MHP HRA Project NO.: 0606-01

August 2006

Health (Cancer) Risk Assessment: Telescoping Through the Cultural Eyes

Executive Report

Health Risk Assessment report for Russian, Latin-American, French, Somali, Sudanese, and Cambodian Communities

Augusta 2006

Prepared for

Maine Cancer Consortium

Prepared by

Kolawole Bankole, M.D., M.S.

Minority Health Program Coordinator / Access Project Director

Public Health Division, Health and Human Services Department

TABLE OF CONTENTS

Page

ACKNOWLEDGEMENTS……………………………………………………………...3

ORGANIZATIONAL BACKGROUND…………………………………………………4

EXECUTIVE SUMMARY**…..…………………………………………………………6

INTRODUCTION………………………………………………………………………..6

METHODOLOGY AND APPROACH...……………………………………………….8

RECOMMENDATIONS…………………………………………………………………9

REFERENCES…………………………………………………………………………15

ANNEX 1 (Executive Summary by TRALE, Inc. pdf file)…………………………..xx

ACKNOWLEDGEMENTS

The Minority Health Program (MHP), Public Health Division, Health and Human Services Department of the City of Portlandwould like to thank the individuals and organizations that contributed to the development and implementation of this health (cancer) risk assessment and educational outreach. Particular individuals and community groups helped to identify participants and provided key platforms for the implementation of the screening project in their communities.

Special thanks are offered to:

  • The community leaders in the ethnic minority communities
  • Awralla Aldus, BS; MHP, Somali Community Health Outreach Worker
  • Nelida Berke, BS; MHP, Latino Community Health Outreach Worker
  • Wilfreid Plallum, BA; Chairman, Acholi Sudanese Association of Maine
  • Jovin Bayingana ~ Leader in African French community
  • Pastor Mutima Peter ~ International Christian Church and African French community
  • Tarlan Armadow ~ Leader in Russian community
  • Sister Patricia Pora ~ Sacred Heart Church, Latin-American community
  • Rafael Galvez ~ Leader in Latin-American community
  • Abdi-Majid Sherif, Director, Somali Youth of Maine; Interpreter and recorder
  • Pirun Sen, Cambodian PAC Coordinator, Office of Multilingual and Multicultural Programs; Chairman of the Board, WattSamakiCambodianBuddhistTemple
  • Vanny Pov, Cambodian PAC member

Finally, MHP extends its gratitude to Tracy Chalecki for her administrative and technical support for this project.

Kolawole Bankole, M.D., M.S.

MHP Coordinator / Access Project Director

ORGANIZATIONAL BACKGROUND

MINORITY HEALTH PROGRAM (MHP), PUBLIC HEALTH DIVISION, HEALTH & HUMAN SERVICES DEPARTMENT OF THE CITY OF PORTLAND.

Ultimate goal: To decrease the health care disparities in the minority communities in Portland, Maine.

The MHP was established to help address the health related issues and desires of all minority communities (ethnic, GLBTQ, social, low-income earners, and the mentally challenged, etc.) in the Greater Portland area of Maine.

The MHP is guided by a vision of a healthy community in which:

  • Diversity within the community is respected and valued by community members and institutions
  • Everyone has access to quality health and social services
  • Everyone has access to resources and conditions required for a healthy lifestyle
  • Institutions and policy makers are responsive to community residents
  • The assets and gifts of community residents are acknowledged and shared
  • MHPwork is conducted in partnership with community organizations and service providers to identify and address health priorities of the minority communities

The racial/ethnic language minority groups include: Khmer, Arabic, Spanish, Acholi, Somali, Serbian/Croatian, Vietnamese, Nuer, French, Chinese, and, Russian.

Objectives:

  1. Improve New Mainers community health indicators (access to health care, physical activities, tobacco use and nutrition, asthma health, mental health, drug and substance abuse, etc.) at the community, family and individual levels.
  2. a. Increase capacity of community groups to establish health and well being priorities and implement a locally defined community health agenda.

b. Strengthen informal and formal social networks and sense of community focusing on the strengthsand assets of the Portland’s largest eleven ethnic/language groups.

3. Ensure that institutions, including the Public Health Division, are more

accessible and responsive to the community interests by building an integrated channel of information through the establishment of a network of community health outreach workers.

  1. Work effectively with policy makers and the legislature on issues that improve the health status of minority groups.

Some of its related programs/projects:

  • Network of eleven community health outreach workers working with the communities (three are FTEs for the Asian, Latino, African and Middle Eastcommunities).
  • Health Policy Interventions: 1) Monthly Blood Pressure and Wellness Clinic for the Russian community; 2) Women Health Education Clinic for the Sudanese; 3) Youth tobacco use prevention video documentary for three communities; 4) cancer risk prevention and awareness campaign among six ethnic communities, using health risk appraisal tools, and 5) Other disease-specific policy interventions.
  • Disease-specific Health Promotions: partner with MaineHealth Asthma program to establish Asthma Helplines for Somali and Latino communities. The Somali asthma helpline is 756-8177, while the Latino Helpline is 756-8188. Asthma, Diabetes/nutrition, Hypertension and mental health community health education. Awarded Trailblazer and award of Excellence in improving Asthma Care by MaineHealth.
  • Coordination ofa community-clinical partnership with five major health care institutions to improve health care access to the ethnic minority communities through implementation of CDCynergy social marketing communication strategies, and Comprehensive Care model.
  • Health Care Collaborative: A bi-monthlyforum for all healthcare service providers to meet for discussions and training with the purpose of educating members regarding ongoing needs and issues in the minority communities, to improve communication and referral coordination among providers.
  • National, regional and local partnerships: 1) Maine partner for National Office of Minority Health, Closing the Health Gap with activities for “Take A Loved One to the Doctor Day”; 2) partnering and collaborating with institutions on different projects (advocacy groups, multicultural groups, hospitals/healthcare professionals, non-profit, and, governmental organizations).
  • Coordinates community meetings, major outreach events and special educational trainings for the minority groups.
  • Ethnographic data collection on minority communities for healthcare planning and policy implementation.
  • Community-Based Organizations (CBOs)/Self-Helps asset building with technical and financial supports.
  • Legislative/Policy making involvement with active participation in legislative task forces and testimonial supports for plans and bills that focus onimproving the health status of the minority communities.
  • Media outreach project: Creation of public service announcements to raise awareness about the healthcare services available for the communities through the Spanish and Somali TV programs on Channel 2 & 4.
  • Diversity training: Provides training to service providers on culturally appropriate approaches to providing services through presentations and dialogues at different forums.

EXECUTIVE SUMMARY

See “Executive Summary” provided by TRALE, Inc. (pdf file). See also, detailed individual group reports (pdf file). The Executive Summary also provides a synthesis of the findings and their implications.

INTRODUCTION

Background information on the health risk assessments

Six distinct populations were convened for this project. The need for a health risk assessment had been identified at a previously conducted series of focus groupsand community meetings with six ethnic groups. The objective of talking to these populations was to gain insight into their cultural beliefs, perceptions, and expectations about health, as well as barriers to accessing services that enhance their individual, family, and overall community health status.

A health risk assessment constitutes a form of scientific social, policy, and public health research to elicit the full range of risk factor determinants of disease specific issues and behavioral attitudes contributing to the development of such diseases. The MHP conducted eleven community meetings and outreach/ educational sessions with representatives of the six ethnic minority groups(Latino, French, Somali, Sudanese, Russians and Cambodian communities) in the Greater Portland area. This was to assess the communities’health risks through the implementation of a computerized software package that includes completing a risk assessment survey, computer scanning with on-the-spot individual results, counseling and referral for services. Some groups had multiple sessions to complete the process.

For the purpose of this report, MHP ethnic minority groups are intended to include:Latino, French, Somali, Sudanese, Russian and Cambodian communities. These cover people who are considered Primary Resettlement Immigrants, Secondary Resettlement Immigrants, Refugees, Asylees, Undocumented Immigrants, and, Non-Immigrants (individuals here on visas).

The survey race/ethnicity categories are identified as follow:

  • African American: includes Somali, Sudanese, and African French
  • Asian: Cambodian and Vietnamese
  • White/Caucasian: Russian
  • Others: Africans who self-identified and not included as African-Americans

The project activities were conducted in two stages over a period of eleven months (August 1, 2005 through June 30, 2006):

  1. Health risk assessments (HRAs) and educational outreach with members of six main refugee and immigrant communities in southern Maine.
  2. Analysis of the findings from the HRAs and the identification of how to develop culturally competent recommendations on programs to address the identified risk areas.

The main purpose or goal of this assessment is to identify health and cancer risk areas as well asstrategic solutions that will enable refugee and immigrant community members to be aware, understand, and access appropriatehealth care services that improve preventative individual and community public health.

This was conducted with an anticipated accomplishment of the following five objectives:

  1. To assess the overall wellness of the representatives from the largest six ethnic groups. The average overall wellness score is an indicator of wellness that takes into account all behaviors surveyed in the assessments.
  2. To assess the awareness and understanding of community members on health and cancer risk factors and determinants.
  3. To explore cultural perceptions and expectations of what constitutes optimum health in the community.
  4. To determine from the community members, strategic solutions that will enhance access to health care services for the community.
  5. To provide cancer health educational outreach and information at community gatherings.

METHODOLOGY AND APPROACH

This is an exploratory, outreach/research project being implemented over an eleven-month period of between August 1 and June 30, 2006. For this health outreach, we used a Health Risk Appraisal (HRA) tool to assess 202 people, spread across the six ethnic groups with at least thirty five from each.

The sample size was non-randomly selected and the individuals were selected based on certain criteria, some of which include being a member of the ethnic community, an immigrant or refugee, and resident of Portland, all ages and sexes, etc. These are some of the measures taken to ensure fair views, reliability and validity of findings. The purpose of the project and its benefits were explained to participants, and each had the opportunity to decline. A verbally informed consent was secured from all participants. This HRA tool includes a general health survey that assesses individual health and lifestyle habits, a scanner, a laptop with installed software, and a printer. It provides a report with information about health risks, healthy and unhealthy habits, and risk reduction strategies. This health risk assessment isnot intended to diagnose any diseases, illnesses or health conditions.

The cancer health risk variables assessed included, gender, age, ethnicity, tobacco smoking status, nutrition, vehicle safety, physical activity, alcohol, stress and depression, current health status, family health history, medical care status, women and men’s health statuses, readiness to change, and biometric measures (height, weight, blood pressure). This computerized tool allowed people to receive a confidential detailed assessment of their risk for a variety of diseases, including cancer and other major health problems. We had interpreters at the sessions who explained the process and assisted with filling out the survey. Once the HRA’s had been completed, culturally-appropriate educational sessions were conducted. All participants were encouraged to discuss the findings with their health care providers. An added benefit of the forum was the ability to refer people to the appropriate resources in the community for services suited to their needs.

Secondary data was collected and reviewed to better understand the political, social, economic, and environmental issues affecting minority health in general and cancer in particular, in Maine and nationwide. Sources of secondary data include the Maine Cancer Consortium Comprehensive Cancer Control Plan, Center for Disease Control and Prevention, National Cancer Institute, the U.S. Department of Health and Human Services, American Journal of Public Health, Federal and State research reports and, Journal of Health Promotion Practice and Health Education.

Analysis:

The responses of the HRA participants were compiled and findings analyzed using the TRALE, Inc. software and are presented in the “Executive Summary” provided by TRALE, Inc. (pdf file).See detailed individual group reports (pdf file).

RECOMMENDATIONS

Our findings are supported by other studies on health risk assessments of ethnic minority groups that health riskshave multivalent, multilayered and multi-social implications, requiring multiple pronged approaches. Four major risk areas came up strongly across the six ethnic groups’health risk assessments to be addressed: Exercise, Nutrition, Stress, and Weight.

The recommendations will attempt to not only look at the four major risk areas and stage of change of participants but will also review their areas of interest for intervention services. As noted in the executive summary, the participants are at different stages of readiness to change, perceived barriers, and /or self efficacy for changing a given behavior. Thus, approaches and intervention programs recommended here tend to enhance/assist the individuals to actually make lifestyle changes in the communities,and make recommendations to service providers to tailor the services in a more culturally appropriate way to facilitate this achievement. Also, attempts are made to reflect the following goals and objectives of the Maine Cancer Consortium Comprehensive Cancer Control Plan (Cancer Disparities, Prevention, Data Collection and Early Detection sections):

  1. Improving awareness and understanding of the ethnic minority groups on U.S.social service system in general and health care services in particular with the intention of changing negativeperceptions.
  2. Strengthening health care providers’ capacities to better understand the health care perceptions among ethnic minorities in Greater Portland area and to create user-friendly infrastructure to meet health needs of the communities.
  3. Acknowledging the value of holistic approaches in health healing within theethnic minority communities.

1. Improving awareness and understanding of the ethnic minority groups on U.S. social service system in general and healthcare services in particular with the intention of changing negative perceptions.

Cultural perceptions, language and expectations from the system play strong roles in accessing health care services in the presence of social and material needs, taking priority over the emotional needs of refugees or new immigrants.There is an important need for a systemic awareness of these peculiarities in order to provide informational an overview of both the social and mental health resources and support systems. It has been proven that refugees/immigrants often express their satisfaction with community peer groups and strong support for their establishment in new places (Bankole, 2003 and Behnia, 2003-4). Therefore, a two-prong holistic approach is recommendedby firstusing a team of professionals in our healthcare settings to address not only the emotional needs but also the social and economic needs of refugees through providing information and connecting them with available support system and resources. The second complementary practical way is to have direct community engagement through conducting community meetings to provide educational outreach sessions and workshops,aiming to empower the ethnic groups in controlling the factors that affect their lives (Bankole, 2004 and Khamphakdy-Brown, 2006).

Supportive literature from most successful outreach intervention programs provide working level of knowledge on infrastructure and social support system essential to ethnic minority groups’ survival and optimum health status, provided by bi-lingual or through interpreter multi-specialists’ team at the community, involving community leaders and building of trust with all the communities (Khamphakdy-Brown, 2006).

Some examples of issues, assessed during focus group meetings,with the ethnic groups prior to the assessments that needed to be addressed include:

  • Misunderstanding and misperception of service provision by the healthcare system.
  • Lack of education and utilization of services provided by the major health and social service providers among the communities.
  • Lack of information on potential job opportunities and developed infrastructure within safety net.

Information is the key for successful refugee/immigrant’s acculturation to new environments. Thus, providing access to resource lists of social and cultural support services in different languages through the most appropriate target community means would enhance their awareness, understanding and service utilization. Resource lists should among others, include information about key intervention programs on Exercise, Nutrition, Stress, and Weight,Cancer Risk Reduction Benefits, and modifiable risk factors of cancers, etc. (Stein CJ, & Colditz GA, 2004).

Changing perceptions among ethnic minority groups on health care service and the provider(s) of such health services could be achieved while gradually exposing the refugees/immigrants to the information on healthcare infrastructures and services in the US. Pertinent to achieving this change in perception is the provision of culturally-appropriate health and socialsupport information which is based particularly on community-identified supportneeds from the ethnic groups’ community. This had been documented to play a significant role in predicting health outcomes by Rober and Sadovoy. (Rober, 2006 and Sadovoy, 2004).