employing community health workers
to improve
health literacy among asian subgroups
Krishna Patel
University of Maryland – College Park
December 13, 2017
Introduction
Heterogeneity
Asians are considered to be the fastest growing population in the United States and are often known to be living successful life styles. “Between 1970 and 1980, the number of Asian immigrants grew 308 percent from 825,000 to 2.5 million, then by 196 percent to 4.9 million in 1990” (migration policy). This ideology, while true to a certain degree, miscounts the presence of heterogeneity within the Asian American population. Heterogeneity is the quality or state of being diverse in character or content (en.oxforddictionaries.com). Leading Causes of Death among Asian American Subgroups (2003-2011), a study performed to assimilate the causes and differences of death within the Asian American population highlights the degree of variability in mortality by causes in the population. This study comprised of total 13,208,036 deaths, recognized as Non-Hispanic Whites and Asians (this data was represented population from 36 states during the years 2003-2011), out of which there were total of 124,600 (Aggregate Asian) female deaths compared to Non-Hispanic White Females. The data was then broken into racial/ethnic subgroups by population. Differences between racial/ethnic subpopulations (Asian Indians, Chinese, Filipino, Japanese, Korean, and Vietnamese) are drastic in overall mortality rates between these groups. For example, female all-cause mortality rates were (Asian Indians – 13,118; Chinese – 37,166; Filipino – 30,806; Japanese – 18,960; Korean – 14,196; and Vietnamese – 10,354) female deaths (Hastings K. et.al, 2015). Each subpopulation represents varying numbers in causes of mortality by disease that cannot be and should not be addressed as an aggregate measure of health and/or cause of deaths. The generalization of Asian population can cause dysfunctionality in understanding relative differences that are represented by racial/ethnic categories. Even though, this is just a demonstrative example of the importance in addressing heterogeneity of populations, there is a clear need for specificity in collecting and analyzing data overall.
Health Literacy
Other than the imposed generalizability due to the lack of data on Asian subgroups, this population faces extraneous barriers to healthcare, one of them being the lack of health literacy. The American Journal of Bioethics, defines health literacy as the ‘degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions’ (Neilsen-Bohlman et al. 2004, 4) (Volandes, A., Paasche-Orlow, M., 2007). Health literacy rates among Asian population varied by subgroups, in 2014, of the population aging 5 and over – “46 percent of Asian immigrants reported having limited English proficiency, compared to 50 percent of all immigrants” (migrationpolicy.org). The distribution varied from the area of origin (Eastern Asia – 57%; South Eastern Asia – 47%; Western Asia 41%; South Central Asia – 34%) (migrationpolicy.org). These percentages amplify the need for implementing linguistically versatile and culturally diverse health information programs. Becerra, Daus, and Martin performed a study to identify the “Determinants of Low Health Literacy Among Asian-American and Pacific Islanders in California”, through which they identified low health literacy indicators as male-specific, belonging to low socioeconomic status, having low English proficiency, and being a migrant (Becerra et.al, 2015). These indicators address a greater need for improvement of health knowledge among Asian-American and Pacific Islanders. Wooksoo Kim and Robert H. Keefe’s (2010) research on Barriers to Healthcare Among Asian Americans in Social Work in Public Health Journal addresses:
Language has been a continuing issue in conducting research on Asian Americans. Due to their limited English-speaking skills, recent Asian immigrants may not be able to adequately answer survey questions and thus either refuse or are considered ineligible to participate in research studies. As a result, much of the research on Asian Americans includes English-speaking and well-acculturated individuals, who have more education, better insurance, and higher incomes than the nonrespondents…The sampling bias, in turn, perpetuates the myth of the well-adjusted Asian American (Volume 25; 2010 – Issue 3-4: Health Disparities).
Lack of health education imposes limitations on the population with lower English proficiency. This creates unnecessary hurdles in communication, which has its own realm of obstacles – such as calling for transportation, picking an HMO plan, being able to explain health problems to a provider that may not understand their language (Clough et.al, 2013). These inequities are a representation of the gaps within the social construct to integrate multi-faceted approaches when providing care to socio-culturally diverse communities.
Cultural Competency
In health care, cultural competence is defined as an encompassing practice of health service groups and providers to be inclusive of one’s “values, beliefs, and behaviors” that are embodied by “factors such as race, ethnicity, nationality, language, gender, socioeconomic status, physical and mental ability, sexual orientation, and occupation” (Georgetown.edu; Issue Brief, 2004). Health providers that are “culturally incompetent…are unlikely to understand their patients’ attitudes and beliefs about illness and expectations in healthcare settings”, which creates a pool of misunderstanding the health problem, available treatments, and advised behavior changes by health providers (Clough et.al, 2013). With increasing immigration and gaps in culturally competent healthcare provider population, the need for programs that fill these gaps has become greater than ever.
Healthcare Access and Utilization
Along with health literacy knowledge, the Asian subgroups also differ in healthcare access and utilization. In “Health Status and Health Services Access and Utilization Among Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese Children in California”, researchers Stella Yu, Zhihuan Jennifer Huang, and Gopal K. Singh compiled data to evaluate the association of outcomes and difference in Asian ethnicities. In comparison with non-Hispanic White children, Korean children were 4 times more likely to lack health insurance; Filipino children were twice as likely to not have had recent contact with a doctor; Chinese, Korean, and Vietnamese children were less likely to have visited an emergency room in the past year” along with increased likelihood of being in “fair or poor health”. Most outcome indicators were attributable to “age, gender, poverty, citizenship –nativity status, health insurance, and parental marital and child health statuses” (Stella et.al, 2010). Further, the research finds that one of the studies also noted the difficulties in access to health care were higher amongst Chinese, Filipino, and Asian Indian children when compared to non-Hispanic White children (2010). The relativity in distinction of these indicators demonstrates disparities within access to services, unequal knowledge of self-care, and overall health.
Community Health Workers
Community Health Workers are both either paid or volunteer workers that are constituents of localities that work “with the local health care system in both urban and rural environments and usually share ethnicity, language, socioeconomic status and life experiences with the community members they serve” (Health Resources and Services Administration (HRSA), 2007). Community health workers assume many roles, such as “community health advisors, lay health advocates, promotores(as), outreach educators, community health representatives, peer health promoters, and peer health educators” through which they are able to provide variety of translation services, health education, and provide assistance with care and counseling (HRSA, 2007). Placing CHWs to increase health literacy among Asian subgroups would help reduce disparities due to the inclusion of cultural competency and the diversified placements at different tiers of the healthcare system.
Proposed Policy Solutions
Program Development and Policy Implementation
The necessity for CHWs to be multilingual cannot be ignored when attempting to achieve cultural competency. Some of the requirements in developing a program to address the health literacy gaps, improve health information, and increase outreach within the Asian communities would comprise of: a) multilingual staff that have working level proficiency of a relevant Asian language; b) has a personal and/or professional interest in being a CHW; c) is provided with sufficient training to design needs-based programs for communities; d) have training sessions to accommodate proper translational, guidance, and assistance services for the targeted population; e) actively work to develop networks and relationships with not-for-profit organizations, religious not-for-profit groups, medical associations, technology advancement firms, researchers, and governmental agencies and personnel (academic institutions, county and state health departments).
To ensure that the linguistic standards are met both by staffers and interested constituents – there will be a rigorous interview process for individuals interested to work for pay. However, the inadequacy of not knowing the language will not be seen as deterring from the position itself; interested parties shall be given the option to go through training and testing process to reapply. Secondly, acceptance of volunteers and/or job acceptance letters will be based through in-person interviews (with a resume and letter of intent requirement). Following the acceptance, individuals will have to attend mandatory training sessions through which they will learn about the program expectations and goals, specific community needs, and specific requirements depending on the roles they have been accepted for. Individuals that have experience working in these communities will also have the responsibility of leading, modifying, surveillance, and developing networks with aforementioned agencies to increase the quality, efficiency, and efficacy standards of the program(s) within their community. Volunteer opportunities through this program will be open to all students enrolled in high-school or higher educational institutions. In order to apply for a paid position, individuals must be 18 years of age or older, go through the interview process, and demonstrate personal interest. Individuals that are 65 years of age or older, shall also be considered through the same process. The Commonwealth Fund’s “Cultural Competence in Health Care: Emerging Frameworks And Practical Approaches” field report of 2002, interviewed experts in the field through which they identify the major factors of cultural competence in health care require:
an understanding of the communities being served as well as the sociocultural influences on individual patients’ health beliefs and behaviors. It further requires understanding how these factors interact with the health care system in ways that may prevent diverse populations from obtaining quality health care. Finally, it entails devising strategies to reduce and monitor potential barriers through interventions – (Betancourt, Joseph; Green, Alexander and Carrillo, Emilio; 2002).
Effective implementation of this program and employment of CHWs would require increased funding, increased research in monitoring effectiveness, and developing frameworks to meet community needs. Some of federal and state-level funding opportunities are made available for the implementation of CHWs initiatives through agencies such as, Aetna Foundation, Annie E. Casey Foundation/University of Arizona, California HealthCare Foundation, Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services, Kaiser Permanente, National Heart, Lung, and Blood Institute, National Institutes of Health, Robert Wood Johnson Foundation (RWJF), American Medical Association Foundation (ruralhealthinfo.org; phpartners.org). While these are the major sources for grants, they are highly impacted through the political inclinations of Congress in passing bills.
Political Climate
Historically, Congressional climate in supporting CHWs has not been so bright; acts such as Asian and Pacific Islander Health Improvement Act of 1990, Community Health Workers Act (2002, 2005, 2006, 2007, 2009), Diabetes Prevention Access and Care Act of 2008, Eliminating Disparities in Diabetes Prevention, Access, and Care Act of 2015, have not been favored in Congress (Congress.gov). Although, “Affordable Care Act Opportunities for Community Health Workers” produced by Center for Health Law & Policy Innovation at Harvard Law School, Amy Katzen and Maggie Morgan, discuss that upon recent provisions of the Affordable Care ACT (ACA) help modify CHWs’ role within the nation’s health system (Katzen & Morgan, 2014). Center for Medicaid Services (CMS) also altered their regulations related to “preventive healthcare services in Medicaid”. In effect January 1, 2014, the amendment added that along with “services recommended by a physician or licensed provider”, and also “provided by a non-licensed provider like CHW” are subject to receive reimbursement. Katzen & Morgan note that section 5313 of the ACA commissioned Centers for Disease Control and Prevention to provide funding through grants to agencies for advancing health in underprivileged areas through the implementation of CHWs (2014). Recent political activity depicts that major parties to disperse grants for the implementation of this program and therefore the employment of CHWs are representatively CDC and CMS. Timeline of this program will be interdependent on the requirements imposed by entities that fund this initiative and the funding itself.
Cost Estimates
Since implementation of CHWs has not received much attention in political climate in the past years; there have not been enough cost estimates directly from the Congressional Budget Office (CBO). “A Cost Analysis of a Community Health Worker Program in Rural Vermont”, study produced in the Journal of Community Health in 2013, examined CHW program costs in a rural hospital setting in the state of Vermont. The study finds that the total program cost was $420, 348, which included cost of personnel which attributed to 67% of overall expenditure and the remaining 33% for program implementation (Mirambeau et.al, 2013). This study was also recognized by Centers for Disease Control and Prevention in their June 2013 report. This report gives a probable cost-expenditure for future programmatic budgeting.
Policy impacts
Implementation of the proposed program and policy solution would have an overall increase in cost-expenditure, but would aim to reduce ambiguity caused due to communication blocks between patients and health care individuals, which would then also reduce overall healthcare cost due to the expected increase in health literacy of this population. The program would also create stronger cultural ties with different Asian-ethnic communities and would make them an integral part of society. “What do health literacy and cultural competence have in common? Calling for collaborative health professional pedagogy” by Lie, Carter-Pokras, Braun, and Coleman, holds that “training providers to attend to both issues [limited health literacy and cultural differences] can reduce medical errors, improve adherence, patient-provider-family communication, and outcomes of care at both individual and population levels” (Lie et.al, 2012). CHWs requirements to be multilingual will enforce the cultural competence and help reduce barriers in terms of access and utilization of healthcare services within all Asian subgroups.
A comprehensive study, “Use of Community Health Workers in Research With Ethnic Minority Women” by Jeannette Andrews, Gwen Felton, Mary Ellen Wewers, Janie Heath, addressed that “access to culturally competent health care resources remains the most significant barrier in reducing disparities and promoting health of ethnic minority women and other vulnerable populations” (2004), the team examined 24 studies through which they found that CHWs are “effective in increasing access to health services, increasing knowledge, and promoting behavior change among ethnic minority women”, other benefits included “social support and culturally competent, cost-effective care” (Andrews et.al, 2004). For example, an individual of a South Asian descent, who speaks Gujarati, is assisted by someone who is fluent in it and is able to transparently communicate information at various phases in their experience with health system and in community, such as helping them understand physician’s recommendations, encountering basic health information clinics in their language at their place of religious practice, attending community needs-based programs, gaining guidance for a number of different reasons varying from calling for transportation to understanding their treatment options within a clinical environment.
Moreover, requiring CHWs to continuously build social networks will help build a community of stakeholders, increase public interest, and would in turn help build societal and political pressure in government to increase funding for such programs. Developing and sustaining networks with technological firms would also help build user-design experience into making technology culturally equipped for the future elder populations, will increase private companies to fund these projects, and would encourage other non-profits to create CHW inclusive programs.
Additionally, because this program is focused on the overall improvement in health literacy of vulnerable populations (Asian American population with low-English proficiency), record-keeping, surveillance for the effectiveness, and general impact association will be one of the hardest factors to relate progress evaluation and estimate impact time-frame at a national level. However, specific program effectiveness and evaluation measures can be done at local, community level. Presumably, five-year marker and multitude of studies and research on changing health behaviors within the Asian subgroups could help gauge the improvements linked to the implementation of CHWs. This comprehensive multidimensional approach would help increase overall health literacy, fill communication gaps, and promote health awareness within the population. Due to limited research, political inclinations, and emerging policies on the inclusion of CHWs, there remains an ambiguity upon the length of time it would take to see an impact; but for sure it will not be a rapid one.
Conclusion
In the coming years, impact of CHWs should become more apparent in terms of the program efficacy and quality improvement standards. Enforcement of a policy combined with a comprehensive approach in employing Community Health Workers (CHWs) at different tiers of the healthcare system has positive hopes in reducing disparities caused due to the lack of health literacy, cultural competency, and misunderstanding the diversity of ethnic groups present in the United States. It is clear that there is not adequate research that showcases the effectiveness of such programs. Application of CHWs integrated programs do require significant health care cost-expenditures. Current political climate imposes the need for this research to increase societal and political pressure in the creation, implementation, modification, and enforcement of policies. The demand to recognize, extrapolate, and examine unconformities within racial/ethnic relationships to the environment is critical. While this study focused specifically on examples of ethnic variances in Asian population; same theoretical approaches can be amalgamated for various populations.
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