Sexual Reproductive Health Education for Immigrant Women living in NYC

Updated: Oct 7, 2021


Devjani Paul, Wandeth Van Grover, Karen Ortiz


ORGANIZATION DESCRIPTION: Cultural Ambassadors Toward Community Health (CATCH) Program through the New York City Health + Hospitals


New York City Health + Hospitals (NYC H+H) is the largest public health care system in the United States. We provide essential inpatient, outpatient, and home-based services to more than one million New Yorkers every year in more than 70 locations across the city’s five boroughs. NYC H+H has won a number of prestigious awards and grants in recent years for its quality of care and innovative community-based programs. We know that sometimes meeting the community where they are at means literally bringing healthcare to their doorstep. Through a medical mobile unit, we visit five different communities every week and provide a doctor’s office on wheels for many New York City residents challenged to find affordable healthcare services within their communities. The clinic on wheels treats many young, working immigrants from Mexico, Central America, South America and West Africa. For many new immigrants, visiting a medical mobile unit may be less intimidating for accessing healthcare than a formal building with uniformed security and metal detectors. Our CATCH Program workers understand the intersecting factors for poor health outcomes that explain disparities among immigrant women living in high-poverty neighborhoods. They employ evidence-informed, asset-based community development through an adaptation of the Promotores de Salud model.

Community-based group health educational programs led by our CATCH Program provide a useful alternative for immigrant women reluctant to seek SRH health care in clinical settings. CATCH can provide risk reduction strategies before clinical treatment is necessary through group educational workshop that help increase social cohesion and coping strategies among immigrant women, creating not just a support network of women of similar experience but also untapped resources from where to pool information about receiving culturally competent care that is simultaneously financially accessible and of suitable quality. The mobile unit is equipped with a patient reception area, two exam rooms, an electronic medical record system and modern diagnostic equipment, staffed with a doctor, a registered nurse, a patient care associate, and a financial counselor. CATCH workers can assist with translation, When a patient needs more specialized expertise not readily available on the mobile clinic, an appointment is made at an H + H and a van is scheduled to provide round-trip transportation. CATCH uses strategies, such as developing advocacy skills and establishing trust with health care providers, that actually diminish dependence of immigrant women on their programs because they are being equipped with tools themselves to navigate health care systems.




STATEMENT OF NEED: Cultural Competency in Sexual & Reproductive Health (SRH) Education and Outreach for Low-Income Immigrant Women in New York City


Immigrants in New York City experience unique factors prior to, during, and after migration that frame their current and future health outcomes.1 As the fastest-growing population in the United States, this is of growing public health concern.2 New York City is home to 3 million immigrants who comprise about 36% of the city’s population, often driven by the lack of economic and educational opportunities in their home countries.1 Before their migration, these are a result of community violence, war, political instability, or persecution, which can be linked to chronic stress that in turn affects other negative health outcomes.3 For immigrant women specifically, pregnancy and prospective parenthood can also be a major motivator for migration. At an individual level, immigrant women experience more heightened fear, restricted mobility, and increased stress than their male counterparts.4 During migration, immigrant women are particularly vulnerable to additional negative health outcomes from the added mental, physical, and emotional trauma of physical assault, and potential sexual exploitation encountered during or for the purpose of migration as well as facing acute prolonged fear of detention by immigration officials because of the documented human rights abuses (toward women specifically, including transgender women), experiencing child separation, inadequate or total lack of health care, inhumane hygienic conditions, and verbal, physical, and sexual assault.5

New York City enjoys sanctuary protections, which includes practices that obstruct cooperation with US Immigration and Customs Enforcement (ICE). Additionally, the New York City Mayor’s Office of Immigrant Affairs (MOIA) has focused on expanding health services in order to combat health inequalities that harm New York City’s immigrant communities.3 While the city has come a long way in helping to close gaps in health outcomes for immigrants, many barriers persist. Due to distrust in authority figures, studies show that immigrant women report reluctance in the use of prenatal care, preventive health care by adolescent mothers, testing for sexually transmitted infections (STIs), compliance in provider recommendations, and use of family planning services,6 despite the fact that this is often the only kind of health coverage they may qualify for.

The gap in health insurance coverage between U.S. citizen immigrant women in New York City, the latter of whom are far more likely to be uninsured, has closed considerably in recent years due to the Affordable Care Act (ACA) and the City’s GetCoveredNYC effort.3 After several years of coverage gains following the ACA, the uninsured rate in New York City increased again in 2019 in line with the national trend due to the concern around federal efforts to alter the availability and affordability of coverage.7 The Public Charge Rule also intimidated immigrant women from registering for health insurance avoiding unfavorable immigration consequences. A 2020 survey of immigrant-serving organizations in New York City reported that a sizeable majority of the families they served avoided public health programs they qualified for locally, even if they had not been included in the federal rule.8

In an attempt to combat these fears, MOIA reported “historic progress” with its Guaranteed Healthcare for All initiative. The plan aims to offer coverage to residents previously ineligible due to affordability or documentation status through H+H’s NYC Care program. However, despite expansions in available free or low-cost health options, studies show new immigrants are reluctant still because healthcare is one of the settings in which they experience discrimination most frequently, along with the workplace and interactions with law enforcement.9 Poor treatment from health providers severs strides made by expanded coverage as immigrant women opt to forego care than tolerate rough handling and misconduct.

A growing body of qualitative research also expands on the need for cultural competence in healthcare. A 2020 study conducted by the Mailman School of Public Health at Columbia University that collaborated with four New York City Hospitals found that Black pregnant people reported a higher incidence of discrimination and abuse during pregnancy and childbirth.12 Interestingly, there was significant overlap between what Black pregnant patients and their partners reported experiencing and what medical staff, including doctors, nurses, midwives, doulas, residents, lab techs, and auxiliary staff who directly interacted with pregnant people reported seeing, hearing and experiencing. The patients in their research shared that they felt that providers used derogatory statements depicting them as uneducated and irresponsible about their health, which they felt resulted in poorer treatment.12 One Obstetrics Resident (OR) was quoted as saying “Haitian Creole women have a reputation for being a little loud during their labor, … seemingly theatrical almost. I wonder if we assume that they’re just pretending they’re in so much pain and having so much difficulty, and then maybe we don’t care for them with the same diligence as someone who can more easily communicate to us,” while a Brooklyn Doula Care Worker stated “A client asked to squat during labor and was told by the provider, ‘Oh we don’t do that here..., you think we’re in the jungle in Africa?’ ”12 Providers reported witnessing their colleagues threaten women about their health or the health of the baby, judge and blame women for causing their own pain, make fun of women for their education level, insurance status, marital status and weight all within earshot of the patients.12 While much of the spotlight on maternal morbidity, and mortality in New York City is on the financial and clinical aspects of care, there is growing appreciation in understanding how a pregnant person’s experiences with cultural disrespect and abuse impact their health.

However, cultural competence and language comprehension go a long way toward bridging the gap.1 Estimates show about 61% of new immigrant women have limited English proficiency.1 CATCH workers have a shared racial/ethnic or immigrant background as well as language proficiencies, that can incorporate social and cultural context to increase access to health programs and link community directly to clinical care within the H+H systems. As lay person community outreach workers who receive training from NYC H+H to provide community-based health education, they can better reach insular populations because they are a part of those communities.

Studies find the work of the Promotores de Salud model to be beneficial to Latinas even when documentation status is not a factor, as is the case for Puerto Rican women living in the continental United States, further underscoring the importance of cultural competence in clinical care as access.10 Based on this logic, we find that the CATCH Program will likely benefit women of color overall due to proximity and intersections in identities. New York City is often seen as a leader in many industries; however, it suffers severely poor maternal health outcomes, lagging behind the state and even further behind the nation as a whole.11 Women of color and new immigrant women, (some of whom are both) have a historical distrust of abusive figures of authority otherwise charged to care for them and a program like CATCH has the potential to relate some cultural competence to this general population as well.



MISSION, GOALS, & OBJECTIVES: Meeting Community Where They Are At


Trying to make the best healthcare decisions can be challenging for immigrant women living in NYC, alongside language barriers, navigating the intersection of low socioeconomic status (SES), and the medical discrimination of ethnic minority communities. With CATCH’s mission to increase knowledge of sexual and reproductive health to immigrant women in NYC to help them make informed health decisions. By meeting our target population where they are and bringing sexual health education to them, one of our goals is to make SRH knowledge accessible. By equipping our clients with knowledge, we also aim to increase confidence and self-efficacy in our clients in the hopes that they are able to better advocate for their SRH needs with their newfound knowledge. Furthermore, through safe sex demonstrations and informing clients about birth control options, we aim to reduce high rates of STD/STIs and unwanted pregnancies present in immigrant communities. Forming a partnership with New York City Health + Hospitals (NYC H+H) to establish a collaboration of a ten-member committee to run a medical mobile unit, the mobile unit committee will conduct outreach within each of NYC’s five boroughs via mobile unit with an enrollment rate of 10 intakes per week. This would entail conducting grassroots efforts to expand awareness of mobile unit (including handing out informational resources containing the hours of operations, weekly locations and weekly directions to SRH access services) along with conducting outreach among densely populated areas (visiting each of NYC’s 5 boroughs one day a week, Monday through Friday). To ensure participants can identify healthy sexual health practices, individual harm reduction counseling will be available via our mobile unit to increase condom usage, rapid HPV, STI/STD and HIV testing will be available to reduce transmission. Our learning objectives include debunking myths and misconceptions regarding seeking sexual reproductive health care and treatment to decrease likelihood of experiencing sexual coercion. Throughout each SRH workshop that is conducted, social support (via psychotherapy) will be provided to patients to address self-esteem issues, negative attitudes toward condom use and to increase self-efficacy. Increase condom dispensers with point-of-contact health messaging,would provide the CATCH program with additional support in attaining the environmental goal of increasing access points to sexual health reproduction education, treatment and services. Ultimately, participants will leave the program learning the tools they need to autonomously identify, improve and maintain their sexual reproductive health status, (participants have the option to stop their participation when they decide they no longer need counseling. Finally, through our efforts, our intervention’s overall outcome goal is to normalize conversations surrounding SRH in immigrant communities where it is highly stigmatized.



Over the span of 10 years, we will conduct community-based workshops highlighting:


  1. Sexual and reproductive health (SRH) education


  1. health literacy and health comprehension

-educate patients on the difference in being insured vs underinsured vs uninsured


  1. Health insurance enrollment:

- educate patients on the different gynecologists are covered under their current health insurer

- help participants identify and access New York City’s SRH clinics that offer free gynecological services

- help participants identify and access New York City’s virtual telehealth options regarding gynecologic appointments (with COVID 19 pandemic regulations)

- help participants navigate New York City’s health marketplace to find optimal insurance options


D. Identifying SMART goals to help participants reach an overarching goal of attaining access to SRH options and treatments along with identifying healthy SRH choices which includes a. increasing condom accessibility within the first year; b. offering HIV/STI testing and information; c. At least 30% of patients will report increased usage of condoms after one year of enrollment; d. Maintain a 70% retention rate each year; e. after one year 50% of participants will have increased knowledge of safer sex practices. We also hope that the availability and visibility of testing will normalize testing practices and safer sex practices. These objectives will help determine whether the intervention was effective and identify areas of improvement.



INTERVENTION AND PLANNED ACTIVITIES


The CATCH program was developed to provide culturally conscious health education to various immigrant women populations in New York City. Through this intervention, we aim to reach and educate an underserved population about their own health. There is power in knowledge and we want to equip our participants with the tools they need to make informed decisions about their reproductive health. Using the evidence-based Promotores de Salud model framework, our intervention will designate trusted members of our target population as CATCH community health educators. Evidence-based interventions are usually treatments that have been proven to be effective to some degree in the past. Therefore, if an evidence-based intervention is implemented appropriately, it is likely to be effective in changing our target behavior. Our educators will be language proficient and share the same cultural backgrounds as our clients. Because New York City harbors numerous immigrant demographics, health educators will be assigned to a population based on shared racial/ethnic background and language proficiency. CATCH educators, trained by our parent organization NYC H+H, will be responsible for reaching and educating community members. Educators will be working everyday and will visit different neighborhoods to increase outreach. CATCH workers will begin their day visiting local community centers and businesses that predominantly hold their target populations. By incorporating relevant social and cultural context in informal conversations, CATCH workers aim to engage immigrant women in SRH discussions they may not have otherwise had opportunities to hold in a culturally competent way that is also medically accurate. Our educators will share important information such as STI/STDs prevention and treatment, gynecological exams, reproductive cancer screenings and prevention, birth control methods, pregnancy options counseling, hormonal therapies, consent & supportive relationships, and answer any intersecting health questions our clients may have. Educators will also share flyers and pamphlets in appropriate languages with the same information that our clients can revisit later and information on how to follow up with next steps if they wish to in their own time. Finally, through our partnership with NYC H+H medical mobile units, our intervention will also offer our clients the option to visit a medical care provider in a nearby mobile unit. Because we know our target population is hesitant to receive medical care in institutionalized environments such as hospitals, this service will provide our clients an alternative to receiving necessary reproductive medical care. Thus, CATCH workers will also be responsible for encouraging clients to visit the mobile unit to address any SRH issues they may have. Through these services, this intervention aims to make receiving SRH education and care accessible and convenient for immigrant women populations in New York City. Overall, our intervention’s goal is to foster a safe and comfortable learning environment where immigrant women are empowered to take back control of their health.




EXPECTED OUTCOMES



Short Term (1-3 years)

1) Increased SRH knowledge among immigrant women in New York City.

2) Increased medical visits for SRH needs

Intermediate (4-6 years)

3) Increased self-efficacy and confidence in clients regarding own health (4-6 years)

4) Decreased rates of STDs and unwanted pregnancies in immigrant communities in New York City (4-6 years)


Long Term Outcome:

5) Decreased stigmatization of SRH topics in immigrant communities in New York City (7-10 years)


In terms of outcomes for our program, we expect changes to occur on both individual and community levels. In the first three years of operations, we expect knowledge of sexual and reproductive health among immigrant women in New York City to increase. With the involvement of the NYC health and hospitals’ mobile medical units, we also expect an increase in medical visits for sexual and reproductive health reasons in immigrant communities during the same time length. Moving along to our intermediate outcomes, by equipping our clients with accurate information and health resources, we aim to empower our clients into taking back control of their bodies and their sexual and reproductive health. So, in 4-6 years, we hope our approach leads to an increase in confidence and self-efficacy in our clients, allowing them to advocate for their health effectively. On a more community level, in 4-6 years, we also hope to see a decrease in unwanted pregnancies and STD rates in our target communities. Finally, after 10 years of being operational, we hope that the CATCH intervention program brings large-scale change and reduces the stigma around sexual and reproductive health in immigrant communities. Normalizing conversations around this topic will lead to improved health outcomes in individuals and uplift whole communities.


EVALUATION PLAN


To evaluate our intervention, we will be conducting process evaluations, impact evaluations, and outcome evaluations. The purpose of conducting a process evaluation is to receive feedback on the program implementation of CATCH. We must first want to lay a strong foundation for our program and ensure our internal dynamics are This evaluation will serve to provide quality assurance of our program activities and their degree of exposure to immigrant women populations. It will also assess our internal operations and their effectiveness in achieving our outcomes. We will be using surveys to collect data from CATCH health educators and operational staff and analyze it qualitatively. Information obtained from this survey will be shared with staff and health educators to improve the performance and quality of the CATCH intervention program.

Through annual impact evaluations, we will be examining how our intervention activities and strategies are affecting immigrant women in New York City. Because we recognize conversations about someone’s experience receiving SRH education may be more comfortable and forthcoming in private, CATCH educators will be using one-on-one in-depth interviews with interested participants to understand how our program has impacted their lives. CATCH health educators will be specifically collecting data on how our approach to sexual and health reproductive health education has been affecting our participant’s knowledge of SRH, along with their attitudes, beliefs, and behavior. The data will be analyzed qualitatively and conclusions will be included in an annual executive report and dispersed to stakeholders, staff, and the general public.

Finally, once the CATCH program has established itself in the community, we will also be implementing an outcome evaluation to measure the long-term effects of the intervention. Because we are interested in learning about community-level social changes elicited by our program, we will be conducting this evaluation through focus groups, in which social interactions and group dynamics amongst the participants can also be studied. In these focus groups, a health educator will facilitate conversations to identify any large-scale change, including increased normalization of conversations around SRH topics.



SUSTAINABILITY

Ultimately, if adopted by local governments, compliance to CATCH protocols would inform policy responses across different sectors, with the overarching goal of enhancing social and structural norms of decreasing the stigmatization of SRH for immigrant women living in New York City. Additional support that will lengthen the effects of our program includes providing educational tools, referrals, informational resources to public health initiatives and public health efforts (including promoting national policy, developing resources and programs, seeking health equity, supporting effective local public health practice and systems). We need a cohesive intergovernmental process that allows the prompt response to improving and expanding affordable sexual reproductive health care education and treatment that provides sufficient coverage for immigrant women living in NYC. Although these policy changes may incur a significant cost, they will be sustainable, and will help to avoid future costs by way of the cost of repeated hospitalizations and healthcare costs. Participants can increase their self-efficacy by becoming peer educators. This accomplishment will allow students to continuously gain knowledge and expertise in sexual health education and feel in control over their personal sexual experiences.



CONCLUSION: Statements of Impact


On Research & Evaluation

Because new immigrant women avoid surveillance there is still much that is unknown about their health.1 This lack of data makes their SRH care barriers difficult to research, especially at the distinct stages of migration. The CATCH Program prefaces questions in data collection by reinforcing that they do not share information with immigration authorities, while also including an explicit option to decline.1 Researchers benefit immensely in collaborating with the CATCH Program and the trusted community partners they work with as they have established confidence with participants and have systems in place to protect the confidentiality of their data. Community-engaged research approaches are critical to building trust with marginalized communities, such as undocumented immigrants because it allows time for them to observe the research from safe distances and have a feeling of control over personal information.1)This approach requires researchers take the time to build relationships with the already established and trusted community partners serving insular or underground communities undocumented immigrants belong to. Collaboration with CATCH may have great potential for data on this population. Future research efforts benefit to draw on intersectional aspects of an immigrant woman’s identity, such as ability, parenthood status, gender expression, race, and sexual orientation, as those can add vast variety to individual experience.


On Family & Community Health

Working with groups and individuals through the CATCH Program can help immigrant women make informed choices about their own health and well-being, as well as the health and well-being of their families and communities. Studies show that women make 80 percent of health care decisions in the United States.2) Because women are the main medical decision makers, CATCH teams know that the conversations they have with immigrant women can have a significant impact on the health of the entire family, and therefore the entire community. This program provides a momentus opportunity for immigrant women to gain health care access for themselves and their families. By focusing on immigrant women's leadership roles in the context of health care decisions, education and outreach through CATCH has implications for reaching broader health and social goals.


More Equitable, Effective Healthcare

Cultural competence in healthcare settings staffed with people from culturally and linguistically diverse backgrounds is a major strategy to respond to evidence of health disparities, structural inequalities, and poorer quality health care and outcomes among immigrant women. Respecting and tailoring care aligned with immigrant women’s values and needs lead to higher satisfaction with care, better adherence to treatments, and improved health outcomes.3)Findings indicate a need for interventions that acknowledge the value of cultural awareness-based approaches in healthcare dissemination, such as a recognition of racism, power imbalances, entrenched majority culture biases, and the need for self-reflexivity.
















Appendices


LOGIC MODEL

Inputs

Outcomes -- Impact

Activities:

Outputs:

Short

Medium

Long

Diverse and experienced operational staff

Diverse health educators

Volunteers

Funding

Time

Operational space

Supplies

Technology

Activity Niche 1: Operational

Runs overall operational activities for program; activities include administrative and bureaucratic roles including but not limited to:

Onboarding new employees


Coordinating routes for health educators


Managing outreach efforts


Creating schedules for employees and volunteers

# of promotional material distributed online and offline and % of our target population of immigrant women in NYC reached as result

# of women active in program activities per year

# of inquiry calls and emails asking further information about program

In 6 months, we expect to have operational staff, health educators, volunteers, funding, operational space, technological equipment, and other operational supplies

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