Bringing Equal Health Outcomes within REACH
Prompted by compelling evidence that race and ethnicity play a major role in Americans’ health status, former President Bill Clinton set an ambitious goal in 1998: To eliminate health disparities between racial/ethnic minority populations and the Caucasian majority in six key areas–including cancer, diabetes and cardiovascular disease (CVD)–by the year 2010. As a result of this initiative, numerous research, prevention and community outreach programs have been launched throughout the nation, all working toward the common goal of closing the gap of unequal health outcomes.
One of the most interesting of these programs is Racial and Ethnic Approaches to Community Health (REACH) 2010, funded by the Centers for Disease Control and Prevention (CDC). REACH 2010 awards grants to groups looking to address the often-overlooked health needs of specific segments of underserved US populations–specifically, African Americans, Hispanics, American Indians, Alaska Natives, Asian Americans and Pacific Islanders.
Currently, REACH 2010 is supporting projects in 35 communities nationwide. In many of these campaigns, the leaders on the front lines are nurses. Utilizing nurses, particularly those from minority populations, is one of the keys to the success of these projects, according to program providers.
“Having nurses within the team is a plus since we can re-emphasize instruction and teaching, giving patients a more clear understanding about their physical conditions,” says Chhan D. Touch, MSN, FNP, RNCS. Touch works with Cambodian Community Health (CCH) 2010, a REACH project in Lowell, Massachusetts.
Sidney Liang, CCH 2010 program director, points out that nurses, more so than physicians, have the time and skills to offer education about diseases such as diabetes and CVD. “Nurses have a personal touch or relationship with the people,” he explains. “They get to know people or at least communicate with them before they start with their work. Relationship building is an important skill that nurses have.”
Battling a Community Health Crisis
Lowell, a Boston suburb, is home to the nation’s second-largest Cambodian-American community. As of the 2000 Census, Lowell had 17,301 Cambodian-American residents out of a total population of 107,000. Local leaders, including those involved with CCH 2010, estimate the actual number to be closer to 30,000. Some 1,300 people are enrolled in CCH 2010, which uses a number of nurses–including several of Cambodian descent–to implement its program.
“Besides being a professionally trained family nurse practitioner, I have general knowledge of the patients’ beliefs and practices since I am a Cambodian myself,” says Touch. “To know and understand how they perceive their lives, physical conditions and health allows me to tailor my instruction toward their specific needs.”
Cambodians in Lowell have numerous risk factors for CVD–including high rates of smoking–and for diabetes, as well as a disproportionate risk for morbidity and mortality associated with those conditions. Their diets and exercise habits also add to the problem. Staples in the Cambodian diet, like noodles and rice, coupled with the sedentary lifestyle many Cambodian immigrants have adopted in the US often contribute to adult-onset diabetes.
“The general health of elderly Cambodians, in particular, is in crisis at an alarming rate,” Touch adds. The most common medical conditions among older Cambodians, he says, are hypertension, diabetes, hepatitis, hyperlipidemia, nephropathy, and cardiomyopathy.
The health care professionals involved in CCH 2010 believe educating people about risk factors and helping them adopt a healthier lifestyle will help in the battle against this crisis. Community residents are taken on tours to help them become familiar with local health care agencies, hospitals, the police department and an ambulance agency. Other services offered through CCH 2010 include peer counseling, prevention education, monthly support groups and t’ai chi sessions.
These offerings help patients overcome their knowledge deficits about their diseases, says Leah Chuon-Reach, RN, BSN, a community health nurse for the Visiting Nurses Association of Greater Lowell, one of the CCH 2010 collaborating agencies. “[Health] education is very important for the Cambodian community,” explains Chuon-Reach, a Cambodian native, “because in Cambodia they never had any background given to them about disease processes.”
Lack of familiarity with Western health care concepts like medication compliance can be a big problem for this population, according to Touch. Sometimes people don’t take their medication because they want to see how traditional remedies like herbs are working. Others may not understand that the prescription is for continuing care and don’t refill it. The importance of eye exams, foot exams and lab work-ups needs to be stressed as well. All of these issues are addressed through REACH 2010.
Cambodian immigrants often face language barriers with medical providers, continues Touch, who fled Cambodia during the time of the “killing fields” and spent four years in a Thai refugee camp. Most Cambodians in this country, especially the elderly, do not understand the complexity of the US health care system, he says, and many are illiterate. “Due to this inadequate knowledge, they can not understand on their own how to care for themselves properly,” he believes.
To combat the problems associated with illiteracy, CCH 2010 airs public service announcements on local TV and radio stations about diabetes, heart disease, general medicine usage, outdoor safety, cholesterol, hypertension and smoking cessation. The project has also established a sustainability committee to educate health care providers in Lowell about traditional Cambodian health practices and cultural beliefs.
CCH 2010 is run by the Lowell Community Health Center (LCHC) Metta Health Center. The University of Massachusetts Lowell, the Cambodian Mutual Assistance Association, Southeast Asian Bilingual Advocates, Inc., and the Massachusetts Department of Public Health are also among the collaborating agencies. The Metta Health Center offers services derived from both Eastern and Western health care traditions. This transcultural approach has been key in reaching the project’s participants and allows an easier information exchange between providers and patients, says Dorcas Grigg-Saito, PT, MSPH, the executive director of LCHC and CCH 2010’s principal investigator. “Then it becomes easier to develop a better disease management program,” she adds.
Touch reports that the CCH 2010 program has had a positive impact on the Cambodian community. “Since the start of this project, great numbers of Cambodian elderly have received proper care via care managers [provided through the program],” he says.
The success of CCH 2010–like its many REACH counterparts nationwide–has come in large part from the local community. During the planning phase, CCH 2010 organizers held community meetings in a number of locations throughout Greater Lowell. This effort, which included creating a Cambodian Elders Council, was designed to get community members involved in developing the action plan.
Touch points out that a number of the REACH 2010 providers are Cambodian refugees, as he is, but they have been in this country for many years and have been educated here. “We needed that knowledge on how to talk to our own people, how to approach our people,” Liang explains, “because many Cambodian immigrants’ beliefs are still attached to the culture from our country.”
As part of this cultural collaboration, CCH 2010 uses community ceremonies and certain religious events as opportunities to talk to people about health issues, such as the importance of screening, says Liang, who came to the US during the Khmer Rouge era. “These are things the Elder Council taught us that are really important,” he emphasizes. “We learn from them and can reach out to more people while staying within the context of Cambodian cultural traditions.”
Gone But Not Forgotten
In nearby Worcester, Mass., cultural sensitivity and community cooperation were factors in the success of its own REACH 2010 project, which targeted Hispanics and Southeast Asians with diabetes and hypertension. This program–which ran for approximately three years and ended last fall when the funding ran out–began by assembling a citywide coalition, including city leaders, community groups, health care providers and local residents. Focus groups were conducted to assess the community’s health needs and identify barriers to care. “People [said they] wanted more exercise, better nutrition and culturally competent providers,” says Cecilia Vicuna-Keady, RN, CS, FNP, MS.
Vicuna-Keady directed the Worcester REACH 2010 program at Great Brook Valley Health Center, part of an inner city housing project in Worcester, the third largest city in New England. The health center collaborated with University of Massachusetts Memorial Health Care and the Family Health Center. A number of other community institutions were also part of the coalition that helped set up the program.
One of the project’s primary strategies was to tailor its health promotion services to the approximately 350 participants’ interests and concerns. For example, the exercise program focused on ethnic dancing. Classes in salsa, bachata and samba were offered at several locations where the residents could feel safe and comfortable attending activities.
“What we had heard [through the focus groups] was that many people felt health clubs and exercise facilities were for people of other races or they couldn’t afford to join them,” Vicuna-Keady explains. And it isn’t enough to tell someone to start exercising, she adds, when the reality is that it might not be safe for inner-city residents to walk in their neighborhoods after 5 p.m. “They don’t own cars and bikes, so they also can’t go to safer places, like parks, to walk.”
In the nutrition classes, participants learned to adapt their own recipes into alternatives that contained less fat, salt and calories. Other services available through the program included support groups and monthly theme days, focusing on such topics as the importance of drinking adequate amounts of water. Because family ties are important in Hispanic and Southeast Asian cultures, each patient was allowed to bring a family member to these events.
Although the Worcester REACH 2010 project has ended, the city’s Hispanic and Southeast Asian communities are still feeling its impact, according to Vicuna-Keady. The program produced a healthy recipes cookbook that is popular among former participants, who still turn to each other for support. An exercise video set to culturally appropriate music is also available. In addition, some of the sites that had provided services through REACH 2010 are still offering some activities, such as an after-school program that provides ongoing exercise and nutrition classes for overweight adolescents.
Emigrating from another country can be difficult and can leave people feeling isolated and alone, says Vicuna-Keady, who settled in the United States from Argentina. “I know because I went through that myself,” she says. “Our REACH 2010 project was a wonderful program because it really united people in the community and supported them. And some of that is still going on.”
In Oklahoma, REACH 2010 has had a similar impact in addressing the growing problems of diabetes and cardiovascular disease morbidity and mortality among the state’s American Indian population. Here, too, the project began with the forming of a coalition: a steering committee of eight Indian tribes/nations, one urban Indian health center and the Oklahoma State Department of Health. Oklahoma REACH 2010’s partners are: the Absentee Shawnee Tribe of Oklahoma, Cheyenne-Arapaho Tribes of Oklahoma, Wichita and Affiliated Tribes of Oklahoma, the Cherokee Nation, Chickasaw Nation of Oklahoma, Choctaw Nation of Oklahoma, Seminole Nation of Oklahoma, Pawnee Nation of Oklahoma and the Urban Health Care Resource Center in Tulsa.
Bringing together all these different entities was no small feat. “We are very proud of the coalition that has developed between the tribes,” says Bobby Saunkeah, RN, BSN, one of many nurses on the steering committee. “One of the most important things we worked on in the early stages before we started the intervention was developing the rapport between the tribes first and working with the state health department.”
Initially there were some obstacles to overcome in creating this complex network of partnerships, continues Saunkeah, who acts as a resource consultant for Chickasaw Nation REACH 2010 and is a member of the Kiowa Tribe of Oklahoma. “These are native tribes and nations, sovereign nations,” he says. “Then we had the state department of health and the CDC, so you are talking about 10 or 11 individual bureaucracies trying to agree on finances and numbers, etc. It was hard to get all that worked out during the first planning year, but we are extremely proud that we stuck together. That is what’s really unique about Oklahoma REACH as opposed to some of the other REACH programs around the country.”
American Indians have the highest diabetes rate of all racial/ethnic groups in Oklahoma, according to the Oklahoma State Department of Public Health. It is also the fourth leading killer of Native Americans in the state, responsible for more than 100 deaths each year. In fact, in 1999 diabetes mortality rates in Oklahoma were 182% higher among Native Americans when compared to the Caucasian population. That same year, the Oklahoma Native American REACH 2010 coalition was formed. One of the project’s key goals was to implement a physical activity intervention to reduce diabetes and CVD disparities in its target population.
Oklahoma REACH 2010 has received funds through two phases of the CDC’s program, which will allow the project to continue through 2007. Many of the entities involved in the coalition have also received diabetes prevention grants from the Indian Health Service to help them run their programs.
“From the largest tribe in the United States to the smallest, the whole spectrum is covered within this grant,” says Janis Campbell, PhD, the project’s principal investigator and the surveillance coordinator for chronic disease in the state’s department of public health.
Every tribe has a slightly different program set up that is unique to its community, Campbell adds, and each program has at least 333 enrollees–the number of active participants required by the grant. Because Native Americans have such a high risk factor for diabetes, the health promotion activities provided through the programs are not restricted to people who currently have the disease. Overall, the focus is on families. “How you get to the family can be different within each project,” says Campbell. “It is community specific.”
Because being overweight increases the risk for both heart disease and diabetes, Oklahoma’s REACH program focuses on fighting obesity through physical exercise. Campbell estimates that between the nine different tribal and urban programs approximately 75 physical fitness events take place each week, ranging from walking, aerobics, line dancing and ballet to martial arts, yoga and Pilates.
One of the main reasons why the American Indian population in Oklahoma is facing such a health crisis when it comes to diabetes and CVD is that their lifestyle and diet have changed dramatically over the years, says Ruby Withrow, RN, MPH, who is the diabetes and REACH coordinator for the Absentee Shawnee Tribe of Oklahoma. “Traditionally, Native Americans did eat a lot of meat,” she explains, “but the meat they ate was game meat, like venison or buffalo, which is very lean. There is very little fat in that meat and that was the staple of their diet.”
In the 1800s, when many Indian tribes and nations were removed from their lands–where they had hunted and fished–and forced to relocate to Oklahoma, their healthy diets changed drastically, as did their activity level. “Today they are not active in the way their bodies evolved with activity,” says Withrow, who is of Potawatomi and Sac and Fox descent. “Their bodies still want them to be active but they are very sedentary.”
Because making a difference will come in small steps, the Absentee Shawnee Tribe chose the name “STEPS” for its REACH 2010 project. “You have to take those first steps to get started,” Withrow emphasizes. STEPS offers monthly fitness events, such as a basketball clinic, softball camp and tennis camp. Another of the program’s activities is a monthly “Healthy Lifestyles Day,” featuring screenings, a healthy meal and education about adding physical activity to participants’ lives. Other ongoing services include aerobics classes, walking groups, line dancing, social gatherings and a monthly newsletter.
“The focus of the entire REACH 2010 program [in Oklahoma] is either adding physical activity or increasing the activity that [Native Americans] are doing,” Withrow maintains. “That means any activity that gets people moving–whether it be walking, mowing the grass or housework.”
Statewide, the project also includes the collection of data that will help measure the program’s effectiveness by calculating participants’ body mass index (BMI) at six-month intervals. “Hopefully, as time goes by, people will show improvement and there will be a decrease in BMI, even though we know that the BMI isn’t the only way to tell if the person is benefiting from physical activity,” says Withrow. “We have gotten the word out to people. They know what is needed and what they have to do in their lives. And it will impact their lives, if not today then sometime in the future.”