta Buenos Vecinos (EBV) Selected Results - 2014
Washtenaw County Adult Latinos – Survey Sample = 487 A Collaboration Between Washtenaw County Public Health, Casa Latina and University of Michigan, School of Public Health
GENERAL DEMOGRAPHICS
Current Employment Status - %
Student 21
Employed For Wages 51
Out Of Work For Less Than 1 Year 4
Out Of Work For More Than 1 Year 3
Primary Caretaker Of The Household 13
Retired 3
Self-Employed 11
Unable To Work 3
Have You Completed Any Degrees After High School? - Yes 51
Have You Ever Served On Active Duty In The United States Armed Forces, Either In The Regular Military... - Yes 0
Do You Have Children Less Than 18 Years Of Age That Live In Your Household? - Yes 54
How Many People Are You Supporting Financially? - 4 Or More 23
What Language Do You Speak With Most Of Your Family? - Spanish Most/All Of The Time 55
I Have Had Difficulties Finding Legal Services. - Agree/Strongly Agree 24
Relationship Status -
Single 22
In A Committed Relationship 23
Legally Married 40
Divorced 4
My Age In Years -
18-29 36
30-44 40
45-64 21
65+ 4
Female 58
Male 42
Lived In USA Since Birth 13
How Do You Usually Get To Work?
Bike 5
Carpool 12
Drive Myself 66
Ride The Bus 13
Walk 10
How Many Hours Did You Work Per Week On Average? - 40 Or More 20
Have You Ever Been Evicted In Washtenaw County? - Yes 2
PUBLIC ASSISTANCE
In The Past 12 Months, Did Anyone In Your Household Receive:-Assistance Or Payments From The State Or Local Welfare Office - Yes
1
In The Past 12 Months, Did Anyone In Your Household Receive:-Food Stamps Or A Food Stamp Benefit Card - Yes 26
In The Past 12 Months, Did Anyone In Your Household Receive:-WIC - Yes 12
NUTRITION
At Least Five Servings Of Fruit And Vegetables Per Day? - Yes 31
How Easy Is It For You To Get The Food You Need? - Easy/Very Easy 70
How Often Do You - 29
Drink Regular (Not Diet) Soda Or Pop That Contains Sugar? Once A Day Or More 29
Go Grocery Shopping? Never/Once A Month 12
Go To A Fast Food Restaurant? – Once a Week Or More 22
WEIGHT STATUS (CALCULATED BASED ON BODY MASS INDEX FOR WEIGHT AND HEIGHT)
Underweight 4
Normal Weight 30
Overweight 38
38
Obese 28
Reproductive Health
Are You Or Your Partner Doing Anything Now To Prevent Pregnancy? (For childbearing age, sexually active adults who do not want children)- Yes 22
Have You Or Your Partner Ever Had An Unwanted Or Unplanned Pregnancy? - Yes 41
PHYSICAL ACTIVITY
During The Past 30 Days, Other Than Your Regular Job, Did You Participate In Any Physical Activities... - Yes 63
In An Average Week, How Many Days Per Week Do You Do Physical Activities Or Exercises For At Least 30 Minutes Or More? - 5-7 Days Per Week
16
ALCOHOL, TOBACCO AND OTHER DRUGS
Do You Drink Alcohol? - Yes 36
Binge Drinker? - Yes 16
Tobacco Smoker? - Yes 7
During The Past 12 Months, Have You Stopped Smoking For One Day Or Longer Because You Were Trying To (Current Smokers)- Yes
54
In The Past Year, Have You Driven When You Were Feeling Intoxicated? - Yes 4
In The Past 30 Days, Have You Used Marijuana Or Hashish? - Yes 7
GENERAL HEALTH
Have You Ever Been Diagnosed With -
A Heart Attack - Yes 3
A Stroke - Yes 1
Asthma - Yes 12
Cancer - Yes 4
Chronic Obstructive Pulmonary Disease (COPD), Emphysema Or Chronic Bronchitis - Yes 4
Depression - Yes 17
Diabetes - Yes 9
High Blood Pressure - Yes 9
High Cholesterol - Yes 19
Vision Impairment In One Or Both Eyes, Even When Wearing Glasses - Yes 21
Is Your Health Fair Or Poor? - Yes 19
One Or More Of Your Permanent Teeth Have Been Removed Because Of Tooth Decay Or Gum Disease? - Yes 19
HEALTH CARE ACCESS
Do You Have Any Kind Of Health Care Coverage, Including Health Insurance, Prepaid Plans Such As HMOS... - Yes 75
Have You Ever Been Refused Health Care? - Yes 6
How Long Has It Been Since You Visited Adventist Or A Dental Clinic For Any Reason? - More Than 5 Years 20
How Long Has It Been Since You Visited Adventist Or A Dental Clinic For Any Reason? Never Visited 11
How Long Has It Been Since You Visited A doctor For A Routine Checkup? (A General Physical Exam, Not For A Specific Injury, Illness, Or Condition). - More Than 5 Years
9
How Long Has It Been Since You Visited A doctor For A Routine Checkup? (A General Physical Exam, Not For A Specific Injury, Illness, Or Condition). - Never Visited
3
How Long Has It Been Since You Visited A hospital Emergency Room/Department? - Less Than A Year 23
How Long Has It Been Since You Visited A psychologist Or Other Psychological Counselor? - Less Than A Year 15
In The Past Year, Did You Need One Of These Services But Were Not Able To Get It Because Of The Cost?
Dental Care - Yes 39
Mental Health Services - Yes 13
Medical Doctor - Yes 19
Mental Health Services - Yes 15
Prescription Medicine - Yes 19
Have You Ever Been Tested For HIV? (Do Not Count Tests You May Have Had As Part Of A Blood Donation. Include Testing Fluid From Your Mouth.) - Yes
41
DISABILITY
Are You Limited In Any Way In Any Activities Because Of Physical, Mental, Or Emotional Problems? - Yes 6
Do You Use A Wheelchair, A Cane, Crutches, Or A Walker? (Other Than For A Temporary Injury) - Yes 3
SOCIAL SUPPORT
How Often Can You Rely On The Following For Help If You Have A Serious Problem?
Friends - Rarely Or Never 82
People From Agencies Or Organizations Rarely Or Never 68
Your Partner - Rarely Or Never 19
How Often Do The Following Argue With You?
Friends - Rarely Or Never 82
People At Work - Rarely Or Never 82
Your Partner Rarely Or Never 61
How Often Do You Get The Social And Emotional Support You Need? - Rarely/Never 26
How Often Do The Following Make Too Many Demands On You?
39
People At Work - Rarely Or Never 77
People Who Live With You - Rarely Or Never 72
Relatives Who Do Not Live With - Rarely Or Never 78
Your Partner Rarely Or Never 68
FINANCIAL STRESS
How Often Do You -
Worry About Having Enough Money To Buy Nutritious Meals? - Often/Always 32
Worry About Having Enough Money To Pay Your Rent/Mortgage? - Often/Always 38
DISCRIMINATION AND CULTURAL STRESSORS
In Your Day-To-Day Life How Often Have Any Of The Following Things Happened To You?-
People Act As If You Are Not As Good As They Are. - A Few Times A Month Or More 25
You Are Called Names Or Insulted. - A Few Times A Month Or More 9
You Are Threatened Or Harassed. - A Few Times A Month Or More 4
You Are Treated With Less Respect Than Other People. - A Few Times A Month Or More 20
My Level Of English Makes Interacting With Others Difficult. - Agree/Strongly Agree 40
NEIGHBORHOOD COHESION
How Much Do You Agree That The Following Statements Describe Your Neighborhood?-
I Feel Like I Am Part Of The Community. - Strongly Agree/Agree 63
I Feel Safe Being Out Alone In My Neighborhood During The Night. - Strongly Agree/Agree 70
I Feel Safe Walking In My Neighborhood. - Strongly Agree/Agree 78
People Can Be Trusted. - Strongly Agree/Agree 51
People Get Mugged, Robbed, Or Attacked. - Strongly Agree/Agree 12
People Help Each Other Out. - Strongly Agree/Agree 53
People Sell Or Use Drugs. - Strongly Agree/Agree 17
People Would Help Me If I Had An Emergency. - Strongly Agree/Agree 69
There Are Grocery Stores I Regularly Use For Food Shopping. - Strongly Agree/Agree 83
There Are Sidewalks, Walking Paths, Or Trails That I Can Easily Use For Walking, Jogging, Or Running. - Strongly Agree/Agree 75
LATINO COMMUNITY COHESION
I Am Involved In Uniting The Latino/A Or Hispanic Community In Washtenaw County. – Agree/Strongly Agree 67
It Is Important To Have A United Latino/A Or Hispanic Community In Washtenaw County. – Agree/Strongly Agree 89
What Activities Do You Do With The Local Latino/A Community Outside Of Your Own Family?
Church – Yes 50
Classes – Yes 18
Community Picnics – Yes 13
Festivals – Yes 30
Helping People With Difficult Situations – Yes 19
Playing Sports – Yes 20
Support Groups – Yes 10
Watching Sports – Yes 22
CHILD HEALTH
Do Any Of Your Children Have An Individualized Education Program (IEP)? - Yes 38
Do Any of Your Children Have An Individualized Education Program (IEP)? - Yes 12
How Often Are You Involved In These Aspects Of Your Child/Children Schooling?-
Attending School Sports - Once A Month Or Less 65
Homework - Once A Month Or Less 21
Speaking With Teachers - Once A Month Or Less 54
How Often Do You Feel Unable To Help Your Child/Children With Problems (He/She/They) Might Have? – Sometimes/Often/Always
32
Has A Doctor, Nurse Or Other Health Professional Ever Said That Your Child Has Asthma? - Yes 12
In An Average School Week, How Many Days Does Your Child Walk Or Bike To School? - Zero 74
Has Your Child Ever Been Diagnosed With Depression? - Yes 4
What I Say Will Have Little Influence On Whether Or Not My Child Uses Drugs - Agree/Strongly Agree 40
Does Child Eat At Least 5 Fruit And Vegetables Per Day? - Yes 8
Was Your Child Ever Breastfed Or Fed Breastmilk? - Yes 84
Has Your Child Ever Been Afraid To Go To School? - Yes 6
Has Your Child Ever Been Bullied? - Yes 10
For Questions: Contact - Adreanne Waller, MPH, Epidemiologist Washtenaw County Public Health [email protected] Revised May 20, 2015
40
Appendix E. – Scientific and Institutional/Agency Presentations – (To Date) Kruger, D.J., Ledón, C., Llanes , M., Lopez, W.D., & Delva, J. (2014, October). Creating a healthy future for Washtenaw County Latino/as through Encuesta Buenos Vecinos. Symposium, Julian Samora Research Institute’s 25th Anniversary conference, East Lansing, MI. Delva, J., Harner, M., Horner, P., Kruger, D.J., LeBrón, A.M.W., Ledón, C., Lopez, W.D., Reyes, A., & Sanders, L. (2014, October). Academic and community partnerships for Latino/a health research: Perspectives from southeast Michigan. Symposium, Julian Samora Research Institute’s 25th Anniversary conference, East Lansing, MI. Ledón, C., Kruger, D.J., Waller, A. (2014, July). Encuesta Buenos Vecinos: A research partnership to promote Washtenaw County Latino/a health. Imagining Latina/o Studies: Past, Present, and Future: An International Latina/o Studies Conference, Chicago, IL. Kruger, D.J., Ledón, C., Waller, A., Llanes, M., & Isela Flores, G. (2014, May). (2014, May). Community involvement promotes success in a Latino/a health survey project. Symposium, Society for Community Research and Action at the Midwestern Psychological Association, Chicago, IL. Riaño-Mojica, E., Ledón, C., Waller, A., Kruger, D.J., Sheldon, S.P., Llanes, M., & Isela Flores, G. (2014, April). Youth leadership in the Encuesta Buenos Vecinos project. Oral presentation, La Academia del Pueblo Latino/a and Latin American Research Conference, Wayne State University, Detroit, MI. Rheingans, C., Ledón, C., Waller, A., & Kruger, D.J. (2014, March). Encuesta Buenos Vecinos: Building capacity to promote Washtenaw County Latino/a health. Oral presentation, Julian Samora Research Institute, East Lansing, MI. Wade, S., Kruger, D.J., & Ledón, C. (2013, October). From Public Health to Planning: Experiences engaging hard-to-reach populations in Washtenaw County. Oral presentation, Michigan Association of Planning, Kalamazoo, MI. Lopez, W., Harner, M., Sanders , L., Ledón, C., Waller, A., Llanes, M., & Kruger, D.J. (2015, May). The impact of an immigration home raid on community psychosocial health. Poster, Society for Community Research and Action at the Midwestern Psychological Association, Chicago, IL. Lopez, W., LeBron, A.M.W., Kruger, D.J., Delva, J., Ledón, C., Waller, A., & Llanes, M. (2014, November). Social patterning of health and service utilization among Latinos: Findings from the Encuesta Buenos Vecinos. Poster, American Public Health Association, New Orleans, LA. Siddiqui, A., Kruger, D.J., Ledón, C., Waller, A., Llanes , M. (2014, August). Enhancing health services delivery for Washtenaw County Latino/as through Encuesta Buenos Vecinos. Spectrum Health Healthier Communities Seventh Annual Community Health Worker Conference. Grand Rapids, MI. Kruger, D.J., Ledón, C., Waller, A., Sheldon, S.P., Llanes, M., Isela Flores, G., Davila, J., Brace, D., Butler, K., & Siddiqui, A. (2014, May). Encuesta Buenos Vecinos: Building capacity to promote Latino/a health. Poster, Society for Community Research and Action at the Midwestern Psychological Association, Chicago, IL.
41
Waller, A., Kruger, D.J., Ledón, C., Sheldon, S.P., Llanes, M., Riaño-Mojica, E., Riaño, L., & Isela Flores, G. (2014, March). Latino Health Equity is Crucial in Washtenaw County. Poster, Partnerships for Patient-Centered Outcomes Research, Ann Arbor, MI. Kruger, D.J., Ledón, C., Waller, A., Epstein, J., Isela Flores, G., Llanes, M., Rheingans, C. (2013, July). Community leadership and participation enhances outcomes in the Encuesta Buenos Vecinos project. Poster, National Association of County and City Health Officials, Dallas, TX. Kruger, D.J., Ledón, C., Waller, A., Epstein, J., Isela Flores, G., Llanes, M., Rheingans, C. (2013, March). Community leadership and participation enhances outcomes in the Encuesta Buenos Vecinos project. Poster, Michigan Institute for Clinical & Health Research Annual Community Engagement Symposium. Ann Arbor, MI. First place poster award.
Riaño-Mojica, E., Ledón, C., Waller, A., Kruger, D.J . Latino Health Equity is Crucial to Washtenaw County: Encuesta Buenos Vecinos' (Survey of Good Neighbors) Partnerships, Community Engagement, Epidemiology and Institutional Commitment. Oral Presentation. Michigan’s Premier Health Conference. October 2014.
Waller, A., Kruger, D.J., Ledón, C . LATINO HEALTH EQUITY IS CRUCIAL TO WELLNESS AND PROSPERITY WASHTENAW
COUNTY. Presentation of Encuesta Buenos Vecinos Results Economic Resilience Forum. Oral Presentation. McKenny Union. Eastern Michigan University. October 2014.
Waller, A., Kruger, D.J., Ledón, C ., Riaño-Mojica, E., LATINO HEALTH EQUITY IS CRUCIAL TO WELLNESS AND
PROSPERITY IN YPSILANTI & WASHTENAW COUNTY. Presentation of Encuesta Buenos Vecinos Results . Ypsilanti Human Relations Commission. Oral Presentation. Ypsilanti Community Center. October 2014.
Waller, A., Kruger, D.J., Ledón, Flores, G. . LATINO HEALTH EQUITY IS CRUCIAL TO WELLNESS AND PROSPERITY
WASHTENAW COUNTY. Presentation of Encuesta Buenos Vecinos Results West Willow Community Impact Team. Oral Presentation. Ann Arbor, Michigan. September 2014. Waller, A., Kruger, D.J., Ledón,. Encuesta Buenos Vecinos: Building Capacity to Promote and Sustain
Washtenaw County Latino Health: Selected Highlights . Presentation of Encuesta Buenos Vecinos Results Washtenaw Health Plan Board. Oral Presentation. Ann Arbor, Michigan. September 2014.
42
ENDNOTES 1 U.S. Census Bureau Projections Show a Slower Growing, Older, More Diverse Nation a Half Century from Now.
December 12, 2012. U.S. Census Website. Accessed December 2014. https://www.census.gov/newsroom/releases/archives/population/cb12-243.html 22
Michigan Department of Community Health Population Estimates - 1990-2013. Michigan Department of Community Health Website. Accessed December 2013. http://www.mdch.state.mi.us/CHI/pop/frame.html
3 Demographic Profile of Hispanics in Michigan, 2011. Pew Research Hispanic Trends Project Website. Accessed
December 2014. http://www.pewhispanic.org/states/state/mi/ 4 CDC Health Disparities and Inequalities 2013. MMWR. Vol 62. No 3. November 22, 2013.
http://www.cdc.gov/mmwr/pdf/other/su6203.pdf 5Social Determinants of Health. U.S. Centers for Disease Control Website. Accessed December 2014.
http://www.cdc.gov/socialdeterminants/FAQ.html#c 6Toosi, M. “Labor force projections to 2020:
a more slowly growing workforce.” Monthly Labor Review. January 2012. http://www.bls.gov/opub/mlr/2012/01/art3full.pdf 7 Humphries, JM. The Multicultural Economy – 2013. University of Georgia. Terry College of Business. Selig
Center for Economic Growth. Accessed December 2013. http://www.latinocollaborative.com/wp-content/uploads/2013/10/Multicultural-Economy-2013-SELIG-Center.pdf 8 Fairlie, RM. “Open For Business: How Immigrants Are Driving Small Business Creation In The United States.”
A Report By The Partnership For A New American Economy. Accessed December 2014. — August 2012 —http://www.renewoureconomy.org/sites/all/themes/pnae/openforbusiness.pdf 9 Steinhardt, R. “Promoting Economic Prosperity by Welcoming Immigrants.” Federal Reserve Bank of
Boston. Banking and Communities. Vol.23. No.4. Summer 2013. Accessed December 2013. http://www.bostonfed.org/commdev/c&b/2013/summer/summer-2013.pdf 10
2013 American Community Survey - http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_1YR_DP05&prodType=table 11
Census Bureau Releases Estimates of Overcount and Undercount in the 2010 Census. May 22, 2012. http://www.census.gov/newsroom/releases/archives/2010_census/cb12-95.html 12
‘Washtenaw County Community Profile. South East Michigan Council of Governments (SEMCOG) website. Accessed December 2014. http://www.semcog.org/Data/Apps/comprof/people.cfm?cpid=4999 South East Michigan Council of Governments 13
“The Hispanic Population of Southeast Michigan: Characteristics and Economic Contributions.” Wayne State University / Center for Urban Studies & Center for Chicano‐Boricua Studies. October 2008. Accessed December 2014. http://www.cus.wayne.edu/media/1563/hispaniccontributionstosem.pdf 14
SEMCOG Community Profiles – Ypsilanti City and Ypsilanti Township. http://www.semcog.org/Data/bycommunity.cfm. Accessed August 25, 2014. 15
Ibid. SEMCOG. http://www.semcog.org/Data/Apps/comprof/people.cfm?cpid=4999 16
Waller, A. ‘Washtenaw County Public Health and Michigan Department of Community Health. Birth Certificate Data – Internal Communication. May 2013. 17
Student Counts. Michigan School Data. Michigan Department of Education and Center for Educational Performance and Information (CEPI). Accessed August 24, 2014. https://www.mischooldata.org/DistrictSchoolProfiles/StudentInformation/StudentCounts/StudentCount.aspx 18
Ibid. Waller, A. Internal Communication. Michigan Department of Community Health, May 2013. 19
Ibid. Waller A. Michigan Department of Community Health, Internal Communication August 2013.
43
20
American Community Survey. U.S. Census website – Factfinder. Accessed December 2013. 20
American Community Survey – 2005-2009. U.S. Census Bureau. http://factfinder.census.gov/servlet/ADPTable?_bm=y&-geo_id=16000US2603000&-qr_name=ACS_2009_5YR_G00_DP5YR3&-ds_name=ACS_2009_5YR_G00_&-_lang=en&-_sse=on 21
Ibid. American Community Survey. http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_13_3YR_B15002I&prodType=table
