1. Migrant and Seasonal Farmworker (MSFW) Immunization Project
Delivering Immunizations to a High-Risk, Mobile Population
New York State Department of Health
Immunization Program
March 5, 2007
Share our experience in delivering immunizations to MSFW
Applicable to other high-risk, mobile populations

2. Learning Objectives
Identify challenges to delivering immunizations to adult MSFWs
Learn effective methods to overcome challenges to immunizing adult MSFWs
Understand the key role that community partnerships play in improving vaccine delivery

3. Background
Set the stage

4. Who is a migrant or seasonal farmworker?
Principally employed in agricultural labor within the past 24 mos.
Migrant: Establishes a temporary abode for purposes of such employment
Seasonal: Not migratory and does not need to establish a temporary abode for purposes of such employment
(Health Center Consolidation Act of 1996, Section 330(g)- Public Law )
Seasonal farmworker could be a member of the community/permanent resident
Note: Federal definition, other agency’s serving MSFW may have a slightly varied definition

5. Farmworker Facts 81% foreign born 84% Spanish as first language
90% neither speak/read English fluently
84% Spanish as first language
95% born in Mexico
80% male
52% undocumented
75% paid hourly ($5.94/hr)
Median education level = 6th grade
20% had less than 3 years of education
(USDA, National Agricultural Workers Survey, 2000)

6. Migration Patterns Restricted Circuit Point to Point Nomadic
Demonstrates countries of origin and migrant streams (east coast, Midwest, western)
Restricted Circuit
Point to Point
Nomadic

7. Why target MSFWs? Risk for vaccine-preventable diseases:
Poor housing conditions
Hazardous occupation
Migratory lifestyle
Foreign-born
Poor housing conditions
-isolated, rural areas-limited access to care
-infectious diseases from overcrowding and poor sanitation
Hazardous occupation
Tetanus exposure
Handle food supply
Migratory lifestyle
Continuity of care
Completing series of doses (e.g. Hep B)
Lack of access to appropriate water and sanitation facilities while traveling
Foreign born
Cultural differences (e.g. language, unfamiliarity with preventative care, different belief systems)
May not have benefited from good immunization practices in their country of origin
History of exposure to endemic diseases

8. A Vulnerable Population
“Migrants not only live in Third World conditions they are subjected to Third World Diseases. Diseases of the past are commonly encountered, dominated by infectious disease.”
(Migrant Clinician’s Network)
Outbreaks of varicella and mumps have occurred in NYS migrant camps
Varicella (Chickenpox)
Low incidence in tropical regions
Mexican-born workers are more than five times more likely than those born in the U.S. to lack immunity to varicella

9. Project Implementation
Public Service Officer vaccinating Mexican migrant workers in El Paso, Texas c. 1963

10. Adult MSFW Immunization
Project Objectives
Adult MSFW Immunization
Ultimate Goal: Promote the immunization of adult MSFWs
1. To improve access to and availability of vaccines for MSFWs
2. To educate on the benefits of immunizations for this population
3. To develop partnerships to promote these goals

11. Project Overview Migrant/Community Health Center (11)
Clinton
Franklin
St Lawrence
Jefferson
Essex
Lewis
Hamilton
Warren
Oswego
Orleans
Niagara
Oneida
Washington
Wayne
Monroe
Fulton
Saratoga
Genesee
Herkimer
Onondaga
Montgomery
Wyoming
Ontario
Seneca
Schenectady
Madison
Cayuga
Erie
Livingston
Yates
Cortland
Otsego
Albany
Rensselaer
Schoharie
Tompkins
Chenango
Schuyler
2003: Pilot Project
6 partners, 6 sites, 9 counties
2004: Interim Expansion
6 partners, 8 sites, 11 counties
2005: Statewide Expansion
15 partners, 20 sites, 26 counties
2006: Today we supply 27 sites with free vaccine
22 partners, 27 sites, 35 counties
Variety of provider types:
Providers have different levels of experience in serving MSFWs, some seasoned, some new. Therefore it’s important to gauge level of assistance needed to get the project rolling with each individual provider.
We supply them with vaccine at no cost. In exchange we ask that they promote/offer our vaccine and submit a monthly report tracking vaccine usage.
Chautauqua
Allegany
Greene
Cattaraugus
Steuben
Tioga
Delaware
Columbia
Chemung
Broome
Ulster
Dutchess
Migrant/Community Health Center (11)
County Health Department (11)
Hospital (2)
Diagnostic and treatment center (2)
Private physician (1)
Sullivan
Putnam
Orange
Westchester
Rockland
New York City
Suffolk
Nassau

12. Types of Vaccines Administered
Data for 2006
Vaccines offered:
Before project, providers offered only Td and Flu.
Clinics more likely to offer/promote vaccines when available at no cost.
Now, as soon as a new vaccine becomes available providers are asking us when it will be available for their migrant clients.
For example: Recently added Tdap, exploring HPV.

13. Number of MSFWs Immunized
Note: Not unduplicated numbers
Numbers have increased, due to increased number of providers and increased awareness of this special needs population, improved effort to immunize.

14. Challenges and Successes
Not an easy path, bumps along the road, but extremely rewarding.
Supplying free vaccine alone is not the answer…

15. Overcoming Barriers to Care
Lack of funds/resources
Free vaccine
Job demands
Clinic hours tailored to work schedules
Coordinate with schools and worksites
Immigration Status
Establish trust
They face barriers to access similar to those faced by other mobile underserved populations, disadvantaged groups, including the poor, and especially rural poor, and recent immigrants.
Lack of funds/resources to seek care
Low-income status: Do not have workers comp or health insurance
Low-income men tend to present in clinics only with acute illness or injury
Not familiar with culture/how to access care
Unmet basic (survival) needs: Deal with survival needs before anything else: food, shelter, running water, clothing, etc.
Job demands
Priority of maximizing income
Preventative care is low priority in the help-seeking behavior of migrants
Immigration Status
Fear/mistrust of “government” agencies
Life Experience – don’t trust authority; many have had family members that were taken away and never heard from again
Fear – of unknown, bureaucracies, INS, deportation, paperwork
Lack of documentation – using an alias, makes history taking and continuity of care difficult

16. Overcoming Barriers to Care
Cultural and linguistic differences
Culturally competent staff and education
Transportation
Outreach
“Community-based activities with migrant and seasonal farmworkers and their family members which improve both utilization of health services and the effectiveness of those services.”
(U.S. DHHS, Migrant Health Program, 1992)
Cultural and linguistic differences
Language: not all Spanish is the same
Indigenous languages (English may be a third language)
Some languages are not written language (e.g. Haitian-Creole)
Lack of low literacy educational information in Spanish
Transportation
Distance from care and lack of transportation
– no public transportation in a rural area
- it’s hard to find where migrants reside, housing is intentionally hidden
- rely on group rides
- very weather dependent

17. Overcoming Barriers to Care
Offer vaccines at off-site clinics:
Mobile clinics
Local catholic
church
Health fair
Headstarts
On the farm
Bring the vaccine to them:
Outreach team (provider + case manager/outreach workers) visit migrant housing to provide routine medical services to the farmworkers.
A neutral place-pop is scared of gov’t agencies and lhd bldg, a church setting gets a better turn out
Send letters to growers
Adapt and be creative

18. Education & Promotion In-Service trainings Education workgroup
Grower outreach
Response to needs of providers:
In-service trainings for new enrollees, at their request, cover project background, adult immunization, and resources. Encourage them to “think outside of the box” when immunizing this population.
Education workgroup established to develop culturally competent materials. Comprised of 6 providers across the state, benefit from their knowledge/expertise in servicing this population
Viticulture expo and Fruit and Veggie Expo- received useful feedback
For example, the farm owners/growers suggested using the OSHA required board or putting flyer with paychecks. To do this collaboration would be required.

19. Partnerships

20. Partners 27 Participating providers State Agencies Other
Department of Health
MSFW Health Program
Center for Environmental Health
Department of Labor
State Education Department
Department of Agriculture
Other
Cornell University
Success of project wouldn’t be possible without our partners
Use their experiences to influence our strategies (ex: Cornell Cooperative Extension’s sanitation education signs for toilet use etc.)
Identify state agencies that service MSFWs
MSFW Health Program has been an integral player, helped us to lay the groundwork
Provides funding to 15 MSFW providers for primary/preventive medical/dental services, screening, referral, health education, outreach, transportation, translation (emphasis on reducing barriers to access).
Center for Environmental Health, Bureau of Occupational Health- conducts housing inspections, provided us with data of number and location of farms
Department of Labor, Rural Services-liaison between growers and workers, also collects data on number of farms
State Ed- Migrant Education Program
Department of Agriculture- ABCD
Cornell U- Cornell Migrant Program

21. Partnership Objectives
Create linkages and networks
Exchange knowledge and expertise
Share resources
Examples:
Statewide agency meetings to find common ground and work together to improve services to MSFW population
Attend each others meetings, venue to present on project, exchange information
Co-host conferences
ABCD Health Services Advisory Committee

22. Lessons Learned MSFWs are a vulnerable and hard to reach population
Adapt to mobility and culture to reduce barriers to access
Collaborate with other agencies that service MSFWs
Conclusions
Hard to reach population
Migrants are at high-risk for vaccine-preventable diseases:
Risks associated with lifestyle conditions
Risks associated with countries of origin
We can improve their immunization rates by promoting our free vaccines:
Improve access, availability, and education
Reduce missed opportunities

23. Resources

24. Contact Information
Valerie Polletta
NYSDOH Immunization Program
(518)