WORKING TOGETHER TO INCREASE IMMIGRANT WOMEN”S

Made possible by the generous support of the Bureau of Women’s Health, New York State Department of Health

Introduction

Family Planning Advocates of New York State (FPA) and the Center for Women in Government & Civil Society at SUNY (the Center) have embarked on a joint initiative that promotes improved and expanded access to culturally competent, quality reproductive health care services for immigrant women. The goals of the initiative are:

· To connect grassroots immigrant women leaders and reproductive health providers from across New York State.

· To identify both barriers to access facing immigrant women and obstacles facing reproductive health providers in delivering culturally competent services to immigrant women.

· To develop innovative change strategies to ensure culturally appropriate, accessible, and affordable reproductive health care for immigrant women.

The first stage of the initiative included a statewide roundtable in NYC on December 11, 2002. The second stage includes three regional meetings, which are being be held in Albany, Rochester, and New York City in 2003.

The Statewide Roundtable identified a multitude of cultural, linguistic and immigration status barriers to care. It highlighted the intersection of nativism, gender, class and race/ethnicity in the lives of immigrant women and the enormous challenges facing providers in reaching and serving them. Yet, it also unveiled a number of promising models and innovative change strategies that can transcend the barriers and build bridges between providers and immigrant women’s communities. These strategies included establishing two-way training and education, and building collaborative relationships between immigrant-serving organizations and family planning providers.

The regional meetings are designed to continue the process of building durable partnerships between immigrant women’s organizations and family planning providers, and to provide training on concrete issues that were identified at the December roundtable. This report documents proceedings of the first two regional meetings held in Albany on April 10, 2003, and Rochester on May 21, 2003. Because the participants were all from upstate communities, and the content, format, and speakers were almost the same, it seemed useful to prepare a single report. Ten family planning providers and eighteen immigrant-serving programs participated in the Albany meeting, while twelve family planning providers and twenty-two immigrant-serving programs participated in the Rochester meeting. Please refer to attachments for each meeting’s agenda, list of participants, speakers’ biographies, and evaluation.

Morning Session

The morning session began with welcoming remarks and an overview of the program by Maud Easter of the Center. A summary of the barriers, strategies, and models identified at the December roundtable was presented by Karen Anderson of FPA, followed by a keynote panel, Breaking the Barriers: Successful Models to Reach and Serve Immigrant Women. Drawing on the main issues identified at the roundtable, three panelists at each meeting explored existing models for strengthening services to immigrant women.

Albany Panel Rochester Panel

Roopa Chakkapan Felicidad Frenette

Yumiko Fukada Alejandra Molina

Deborah Bach Deborah Bach

The following is a summary of the key points of each model:

Model #1

Immigrant Serving Programs as Advocates for Their Communities

Roopa Chakkapan presented the SAKHI for South Asian Women Model (Albany meeting)

Ms. Chakkapan explained how SAKHI, meaning “woman friend,” tries to create a safe environment in New York City for South Asian women who are survivors of domestic violence. The agency operates with a staff of 5 employees and more than 100 volunteers. Over the past 5 years SAKHI has served over 3,500 survivors. While SAKHI’s focus is domestic violence, not reproductive health, its work linking immigrant women with health providers and other services illustrates the invaluable bridging role which can be played by agencies embedded in immigrant communities.

· Domestic violence is a serious problem in the South Asian community and opens the door to multiple challenges facing immigrant women. Traditional cultural norms prevent many South Asian women from reporting incidents of domestic abuse because they do not want to bring shame on their families. In addition, many women do not report domestic abuse because they are fearful of deportation.

· SAKHI’s services include referrals to health and legal services; health communication classes to improve both health knowledge and English communication skills; ongoing support groups; and economic empowerment, for example, computer classes.

· To facilitate access to culturally and linguistically appropriate health care providers, SAKHI has launched a Women’s Health Initiative. SAKHI has created a database of health care workers sensitive to cultural and gender issues, with information on language skills and the availability of probono or sliding scale services.

· SAKHI also recruits South Asian providers to train mainstream providers on the needs of South Asian women and the cultural context of this community.

· Outreach and education is also carried out at local health fairs, professional conferences, and religious and cultural events.

Felicidad Frenette presented the Refugee Cultural Competency Training Model (Rochester meeting).

Ms. Frenette described a model for providing culturally competent health services to refugees. This model is the result of collaboration between the International Institute of Buffalo, a refugee/immigrant serving agency, and the University of Buffalo Department of Family Medicine, a mainstream health care provider.

· The International Institute of Buffalo provides core services, including basic health screening, for a limited period of time to federally sponsored refugees, but wants to be able to link them with ongoing and comprehensive health care.

· The Institute refers clients to specialists and ensures that clients keep follow-up appointments.

· Institute staff members link refugees to clinics, advocate for interpreters, and arrange transportation.

· A Refugee Cultural Competency Training Program teaches medical students from the University at Buffalo Department of Family Medicine basic anthropology and the concept of culture, and it briefs medical students on the psychosocial problems affecting refugees and the medical problems common to the refugees’ homelands.

· The medical students gather the patient’s life story and health history, before conducting the physical examination with the attending physician. When necessary, diagnostic tests are ordered. The refugee patients receive increased personal attention and follow-through.

· After refugees are seen, students share their biomedical and emotional experiences at a debriefing session, and make suggestions for future care.

Model #2

Peer Education: A Culturally & Linguistically Sensitive Model for Reaching Immigrant Women

Yumiko Fukada, presented the Asian and Pacific Islander Coalition on HIV/AIDS, Inc., (APICHA) model (Albany meeting).

Ms. Fukada described how the APICHA program of New York City offers “one stop shopping” where education, preventive and testing services, and primary medicine are provided in one place, and where the peer educator model is used for effective outreach to Asian and Pacific Islander immigrants.

· APICHA serves Limited English Speaking (LEP) clients living with AIDS. The agency uses the peer educator model to provide services to approximately 150 clients affected with AIDS, 98% of whom are Asians. The agency is staffed by 30 full-time staff members, 50 stipend workers, and 30-50 volunteers. Every 6 months, 6-10 volunteer peer educators are recruited and trained to provide outreach education workshops to the community. After 6 months, trainees graduate and some are recruited as ongoing staff peer educators. 15% of APICHA’s staff is from this pool.

· An $8/hr training stipend makes it possible for people to participate in the program. During the training, the volunteer peer educators increase their understanding of ethnic identity and empowerment issues, building on their original motivation to address HIV/AIDS issues.

· Peer educators provide effective outreach and inform the entire agency concerning the dynamics of specific Asian cultures.

· APICHA serves a community of more than 100 different dialects. Services are provided in 7 major languages, and the majority of peer educators are bi-lingual.

· The coalition recognizes that to reach Asian clients successfully, addressing reproductive health issues is not the place to start. Instead, peer educators encourage clients to voice survival concerns, legal issues, general health issues, and eventually HIV/AIDS and domestic violence, which are more stigmatized issues in the community.

Alejandra Molina presented the Farmworker Women’s Institute Empowerment Model (Rochester meeting).

Ms. Molina described the Farmworker Women’s Institute, formed two years ago to enable farmworker women to break the isolation of their lives through empowering, group experiences. The Institute uses peer educators and uses theater to strengthen English (ESL) classes, education, and legal clinics.

Peer Educators

· The Institute encourages parents to read to their children using bilingual texts. Eventually, these parents are trained to reach out to involve their peers, other parents. The Institute uses immigrant women who have acquired some knowledge of English to teach newcomers. A major challenge is teaching English to those whose Spanish literacy is low.

· One goal of the Institute is to provide on-the-job training for farm-worker women as outreach workers linking providers and the community, so that the women can be permanently hired as peer educators.

Theater Model

· Immigrant women share real challenges in their lives using a model, developed in Florida, in which rural women dramatize harvesting dreams. The story line is similar to a soap opera in which the characters complain of problems such as tension, dizziness or illness associated with pesticide poisoning, or of ongoing illness such as diabetes. This model is popular due to the low literacy level among farm workers. Younger farmworker women have slightly higher literacy levels, but the average level is 3^rd grade, with 6^th grade being the highest.

· A farm-worker women’s leadership project involves working with a Cornell University drama group, which presents a play depicting the tragic story of women and children left behind in Mexico. After the presentation, the play is discussed by farmworker women and men.

· The goal of the project is that, eventually, farm-worker women will themselves perform the play and lead the discussion.

Both these models also address farmworker women’s need for socialization to break the cycle of isolation that is one of the factors contributing to their disempowerment.

Model #3

Taking the Service to Immigrant Women: The Mobile Unit Approach

Deborah Bach, of Planned Parenthood, Buffalo, presented The Mobile Unit Model (Albany and Rochester meetings).

Ms. Bach described how the mobile unit resulted from collaboration between the Planned Parenthoods of Niagara and Erie Counties. The mobile unit provides services to low-income persons of all ethnic groups in Western NY where the rates of unintended pregnancies, STDs, and breast cancer are all high.

· The mobile unit operates within a “spokes of the wheel” concept, a broad coalition of 30 partnerships with other health care providers, community centers, soup kitchens, churches, schools, domestic violence shelters, rehabilitation facilities, etc. The unit is at the center of the wheel and is the link between coalition partners and clients. The circle (wheel) represents the continuum of care clients receive.

· Since it was introduced in 2001, the unit has treated 1700 clients, 10% of whom are immigrants, 40% of whom are male, and 60% of whom are minorities.

· The unit is staffed by 1 full-time Nurse Practitioner (Caucasian), 2 full-time Clinic Specialists (1 Hispanic, 1 African American), 1 full-time Educator/ Domestic Violence Counselor (of Middle Eastern descent), 1 per-diem Women’s Health Practitioner (of Asian descent)), and 1 Coordinator.

· Services include STD testing & treatment (women and men); cancer screening (women and men); gynecology exams for women; condom distribution; birth control prescriptions; podiatry; and eye care.

· The mobile unit provides services in settings that feel accessible and safe to community members, and to which they come for other purposes.

· A lack of interpreters has to date hindered adequate outreach to immigrant populations.

· The clients’ lack of documentation, which is required for the complicated application processes of public health benefit programs, limits the program’s access to reimbursement funding.

Lunch Session: Confronting Gender: Strategies for Empowering Women

One of the frequently raised issues at the December 2002 Statewide Roundtable and, in fact, one of the major barriers facing immigrant women, is male domination. Gender disparities in their countries of origin often influence immigrant women’s health care choices. Dr. Vivien Ng, Associate Professor of Women’s Studies at the University at Albany, SUNY, was invited to discuss this issue over lunch, at both meetings. Dr. Ng initiated lively discussions on gender, race, and class issues, and she challenged participants to think critically when dealing with potentially stereotyped information about immigrant women. Included below are some of the main points raised by Dr. Ng.

· Immigrant communities are not uniformly poor, illiterate, and needy. Women within the same group may share the same language, but they are often divided by class and regional issues.

· Societal ills, such as racism, classism, sexism, heterosexism, and xenophobia are some of the challenges faced by immigrant women as well as other communities of color.

· Our own issues of racism and classism are barriers to serving immigrant women.

· Being “well-intentioned” does not mean that we do not create barriers by our attitudes and behavior.

· Racism and ethnocentrism are two different realities, both important to understand.

· We need to recruit peer educators and interpreters who are sensitive to class issues.

· It is important to avoid making cultural assumptions. For example, the assertion that domestic violence is more prevalent in immigrant communities than in the US (where it is widespread) could inaccurately affect our image of those communities. What is important to providing safety to a woman is how domestic violence operates in her culture.

· We need to provide not only interpreters, but also support groups, being mindful of regional and class differences among the women who need support.

· It will take more than a one-day conference to bring about social justice; it requires a lifelong commitment.

· Culture can be very empowering to immigrant women, and it can be very oppressive. It is critical to allow space for embracing culture, yet also to address the oppressive elements in a non-threatening manner.

Afternoon Session

The afternoon session was divided into two workshops, one to address language barriers and the other to discuss legal issues.

Workshop A: Overcoming Language Barriers: Basics of Interpreting in a Multicultural Setting

This workshop was presented by Cornelia Brown, Nadezhda Moyseyuk, Ofelia Dale, Roger Smith, and Raquel Tavarez, of the Multicultural Association of Medical Interpreters (MAMI).

MAMI is a not-for-profit language bank (agency) in Utica, NY. The network offers professional interpreting services and translation of health-related documents in Oneida and Herkimer counties. The participants from MAMI, led by Cornelia Brown, conducted skits to demonstrate:

· Problems that occur in the absence of a trained interpreter.

· The health risk when a limited English proficiency (LEP) patient meets with a health care provider alone, without interpreting assistance.

· The health risk when an LEP patent is assisted by an adult ad-hoc “interpreter.”

· The health risk when an LEP patient is assisted by a child ad-hoc “interpreter.”

· How health facilities often seek to avoid compliance with legal requirements for language services (as required under the US Civil Rights Act and under an Executive Order).

· The cost to health facilities of non-compliance.

· The need of immigrant women for advocacy for language services.

· The importance of accurate and transparent translation.

· How a trained interpreter works.

· The importance of the ~~translator~~ interpreter being the Conduit, the “voice of the voiceless,” using first person language and encouraging direct communication between the provider and the patient.

· The need, sometimes, for the interpreter to intervene and act as Clarifier, if the patient does not understand.

· The role of the interpreter as Culture Broker, in the event that a cultural issue, which blocks communication between health care provider and the patient, arises.

Workshop B: Impact of Immigration Status on Access to Reproductive Health Care

This workshop was presented by Barbara Weiner of Greater Upstate Law Project (GULP).

GULP is a non-profit legal resource center that provides technical assistance to local legal services programs and other community groups in upstate New York. GULP works on a broad range of legal matters, including immigrants’ access to public benefits. The following issues were raised:

· Issues common to immigrants and non-immigrants include the cost of health care and whether or not the person is insured.

· Issues unique to immigrants are language, culture, and immigration status.

· Undocumented persons have generally been ineligible for other than emergency assistance. Of great importance to serving undocumented immigrant women, however, NYS residents are currently eligible for certain programs regardless of immigration status:

ü PCAP

ü Emergency Medicaid

ü CHIP

· Under the PRWORA (1996 federal Welfare Reform Act), some legal immigrants, Persons Residing Under Color of Law (PRUCOL) who had previously eligible for benefits, were barred from most federal means-tested benefit programs. Even those immigrants whose status allowed them access to benefit programs were subject to restrictions if they entered the U.S. after August of 1996.

· NYS eliminated some of the harshest impact of the federal PRWORA following a successful lawsuit, Aliessa v. Novello, in which the Court of Appeals held that in NYS legal immigrants must be provided access to publicly funded health care on the same basis as citizens. This court decision was based on NYS constitutional responsibility for poor and needy persons, including immigrants.

· Generally, immigrants qualified for benefits are:

Lawful Permanent Residents (green-card holders), refugees, persons seeking asylum,

persons with deportation withheld, Cuban/Haitian entrants, Amerasians, cross border

Native Americans from Canada, conditional entrants paroled for 1 year or more,

certain battered spouses and children (married to or parented by a US citizen or Legal

Permanent Resident (LPR) and in process with INS to gain admittance as LPR).

· After PRWORA, Persons Residing Under Color of Law (PRUCOL) are qualified only for state means-tested benefits. PRUCOL is not an immigration status itself. It refers to categories of immigrants who do not have permanent residence status, but are considered to be in the U.S. “ under color of law.” It is a concept developed in the context of public benefits’ eligibility and pre-dates PRWORA. PRUCOL immigrants include, for example, persons under “Deferred Action” or subject to an “ Order of Supervision.” ItThe PRUCOL category does not include undocumented persons and non-immigrants, such as students, visitors, and people on employment visas.

Closing Circle: Planting Seeds of Change

Maud Easter, Center for Women in Government & Civil Society

Gemma Pujadas Ribeiro, Family Planning Advocates of New York State

At the closing session of each meeting, soil and seeds were provided. Participants were asked to reflect on the day’s discussions and to plant a seed as a symbol of what was achieved and/or expected outcomes. Participants planted seeds expressing how the day had increased their sense of commitment, solidarity, perseverance, justice, passion, and friendship, in the struggle to increase reproductive health care for immigrant women.

Evaluation and Recommendations

What was most striking about the two Upstate Regional Meetings was the relative lack of previous contact between family planning providers and immigrant women’s programs. While a few family planning participants had already made local connections with immigrant-service programs, everyone expressed a need to deepen their relationships and requested assistance in connecting with legal and language resources. The recruitment process for both meetings underscored that immigrant women leaders have not been aware of the range of health services available for their communities through family planning providers, and that many family planning programs had not fully appreciated the seriousness of culture, language, immigration status and health insurance obstacles to their care. There was consensus among participants on the need to identify and promote strategies to overcome existing barriers and resources available in their communities.

Participants completed written evaluations of both events (see Attachment #8). Overall, participants’ responses to both meetings were very positive, indicating high ratings for all the regional meeting components and particular enthusiasm for the diversity and openness of the participants, the positive models presented, and the opportunity to network. One participant noted the value of the sharing, saying “I did not know a thing going in.” Addressing future needs to strengthen the collaboration initiated at these events, participants expressed a desire to plan specific projects and to have more time for networking.

The Center and FPA recommend the provision of ongoing technical assistance to local partners in both their networks, to deepen the relationships that were initiated at the regional training, and to support local collaboration. Intensive technical assistance in organizing an ongoing collaborative relationship, provided to several selected local communities, would create models for mutual assistance that could strengthen reproductive health care for immigrant women across the state.

Attachment #1: Albany Meeting Agenda

Thursday, April 10, 2003

10:00 – 10:30 Registration

10:30 – 10:40 Welcome - Overview of the Program - Objectives of the Day

Maud Easter, Center for Women in Government & Civil Society

10: 40 - 10:50 Highlights of the Statewide Roundtable

Karen Anderson, Family Planning Advocates of New York State

10:50 – 12:15 Breaking the Barriers: Successful Models to Reach and

Serve Immigrant Women: Keynote Panel

· Peer Education: A Culturally & Linguistically Sensitive Model for Reaching Immigrant Women

Yumiko Fukuda, Asian and Pacific Islander Coalition on HIV/AIDS, Inc.

· Immigrant-Serving Programs as Advocates for their Communities: The SAHKI Model

Roopa Chakkapan, SAHKI for South Asian Women

· Taking the Service to Immigrant Women: The Mobile Unit Approach

Deborah Bach, Planned Parenthood of Buffalo

Moderator: Dina Refki, Center for Women in Government & Civil Society

12:15 –1: 15 Lunch

Confronting Gender: Strategies for Empowering Immigrant Women

Vivien Ng, Professor, Women’s Studies, University at Albany

Introduction: Gemma Pujadas Ribeiro, Family Planning Advocates of New York State

1:15 – 2:15 WORKSHOP A: Overcoming Language Barriers: Basics of

Interpreting in a Multicultural Setting

Cornelia Brown, Multicultural Association of Medical Interpreters (MAMI)

Nadezhda Moyseyuk, MAMI

Ofelia Dale, MAMI

Roger Smith, MAMI

Workshop A will be held in Milne 200

WORKSHOP B: Impact of Immigration Status on Access to Reproductive Healthcare

Barbara Weiner, Greater Upstate Law Project

Workshop B will be held in Page Hall Lounge

2:15 – 2:30 Break

2:30 – 3:30 WORKSHOPS

(Same workshops, Participants switch)

3:30 – 4:00 Closing Circle: Planting Seeds of Change

Maud Easter, Center for Women in Government & Civil Society

Gemma Pujadas Ribeiro, Family Planning Advocates of New York State

4:00 Adjourn
Attachment # 2: Rochester Meeting Agenda

Wednesday, May 21, 2003

9:30 – 10:00 Registration

10:00 – 10:30 Welcome - Overview of the Program - Objectives of the Day

Maud Easter, Center for Women in Government & Civil Society

10:30 - 10:45 Highlights of the Statewide Roundtable

Karen Anderson, Family Planning Advocates Of New York State

10:45 - 12:15 Breaking the Barriers: Successful Models to Reach and

Serve Immigrant Women: Keynote Panel

· Peer Education: A Culturally & Linguistically Sensitive Model for Reaching Immigrant Women

Alejandra Molina, Farm Workers’ Women’s Institute

· Immigrant-Serving Programs as Advocates for their Communities

Felicidad Frennette, International Institute of Buffalo

· Taking the Service to Immigrant Women: The Mobile Unit Approach

Deborah Bach, Planned Parenthood of Buffalo

Moderator: Dina Refki, Center for Women in Government & Civil Society

12:15 –12:30 Break

12:30 – 1:15 Lunch

Confronting Gender: Strategies for Empowering Immigrant Women

Vivien Ng, Professor, Women’s Studies, University at Albany

Introduction: Gemma Pujadas Ribeiro, Family Planning Advocates of New York State

1:15 – 2:30 WORKSHOP A: Overcoming Language Barriers: Basics of

Interpreting in a Multicultural Setting

Cornelia Brown, Multicultural Association of Medical Interpreters (MAMI)

Lyubov Vasyukhnevich, MAMI

Ofelia Dale, MAMI

Raquel Tavarez, MAMI

2:30 – 2:45 Break

2:45 – 4:00 WORKSHOP B: Impact of Immigration Status on Access

to Reproductive Healthcare

Barbara Weiner, Greater Upstate Law Project

4:00 – 4:30 Closing Circle: Planting Seeds of Change

Maud Easter, Center for Women in Government & Civil Society

Gemma Pujadas Ribeiro, Family Planning Advocates of New York State

4:30 Adjourn

Attachment #3: Albany Regional Meeting Participants

ACCESS TO REPRODUCTIVE HEALTH CARE

Report on Upstate Regional Meetings

Albany - April 10, 2003

Rochester - May 21, 2003

Workshop B: Impact of Immigration Status on Access to Reproductive Health Care

Closing Circle: Planting Seeds of Change

Maud Easter, Center for Women in Government & Civil Society

Gemma Pujadas Ribeiro, Family Planning Advocates of New York State

Evaluation and Recommendations

Thursday, April 10, 2003

10:00 – 10:30 Registration

Maud Easter, Center for Women in Government & Civil Society

Roopa Chakkapan, SAHKI for South Asian Women

Workshop A will be held in Milne 200

Wednesday, May 21, 2003

Maud Easter, Center for Women in Government & Civil Society

Felicidad Frennette, International Institute of Buffalo

2:30 – 2:45 Break

Thursday April 10, 2003

Upper Hudson Planned Parenthood

Centro Civico of Amsterdam

Refugee Assistance Program