June 2023 | ISE Magazine 41
Using ISE tools to uncover
structural racism
Hispanics in US mountain west region face healthcare access obstacles
By David Claudio, Sally Moyce, Liz Aghbashian, Génesis Chávez Reyes and Danika Comey
e Hispanic immigrant community in the U.S. In-
termountain West – a region located between the
Rocky Mountains on the east and Cascade Range
and Sierra Nevada on the west – is growing at a sig-
nicant rate. Hispanic immigrants from South and
Central America are ocking to the area to respond
to the boom in construction, service and tourism jobs. However,
communities in the area are ill-prepared to welcome Hispanic
immigrants to their communities despite the desperate need to
ll the jobs that the tourism economy relies upon.
Many medical facilities, community organizations and so-
cial support service providers are struggling to oer services in
Spanish that meet the needs of the growing community in a cul-
turally responsive manner. Hispanic community members face
more barriers and challenges when trying to access healthcare
The U.S. Intermountain West region includes Montana, and
is found between the Rocky Mountains on the east and
Cascade Range and Sierra Nevada on the west.
Photos courtesy of the authors
Many medical facilities, community
organizations and social support service
providers are struggling to oer services in
Spanish that meet the needs of the growing
community in a culturally responsive manner.
42 ISE Magazine | www.iise.org/ISEmagazine
services when compared to non-Hispanic whites. Addition-
ally, Hispanics are oen faced with discrimination, othering,
and blatant racism from the majority white community. With
support from the Robert Wood Johnson Foundation, an inter-
disciplinary research team is aempting to discover barriers to
receiving free breast and cervical cancer screenings for Latina
Sally Moyce and David Claudio met at Montana State Uni-
versity in 2019. Moyce is an associate professor and researcher
at Montana State Universitys Mark and Robyn Jones College
of Nursing. Claudio was an associate professor of industrial and
management systems engineering at the Norm Asbjornson Col-
lege of Engineering. ey noticed an increase in the Hispanic
community moving to the Intermountain West, and the chal-
lenges this community faced when trying access healthcare
services. Moyce and Claudio decided to take action and work to
improve access to healthcare services for the growing Hispanic
ey partnered with Liz Aghbashian, a public health special-
ist at the local city-county health department who administered
the federally sponsored program to provide free cancer screen-
ings to eligible women. As a team, they wrote a proposal to the
Robert Wood Johnson Foundation to explore structural racism
in healthcare. In 2020, they were awarded a prestigious Robert
Wood Johnson Foundation Fellowship to explore dierences in
access to healthcare services for Hispanic women in the Inter-
mountain West. ey recruited the assistance of two additional
researchers at Montana State University, Génesis Chavez-Reyes
and Danika Comey.
e team also recruited a Community Advisory Board (CAB)
comprised of Latina women from a variety of backgrounds who
had experience with the cancer screening program. An engi-
Figure 1
Program disparities
Data showed that while Hispanic women enrolled in a cancer screening program increased from 10% to 33% from 2016-2022, the percentage
that did not complete the screenings was 10 times higher than among non-Hispanic women.
Using ISE tools to uncover structural racism
Researchers, from left, Sally Moyce, David Claudio and Liz Aghbashian,
helped form a research team to investigate cultural barriers to
healthcare services for Hispanic women in a community in the U.S.
Intermountain West region. Moyce and Claudio met as faculty members
at Montana State University, while Aghbashian is a public health
specialist in the region.
June 2023 | ISE Magazine 43
neering systems approach was used to determine potential
sources of systemic racism that prevent Hispanic women from
accessing the programs services.
Based on historical data, it was discovered that the percentage
of Hispanic women enrolled in the program increased from 10%
in 2016 to 33% in 2022. Data also showed that the percentage
of women who do not complete the screenings once enrolled in
the program was 10 times higher for Hispanic women than non-
Hispanic women (30% versus 3%, respectively). See Figure 1.
As a rst step in the research process, the team wanted to un-
derstand the cycle and the experiences women have once they
are enrolled in the program. Working with the CAB and a local
primary care provider, members used a SIPOC analysis (suppli-
ers, inputs, process, outputs and customers) to map the process
from referral into the program, enrollment, cancer screening
and follow-up (Figure 2).
Next, they used enrollment records to stratify women into
one of four groups: Hispanic women who completed screenings,
Hispanic women who did not, white women who completed
screenings and those who did not. is approach was employed
to consider dierences between the womens experiences that
may inuence their screening rates.
Interviews were conducted with the sample, in either English
or Spanish, based on the participants choice. e team designed
an experiment with four groups of women who sought free
mammogram services. e women were categorized into four
groups: complete non-Hispanic, noncomplete non-Hispanic,
complete Hispanic and noncomplete Hispanic. Complete in
this instance means that a woman completed the free mammo-
gram program application, was enrolled in the program and was
able to access a mammogram. Noncomplete means the woman
expressed interest in the free mammogram program but did not
complete the program and did not receive a free mammogram.
Following the interviews, the responses were analyzed by us-
ing shbone diagrams to complete a root cause analysis (Figure
3, Page 45). e main categories for the shbone diagram were
based on the clinical nurse leader 5P assessment: providers (pro-
fessionals), processes, people (patients and family members),
policy, payment and place.
Using the shbone analysis, the researchers were interested
in identifying what enablers and barriers prevented women from
completing their mammogram. Results showed that for both
Figure 2
SIPOC analysis
Suppliers, inputs, process, outputs and customers were mapped to understand the cycle and the experiences women have once they are
enrolled in the cancer screening program.
As a rst step in the research process, the
team wanted to understand the cycle and
the experiences women have once they are
enrolled in the program.
44 ISE Magazine | www.iise.org/ISEmagazine
Using ISE tools to uncover structural racism
groups, doctors, providers and clinical sta members are willing
to help women complete and enroll in the screening program.
However, dierences were found in barriers to completing
screenings based on ethnicity. For non-Hispanics, the non-
completion of all the recommended screenings was oen due
to personal reasons such as not having enough time, not priori-
tizing personal health or being occupied with other priorities.
However, for Hispanic women, reasons were more systematic
and due to errors in billing, language and cultural barriers and
gaps in the system that prevented women from completing
Team members were excited to move on to analyzing and up-
dating processes to see where systemic racism is embedded in
local policies that claim to improve access to healthcare services
and to create changes in the system to modify these policies. Up-
dating local laws and policies will help dismantle health inequi-
ties and health disparities for Hispanics in the Intermountain
Engineers have an ethical and social responsibility to employ
their abilities toward the beerment of society. ISE profession-
als can play a key role in analyzing and dismantling embedded
discrimination in policies and processes. e same tools and
methods oen used to improve and optimize processes can also
be employed to dismantle systemic racism and move society to-
ward the aainment of equity and fairness.
David Claudio, Ph.D., PE, CPIM, is an associate professor and
industrial engineering program director at the University of Mas-
sachuses in Lowell, Massachuses. Prior to his work at UML,
Claudio worked as an associate professor in the Department of Me-
chanical and Industrial Engineering at Montana State University’s
Norm Asbjornson College of Engineering in Bozeman, Montana.
He is an advocate and champion for using industrial engineering
amework to dismantle health inequities and disparities.
Sally Moyce, Ph.D., RN, is an associate professor at Montana State
University Mark and Robyn Jones College of Nursing in Bozeman,
Montana. She is passionate about reducing health disparities by us-
ing health promotion to work with Hispanic immigrants. She con-
ducts community-based research with the Hispanic community to
Study shows overall healthcare disparities in US
Studies have revealed that Hispanics in the U.S. face many challenges in gaining access to healthcare and medical
treatments. A Pew Research Center survey from June 2022 showed that Hispanic adults are less likely than others to have
health insurance and preventive medical care, often due to language, cultural barriers and higher levels of poverty, much of
which worsened during the COVID-19 pandemic.
Among the study’s findings:
53% of Hispanic Americans in the U.S. said working jobs that put them at risk for health problems is a major reason for
health disparities; 27% consider it a minor reason and 19% say it is not a reason.
48% blame less access to quality medical care where they live as a major reason for worse health outcomes; 27% said it
is a minor reason.
44% said communication problems from language or cultural dierences in navigating the healthcare system led to
worse health outcomes.
40% said preexisting health conditions are a factor in worse health outcomes.
30% say healthcare providers are less likely to give Hispanic people the most advanced medical care, while 27% say
hospitals and medical centers giving their well-being lower priority is a major reason for care disparities.
Hispanic Americans have mixed views on how much progress has been made in health outcomes in the last 20 years;
51% say outcomes for Hispanic people have gotten a lot (17%) or a little (34%) better; 34% say they have stayed about the
same; 13% say they have gotten a lot or a little worse.
Hispanic adults are less likely than all U.S. adults to say they have seen a healthcare provider within the last year (70%
versus 82%).
Hispanic adults with health insurance are 28 percentage points more likely than those without to have seen a doctor or
other healthcare provider in the last 12 months (77% versus 49%). Half of Hispanic adults without health insurance say
they have not seen a provider within the last year.
Engineers have an ethical and social
responsibility to employ their abilities toward
the beerment of society.
June 2023 | ISE Magazine 45
increase access to care and uses her nursing background to imple-
ment evidence-based programs with the community.
Liz Aghbashian, MPH, is the director of resource coordinators at
Community Health Partners, a Federally Qualied Health Center
in Bozeman, Montana. Prior to her work at Community Health
Partners, she worked at the Gallatin City-County Health Depart-
ment as a health promotion specialist. Before moving to Bozeman,
Montana, Aghbashian worked with migrant workers in the Central
California Valley. She is an advocate for change and a disruptor of
structural racism.
Génesis Cvez Reyes, MSc, is a bilingual resource coordinator at
Community Health Partners in Bozeman. She worked as a research
assistant for Moyce Immigrant Health Lab at Montana State Uni-
versity while pursuing her masters degree. She is enthusiastic about
studying the interlinkages between the food and healthcare systems
to prevent the rising of noncommunicable diseases. Before coming to
the U.S., Chávez Reyes earned a bachelors degree in food science
and technology in Honduras. She advocates for making healthy food
aordable and accessible to all social groups.
Danika Comey, MPH, is the research lead at Proyecto SALUD
within the Mark and Robyn Jones College of Nursing at Montana
State University. She studied social determinates of health at Co-
lumbia University’s Mailman School of Public Health. Prior to her
time at Montana State University, Comey worked as a health edu-
cator, a research assistant and a public health advocate. She has a
passion for using public health research to advocate for local policy
change to promote community health and inclusion in Montana.
Figure 3
Fishbone diagram
Input from interviews were analyzed to complete a root cause analysis.
The Montana research team investigated findings that showed
Hispanic women were less likely to complete a cancer screening
program even as enrollment increased.