Advancing)Health)Equity)in)Asian)American) Communities:))Context,)Challenges,)and) Opportunity American)Academy)of)Health)Behavior March)6 th ,)2018 Nadia)Islam,)PhD Associate)Professor Department)of)Population)Health NYU)School)of)Medicine
Learning'Objectives • To$ demonstrate$the$role$of$ context'and' opportunities' for$advancing$health$equity$ • To$explain$how$ community1based' participatory'research' can$advance$health$ equity • To describe$the$ lessons'learned in$ advancing$health$equity$in$Asian$American$ populations
“Opportunity—the(chance(to(thrive(in( health(and(other(aspirations—is(unevenly( distributed(across(society.” Source:(Woolf(SH,(Purnell(JQ.(The(Good(Life:(Working( Together(to(Promote(Opportunity(and(Improve(Population( Health(and(WellCbeing. JAMA. 2016I315(16):1706C1708.
Context'&'Opportunity IDENTITY OPPORTUNITY CONTEXT AGENCY
Context Asian&Americans
Asian&Americans:&The& fastest&growing& minority& group AA&population&is& projected&to&be& 43.2%million% in& 2050&– or&10%&of& the&entire&U.S.& population Source:&Pew&Research&Center
Asian&Immigrants&&&Their&Children
LEP$Rates$among$AA$and$NHPI$Subgroups In$NYC ,"60%"of"Asians"citywide"are"LEP"with"rates"varying"across" Asian"ethnic"groups"(Chinese:"67%@"Korean"63%@"Vietnamese"61%@" Hindi"30%).
Asian&American&Diversity
Data$on$Asian$Americans$are$Sparse • Aggregated)data)– lack)of)or)limited)subgroup)categorization • Small)sample)sizes • Inconsistent)definitions)of)Asian)Americans) • Uneven)distribution)by)geographic)region • Barriers)to)participation)due)to)immigration)status)and)language)access)(limited)English) proficiency) • Lack)of/or)inconsistent)collection)of)race/ethnicity)data
Identity The$Model$Minority$Stereotype
What%is%the%Model%Minority% Stereotype? Asian&Americans&are&popularly&believed&to&have: • High&educational&attainment • High&median&family&income • Low&crime&rates • Lack&of&juvenile&delinquency • Lack&of&mental&illness • Close&family&ties • Law@abiding • Hard&workðic Sources:&Cheng,&J&of&Applied&Behavioral&Science&1997H&Kawai,&The& Howard&Journal&of&Communication.&2005.
The$“Model$Minority”$Stereotype Aug$31,$1987
The$Scripps$National$Spelling$Bee$Has$Co5Champions,$Again Katy%Steinmetz @katysteinmetz May%28,%2015
Challenges)of)the)Model)Minority)Stereotype –Success'isn’t'evenly'distributed'across'and' within'Asian'American'subgroups –Inequalities'are'obscured'and'masked'among' subgroups'– those'who'suffer'are'invisible –Stigma'and'self>hatred'among'those'who' underperform'or'suffer'from'poor'mental'and' physical'health
Example(1: Are(Asian(Americans(Healthier( and(Are(We(All(Alike?
Age$adjusted+diabetes+prevalence+among+ select+racial/ethnic+subgroups:++NYC+2009$2001 19.0 16.5 14.3 10.8 10.7 9.3 Blacks Hispanics Asians Asian Koreans Chinese overall Indians Islam&N ,@Wyatt@L,@Kapadia@S,@Marian@R,@TrinhIShevrin@C,@Kwon@S.@Diabetes@and@Associated@Risk@Factors@among@Asian@American@ Subgroups@in@New@York@City.@Diabetes@Care.@2013T@36:@e5.@@PMCID@3526197
Diabetes(provider.management(by(select( racial/ethnic(subgroup,(NYC:(2009.2011 Blacks Hispanics Asians0overall Asian0Indians Koreans Chinese 3.31 3.23 3.06 2.91 2.73 2.56 2.14 2.00 1.98 1.83 1.16 0.81 Mean0yearly0HbA1c0checks0by Mean0yearly0feet0checks0by doctor doctor Islam&NS ,0et0al.0Asian0Americans0in0New0York0City0Face0Disparities0in0Diabetes0Management0Compared0to0Other0Racial/Ethnic0Minority0Groups0 (2014).0 American&Journal&of&Public&Health .[Supplement03,02015,0Vol0105,0No.0S3
DATA$USE:$REAL$WORLD$EXAMPLE “We…focused+on+non-Hispanic+ Whites,+non-Hispanic+Blacks,+and+ Hispanics+in+line+with+much+of+the+ literature+on+health+disparities.”
Example(2: Are(Asian(Americans(Wealthier(&( Wiser?
Value&of&Disaggregated&Data Source:(Ahmad,(Farah(Z,(and(Christian(E.(Weller,( Reading(Between(the(Data:(The( Source:(Asian(American(Center(for(Advancing(Justice,(A(Community(of(Contrasts:( Incomplete(Story(of(Asian(Americans,(Native(Hawaiians(and(Pacific(Islanders,( Center(for( Asian(Americans(in(the(United(States:(2011. American(Progress(,(February(2014.
Asian$Americans$are$a$Low$Income$Group$in$New$York$City 35 29 30 25 2012$Poverty$Rate,$% 25 22 Non+Hispanic2White 20 Non+Hispanic2Black Hispanic 14 15 Non+Hispanic2Asian 10 5 0 Source:(The(Center(for(Economic(Opportunity((CEO)(Poverty(Measure,(2005(@ 2012.(An( Annual(Report(from(the(Office(of(the(Mayor.(
Intervention)approaches)for) advancing)health)equity Community)Engagement)&)CBPR
Spectrum)of)Community)Engagement INFORM CONSULT INVOLVE COLLABORATE EMPOWER We#will# We#will# We#will# work# consider# ensure#that# We#will# together# your#input# We#will# your#input# implement# and# and#give# is# keep#you# what#you# incorporate# feedback# considered# informed your#views# decide about#how# among#the# as#much#as# it#informed# (CBPR) choices#we# possible our# implement decisions (CBPR)
CBPR*GUIDING*PRINCIPLES ! Fundamental*Principles*of*CBPR: " promotes(active(collaboration(and( participation(at(every(stage(of( research " facilitates(co5learning " ensures(research/interventions(are( community5driven " disseminates(results(in(useful(ways( for(community(stakeholders " ensures(research(and(intervention( strategies(are(culturally(appropriate " defines(community(as(a(unit(of( identity.
Project(Overview Diabetes(Research,(Education,(&(Action(for( Minorities((DREAM)(Project( Funder(s): NIMHD(&(CDC Overall(Goal: To(develop,(implement,(and(test(the(efficacy(of(a( CHW(intervention(designed(to(improve(diabetes(control(and( management(in(the(Bangladeshi(community(of(NYC
Background Bangladeshi Community of NYC: ≈ 64,000* ! 54% LEP ! 31% live in poverty ! 74% foreign-born US-Census,-2010*
Background Bangladesh/is/one/of/the/top/10/countries/estimated/to have/the/highest/cases/of/diabetes/worldwide/by/2030 List of countries with the highest number of estimated cases of diabetes for 2000 and 2030
DREAM& Community&Coalition Faith6Based& Organizations Community& Leaders&and& Ethnic&Media Representatives& of&Target& Community DREAM& Project& Coalition
Who$are$CHWs CHWs%are%frontline%public%health% professionals%who%have%an%unusually% close%understanding%of%the%communities% they%serve%through%shared%ethnicity,% culture,%language,%and%life%experiences. Also%referred%to%as%… Promotor.es/.as Outreach$Workers Community$Health$Representatives Patient$Navigators/
CHW$Approaches$ ! Improve(access(to(health(care(resources ! Improve(the(quality(and(cultural(appropriateness(of(service(delivery ! Help(others(integrate(disease(prevention(and(management(into(their( daily(lives( ! Organize(communities(to(improve(environmental,(physical(and(social( wellbeing ! Negotiate(cultural(&(linguistic(barriers(to(health ! Help(others(become(active(participants(in(their(own(health USAID,( Community)and)Formal)Health)System)Support for)Enhanced)Community)Health)Worker Performance)Report ,(2012 http://www.coregroup.org/storage/Program_Learning/Community _Health_Workers/chw%20evidence%20summit%20final%20rep ortP19dec2012.pdf
DREAM&CHWs Shared&Experiences&of& working&with&the& Bangladeshi&community
Social'Determinants'of'Health' Approach
Study&Design&and&Methods I/E&Eligibility: Bangladeshi&NYC&resident,&ages&25&– 85 ! Confirmed&Hemoglobin&A1c&of&≥&6.5 ! Cannot&be&pregnant,&on&renal&dialysis,&or&have&had&coronary& ! event&within&the&3&months&preceding&the&intervention Study&Design:&RCT& Treatment Control+ 5&monthly&education&sessions&&&&&&&&&&&&&&&&&&&&&Introductory&Session&Only& 2&1v1&Visits&with&a&CHW “Wait&list”*Control*group*receives*introduction*education*session*only.**
CHW$Levels$of$Intervention Policy Systems Community Individual
Individual)Level ! Culturally(tailored(health(education ! Linguistically(tailored(access(to(care(and(patient(navigation ! Culturally(tailored(health(promotion(strategies ! Empowerment(&(enhancing(self:efficacy ! Providing(linkages(to(housing,(immigration,(and(other(services
Community)level ! Promoting)positive) health)contexts)that) changes)access)to) material)resources " Increasing)access)to) affordable)physical) fitness)opportunities " Environmental) changes)in)faith: based)organizations,) ethnic)grocery) stores,)and) restaurants ! Building)organizational) capacity
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