Understanding factors that influence health care utilization among Mixtec and Zapotec women in a farmworker community in California

Abstract

This paper examines health care utilization among indigenous immigrants from Oaxaca, Mexico, who have settled in a farmworker community in southern California. In 2016, two trained Spanish-Mixteco and Spanish-Zapoteco bi-lingual interviewers conducted in-depth interviews with 44 indigenous women residing in Oxnard, California on issues that affect health care utilization. Interviews were conducted in Mixteco, Zapoteco and Spanish and were coded to identify structural, cultural, and provider-related barriers to health care utilization. Five bilingual Spanish-Mixteco indigenous interpreters employed at local clinics were also interviewed.

Many women reported lack of health insurance, inability to pay, language barriers, long waiting times, rushed encounters with providers, and seeking western medical care only after home remedies did not work. However, several women were able to access routine health care services, often with support from indigenous interpreters employed at clinics. Interviews with five interpreters found that they provided assistance with interpretation during medical encounters and appointment making. They also educated patients about upcoming exams, identified low-cost services and insurance programs available to patients, assisted with paperwork and occasionally educated physicians on behalf of their patients.

In addition to addressing barriers to health care access our findings suggest the importance of identifying and leveraging community assets, such as indigenous navigators, when developing programs for such underserved communities. Our findings can inform best practice in settings that provide health care to indigenous populations and may also apply to settings that provide health care to other immigrant communities that have very limited familiarity and contact with western health care.

Introduction

An estimated 250,000 indigenous Mexican farm-workers and family members are living in California. Half of this indigenous farmworker population is Mixteco-speaking (82,000–125,000), and 1/3 of them are located in the Central Coast region (Oxnard and Santa Maria; http://www.indigenousfarmworkers.org/, accessed 2/12/17). A smaller number of Zapotecs, another indigenous group, have also settled in Oxnard. Mixtecs and Zapotecs originate from one of the poorest areas in Mexico [1, 2]. Many are unable to read and write even at a basic level, and speak neither Spanish nor English, but only their native non-written Mixteco or Zapteco language. In both Mexico and the US, this group rarely has access to Western medicine, and they report a high level of distrust of medical providers [3, 4].

Access to care, having a regular provider and having health insurance are determinants of health and important predictors of health care utilization, morbidity and mortality. Access to care is especially challenging for undocumented immigrants, individuals with low levels of education, and people who face language barriers [5, 6]. This paper will report findings from in-depth interviews that explored barriers and facilitators of health care utilization among Mixteco and Zapoteco women in Oxnard, California. A better understanding of factors that influence health care utilization is the first step towards improving access to care for this population.

Understanding and addressing the health needs of a marginalized population without any written language presents a unique challenge. We partnered with the Mixteco/Indigena Community Organizing Project (MICOP) is a 501(c)(3) nonprofit corporation that provides leadership, services and advocacy for the indigenous Mixtec and Zapotec community in Oxnard, Ventura County. Among numerous other activities, MICOP has trained many indigenous women to serve as promotoras in health-related projects. Some of these promotoras are now employed by local clinics to serve as interpreters and navigators for indigenous patients. MICOP and the University of California Los Angeles partnered in 2011 to enhance the capacity for health promotion in the indigenous community in Ventura County [7, 8]. The study we discuss here focused on understanding access to care and navigation of health care services among indigenous women.

Methods

Two trained Spanish-Mixteco and Spanish-Zapoteco bilingual promotoras conducted one-on-one in-depth interviews with indigenous women who were recruited at parks, clinics, school-based sites, and community meetings. Respondents received $40 gift cards for Walmart stores. Women 18 years and older were eligible to participate in the study. We aimed to conduct interviews with an equal number of women between 18 and 30 years of age, 31 and 50 years of age and 50 and 75 years of age to obtain a range of experiences with respect to factors that influence health care utilization, as these factors can be expected to change with age, education, duration of residence in the US, and language skills. Following an outline, interviews explored health beliefs, ways to stay healthy, how to prevent disease, access to health care, communication with health care providers and sources of health information. Interviews lasted approximately 40–60 minutes. Promotoras obtained verbal informed consent and conducted interviews in Mixteco, Zapoteco or Spanish.

Promotoras audiotaped all interviews and provided oral, audiotaped Spanish translations of interviews that were conducted in Mixteco and Zapoteco. These translations and the Spanish-language interviews were subsequently translated and typed in English. English transcripts were coded to identify structural, cultural, and provider-related barriers to health care utilization and factors that facilitate health care utilization.

In addition, one of the investigators (SY) conducted one-on-one interviews with 5 indigenous promotores who are employed as interpreters and navigators in some of the local clinics, to learn from their experiences on how they assist community members to navigate the health care system. These interviews were conducted in Spanish and translated and transcribed in English.

All interviews were conducted and translated in 2016. The study was approved by the University of California Los Angeles Institutional Review Board and the MICOP Advisory Board, which includes members of the indigenous community.

Results

Characteristics of the Community Sample

A total of 44 women (34 Mixtec, 10 Zapotec) completed interviews in Spanish (N=23), Mixteco (N= 16) and Zapoteco (N=5). The average age of the women was 40 years. All ages were well represented with 13 women between ages 21 and 29, 11 women between ages 30 and 39, 8 women between the ages of 40 and 49, 7 women between ages 50 and 59, 4 women between ages 60 and 73, and 1 woman with unknown age.

Structural Barriers to Health Care Access

Common structural barriers included inconsistent access to interpreters that speak Mixteco or Zapoteco; inability to pay and lack of insurance; lack of information regarding how to obtain insurance or how to apply for discount programs; and long waiting times. Several women reported that they had to forgo getting needed medical care due to these barriers. A few women described very specific barriers such as getting no reminder calls for appointments, having difficulties completing paperwork, and lack of transportation or having to rely on public transportation (see Table 1).

Table 1.

Structural barriers to health care access among indigenous women– sample quotes

Sample Quotes	Informant
Inconsistent access to interpreters (frequently mentioned)
“Sometimes they provide me an interpreter and other times not. I speak and understand a little bit of Spanish. So many times I speak a little bit of Spanish and they start talking to me in Spanish so they don’t send me an interpreter.”	GM 16 26 y/o Mixtec female, 4th grade education, predominantly Mixteco speaking and some Spanish, in the US for 7 years, picking strawberries
Inability to pay and lack of insurance (frequently mentioned)
They referred me to another clinic perhaps to have a more in-depth examination. But the doctor told me that they will also charge me. I will have to pay more out-of- pocket, that is why I decided not to go because I don’t have money to pay.”	G 20 24 y/o Mixtec female, 2nd grade education, monolingual Mixteco, working in the strawberry fields
“If I go to the doctor, they are going to charge me. I don’t go because I don’t have insurance. The insurance is only for emergencies and doesn’t cover other things.”	G4 31 y/o Mixtec female, 6th grade education, in the US for 5 years, mother of 5, speaks Spanish
Lack of information on how to obtain insurance, how to apply for discount programs or how to obtain free services (frequently mentioned)
“I would like if there were more help for us, more information that would say what types of insurance we would qualify for, for example dental [insurance]. I need a lot of services, but I can’t obtain them because I don’t know where there is help or where I can obtain it.”	G2 73 y/o Mixtec female, never went to school, in the US for 23 years, mother of 9
If someone would tell me [about where to obtain free health services], yes, I would take these services. The reason why I don’t get these services is because I don’t know where they are.”	G14 Mixtec female, 2nd grade education, in the US for 1 year, mother of 16 (10 living), stays at home
Long waiting time (frequently mentioned)
When I took my children to the urgent care there they made me wait about 5 hours. That is a long time.”	GM 11 39 y/o Mixtec female, never went to school, in the US for 18 years, monolingual Mixtec, picking strawberries
No reminder calls for appointments
The only thing that I don’t like is that the front desk staff do not do appointment reminders. I have to come here and ask when I have my appointment. I have to be asking them all the time because I don’t know how to read or write, they give me the paper but I don’t understand.	GM 11.2 69 y/o Mixtec female, monolingual Mixteco, never went to school, in the US for 20 years, not working.
Difficulty completing forms
“They tell you what to fill out and give it back if it’s not filled out correctly and they give you another number and ask you to come back.”	G 12–18 38 y/o Mixtec female, speaks Mixtec, Spanish and some English, 6th grade education, in the US for 17 years, stay-at-home mother of 2
Lack of transportation or having to rely on public transportation
“I told the young woman that I was running a bit late because I had to take the bus since I didn’t have the car. And she said, “You do know that you lost your appointment, right? You lost your appointment and I can’t take care of you.”	G 12–18 38 y/o Mixtec female, speaks Mixtec, Spanish and some English, 6th grade education, in the US for 17 years, stay-at-home mother of 2

Cultural Barriers to Health Care Access

Cultural barriers included being embarrassed to ask questions or during a physical exam and being afraid of unfamiliar procedures, especially during child birth. Several women mentioned that the health care services that they have received in the US did not meet their expectations. They described encounters in which they were examined or had blood drawn without receiving any medications or injections. Several women mentioned that they did not go to the doctor in Mexico; some used home remedies instead. Home remedies were used when western treatment was unaffordable, to avoid long wait times at the clinic or as a first course of treatment (see Table 2).

Table 2.

Cultural barriers to health care access among indigenous women–sample quotes

Sample Quotes	Informant
Being embarrassed
“Sometimes they ask me if I have any questions and I tell them “No” because I am embarrassed to ask.”	A 3 56 y/o Zapotec female, in the US for 16 years, monolingual Zapoteco, 3 children, picking blackberries
We were not used to doctors examining our private areas or vaginas. That is very embarrassing for us. We don’t see that in our hometown, so it was hard for me to assimilate to that.”	G 10 32 y/o Mixtec female, never went to school, in the US for 12 years, stay-at home mother of 4
Being afraid of medical procedures during delivery
“I was afraid. They would tell you that if you go to the hospital they would put their hands inside you and take the baby out. That is why I gave birth to my three children at home.”	G 13 54 y/o Mixtec female, 1 year of schooling, lived in the US for 27 years, mother of 5
Only go to the doctor when sick or in pain, not for routine check-ups (frequently mentioned)
We go [to the doctor] when it hurts very much. We don’t go just to get checked.	A 3 56 y/o Zapotec female, in the US for 16 years, monolingual Zapoteco, 3 children, picking blackberries
Health care services in the U.S. do not meet expectations
“Every time they take me to see the doctor, they only see and analyze me, but they don’t give me medicine. That is why I don’t like to go to the doctor here. In my town is different. You go and they tell you what is wrong and give you an injection immediately to get better.”	G 14 Mixtec female, 2nd grade education, in the US for 1 year, mother of 16 (10 living), stays at home; usually has her daughter- in-law interpret for her.
“Every time I went to get checked they would draw a lot of blood. I don’t like that because I am already weak and they kept drawing blood. ....I just don’t like going [to the doctor] because they don’t give you any medicine.”	G 6 47 y/o Mixtec female, 1st grade education, in the US for 8 years, stay-at-home mother of 9
Use of home remedies (frequently mentioned)
The medicine didn’t even work, that is why I use home remedies because they charge me [for the medicine] and it doesn’t have an effect.”	G 15 56 y/o female, 6th grade education, in the US for 7 years, stay-at-home mother of 11 (7 alive)
“… when my stomach is hurting sometimes, I don’t go anymore. I prefer taking anything here at home, instead of being there for hours.”	M 1 40 y/o Mixtec female, 6th grade education, in the US for 20 years, stay-at-home mother of 2
“When the home remedies don’t work for more severe illnesses is when I go to see a doctor	G 3 49 y/o Mixtec female, never went to school, in the US for 30 years, speaks Mixteco and Spanish, mother of 3

Provider-related Barriers to Health Care Access

Only few women described provider-related barriers, including perfunctory or disrespectful communication from providers or staff and not having a consistent provider (see Table 3).

Table 3.

Provider-related barriers to health care access among indigenous women–sample quotes

Sample Quotes	Informant
Mistreatment
“Sometimes the receptionists don’t have patience with you. They don’t treat you well. There are some of us who cannot express ourselves well or understand well—even if we speak Spanish, there are some words they use that we don’t understand. “	GM 9–5 30 y/o Mixtec female, 6th grade education, in the US for 15 years, speaks Mixtec and Spanish, picking strawberries, pregnant with 3rd child
Provider does not spend enough time with me (frequently mentioned)
“Well, the doctors only come in and tell you what they need to say, and you ask what you want to ask. Then they leave right away. They don’t give you time for that. They come in and leave quickly.”	G 10 32 y/o Mixtec female, never went to school, in the US for 12 years, stay-at home mother of 4.
“We spend more time waiting for the doctor with my son than when they treat us.”	G 12–18 38 y/o Mixtec female, speaks Mixtec, Spanish and some English,, 6th grade education, in the US for 17 years, stay-at-home mother of 2
Provider does not answer questions
“There were times when I asked questions and the doctor would simply ignore me. Like she pretended she didn’t hear me, as if she didn’t care about what I was saying. There are times she pays attention to me only when she wants to. When she doesn’t pay attention to me, I ask her things and she doesn’t answer me—she just ignores me.”	GA 20 24 y/o Mixtec female, 2nd grade education, monolingual Mixteco, working in the strawberry fields, talking about an encounter when she did have an interpreter
No regular provider
“I haven’t gone to the doctor because I don’t even know who my family physician is. And every time I go, I go to the emergency department. So there isn’t a doctor that follows up with my case.”	G 2 73 y/o Mixtec female, never went to school, in the US for 23 years, mother of 9

Factors that facilitate health care utilization

Despite the barriers described above, some women stated that they received routine health care such as breast and cervical cancer screening or that they were seen on a regular basis for a chronic disease such as diabetes or for prenatal care. As illustrated in Table 4, key reasons why women are accessing services for routine medical care are availability of free services that are sometimes promoted through community organizations, having language support and having help with making appointments and completing paperwork. One woman mentioned going to a specific provider whenever she needed medical care because she likes the fact that she receives an injection every time she sees him.

Table 4.

Quotes from women who received routine health services

	Sample Quotes	Informant
Availability of free services
Receipt of free mammogram and Pap test	Question: “Have you ever had a mammogram? “ Answer: “Yes, I recently went about 2 months ago. They told me I qualified for a free mammogram through a program. That is why I had it done.” Question: “Have you had the Papanicolaou test as well?” Answer: “Yes, they also did that at that time. They do both things simultaneously. They first do the pap smear and then the mammogram.”	G 3 49 y/o Mixtec female, never went to school, in the US for 30 years, speaks Mixteco and Spanish, mother of 3
Receipt of free flu vaccine at community events	“I get the flu vaccine yearly. MICOP has told us that those vaccines help us to combat the flu. They tell us that the vaccine helps us become immune or get less sick. That is why I take that vaccine that they gave recently at the Harrington school. “ Question: “How do you know of these services that are being provided in those places?” Answer: “Other people tell us. They tell me the days that they can give the vaccine for free. That is why I obtain these services.”
Receipt of free health exams	Question: How often do you visit the doctor’s office? Answer: “I went in 2010 to the Guadalupe church because we do not have money to go to a private doctor. They said it would be free. I wouldn’t have to pay for studies that check if I have a disease or not. I only have gone once over at the church for a Papanicolaou test [in the 8 years I lived here]”.	A 1 43 y/o Zapotec female, 6th grade education, in the US for 8 years, predominantly Zapotec speaking, very little Spanish, 3 children, picking strawberries
Utilizing free medicine for diabetes treatment	“I get the medicine for free. My daughter helps me. She asked for information and filled out an application. I am not sure exactly what it is, but she filled out an application that is for people with low income…. My daughter is the reason why I get my medicine for free because I don’t know how to read and write. I think it’s for low income and elderly people. ....The doctor that had seen me also told me that I qualified for the free medicine.“	G 2 73 y/o Mixtec female, never went to school, in the US for 23 years, mother of 9
Getting regular Pap smears despite feeling uncomfortable	Question: “Have you ever had the Papanicolaou test---the annual routine check or every six months?” Answer: “Every year. “ Question: “How have you felt? Comfortable or shy? Tell us about that.” Answer: “Uncomfortable.”	A 3 56 y/o Zapotec female, in the US for 16 years, monolingual Zapoteco, 3 children, picking blackberries
Regular appointments with primary care physician to monitor blood sugar	“I used to go only to through emergencies because they were checking me for some illnesses that I have, the doctor told me that I needed to see a specialist and that I needed a primary care physician who I needed to visit frequently so I could monitor my illness. They referred me to this clinic. That is how I started to come to this clinic.”	GM 11.2 69 y/o Mixtec female, monolingual Mixteco, never went to school, in the US for 20 years, not working.
	Question: “Did you have to pay for your visit today? “ Answer: “No, I didn’t have to pay anything because my Medical covers all of this and Medicare pays a part of it, so I didn’t pay anything. When I went to pick my medicines--I only pay a little bit. Sometimes I pay $2–$3 dollars but only when I pick up my drugs. I pay very little, that is the only time I have to pay”
	Question: “Did the front desk staff ask you if you needed language support/interpreter?” Answer: “No, they didn’t ask me. They didn’t tell me anything. When I arrived in the front, I told them that I needed someone who speaks Mixtec. So they filled out a paper and sent it to the back, and then the Mixtec-speaking person arrived.”
Receipt of colonoscopy	“Most of the time Medical or Medicare covers all the treatments. .... Actually, they sent me to get an exam done in Ventura—it’s a tube they put inside you to see what’s wrong. I’ve gone to all the treatments that they have send me to.	GM 11.2 69 y/o Mixtec female, monolingual Mixteco, never went to school, in the US for 20 years, not working.
Receipt of prenatal care	“They had told me that this type of insurance would help me cover the birth costs so I wouldn’t have to pay any type of money. That insurance would cover everything…: I had family who went to the Las Islas clinic, and they showed me where I needed to go for my pregnancy. They told me it was a good clinic and they would help us there.”	G 6 47 y/o Mixtec female, 1st grade education, in the US for 8 years, stay-at-home mother of 9
	Question: “How were you able to make the first appointment for your pregnancy? Answer: “Miss E., Irene’s sister, would always help me make the appointments because she spoke Mixtec and I didn’t speak Spanish.”
	“[The doctors] would ask me if I needed an interpreter, and I said yes. After that, the interpreters would come in the room and we would continue with the appointment.”
Treatment includes an injection
	“I think that they have treated me well. There is a doctor there who is called [Name of doctor], who is at [Name of clinic] --I go there when I have any type of illness—and they have treated me well… Every time I go see this doctor, he gives me an injection and I think that is good.	G 16 65 y/o Mixtec female, never went to school, in the US for 21 years, monolingual Mixteco; mother of 8; daughter speaks Spanish and helped her obtain Medical insurance and her legal documents.

Information obtained from Interviews with indigenous interpreters at local clinics

Five indigenous Interpreters who work at local clinics (1 male, 4 females; between 23 and 50 years of age, in the US from 11 to 28 years, 2^nd to 6^th grade education) reported that they tried to help patients with whatever needs they had, in addition to providing language support.

“My responsibility is to help Mixteco patients as much as I can with everything that is within my reach within the clinic. I feel as if their needs are my needs. I will defend them as much as I can.” (Interpreter 4).

Interpreter 2 reported talking to patients for 30 to 45 minutes before they see a provider to educate and prepare them for the upcoming exam (e.g., Pap smear). Interpreter 3 stated:

“Mexico does not have a culture of preventative medicine much less Pap smear. To go into a clinic and be touched by a stranger is foreign to the community. Our job is to educate them on the new services to them. It is almost like introducing a child to their first doctor visit.” (Interpreter 3)

One Interpreter listed several responsibilities besides interpreting, including

“being a health educator, family planning, whenever a patient is diagnosed with high cholesterol, diabetes, asthma, high blood pressure, we give education on all of this, plus I help patients with their paperwork for disability and paid family leave.” (Interpreter 3)

Interpreters reported that patients are usually very confused about the fee schedule and that part of their task was to inform patients about different discount programs that are available.

“If a patient comes in, the first thing they will ask is how much it would cost to see a provider. What concerns them most is the cost, because the majority of the community is low income and paying hundreds of dollars for a visit is a lot for them.” (Interpreter 4).

With respect providing language support, interpreters stated:

“Many times the provider will say the patient isn’t understanding them. They will want us to summarize an entire visit in three minutes, but that is not how our interpretation works. There are many words that are lost in translation that we have to find a way of explaining to patients. In my point of view, it [the translation] is not 100%. It is a big help but not a full understanding.” (Interpreter 3)

“The providers ask the patients if they understand English or Spanish and the patient will say yes and the provider will think that they understand. The community says they do [understand English or Spanish], so they won’t seem disrespectful, but many times they do not understand.” (Interpreter 5)

Interpreters also explain to patients any instructions that they have received from the provider or any prescriptions. One interpreter stressed that a lot of patience and very detailed and basic information is needed for their community to become familiar and to integrate with the health care system.

While one interpreter mentioned that she does not help patients fill out forms because it is against clinic policy, three interpreters reported that they help new patients to fill out paper work.

“I helped them with disability insurance. They had trouble when it was first filled out and documents were returned to them with many errors. We started from the beginning with new paperwork.” (Interpreter 5)

In addition to helping patients, two of the interpreters also reported that they educate providers on behalf of their patients.

“Sometimes certain providers don’t understand why the patients are timid or hesitant to let them examine them. Then that is when I would help explain to the provider that for example the patient is married or that she comes from a different culture than they are used to treating, so it is difficult for them to show certain intimate parts of their body or allow themselves to be touched for a gynecological examine or to examine their breasts to check for breast cancer.” (Interpreter 2)

“I have had confrontations with the doctors that the community needs to know certain things. I know how doctors work. They have a lot to do but at the moment we are with a patient, we need to give the time for a patient to fully understand what is going on.” (Interpreter 5)

When asked about what stops women from seeing a provider if they feel ill, several interpreters mentioned cost as the most important barrier.

“Not being able to afford the services is probably the biggest concern. Not knowing how much a visit will cost them.” (Interpreter 1)

“First, I would say medical coverage and second I would say their beliefs. Third would be they are not accustomed to having a stranger see their intimate areas. In Mixteco culture, women will only let their husbands near them. But the biggest [barrier] would be finances. I say this because the first question patients always ask me is how much it will cost to be seen.” (Interpreter 4).

Discussion

Barriers to health care access

Only few studies have reported health care utilization among indigenous immigrant women from Mexico [9, 10]. Our study confirms findings from the limited literature and quotes provide a “human side” to this issue. Consistent with the few prior studies in this population [9, 10], many women in our study described structural barriers to health care access, such as inability to pay and lack of insurance, inconsistent access to interpreters and long waiting times. Cultural barriers included being embarrassed or afraid of medical procedures and using home remedies as a first course of treatment. A few women also described provider-related barriers. Although many of the women who participated in our study had resided in the US for a long time, 7 to 30 years, many reported very limited contact with the health care system, both in Mexico and in the US.

The lack of western medical care in many rural areas in Oaxaca [3] explains the use of home remedies as a first course of treatment and seeking medical care only in severe cases and after all other options are exhausted. Many women never had medical care before coming to California since in rural areas in Oaxaca, babies are usually delivered at home, with the help of a midwife [11]. Due to lack of access in their home country, this population does not have a tradition of using preventive care services.

Barriers to health care that were described by our sample are similar to those described by other populations with low levels of income and education [12–15]. Hacker and colleagues (2015) reviewed barriers to health care for undocumented immigrants and recommended educating immigrants on how to navigate the health care system; cultural competency training for providers; offering special insurance programs; and expansion of free and low-cost clinics [16]. Our findings support these recommendations.

Community assets

Our study adds to the literature by identifying assets in this community that should be considered when developing programs to improve access to health care, including access to preventive services. Interpreters who participated in this study showed a strong desire to share their knowledge with community members. These interpreters/navigators are very committed to helping their community and are an important link between health care providers and patients. Trained community members have been successful in facilitating access to care in many underserved populations. They are also known by many other names, including promotoras, community health workers, natural helpers or lay health advisors [17–22]. The promotora/navigator concept fits very well with the indigenous concept of “tequio” meaning cooperation and community service which is expected in indigenous southern Mexican communities [23]. Tequio is a call to perform communal work for a mutual benefit; it is essentially a mandatory community service project that asks residents to contribute their labor free of charge. Tequio dictates that members of a community should contribute to fulfil community needs. In addition to tequio, promotoras have been active in some indigenous villages in Oaxaca (S. Young, personal communication 7/13/2014). Therefore, the community is quite comfortable interacting with promotoras. The promotora/navigator concept is also consistent with our finding that “word of mouth”, information is a very important channel for indigenous women for finding out about services, clinics and procedures. A strong preference for communicating information verbally is understandable, given that many of the women we interviewed had limited education and many only spoke indigenous, non-written languages.

Our study also shows that some indigenous women access preventive care during pregnancy, for immunizations or for routine screening exams if it is free or low-cost, and if they have language support and help with navigating the health care system. This suggests that women value health and will utilize the health care system to stay healthy, if feasible. Although many clinics in the Oxnard area employ indigenous interpreters who assist members of their community to overcome language and other barriers to accessing health care, these interpreters/navigators typically interact with community members who come to their clinic. Such navigation services could be expanded by conducting outreach to women in non-clinical community settings. This would be an opportunity to promote a wellness visit among women who rarely utilize medical care. The wellness visit constitutes an important entry point to the medical care system because it serves to establish a provider and to encourage patient-provider communication and trust (http://healthfinder.gov/healthtopics/population/women/doctor-visits/get-your-well-woman-visit-every-year, accessed 2/22/2017).

Strengths and Limitations

One strength of our study is that we interviewed both indigenous community members and interpreters employed at local clinics, and the accounts from both of these groups complement each other. In addition, we conducted interviews in three languages in order to reach women with a range of health care experiences.

We did not ask about women’s legal status and its effect on healthcare use, because these questions would have presented an enormous barrier to recruitment. However, based on MICOP’s experience, a large proportion of interviewees are undocumented, which is a barrier to health care utilization [10]. Promotoras who recruited the women and conducted the interviews did not keep a systematic record of refusals although they reported that almost everybody agreed to participate. Therefore, the generalizability of the finding to the larger indigenous community may be limited. While our study is one of the first to conduct interviews in two indigenous languages in addition to Spanish, nuances of responses may have been altered by translations from indigenous language to Spanish and from Spanish to English.

Conclusions

Barriers to health care utilization among Mixtec and Zapotec farmworkers in Oxnard, California, as well as community assets need to be considered when developing programs for this community. Our findings can inform best practice in settings that provide health care to indigenous populations from Mexico and may also apply to settings that provide health care to other immigrant communities that have very limited familiarity and contact with western health care.