Attacking Healthcare Inequality on the Local Level: Employing Community-Based, Culturally Tailored Approaches to Reducing U.S. Health Disparities

Attacking Healthcare Inequality on the Local Level: Employing Community-Based, Culturally Tailored Approaches to Reducing U.S. Health Disparities
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In New York City’s Chinatown district, Mandarin-speaking case workers regularly visit an elderly couple in their fourth-floor walkup apartment to make sure they’re getting the health support they need. A few miles north in a low-income section of the Bronx, a psychiatric social worker working for a city-funded crisis intervention program gets a call from a local high school about a dangerously depressed student. Within two hours she is on the scene, working with the young woman and her high school guidance counselor to deescalate the situation and set up a long-term treatment plan. Meanwhile, in a midtown Manhattan office building, home health aides receive training from a national support group for LGBT seniors that will make them more culturally attuned to the needs of their LGBT clients.

These are all examples of how the Visiting Nurse Service of New York (VNSNY), where I work, is using culturally tailored approaches to close gaps in health outcomes, disease prevalence and medical support across different populations. These gaps, which are commonly referred to as health disparities, can affect various ethnic and racial groups, sexual or gender orientations, income categories, or geographic locations. In the introduction to its comprehensive 2013 report on U.S. health disparities, the Centers for Disease Control and Prevention (CDC) highlighted several major areas where America has starkly uneven health outcomes: heart attacks and strokes, which non-Hispanic black adults under age 75 are at least 50% more likely to die from than non-Hispanic whites in the same age group; adult diabetes, which is more prevalent among Hispanics and non-Hispanic blacks than among Asians and non-Hispanic whites, and also more common among adults who don't have a college degree or come from a lower-income household; infant mortality rates, which are more than twice as high for non-Hispanic blacks compared to non-Hispanic whites, and are also higher in the South and Midwest; and suicide, which disproportionately impacts men, Native Americans and non-Hispanic whites.

Working Directly with Communities to Design and Implement Solutions

The reasons for these disparities are complex, and can include cultural, social and economic barriers that prevent various groups from accessing needed medical care and social support. As the healthcare field gets better at understanding these barriers to care, we’re also learning that the best solutions often involve working directly with the communities themselves to address specific health inequities. This means having staff versed in the cultural nuances of their client population—understanding, for instance, that Chinese American elders are often reluctant to articulate feelings of depression, a concept that is now part of the staff training for VNSNY’s Chinatown Neighborhood Naturally Occurring Retirement Community (NNORC) program; that African Americans may be hesitant to seek out pain- and anxiety-sparing end-of-life-care due to their religious beliefs—a concept VNSNY’s hospice is working to counter through our Project HOPE hospice outreach project in Harlem; and that LGBT men and women have been historically less likely to seek out medical care or admit healthcare workers into their homes because of a perceived bias against their sexual or gender orientation—an issue that is addressed head-on in the SAGECare cultural sensitivity training that all of our home care and hospice clinicians and support staff, and home health aides are required to take.

It also means having caregivers who speak the same language as non-English speaking clients and patients, and going to where our populations reside—reaching out to isolated seniors struggling with depression or anxiety where they live, and bringing trained nurses into the homes of young, first-time mothers to teach parenting and life skills, as VNSNY does with our Nurse-Family Partnership program. And it involves collaborating with other local organizations and governments to actively engage community members and gain their buy-in. VNSNY’s Chinatown NNORC partners with a number of local business associations and gets funding support from New York State, New York City and local philanthropy, while our Children’s Mobile Crisis Team is funded by the city and works closely with local public schools.

Community-Level Interventions: An Idea That’s Gaining Momentum Nationwide

As the nation’s largest not-for-profit home- and community-based healthcare provider, VNSNY is one of many organizations and institutions that are now actively implementing this approach. Increasingly, academic medical centers across the U.S., from NYU Langone to the University of Miami to the University of Texas to UC Berkeley, are establishing programs focused on reducing health disparities through culturally tailored approaches at the community level. These may involve training trusted members of underserved communities to help their neighbors connect with various healthcare resources—for example, engaging African American men in local settings and connecting them with screening services for high blood pressure (a condition this population is at heightened risk for)—or developing culturally relevant dietary approaches to preventing and controlling type 2 diabetes. Healthcare systems like Kaiser Permanente are also deeply involved in reducing health disparities among at-risk populations, and local community organizations are taking the lead as well, leveraging federal funding to implement interventions ranging from culturally tailored smoking cessation initiatives to programs that encourage preventive cancer screening.

Careful Research Points the Way to What Works

Just as importantly, in most cases the healthcare organizations that are implementing these programs are carefully tracking the results of these interventions and gathering feedback from the communities they’re working with, in order to assess what really works and then refine these approaches to make them even more effective moving forward. This research is being spearheaded by the National Institute on Minority Health and Health Disparities and the federal Agency for Healthcare Research and Quality, in conjunction with state and local governments, academic medical centers, health care providers and community organizations across the country.

VNSNY’s own Center for Home Care Policy and Research is currently involved in a number of research projects involving culturally tailored care delivery, including a study evaluating whether home care outcomes are improved among non-English speakers when their care provider speaks the patient’s native language; a recently published study on how activities of daily living disability varies among racially and ethnically diverse seniors who receive in-home care following discharge from the hospital; and a study investigating whether home care support from a culturally appropriate health coach in addition to a nurse practitioner can help black and Hispanic stroke patients lower their systolic blood pressure and reduce their risk for a second stroke.

As the disparities outlined by the CDC at the start of this article indicate, we have a long way to go to completely eliminate health disparities in the United States. But as we continue to learn more about the kind of health care support people respond to on the community level, we’re getting a much better picture of how to extend our healthcare knowledge and resources to all Americans, regardless of race, ethnicity, income, gender or sexual orientation. One thing that’s clear is that home- and community-based healthcare organizations like VNSNY will be on the front lines of this growing effort to provide equitable healthcare for all. I know I speak for my home care colleagues across the nation when I say that this is a challenge we are ready—and eager—to take on.

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