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Workshop
C-5: Designing and delivering culturally appropriate health services:
strategies for maximizing community participation
Peer-to-peer
practice advancement session
The goal of peer-to-peer practice advancement sessions is to allow professional
peers the opportunity to discuss, before an audience, issues of common
concern as a way of advancing the state of practice in their respective
fields. These two-hour sessions will have 5-7 featured experts who will
be led in a discussion of key issues related to the theme of the session.
Speakers will not make formal presentations, but instead provide critical
details of their programs to each other and to the audience in 2-page
handouts. During the session, each expert will concisely address specific
questions or topics developed and distributed in advance before engaging
in a moderated discussion with each other. The last half hour will be
reserved for audience Q&A
This session will focus on how health care and other organizations can
maximize opportunities to work with patients, communities, and CBOs to
design, deliver and evaluate culturally and linguistically appropriate
health programs. The discussion will evolve from the following stage-setting
questions:
- What kinds of activities are best suited to collaborations with communities,
and what kind of input is the most feasible to get from the communities
and community organizations involved in health-related programs
- What key strategies can be used to involve communities in these programs?
- Which approaches have been the most successful and why?
- Which approaches have not worked so well?
- In building community partnerships, what can go wrong? How do misunderstandings
occur, and can you get back on track?
- How can organizational staff become more receptive to the involvement
of communities (individuals as well as organizations)?
The participants in this session are:
Alison Alfonzo Pence Community Services Director,
The Cross Cultural Health Care Program (Seattle, Washington)
Martha Geraty Director, Community Outreach
Programs, UC Davis Center for Healthy Aging, Event Chair, Healthy Aging
Summit 2002-2003 (Sacramento, California)
Nathaly Herrel, MSc Project Coordinator,
Minnesota International Health Volunteers (Minneapolis, Minnesota)
Robert Phillips, MPA Principal, Carter Phillips
LLC; Board Chair, Health Access California; Board member California Donor
Transplant Network; former Board Treasurer, Alameda County Medical Center;
Participant in Worlds Apart Film (San Francisco, California)
Sharon Sherlock, RN, BSN, MSA Executive Director,
Reach Out of Montgomery County (Dayton, Ohio)
Winston Tseng, PhD Postdoctoral Fellow, Behavioral
Factors Training Grant, University of California, Berkeley, School of
Public Health (Berkeley, California)
Participant abstracts and bios can be found on the following pages
Alison Alfonzo Pence Community Services Director,
The Cross Cultural Health Care Program, Seattle, Washington
The Cross Cultural Health Care Program (CCHCP) is a non-profit organization
dedicated to recognizing the diversity of culture and the different ways
to health. Our vision is to serve as a bridge between communities and
health care institutions to ensure full access to quality health care
that is culturally and linguistically appropriate.
CCHCP’s Community Health & Nutrition Demonstration Project
is focusing on diabetes, cardiovascular disease, hypertension and obesity
in underserved and un-served communities in the Seattle/King County area.
Currently, we are working in marginalized communities in the greater Seattle/King
County area. In most cases, we are working in communities where no mainstream
organization has ever ventured. We are teaching community members about
the affects of diabetes and related diseases in a culturally and linguistically
appropriate manner. We are working with the Tongan, Samoan, Native Hawaiian,
Filipino, Native American and Alaska Native Communities.
Because we were using the City of Seattle’s senior nutrition sites
to perform our outreach, we began encouraging the City of Seattle Nutritionist
to monitor the foods that were being served to the senior citizens/elders
for lunch. Although we understood that the meals could not be meals for
a diabetic, by subsidizing the nutrition programs we were able to encourage
fresh fruits and vegetables, 100 percent fruit juices and periodically
serve traditional foods in each of the communities. At every luncheon
site, hundreds of nutritious lunches have been served to senior citizens/elders
each year who were unable to afford the $2 donation per lunch. Also, by
making sure the lunches were nutritious, we were able to help the elders
make wise food choices and portion control.
In any community, the word “exercise” will usually provoke
groans and grimaces. In our program we do not use the word “exercise”.
Instead, we promote traditional dance and movements. With the permission
of the senior citizens/elders we have taught hula dancing. Both men and
women join in the traditional dances. It helps to obtain buy in from the
community leaders. Members like to see their leaders dance and somehow
they are not as shy to dance. In each of the communities we teach hula
to able bodied as well as those in wheelchairs and walkers. Hula can be
done in a sitting position too!
The Health & Nutrition Team was fortunate to learn a Samoan dance
taught by elders. We incorporated their native dance into our hula class.
We felt fully accepted into the community when the asked us if they could
teach us their dance.
The project’s goals are to teach community members about the affects
of diabetes and other related diseases in a culturally and linguistically
appropriate manner. We also plan to show ways of avoiding these diseases
through a sensible diet and ways to exercise. This goal can be accomplished
by teaching our basic curriculum and introducing indigenous movement for
exercise.
Communities:
Native American & Alaska Natives
Filipino
Samoan & Tongan
Native Hawaiian
Staff includes:
Alison Alfonzo Pence, Project Director
Rose Reyes Long, Coordinator
Jason Aikona Crying Wolf Sloan, Specialist
Shannon Turner, RD, Registered Dietitian
Gloria Napualani Fujii, Kumu Hula
Jovi Sanchez Swanson, Evaluator
Sue Charles, Videographer
Robert Putsch III, MD, Medical Advisor
Sara Okubo, MPH Candidate, Intern
Budget: $458,000 for two years
When we first began working in the Samoan and Tongan communities we
did not know what barriers we would encounter other than the language
barriers in the communities we are not native to. Not only does this barrier
continue to exist, we did not know that there was only one certified Samoan
interpreter in the whole state of Washington. Unfortunately, the church
politics in this community prevented us from hiring this one interpreter.
Another barrier occurred in the Tongan community. There are no interpreters,
certified or otherwise. Finally, the president of TAPA (Tongan American
and Polynesian Association) whose mother is Samoan and Father is Tongan,
agreed to interpret for us. Being an untrained interpreter posed more
barriers for the Health & Nutrition (H&N) Team. However, this
was one more barrier we overcame in time. Fortunately, another program
within CCHCP trains interpreters. CCHCP has agreed to give a scholarship
to a Samoan woman who is interested in becoming a certified interpreter.
We continue to seek someone to work as an interpreter from the Tongan
community.
In November 2002, an informal survey was taken at TAPA. 15 of the 17
surveyed said they were once diagnosed with diabetes, cardiovascular disease,
or hypertension within the last ten years and only two had medical insurance!
One man told us that he was diagnosed with diabetes about ten years
ago, and was given some pills. He took the pills and never returned to
the doctor. He said he has no money to get more pills. He was hoping that
we (H&N Team) would be able to give him his pills.
Another man said he did not have diabetes but had bad headaches along
with high blood pressure readings. He lost his medical card and wanted
the H&N Team to help him get his card back so he could go see a doctor.
He had all the signs of being diabetic and hypertensive. After many months
of encouraging him to go to one of the local community clinics, he finally
went. He obtained a new medical card with our help, went to a provider
at a clinic we referred him to, and was immediately diagnosed with Type
2 Diabetes and high blood pressure.
All who do not have medical insurance said they go to the emergency
room at the hospital when they are sick.
The two that do have medical insurance said they did not know the names
of the medication they were taking. We encouraged them to bring in their
medications so we could explain to them what they were taking and for
what purpose. With the help of Dr. Bob Putsch, our medical advisor, the
team has been able to seek his medical advice and wisdom. However the
bottom line has always been to encourage the community members to see
a medical provider.
Alison Alfonzo Pence has been a community and political activist
for over 30 years. Her political activism began when she started advocating
for women’s and children’s issues. Alison’s years of experience
includes working as a staff person in the Washington State House of Representatives
working on issues including health care for the underserved. Since coming
to CCHCP, Alison has worked with community sexual assault programs throughout
the state. When she was named the Community Services Director, Alison
was at the helm of the Kidshealth.2001 program, which oversaw the outreach
to several ethnic communities. Alison authored the Cross Cultural Community
Health and Nutrition Demonstration Project – a proposal to the state
to work in underserved communities on diabetes, cardiovascular disease,
obesity and nutrition. Alison continues to work with grass roots community
groups on issues that affect immigrant, refugee communities and communities
of color.
Alison Alfonzo Pence, BA
Community Services Director
Community Services
Cross Cultural Health Care Program
270 S. Hanford Street, #100 A
Seattle, WA 98134
(206) 860-0329 phone
(206) 860-0334 fax
alisonp@xculture.org
www.xculture.org
Nathaly Herrel, MSc Project Coordinator, Minnesota
International Health Volunteers, Minneapolis, Minnesota
Minnesota has become the ‘Somali capital of the United States’
and is home to over half of all the Somali refugees living in the US.
Population estimates range from 20,000 to 40,000. Although Minnesota prides
itself on being one of the healthiest states in the nation, there are
still very large health disparities that persist within immigrant and
refugee communities. Accessing health care is one of the numerous challenges
Somali refugees face in their new home. Language and cultural barriers,
lack of health insurance, and unfamiliarity with the US preventive health
care system all contribute to health inequities in this population. Minnesota’s
health care providers also face challenges when trying to provide culturally
appropriate quality health care for their Somali patients.
To bridge the health gap between the Somali community and other Minnesotans,
Minnesota International Health Volunteers (MIHV) successfully launched
the Somali Health Care Initiative (SHCI) in March 2002 in partnership
with two Somali-led community organizations: the Confederation of Somali
Community in Minnesota, and the Leadership, Empowerment, and Development
Group. MIHV has applied many of the lessons learned from 25 years of community
health programs in East Africa to this project. The SHCI is funded through
the Minnesota Department of Health and addresses six health topics: breast
and cervical cancer, diabetes, cardiovascular disease, infant mortality,
HIV/AIDS, and immunizations.
This collaborative project has successfully implemented research, education,
and outreach to the Somali community as well as to health providers. Some
of the project’s highlights include: (i) building a solid partnership
with two Somali-led community organizations, (ii) implementing health
forums in the Somali community, (iii) mobilizing the community through
positive relationships with Somali media outlets (especially Somali cable
TV), (iv) conducting annual cultural competency sessions for health care
providers, (v) implementing participatory research with the Somali community
(especially a large community-wide health survey), (vi) implementing activities
through Somali Community Health Workers.
In terms of challenges, we found that it was difficult to have project
structures that straddled different agencies (e.g. staff at one agency
supervising staff based at another agency). Also, because the project
supported staff at three different agencies, it was at times difficult
to coordinate schedules across organizations. We therefore instituted
weekly partner meetings, developed a “Collaboration Charter”,
and wrote detailed Memorandums of Understanding. The challenge of working
with a relatively low literate community was overcome by utilizing Community
Health Workers, oral and visual media, and word-of-mouth through community
organizations and leaders.
Our presentation will include a discussion of the tools needed to implement
successful community health programs to address disparities within immigrant
and refugee populations. Specific resources that will be shared will include
bibliographies of publications on Somali immigrant/refugee health, steps
involved in conducting a health survey with full community participation,
conducting an asset-mapping exercise, and creating and maintaining healthy
community partnerships. We will also discuss the potential for replicating
this project with other immigrant and refugee communities elsewhere.
Nathaly Herrel holds a BSc from the University of Bristol, England,
in Biology. She completed her Masters of Science at the London School
of Hygiene and Tropical Medicine with a focus on Infectious Disease Control
and Public Health in Developing Countries. She worked for two years in
Pakistan as the principal investigator of a research initiative on malaria
and irrigation and has several publications in peer-reviewed journals.
From March 2002-June 2004, she coordinated the Somali Health Care Initiative
at MIHV in Minnesota. This position has involved training CHW's, coordinating
outreach to the Somali community, organizing cultural competency seminars
for health providers, developing culturally-sensitive health education
materials for Somalis, and conducting community-based participatory research
with the Somali refugee population of Minnesota.
Nathaly Herrel, MSc
Project Coordinator (Former), Somali Health Care Initiative
Minnesota International Health Volunteers (MIHV)
122 West Franklin Avenue, Suite # 522
Minneapolis, MN 55404-2480
Phone: 612-871-3759
Fax: 612-230-3257
nherrel@mihv.org
www.mihv.org/somalihealthintiative.htm
Robert Phillips, MPA Bay Area Patient; Community Advocate; Participant
in Worlds Apart Film, San Francisco, California
How Robert Phillips Thinks about Community Involvement
With the United States becoming increasingly diverse, the value of community--both
in what they offer, and what they believe--will play a large role in shaping
health-related values, beliefs, and behavior. I see this as a great opportunity
for medical providers to change the definition of what it means to be
a provider in the U.S. by becoming a “community provider.” What
do I mean by a “community provider?”
- A provider that looks not only at issues of ensuring that people
are not denied access to the essential health care services that are
offered, but also that extraordinary levels of care are delivered to
everyone from the low-income and uninsured individual to those who have
the ability to pay.
- A provider that has evolved from making assumptions about patients
on the basis of their background to using the skills of exploration,
empathy, and responsiveness to a patient’s, and by extension that
community’s, needs, values, and preferences.
Many will see this as a challenge facing health providers and institutions,
because they will have to decide whether or not they will be able to move
beyond the perception that just being a health provider is altruistic
enough to maximize their benefit to community. In the present political,
economic and health care environment, some policymakers have reasoned
that the goal of creating “community providers” is not the most
critical to their constituents. Whether it is,
- funding to help hospitals meet seismic safety standards,
- increasing provider rates,
- consolidating public health insurance programs,
- or to establishing a direct subsidy to community health providers,
public resources haven’t been allocated in a way that advances
a broad mission to create “community providers,” precisely
because of this view.
In spite of this pessimistic view, the opportunity for a new approach
shines through, because whether you call the approach cultural competence,
cultural humility, patient-centered care, or even common sense, engagement
of community in a reasoned way has emerged as an important goal for providers
for very practical reasons. As the United States becomes more assorted,
providers will increasingly engage communities with a broad range of perspectives
regarding their health. And what they present will be very different from
what has been taught formally through the academe, they will have different
expectations or thresholds for seeking care. Moreover, their beliefs will
influence whether or not they follow health providers recommendations.
Given that effective provider–patient communication is linked to
patient satisfaction, adherence to recommendations, and health outcomes.
When socio-cultural differences between patient and provider are not acknowledged
and conveyed, patient dissatisfaction, non-adherence, and poorer health
outcomes will be the rule rather than the exception. Which begs the question,
will providers chose to become bad doctors or hospitals because they see
the aforementioned approach as marginal?
I think not. This explains my optimism. While I am not saying we are
at a point where we can solve all of the ills of the health field. And
I am not asserting that we are on the verge of the panacea that improves
all health outcomes and eliminates disparities. I am saying that circumstance
dictates that engagement of community will force providers to gain a necessary
set of skills for providers if they wish to deliver high-quality care
to all patients.
About Robert Phillips
“Three mornings a week from 6 am to 10 am, Robert Phillips
sits in a reclining chair, tethered to a machine that laboriously performs
the work of his own kidneys. . .” wrote the June 18, 2004 front page
of the Wall Street Journal. This statement describes very succinctly what
the majority of Robert’s time is spent on over the last 5 years,
and why he was included in the “Worlds Apart” vignette series.
As result of his health status, Robert has become an advocate for reforms
in policies to close the gaps in access to organ transplantation and wait
times between African Americans, Latinos and white transplant patients,
as well as disparate treatment in care for end-stage renal disease patients.
Prior to going on dialysis, Robert was a rising star in the field of
public policy. These days as co-founder of Carter Phillips, Robert Phillips
spends his non-dialysis time providing community groups, unions and public
hospitals with strategic development and direction on political/legislative
matters and public policy issues.
Previously, Robert was responsible for crafting and implementing strategies
for progressive investment and political solutions to health-care restructuring
for the Service Employees International Union (SEIU). He also coordinated
the effort that developed the California Pension Trustees Council. He
has provided policy analysis on health and other issues for the AFL-CIO.
Robert currently serves a President of the board of Health Access California
Foundation, and as a founder and president of the Northern California
Coalition for Civic Participation. He has recently been invited to join
the Board of the California Donor Transplant Network. He was formerly
a member of the Alameda County Medical Center Board of Trustees. He holds
a master's degree in Public Affairs from the Maxwell School of Citizenship
and Public Affairs at Syracuse University and a Bachelor’s from Morehouse
College in Atlanta.
Robert Phillips, MPA
Carter Phillips LLC.
3505 20th Street
San Francisco, CA 94110
P: 510.932.5229
F: 510.223.5417
carterphillips@comcast.net
Martha Geraty Director, Community Outreach Programs,
UC Davis Center for Healthy Aging, Event Chair, Healthy Aging Summit 2002-2003,
Sacramento, California
Who Are We? Launched in 1999 and consisting of more than 70 volunteer
member organizations, the Healthy Aging Coalition of Northern California,
the Healthy Aging Coalition of Northern California is a unique consortium
whose mission is to improve the health and lives of older Americans throughout
Northern California. The coalition’s efforts help demystify the process
of aging and provide a forum for people of all ages to learn how to minimize
the effects of aging through exercise, diet, nutrition and proper medical
management. This is accomplished through specific health education workshops,
designed and tailored to address specific cultural and health issues for
the diverse ethnic-geriatric communities that live in the greater Sacramento
region of Northern California. Through a series of specially designed
workshops, often in language, individualized free health checks and screenings,
and community resource faires, the Healthy Aging Coalition of Northern
California has now served thousands of older adults from the African American,
Latino, Chicano, Mien, Lao, Hmong, and Korean communities. Health Checks
and Healthy Aging Workshops include but are not limited to following since
each specific program is designed to appropriately address specific health
and medical needs for each ethnic-geriatric community group: Alzheimer’s
Disease _ Blood Pressure _ Cholesterol _ Depression _ Diabetes _ Falls
& Balance _ Memory Loss _ Osteoporosis _ Stroke Risk _ Vision &
Hearing _ Weight & Body Fat _ Medication Management _ Fitness Evaluation
_ Hypertension _ Fitness Evolution _ Advocacy/Legal Rights _ Access to
Health Care _ Health & Nutrition _ Elder Abuse _ Managing Depression
_ Sexuality & Aging _ Spirituality & Aging _ The Sandwich Generation:
Caregiving Today & Tomorrow _ Talking to Your Doctor _ Memory Loss
& Dementia _ Validation Therapy _ Pain Management _ Your Legal Rights
_ Men & Women’s Health.
Who Do We Serve? California is expected to be one of the fastest
growing States in the nation in total population for older adults. The
Sacramento region and Sacramento, California (now considered the most
diverse city in the nation) is also growing equally fast and increase
in elderly population, especially among specific ethnic-geriatric communities
is expected to double by the year 2020. And, the influence of the 85 and
over age group on California, and in this region, will emerge most strongly
between 2030 and 2040 as the first of the baby boomers reach 85 years
of age. As a whole, the elderly age group will have an overall increase
of 112 percent during the period from 1990 to 2020.1 More
than half the counties will have over a 100 percent increase in this age
group. Eleven of these counties will have growth rates of over 150 percent.
These counties are located throughout the central and southern areas of
the State. The influence of the 60 and over age group on California is
expected to emerge most strongly between 2000 to 2020.In California, the
elderly population is expected to grow more than twice as fast as the
total population and this growth will vary by region. The oldest old age
group will increase at even a faster rate than the elderly, having an
overall increase of 143 percent during the period from 1990 to 2020. Of
the State's 58 counties, 38 will have increases of more than 150 percent,
26 will have increases of more than 200 percent, and 11 will have over
a 300 percent increase in the number of persons aged 85 and older. Of
these 11 counties, all but one is located in the central and northern
areas of the State.
How Are We Funded? The Coalition is funded through direct financial
support from member organizations and other groups whose products, services
and community groups focus on serving the variety of needs of older individuals.
This direct funding usually exceeds $150,000 annually in support of specific
Healthy Aging Summits. And, much of the coalition’s funding also
comes from in-kind contributions that include personnel, equipment, materials,
supplies, resources, computer and related media (television, print, radio)
promotion and advertising. To date, the Coalition’s membership exceeds
70 organizations (both profit and non-profit), and includes over a hundred
volunteers from these respective organizations and the community-at-large.
The Coalition is organized into specific working groups, each holding
a specific role and function to support event and program planning, promotion
and advertising, fund-raising and sponsorship, event “day-of”
logistics, and health screening evaluations. Collectively, working groups
report to the Coalition’s oversight committee that functions as a
board of directors to ensure that the overall mission of the Coalition
is guaranteed.
What Are Our Successes, Challenges & Lessons Learned:
Successes: organized leadership and infrastructure with a sustained
program since 1999; strong community-based support from policy leaders,
health care providers, and ethnic-geriatric organizations; regional and
national recognition including the American Society on Aging 2003 Award
for Innovation and Quality in Health Care and Aging; voluntary coalition
that includes both public and private organizations-serving a common mission
and purpose;
Challenges: initial buy-in and time commitment from organizations;
financial and resource related infrastructure;
Lessons Learned: “this is a journey, not a sprint,” creating
a common theme, mission and one-vote, one-organization culture and philosophy;
commitment from community, healthcare, industry (private sector) and policy
leaders.
Martha Geraty is a graduate of UC Berkeley and serves as the Director
of Community Outreach for the UC Davis Center for Healthy Aging. Martha
has formal training in Human Development/Geriatrics, and possesses over
15 years of program expertise developing grass roots, multi-cultural events.
She has successfully delivered over 600 education and training programs
and organized 50 large conferences, health fairs, summits and walks aimed
at improving the lives of older adults. In 1999, she created the successful
“Coming of Age Lecture Series ” which serves over 3000 individuals
with 26 lectures each year. Martha is an appointed Commissioner for the
Sacramento Adult and Aging Commission. During her tenure, she has received
honorable awards and resolutions for her commitment to diversity and personal
achievements. Drawing from her expertise in community relations and aging,
she has been dedicated to outreach and education while nurturing ongoing
relationships with Sacramento’s older adult, professional and educational
communities.
Martha Geraty, BA
Director Community Outreach Programs
Chair, Healthy Aging Summits for Diverse Communities 2002-2004
UC Davis Center for Healthy Aging
4625 2nd Avenue, Suite 2004
Sacramento, CA 95817
916-734-4768
fax: 916-734-4773
megeraty@ucdavis.edu
http://healthyagingsummit.ucdavis.edu
1 Source: State of California, http://www.aging.state.ca.us/html/stats/demographics.html
Sharon Sherlock, RN, BSN, MSA Executive Director,
Reach Out of Montgomery County, Dayton, Ohio
Reach Out of Montgomery County addresses how communities with a new
emerging Hispanic or Latino population can develop access to primary,
urgent and specialty health care services, especially for uninsured populations.
During the last four years, the Hispanic population has become the fastest
growing minority population in Dayton Ohio, a mid size, urban area. Over
the last four years, this agency has:
- successfully integrated the Latino population into an existing system
of free clinics staffed by volunteer health professionals,
- created and placed kiosks containing information on 150 local health
resources and 180 health information topics in Spanish and English in
locations throughout the county,
- provided cultural competency training to health professionals including
first responders, and
- created a health education program for Hispanic women and their families—aimed
increasing healthy eating, activity levels, access to health screenings,
and primary care.
In serving a new population, we have learned the importance of formulating
new partnerships and overcoming barriers. To increase access to our clinics,
Reach Out of Montgomery County entered into an exciting partnership with
the local council of the League of United Latin American Citizens who
recruited persons to act as volunteer interpreters. In delivering care
through our clinics, we also discovered the importance of having a bilingual
case manager who could help this population access other specialty care
services and primary care.
We also learned that health professionals have equally as many concerns
regarding cultural differences. We are constantly learning and sharing
information about challenges facing the Latino population. Many challenges
remain on filling the demand for interpreter services. To address these
issues, we learned to provide training to all health professionals, including:
medical students, residents, physicians, nurses, and first responders.
In a rather segregated community where low income African Americans
and Appalachian populations have always experienced disparities in accessing
care, Reach Out of Montgomery County has also learned that they must educate
business leaders, government officials, public health systems and other
community members regarding the needs of this special population. The
development of a kiosk project called Rotary HEALTHLINKS assisted with
this effort by placing 8 terminals in various locations throughout the
community. This project grew out of an active relationship between the
Rotary Club of Dayton, Reach Out of Montgomery County and an array of
other agencies including local colleges.
While we met primary health care needs, we were still struggling with
the need to provide health education, unique to the issues facing Latinos
in our community. This led us to another joint venture with a neighborhood
development group called East End Community Services. Together we began
developing health education programs for the Latino women and sought funding
through the Ohio Commission on Minority Health. This program is called
Milagro de Mujer or the “miracle of women.”
Lesson learned is that a health disparity population needs an “extra”
voice to help them access healthcare services. The question remains, if
one can mobilize a community fast enough to respond to their needs before
the door of wellness closes…..…too little, too late.
Sharon Sherlock, RN, BSN, MSA, has worked 26 years as a clinician
and in various management positions throughout healthcare. Sharon’s
employment background extends from hospitals, to home care, to managed
care organizations, and currently into community health. As executive
director for Reach Out, Sharon has successfully grown a grassroots organization
into one of Dayton’s largest healthcare partnership programs with
local support from community groups, Universities, service clubs, health
department and charter schools. Sharon has assembled volunteer physicians,
nurses, pharmacist, translators as well as other health professionals
to deliver free health care services to the Underserved in Dayton, Ohio.
Reach Out was a 1994 recipient of Robert Wood Johnson’s physician
initiative project and has grown to be a sustainable volunteer program
serving a culturally diverse population. Ms. Sherlock has been asked to
speak in various venues regarding the needs of the Latino population and
health care for the uninsured and underserved populations. She is currently
completing her doctorate in health administration with Central Michigan
University.
Sharon Sherlock, RN, BSN, MSA
Executive Director
Reach Out of Montgomery County
1344 Woodman Drive,
Dayton, Ohio 45432
Phone 937-259-1898
Fax: 937-259-1897
reachout@choiceonemail.com
Winston Tseng, PhD Postdoctoral Fellow, Behavioral
Factors Training Grant, University of California, Berkeley, School of
Public Health, Berkeley, California
My remarks are based on my PhD dissertation research about the role
of ethnic community organizations in the development of healthy Chinese
and Vietnamese immigrant communities.
Individual health is not isolated from the physical environment and
socio-cultural contexts of health. According to the WHO Ottawa Charter
for Health Promotion (1986), “the fundamental conditions and resources
for health are peace, shelter, education, food, income, a stable ecosystem,
sustainable resources, social justice and equity. Improvement in health
requires a secure foundation in these basic prerequisites.” Addressing
these fundamental conditions can facilitate healthy community and national
development and increase the overall quality of life for all. Under these
contexts, I propose that health care and social welfare institutions represent
fundamental building blocks that facilitate the development of healthy
communities. The health of immigrants is no exception and also depends
on the conditions and resources of immigrant community institutions.
This study examines immigrant services structure at two Chinese and
two Vietnamese community based organizations (CBOs) in San Francisco Bay
Area. In particular, utilizing resource dependence theory, the study examines
ethnic community resource interdependencies and networks of these organizations,
processes of acquisition and exchange of ethnic community resources, and
ethnic community challenges pertaining to organizational survival and
advancing organizational goals. The multiple qualitative community participatory
research methodologies included collective case study and ethnography.
Procedures included development of field note protocol and interview guide,
concentrated participant observation at each of the four organizations
(i.e., spending three to four weeks at each organization full-time as
active volunteer participant and observer of daily organizational operations
and programs), interviews of sixty-one key informants including ten organizational
executives and forty-one administrative and program staff, five clients,
and five other informants from outside these organizations, collection
of organizational documentary materials (e.g., organizational brochures,
program pamphlets, annual financial reports, board meeting minutes and
reports), and analysis of the fieldnotes, interviews, and documentary
materials.
The findings suggest that Chinese and Vietnamese immigrant services
organizations and their respective ethnic communities depend on each other
to provide community resources and support. These organizations work together
with other ethnic CBOs, ethnic community leaders, self-sufficient ethnics,
and newcomers in their communities to acquire key financial, legitimacy,
human/labor, informational, and clientele resources necessary to survive
and maintain their organizational missions. At the same time, these organizations
serve as centers of community service and empowerment and provide legitimacy,
human/labor, leadership, cultural proficient, self-sufficiency, and community
development resources to immigrant populations. In sum, the structure
and resources of immigrant service organizations reflect social adjustment
and community empowerment needs facing immigrant populations. Ethnic community
leaders and self-sufficient ethnics play critical roles as immigrant service
providers through ethnic CBOs. And strengthening community based immigrant
services programs can dramatically ease the challenges of immigrant health,
language, cultural, and structural adjustments.
However, health and social resources available through immigrant and
minority communities are limited. The engagement of government public
health and social welfare institutions is also vital to the development
of healthy immigrant and minority communities. In the post-civil rights
period, there has been growing government support for Asian CBOs in part
due to the dramatic rise in the Asian population over the past four decades
from less than 900,000 in 1960 to more than 13 million in 2004. Nevertheless,
as a consequence, Asian CBOs and the communities they serve have become
increasingly dependent on government support and have been adversely affected
by welfare and immigration reform cuts over the past decade. There is
currently a fiscal crisis in health and human services in which the safety
net for immigrant and minority communities has been most vulnerable. And
the continuing devolution together with the current economic recession
and war on terrorism has further shifted government budgets traditionally
allocated for health and human services and redirected such funding streams
for corporate recovery, national defense, and homeland security. The viability
of Asian CBOs depends on its capacity to readily adapt with the changing
welfare and immigration policies, economic cycles, and community developments.
In conclusion, ethnic CBOs serve a critical role in providing cultural
proficient programs and resources for successfully incorporating immigrant
and minority populations into American society. Immigrant and minority
populations represent valuable sources of human capital for building vibrant,
healthy communities and are vital contributors to American capitalism,
democracy, and civil society. Finally, ethnic community institutions and
immigrant communities represent the historical fabric of America and they,
like any other that have come before them, deserve a rightful American
place.
Program successes/Innovative approaches
Community based participatory methods was key to the overall success
of my study. The most successful strategies included identifying and getting
support from legitimate and reputable leaders and organizations from the
community, actively participating in community activities and events over
time, sharing my expertise and time in non-research contexts that benefited
the community, getting community feedback about study findings, sharing
study results, presenting study findings in public forums that served
community interests, and developing continuity by showing that I plan
to stay involved with the community for the long-term. These approaches
helped me build legitimacy, trust, relationships, and commitment with
the communities of interest about my research study, open doors for community
informants to be willing to share insider information about their organizations
and communities, and facilitated successful data collection and completion
of the study.
In addition, the study primarily focused on community based service
provider perspectives to examine immigrant community contexts. I argue
that community provider perspectives have distinct advantages. Most of
these providers are from the immigrant communities, have been American
trained professionally, are experts in beliefs and practices of both their
own ethnic community and American mainstream, and speak native and English
languages fluently. In other words, they bring both insider community
perspectives and outsider professional perspectives to understanding both
the micro and macro community contexts and provide rich depth and knowledge
about the immigrant communities of interest.
Challenges
As an outsider, it is often difficult to build trust with the communities
of interest. It is very helpful to recruit a few community insiders to
help you build trust with the communities. In addition, it is important
to ease to community concerns and explain clearly the research process
and make sure the study does not interfere with routine community activities.
There was a Vietnamese organization that I tried to recruit for my study.
They were initially hesitant to participate. And I later found out that
a few years ago, they had a bad experience with a young volunteer. This
volunteer as part of an anti-communist Vietnamese political faction initiated
a major political demonstration on the organization that almost led to
the organization’s loss of community legitimacy and closure. However,
the organization did finally agree to participate because I previously
worked with other Vietnamese organizations and leaders that they trusted
and supported me. Nevertheless, even during the time I was at the organization,
a number of staff continued to keep distant and observed me for a while.
It was only after I showed them through my voluntarism and sincere interest
in helping and not hurting their organization, that they became more open
to talking with me and helping me with my research project. In addition,
for a Chinese organization I tried to recruit, the executive director
was initially hesitant to agree to participate in the study. She said
that the organizational staff were all so very busy with daily program
activities and would not have time to help with the study. However, I
assured her that my study would not affect their daily program operations
and also that during the time of my study, I’d be pleased to serve
as a volunteer for the organization to help with some projects she’d
like to work on but haven’t had time to do. These suggestions helped
ease her concerns about my study and she consequently agreed to participate
in my study.
Lessons learned
One contribution of this study is to supplement traditional frameworks
of public health research that focus on individual behavioral and disease
outcomes to include a broader structural conception of health based on
the premise that healthy nations and communities foster healthy individuals.
The study argues that identifying and addressing the fundamental political,
economic, and social determinants of health and disease themselves can
serve to cultivate overall population health and complement traditional
public health approaches of individual behavioral and disease prevention.
In addition, the study proposes that community based participatory research
methods that provide the capacity for community insiders themselves to
identify and voice their own community health problems and take the lead
to resolve them themselves with professional help are most likely to succeed
in fostering healthy communities and improving individual behavioral and
disease outcomes across the board. Furthermore, the study suggests that
immigrant and minority populations are critical sources of human capital
that contribute to building a vibrant American capitalist, democracy.
Finally, the study proposes that community health and social welfare institutions
represent fundamental building blocks and indicators of healthy communities
and nations.
Winston Tseng, PhD: I am currently a postdoctoral fellow at UC
Berkeley School of Public Health. I received my PhD in medical sociology
from UCSF in 2003. My research interests focus on the impact of ethnic/racial
and socioeconomic inequities facing immigrant and minority communities
and the role of community institutions in mediating these inequities and
neighborhood quality of life. My research contribution seeks to build
upon existing built and social environment frameworks of health, focusing
on community institutions and development. I argue that building healthy
communities is fundamental to addressing a range of downstream individual
behavioral and disease outcomes across the board. In addition, my research
approach seeks to engage both community and academic research institutions
to become more involved with community action research and public policy
intervention. Overall, my major research interests include immigrant and
minority health, nonprofit organizations, and community development.
Winston Tseng, PhD
Postdoctoral Fellow
School of Public Health
University of California, Berkeley
140 Warren Hall #7360
Berkeley, CA 94720-7360
Tel: 510-643-4456; Fax: 510-643-9922
winston@berkeley.edu and wtseng@pacbell.net
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