Health of the Brazilian Population on Martha’s Vineyard

Island Health Care (IHC) and the Inter-Island Public Health Collaborative embarked on a research effort to better understand the health concerns and needs among the Brazilian population on Martha’s Vineyard. This research is to enhance IHC’s delivery of care and to contribute to a full Health Needs Assessment of the Island’s population.

Key Findings: In quick summary, the research revealed:

1. A need for better communication with the Island's Brazilian population and in particular, increased use of the Portuguese dialect spoken by new arrivals. This should also include formatting information delivery in a mode that is easy to comprehend such as video and spoken word.
2. Stigma was a major barrier that keeps individuals from seeking care. This can include fear of 'discovery' or deportation due to immigration status. It can also include fear of seeking services that are culturally ridiculed or avoided such as treatment for mental illness, substance misuse, or reproductive health.
3. One of the most telling outcomes was the importance placed on the Social Determinants of Health (SDOH). While Islanders, including the Brazilian population, face long wait times for primary care appointments, many of the survey responses and focus group insights did not dwell on the availability of care, but instead highlighted the need for support and wraparound services related to housing, substance misuse, food security, and mental health counseling.

Methodology This research initiative was split into two main avenues. The first was a 23-question digital survey available in both English and Portuguese. Paper copies were provided upon request and the survey was administered over a 3-week period between July and August 2022.

Two key informant interviews and a small focus group were also conducted in late July and early August 2022.

Limitations While we received enthusiastic support from the Brazilian Community regarding the project, the response/participation rates for the survey and focus group were low. Luckily, we were able to supplement with some key informant interviews. We conducted this survey in the summer in preparation for an annual reporting deadline, but in hindsight it would have been wise to conduct the survey and focus group/interviews in the Island's November - March "off-season". Given the low participation rates across the board, the results of this research should be used merely as a guide for researchers and decision makers rather than a definitive description of the entire Brazilian population on MV.

We plan to conduct the survey again at a more appropriate time and will update this page when new information is available.

As noted above, this community research effort is a part of IHC’s routine Community Health Needs Assessment. In the past, the assessment had highlighted the needs in the Brazilian Community, but little was known about their opinions and lived experiences on Martha’s Vineyard. In the interviews and group discussion, participants were candid in their responses and identified challenges related to:

· Health care provider availability and capacity · Increasing trust in health care institutions and reducing stigma · Reaching engaged members of the Brazilian Community in a meaningful way · A need for more community health education · Improved language logistics and accessibility

Brazilian-Portuguese Language Logistics

Brazilian-Portuguese Focus

• When available, providers should be requesting a Brazilian-Portuguese interpreter.
  • There are distinct differences between European Portuguese and Brazilian Portuguese.
  • There are also regional dialects of Portuguese within Brazil. In Minas Gerais, the state where most MV Brazilians originate from, the main dialects are Mineiro, Caipira, & Baiano.
• When possible, consider a Portuguese-leading format, instead of English leading. Starting conversations in English can deter folks from making initial contact or feeling comfortable contacting their ‘medical home’ (Patient-Centered Medical Home).
  • This approach could also include dedicated Portuguese websites and phone lines

Provider-Patient Communication

• Providers should be conscious of word choice when speaking directly with a patient or with an interpreter, then a patient. The more complex the message, the harder it will be for the patient to understand or for the interpreter to convey in a way that is meaningful.
  • As noted earlier, the Brazilian-Portuguese reading level for many members of MV's Brazilian population is at about a 5th grade level.
• Likewise, in the other direction, English-understanding patients often know when their message is not being fully relayed, which adds to frustration and mistrust.
  • Perhaps additional training or the development of best practices for health interpretation for the MV Community would help.

Community Health Education

Meeting the Community Where They're At

• Since many Brazilians arrive to the Island with low literacy rates and either missed the opportunity for health education in Brazil or received partial health education; revisiting these topics could be extremely helpful. Potential topics include basic nutrition, reproductive health, physical activity, alcohol/substance misuse, mental health, and mindfulness.
  • Info sessions around health system navigation and the differences between the US and Brazil would be great too, like the differences in routine tests and needing a PCP
• Any programming for health education should also be delivered at a literacy level that is inclusive for all without belittling the audience.
• Since all respondents mentioned the internet and social media as a main avenue for health information, building education and outreach campaigns on these platforms would be a proactive way of reaching people where they already engage with information.

Reaching the Engaged Brazilian Community in a Meaningful Way

• Churches: Most of the respondents brought up the churches as hubs of social support and information exchange among the MV Brazilian Community, so future outreach campaigns should explore integration with the churches, their existing programming, avenues of communication, etc.

• Community Influencers: Members of the Brazilian Community who work in health care or adjacent to healthcare utilize that connection to answer personal or community health questions. They also act as a bridge between community members seeking care and the services available at the various MV healthcare organizations.
  • Identifying these individuals and regularly reaching out to them with information or having them meet with the CHWs, or possibly act as a precursor to a Community Advisory Board would be helpful in nurturing community trust and improving health care utilization.

Increasing Trust Among the Community: Healthcare Institutions & Reducing Stigma

• This area needs some further exploration, perhaps with a Brazilian Community Advisory Group, but hopefully with progress and time, additional trust will be built and some stigma reduced.
• Other ideas drawn from similar initiatives include peer-support groups and affinity groups led by a CHW-type of individual who is from the target community. On MV, this could look like a support group led by a Brazilian individual who has had success navigating the healthcare and/or insurance landscape on the Island.
• An approach for more general health literacy outreach: CHW-led sessions on health education/health literacy tailored specifically for the Brazilian Community where participants are given the opportunity to peer learn from one another. This is another way to spread information but also build upon traditional knowledge while strengthening trust in a healthcare institution.

Our 23-question digital survey was administered via Google Forms and shared via email, social media, and Community members were asked to share it with their peers. We also captured a majority of responses at a mobile COVID-19 vaccine clinic at Martha's Vineyard Regional High School in July of 2022. Depsite the low number of respnses, we feel the information is useful and will help frame larger research efforts in the future among the Island's Brazilian Population. n = 15

Result Highlights:

· Thee three most important characteristics for living a healthy life on Martha's Vineyard included Good Jobs and a Healthy Economy (46.7%), Good Place to Raise Children (46.7%), and Access to Affordable Housing (33.3%) · The three most important health issues identified by the Brazilian Community were Dental Problems (46.7%), Infectious Disease (40%), and Obesity (40%) · The three most adverse health behaviors identified by the Community were Alcohol Abuse (80%), Drug Abuse (53.3%), and Poor Eating Habits (53.3%) · Respondents' confidence in navigating the US Healthcare system arked from A Little Confident (33.3%), Confident (46.7%), and Very Confident (20%) · Only 66.7% of respondents had a Primary Care Provider (PCP)

Factors for Living a Healthy Life - The Brazilian Community is strongly motivated to seek out and create a better quality of life for their family. Island-based healthcare providers should explore framing health initiatives with this goal in order to engage the Community on new health topics or community-wide health programs. This notion also seems to hold true for preventative programming and programming addressing risk in the Community

Growing Older on MV - Given the limited open responses about elder health in the Brazilian Community and the natural limitations of this project, future community outreach and research efforts should ask about the unique needs of elder Brazilians and their family caretakers.

Housing - More information on the realities of housing conditions among the Brazilian Community and how they compare with local public health standards is important for pursuing improvements in this area. Advocates and policy leaders cannot campaign for what they are unaware of, so capturing this information in a strategic and respectful way is key.

Communication - Several survey and focus group respondents brought up the need for improved interpretation services, especially around the concept of differing cultures of health. Ensuring a patient's message is fully relayed is a major first step in building and maintaining trust, so understanding where those misconnections are is important for making progress. Secondly, many respondents referred to a lack of awareness of programming on the Island for health services, specifically for addiction counseling and recovery services. Ensuring program information is translated and provided in Brazilian Portuguese is a crucial first step, but continually and actively engaging the Community and ensuring the program itself is culturally responsive are equally important.