FEATURES

BONUS FEATURE

Portable health care

Managing diabetes can be a challenge for anyone. Managing diabetes when you don’t have health insurance and your job takes you 1,600 miles from home for much of the year is an even bigger challenge. The author has developed a program to help meet that need.

by Loretta J. Heuer

Maribel Garcia and author Loretta J. Heuer

My relationship with Maribel Garcia, a Hispanic migrant farmworker, began in 1998 when I was developing a diabetes management program for Migrant Health Service Inc. (MHSI), headquartered in Moorhead, Minn. Garcia, who is bilingual, was a health outreach worker at one of our nurse-managed, satellite health centers, a seasonal facility located in Grafton, N.D. Her questions and concerns about her community inspired me to conduct a grass-roots research project that explored health care needs of Hispanic migrant farmworkers diagnosed with diabetes.

Diabetes in Hispanic Americans is a serious health problem. Each season, MHSI staff members provide health and educational services to an estimated 7,000 migrant workers, the majority of whom travel from their home base in Texas, near the southern border of the United States, to Minnesota and North Dakota, states located on the northern border. In August 2003, the MHSI diabetes registry included 1,754 patients, with services being provided to 623 registrants during that year.

As part of my research, I interviewed patients and family members about their perceptions of health care needs. I learned that Hispanic migrant farmworkers encounter many difficulties when attempting to receive health care and preventive education. They tend to be “invisible” because they are impoverished, uninsured and frequently do not have regular health care providers or advocates (National Center for Farmworker Health, 2005). In sharing their stories, these workers told of struggles in obtaining health care services, prescriptions and supplies to self-manage their diabetes. The most poignant and recurring request I heard during these interviews was for medical assistance and support during the winter months, when they are in their home state.

This led me to the idea of adapting the community health worker concept to fit the needs of this migrant population. In reviewing the literature, I found documentation describing successful use of community health workers in established communities but found no programs where community health workers provided support by traveling long distances, from one state to another. I was unsure if a lay educator program would be successful if the educators were required to migrate with a population among Minnesota, North Dakota and Texas, but I decided to write a grant and give it a try.

Diabetes Lay Educator (DLE) Program
In the spring of 2000, when I introduced the DLE Program during training of MHSI seasonal staff members, Garcia was the first person to apply. Not only was she enthusiastic about this new opportunity, which would pay a stipend, but within an hour she also had recruited five more applicants. When I asked her why she wanted to be a diabetes lay educator, she replied: “I want to do this because this program will help my people get health care. We can make a difference for them.”

All applicants accepted for the program were already employed full time, so they were unable to attend a two-week training session. After visiting with the new DLEs, I decided training needed to be conducted in segments, with initial formal training consisting of two eight-hour days provided by the staff of Altru’s Diabetes Center in Grand Forks, N.D. The curriculum I selected for this training was Words to the Wise: A Bilingual Course for Diabetes Promotoras (Matiella & Heilman, 1997), published by the New Mexico Department of Health. In addition, I taught Garcia and the other DLEs how to take blood pressure and glucose readings, troubleshoot equipment and complete necessary paperwork.

We also discussed two other important issues: their title and the program logo. I had chosen the title of diabetes lay educator in writing the grant but let them know it could be changed if desired. Garcia liked the title of educator, because she thought it gave them status in the community. The others agreed, and they voted to keep the title.

The DLEs believed the logo should represent them as educators in the communities of three states. They chose a logo that consists of an open book as a symbol for education, with maps of Minnesota and North Dakota on one page and Texas on the other. A family standing between the two pages represents the Hispanic migrant farmworker population.

Garcia and the other DLEs now provide support group meetings and diabetes education in Minnesota and North Dakota from March to September. When they return to their homes in southern Texas, they provide support group meetings and home visits to migrant clients from October through February (Heuer, Hess, & Klug, 2003). Annually, during the winter months, I travel to Texas to hold an additional education session with them, meet with area health care providers, attend support group meetings and visit MHSI clients.

These trips help me better understand lifestyle and health care issues that the Hispanic migrant farmworker population encounters on a daily basis. I also gain additional insight into what it is like for Garcia to live and work between two cultures. As a Hispanic migrant farmworker with diabetes who works with health care providers, she has the background to effectively deal with the health care needs of this population.

Challenges associated with the DLE Program
As the MHSI diabetes coordinator, I have faced a number of challenges in managing a program that spans 1,600 miles and serves three states. During the first year, the DLEs felt isolated when working in Texas without MHSI staff support. To address this need, I instituted biweekly conference calls to discuss successes and problems, and to provide educational updates by dietitians and diabetes educators.

Initially, I had difficulty retaining DLEs from season to season, because they were mostly 25-40 years old and tended to “settle out” for various reasons—e.g., to pursue education, care for a family member or find other employment, or because they considered the DLE role too rigorous. After speaking with Garcia and the other DLEs, I provided added incentive by increasing the pay they received for facilitating support group meetings and biweekly conference calls and for making home visits to MHSI clients in Texas. As a result of these changes, I have retained five DLEs.

My most problematic challenge has been securing permanent funding to continue the program. Initially funded by a grant from Rural Health Outreach, the program is now supported with federal funds granted to MHSI. However, the unpredictability of funding from the federal government or from foundational health or migrant health sources puts the program in annual jeopardy. In addition, the DLEs have requested that their positions be changed from part-time, stipend-paid status to full-time employment.

Successes of the DLE Program
Over the years, my relationship with Garcia has evolved into one of trust, respect and friendship. Both of us started out as novices in each other’s world, but our passion for increasing access and quality of health care for migrant farmworkers has created a bond between us.

Recently, Garcia participated in a case study that entailed multiple interviews about her role as a DLE. In the process, she provided insight into the characteristics that DLEs need to have to achieve positive client outcomes. They need to have a strong internal desire to help the population, a knowledge base of diabetes and advocacy skills to work between two cultures.

Conclusions
The Diabetes Lay Educator Program grew from a research project inspired by my clinical work and the interest of people such as Garcia. The program has proven effective in improving health care services and education to a mobile population. The DLEs perceive the services they offer as beneficial, because they increase access to health care and teach self-management skills to migrant farmworkers and their families. They are respected members of their communities and take pride in providing much-needed services.

Because of the mobility of the migrant farmworker population, it is difficult to gather precise outcomes. However, it is clear from the attendance at support group meetings, requests for home visits and increased phone contacts that the DLEs provide much-needed support and education. Most importantly, they show that community health workers who migrate as part of a farmworker community contribute to successful outcomes. RNL

Loretta J. Heuer, RN, PhD, 2002 Robert Woods Johnson executive nurse fellow, is associate professor and interim chair, practice and role development, at the University of North Dakota, Grand Forks.

References

Heuer, L., Hess, C., & Klug, M.G. (2003). Meeting the health care needs of a rural Hispanic migrant population with diabetes. The Journal of Rural Health, 20(3), 265-270.

Matiella, A.C., & Heilman, N.J. (1997). Words to the wise: A bilingual course for diabetes promotoras. New Mexico Department of Health, Public Health Division.

National Center for Farmworker Health. (2005). Overview of American farmworkers. Retrieved January 14, 2005, from http://www.ncfh.org/