Addressing minority health access through community-

based health literacy research

Susan J. Shaw, Ph.D., University of Arizona

Today’s Aims

Theoretical overview

Doing community-based health literacy research

Health literacy findings for minority health access Barriers to medication adherence Food insecurity

Recommendations

Conclusions

Theoretical approach

Political economy

Culture as meaning: Changes over time (think slang, sagging,

gender norms) Permeable boundaries Multiple, contradictory and overlapping

Culture as practice: exploring cultural differences by looking at everyday behavior

Culture: Two definitions

“the integrated pattern of human behavior that includes actions, communication, beliefs, values and institutions” (NCCC 2001)

Learned patterns of thought (knowledge) and behavior shared by a social group and acquired through acculturation

Why culture and health literacy?

What is health literacy? the ability to understand and act on a doctor’s

instructions

Culture influences health and health care: What causes disease and illness What is an appropriate treatment How to take care of yourself and prevent disease How the human body works (human physiology) What is appropriate doctor and patient conduct Perceptions of symptoms and emotional states.

“There is no culture-free way to think about disease”

--including

the culture of science

Doing community-based health literacy research

1. Supporting medical interpreters

2. Community-based research design

3. Community buy-in is critical

4. Building vs. draining expertise

5. Doing community-based research with limited resources

Community-based Research Design

Epi Surveys

Medical Chart Data

In-depth interviews, focus groups, home

visits, chronic disease diaries

CHC Pts & HCPs

Quantitative Methods

Data Collection

Qualitative Methods

Data Collection

Community-based research design

Focusing on topics generated by clinic staff/patients

Prospective/longitudinal design, not experimental

Designing research protocols in conjunction with clinic screening methods were developed in response to

input from clinical staff (medical assistants and medical interpreters)

Staff identified methods to protect participant confidentiality and promote trust

Community buy-in is critical

Clinic staff (including administrative supervisors) provided full endorsement of research and showed great interest in research topic and process

Hiring clinic staff provides opportunities to expand skills & experiences

Community members feel that the study is addressing a real community need; one they can relate to from personal experience.

Building vs. draining expertise

Pros and cons of hiring clinic’s medical interpreters as outreach interviewers Building research expertise among trained

interpreters (bilingual, bicultural) Draining expertise from clinic (experienced

interviewers)

Where to cut? Community-based research with limited resources

Research design originally included 5 ethnic groups

After a 29% budget cut, could not sustain translation & personnel costs

How to decide which group to exclude?

Actively seeking funding to include them in future research

Longer term research goals

Sustain community involvement

Ethnographic interviews to address new and emerging community-identified themes

Actively collaborate with community and agency staff to: Build community capacity for research Transfer research staff to programs Integrate research tasks with EMR

Caring Health Center Patient Population

Vietnamese 10%

White/Other

Research site: Caring Health Center, Springfield, MA

• Springfield: pop. 157,000• Section 330 community

health center• Medically underserved,

refugee resettlement area• >50% of CHC’s adult

patients require translation services

Black 34%

Hispanic 37%

Methods Overview

Multi-method design combining qualitative and quantitative approaches to data collection Self-report survey (Baseline, 12 months)

Health literacy Cancer screening attitudes Chronic disease self-management (diabetes,

HTN) Medical Chart Abstraction (Baseline, 12

months)

Methods Overview

Qualitative methods (subsample) Formative focus groups (n=47) In-depth interviews (n=35) Chronic Disease Diaries (n=15) Home Observations (n=12)

Triangulation of qualitative data with survey data and chart abstraction data

Instrument Development

We adapted existing scales for health literacy and acculturation for use in four ethnic groups (African-American, white, Latino, and Vietnamese) by: Conducting focus groups with members of

each ethnic group to generate culturally relevant terms

Translating existing scales into Spanish and Vietnamese where needed

Pre-testing revised scales with members of the target populations.

Sample Overview (n=273)

• 83% of Latino (PR) participants speak Spanish at home

• 34% of participants had <8th grade ed.

• 67% rated their health as fair to poor

• 59% are disabled• 74% estimate their household

income between $400-1,200/mo.

Total sample0%

20%

40%

60%

80%

100%

whiteAfrican-Amer-icanVietnameseLatino

n=100

n=87

n=64

n=40

Health literacy findings on minority health access

Barriers to medication adherence Fears and beliefs about medications Formulary changes

Food insecurity

Fears and Beliefs about Medications

Lack of trust

“Denial that I’m sick”

Fear of side effects

Fear of addiction

Lack of trust in medicines

A: This is called Actoplus Met [oral diabetes med]. I don’t take it regular either. I think I have a denial factor that I’m sick.

Q: So you don’t take your medication regularly?A: I don’t.Q: Why not?A: Because I don’t really know if it does anything. It don’t

seem to do anything anyway. …I know my family’s after me to take it. My daughter especially, she wants me to take it. But I just don’t feel any differently when I do. And we don’t even know if the medication is real or not real. I was just watching the episode on 60 Minutes about the fake medicine. That really opened my eyes and I don’t like it. Who knows what it is?

Fear of side effects

“The first medication that she gave me I had to leave them, because when I would take them I would get a really bad reaction. I would get really nervous, plus my heart would beat too fast! Pum pum pum pum! And I would get so bad that I wouldn’t take them. I took them twice and I didn’t want them anymore.”

Fear of side effects

Q: I wanted to follow up on what you were telling me about when you stopped taking your insulin for a year?A: Yeah, my kidneys were failing and I swelled up like a balloon. And I said, I’ve been on this insulin and I’m getting sick too. When I stopped taking my insulin, my kidneys started working little by little. And now my kidneys are working. I guess it was... probably the kind of insulin it was! Because [my] doctor told me both my kidneys were failing. They was gonna be putting me on dialysis, or a kidney transplant. And I told them I don’t want neither. I said, when I’m meant to die, let me die, ‘cause I, I didn’t want to be on no machine and I don’t want nobody else’s kidney. You know. And for some reason, it’s like God gave me a second chance. I guess God gave me this chance to look out for my family, I think.

More side effectsP2: ...my back hurts, it hurts to get up in the morning. I can't get out of bed and I have arthritis in my spinal column. Everything would hurt for me, but it wouldn't hurt that much. I don't like to take pills.Q: And what is it that you don't like about taking your pills?P2: I don't know. It's like I have a fear of how my body is going to react. Maybe it’s from an experience that I had, of pills that I took and I felt, I don't know, that it wasn't me. And I am afraid of that. …P3: Let's just say it, there are pills that in one way make you better but in another hurt you. Because even Advil is bad for your liver.P4: True. The way that you take them and the quantity...P3: It's no good, and you never know how much. …P2: You are helping you there and hurting you here.P3: That's how it is.

Fear of addictionA: I don’t know if I’m right or wrong but it seems to me that us black folk, we don’t tend to want to take a lot of medicine. We don’t wanna become… My mother always [used to say], yeah, you get addicted to this. You get addicted to that. Like, she takes a sleeping pill but I don’t give it her. Her doctor recommends it but I don’t give it to her every night because she don’t need it every night. You know what I’m saying? She don’t need it. You know, she’s 84 and she’s tired. She’ll go to sleep. Now that she’s in the [beginning] forms of dementia, she remembers, ‘I didn’t get my medicine’. And I say, ‘Mom, you know, I don’t think you need it.’ I don’t know if that’s right or wrong, but I don’t see the need for her to have to take a sleeping pill every night.

Passed under Gov. Romney in 2006, MA health care reform mandated individual health insurance coverage for all state residents

Minimally creditable coverage

Fee (tax?) for those who are uninsured (~$3200/yr.)

Expanded Medicaid (MassHealth) eligibility for children and some special populations

“The Connector”: the on-line state-run “exchange,” a marketplace for health insurance plans

Cost control measures:Massachusetts health care reform

Two years after implementation, costs exceeded estimates by $150m

Cost control measures:

Churning the rolls

Formulary changes

“Bureaucratic disentitlement” (Danz 2000)

Insurance coverage increased to 97+%, but

Racial/ethnic disparities in health coverage and access remain

7% of Black and 10% of Hispanic Springfield residents were uninsured in 2009, compared to 5% of whites, and to 1.9% of all MA residents (MDPH 2009).

Hispanics in Springfield were twice as likely as whites to report that they were unable to see a doctor because of cost (MDPH 2010b).

Massachusetts health care reform in practice

Effects of formulary changes

Provider 2: One barrier … is health insurance. Because, you see, insurances, some of them have specific medications they will pay for, like .... MassHealth doesn’t cover this particular diabetic med … And so they have to switch to something else, which doesn’t work as well.

Provider 3: That’s why they lose control. That’s when they lose track.

Provider 2: And then the patients are frustrated because they think, well, that one used to work so well but they don’t pay for it.

Susan: And that’s when they lose control of their blood sugar?

Provider 3: The blood sugar, everything! The tracking, everything! Because they change so much their medication so often they may be taking their meds twice a day instead of once. They lose control. They get tired. They don’t want to do it anymore.

Responses to formulary changes

Hoarding pills

Trading pills with friends

Substitute over-the-counter for prescription medications

Formulary changes & lack of trust

A: When I had the colonoscopy done... the doctors prescribed me that Prevacid. I took it to the pharmacy, and the pharmacy says the insurance won’t cover it. And that seems like, well why would they give me a prescription if you can’t honor it? Either it costs too much or you’re second-guessing the doctor and you’re thinking I don’t need it. So, that’s counter-productive to me. I think the insurance company should…not look at it from a dollar sign point of view. [They should] call the doctor who prescribes the pill and talk with him, and [that would] cut down on me going back and forth and in the meantime I have nothing to take in place of it. So I’m losing valuable time and then I have to suffer, until the problem [is] rectified.

Food insecurity is widespread

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60

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Food insecure%

Food insecure people have less access to health care…

χ2=6.39; p<.04

Food insecure Food secure02468

101214161820

16.8

5.8

Percent unable to see a doc-tor

because of cost in last 12 months

Food in-secure

Food secure0

10

20

30

40

50

48.7

12.3

% unable to afford medica-tion/supplies in last 12

months

χ2=44.42; p<.0001

…are more likely to be overweight/obese,

84.9% of participants who are food insecure are overweight, obese or morbidly obese (BMI >25)

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5

10

15

20

25

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40

Normal(<25)

Overweight(25.1-30)

Obese(30.1-35)

Morbidlyobese(>35.1)

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Food Secure Food Insecure

…and have more complications from diabetes

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10

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70

Problemswith

circulation

FrequentInfections

Neuropathy Needs tolose weight

HeartDisease

Impotence

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Food Secure Food Insecure

Food insecurity and medication nonadherence

A: See, right now I got a problem. My ex-wife lost her job, right? And I got kids by her, right? So I’ve been trying to stretch my money buying groceries over there, helping her out, and buying groceries for me, but I, I ain’t got enough for myself, you know. … So, so’s what I do is buy one big compra [a purchase], and I bring it to her house if I could eat it over there while she cooks. But my kids, they eat, they eat, and they eat. And the groceries go quick, you know... Like, last month, I had to borrow her, her car insurance money, right? To buy groceries for that month and then pay it back so she can pay for her car insurance, you know …

…medication nonadherence, cont…

… Sometimes I’m don’t take my insulin, because I’m scared I might get a insulin stroke, when it, when [my blood sugar] gets too low... but that’s between you and me. I won’t shoot my insulin, you know, when I’m scared-- if I take it I might go into insulin shock and maybe die, you know? And my kids don’t see that, you know? I try to do the best I can. [voicing his kids’ concern] ‘Oh, you didn’t take your insulin today.’ They fight with me you know? [But they don’t understand that] there’s a reason I don’t take it sometimes.

Coping responses to food insecurity

Modifying medication

Modifying diet

Social support (family)

Charity (soup kitchens, food pantry)

Recommendations for Clinicians and Researchers

Refer low-income patients to resources such as food stamps to mitigate food insecurity Provide additional supports (e.g., diabetic supplies)

to address increased risk of barriers to health care access

Elicit and address patients’ fears and beliefs about medications to find points of cultural consonance

Brainstorm culturally-appropriate solutions to common health literacy challenges (e.g. Rx list cards for the wallet)

Concluding thoughts

Community-based minority health research is an effective way to: Build community research capacity Produce usable findings Strengthen community-campus partnerships

Cost control measures such as formulary changes and churning the rolls negatively affect patients’ ability to adhere to their chronic disease medications Widespread fears and concerns about medications

may be exacerbated by cost control measures

Concluding thoughts, cont.

Food insecurity is associated with limited access to health care, increased obesity, and more complications from diabetes

Economic barriers intersect with and exacerbate other cultural barriers and health beliefs Separating cultural from economic barriers can be

difficult: sometimes cost, not culture, is the most important factor

Acknowledgments

This research was supported by grant #R01CA128455.

Co-authors: Julie Armin, ABD, School of Anthropology,

Research Assistant James Vivian, PhD, University of Connecticut Medical

Center, Data Analyst Cristina Huebner Torres, MA, Caring Health Center, Project

Director

Special thanks to the providers, staff and patients at Caring Health Center for sharing their expertise.

Background Previous research

Culturally appropriate health care Community health advocate program (WtW)