Community-Based Organizations as Trusted Messengers in Health.

Trust is a key component in delivering quality and respectful care within health care systems. However, a growing lack of confidence in health care, particularly among specific subgroups of the population in the United States, could further widen health disparities. In this essay, we explore one approach to building trust and reaching diverse communities to promote health: engaging community-based organizations (CBOs) as trusted community messengers. We present case studies of partnerships in health promotion, community education, and outreach that showcase how CBOs' programs build and leverage trust in health care systems through their workforce, services, and engagement with the community.

Stakeholder Perspectives on the Impact of COVID-19 on the Implementation of a Community-Clinic Linkage Model in New York City.

Community-clinical linkage models (CCLM) have the potential to reduce health disparities, especially in underserved communities; however, the COVID-19 pandemic drastically impacted their implementation. This paper explores the impact of the pandemic on the implementation of CCLM intervention led by community health workers (CHWs) to address diabetes disparities among South Asian patients in New York City. Guided by the Consolidated Framework for Implementation Research (CFIR), 22 stakeholders were interviewed: 7 primary care providers, 7 CHWs, 5 community-based organization (CBO) representatives, and 3 research staff. Semi-structured interviews were conducted; interviews were audio-recorded and transcribed. CFIR constructs guided the identification of barriers and adaptations made across several dimensions of the study's implementation context. We also explored stakeholder-identified adaptations used to mitigate the challenges in the intervention delivery using the Model for Adaptation Design and Impact (MADI) framework. (1) Communication and engagement refers to how stakeholders communicated with participants during the intervention period, including difficulties experienced staying connected with intervention activities during the lockdown. The study team and CHWs developed simple, plain-language guides designed to enhance digital literacy. (2) Intervention/research process describes intervention characteristics and challenges stakeholders faced in implementing components of the intervention during the lockdown. CHWs modified the health curriculum materials delivered remotely to support engagement in the intervention and health promotion. (3) community and implementation context pertains to the social and economic consequences of the lockdown and their effect on intervention implementation. CHWs and CBOs enhanced efforts to provide emotional/mental health support and connected community members to resources to address social needs. Study findings articulate a repository of recommendations for the adaptation of community-delivered programs in under-served communities during a time of public health crises.

Promoting Physical Activity Among Immigrant Asian Americans: Results from Four Community Health Worker Studies.

Racial/ethnic minorities have demonstrated lower rates of physical activity (PA) than non-Hispanic Whites. This study examined outcomes in PA measures after participation in a community health worker (CHW) intervention. We performed a secondary data analysis from four randomized controlled trials utilizing CHWs (n = 842) in New York City (Bangladeshi-diabetes management, Filipino-hypertension management, and Korean and Asian Indian-diabetes prevention). Outcomes included total weekly PA, PA self-efficacy, PA barriers, and PA social interaction. Each measure was examined at baseline and study endpoint. Generalized estimating equation models were fitted to assess the repeated measures over time, while accounting for study group and socio-demographic factors. Moderate PA, recommended PA, and self-efficacy increased significantly among treatment group participants. PA social interaction increased significantly among Filipinos and Asian Indians. In adjusted regression analysis, time x group interaction was significant for all PA outcomes except for PA barriers. Culturally-adapted lifestyle interventions may potentially improve PA-related outcomes in Asian immigrant communities. Trial registration at ClinicalTrials.gov includes: NCT03530579 (RICE Project), NCT02041598 (DREAM Project), and NCT03100812 (AsPIRE).

COVID-19 and Asian Americans: Reinforcing the Role of Community-Based Organizations in Providing Culturally and Linguistically Centered Care.

Introduction: Community-based organizations (CBOs) have provided critical resources during the pandemic, particularly for marginalized communities, and are trusted liaisons who connect socially and linguistically isolated community members, such as the highly diverse Asian American population, to care during public health emergencies. Stereotypes such as the model minority myth have permeated public perception of Asian Americans' health status and health care access needs, fueling widespread belief that Asian Americans do not experience health disparities, and mask the high rates of coronavirus disease 2019 (COVID-19) infection, hospitalization, and mortality among Asian Americans. The unequal burden of COVID-19 on Asian American communities has largely remained absent from the public health and national discourse, with exceptions such as community voices that have directed news media coverage and leading roles of CBOs in offering culturally adapted, in-language programming on COVID-19 infection prevention and control. Methods: CBOs and their staff are well-equipped with the cultural acuity, language capacity, and familiarity with local norms to improve structural gaps affecting health outcomes and support health care delivery. Results: We discuss the roles and responsibilities of CBOs in strengthening the health care workforce and expanding community-clinic linkages and provide two case studies illustrating the efforts of two community organizations serving Asian American and immigrant communities, who have been disproportionally affected by the COVID-19 pandemic. Discussion: CBOs are essential to supporting health service coordination and care delivery for structurally vulnerable populations, and are vital to sustaining the coordinated, multilevel public health response to improving community health. Conclusion: Bolstering the current infrastructure to support CBOs is necessary to facilitating immediate responses to serve community needs.

Small Practices, Big (QI) Dreams: Customizing Quality Improvement (QI) Efforts for Under-Resourced Primary Care Practices to Improve Diabetes Disparities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s13063-019-3711-y.

The Mutually Reinforcing Cycle Of Poor Data Quality And Racialized Stereotypes That Shapes Asian American Health.

The Asian American health narrative reflects a long history of structural racism in the US and the complex interplay of racialized history, immigrant patterns, and policies regarding Asians in the US. Yet owing to systematic issues in data collection including missing or misclassified data for Asian Americans and practices that lead to indiscriminate grouping of unlike individuals (for example, Chinese, Vietnamese, and Bangladeshi) together in data systems and pervasive stereotypes of Asian Americans, the drivers and experiences of health disparities experienced by these diverse groups remain unclear. The perpetual exclusion and misrepresentation of Asian American experiences in health research is exacerbated by three racialized stereotypes-the model minority, healthy immigrant effect, and perpetual foreigner-that fuel scientific and societal perceptions that Asian Americans do not experience health disparities. This codifies racist biases against the Asian American population in a mutually reinforcing cycle. In this article we describe the poor-quality data infrastructure and biases on the part of researchers and public health professionals, and we highlight examples from the health disparities literature. We provide recommendations on how to implement systems-level change and educational reform to infuse racial equity in future policy and practice for Asian American communities.

Prevention Research Centers and COVID-19: Models of a Community-Engaged Response to a Public Health Emergency.

For more than 30 years, the network of Centers for Disease Control and Prevention (CDC)-funded Prevention Research Centers (PRCs) has worked with local communities and partners to implement and evaluate public health interventions and policies for the prevention of disease and promotion of health. The COVID-19 pandemic tested the PRC network's ability to rapidly respond to multiple, simultaneous public health crises. On April 28, 2020, to assess the network's engagement with activities undertaken in response to the early phase of the pandemic, PRC network leadership distributed an online survey to the directors of 34 currently or formerly funded PRCs, asking them to report their PRCs' engagement with predetermined activities across 9 topical areas and provide case studies exemplifying that engagement. We received responses from 24 PRCs, all of which reported engagement with at least 1 of the 9 topical areas (mean, 5). The topical areas with which the greatest number of PRCs reported engagement were support of frontline agencies (21 of 24, 88%) and support of activities related to health care (21 of 24, 88%). The mean number of activities with which PRCs reported engagement was 11. The PRCs provided more than 90 case studies exemplifying their work. The results of the survey indicated that the PRCs mobilized their personnel and resources to support the COVID-19 response in less than 6 weeks. We posit that the speed of this response was due, in part, to the broad and diverse expertise of PRC personnel and long-standing partnerships between PRCs and the communities in which they work.

Implementation of a multi-level community-clinical linkage intervention to improve glycemic control among south Asian patients with uncontrolled diabetes: study protocol of the DREAM initiative.

BACKGROUND: A number of studies have identified patient-, provider-, and community-level barriers to effective diabetes management among South Asian Americans, who have a high prevalence of type 2 diabetes. However, no multi-level, integrated community health worker (CHW) models leveraging health information technology (HIT) have been developed to mitigate disease among this population. This paper describes the protocol for a multi-level, community-clinical linkage intervention to improve glycemic control among South Asians with uncontrolled diabetes. METHODS: The study includes three components: 1) building the capacity of primary care practices (PCPs) to utilize electronic health record (EHR) registries to identify patients with uncontrolled diabetes; 2) delivery of a culturally- and linguistically-adapted CHW intervention to improve diabetes self-management; and 3) HIT-enabled linkage to culturally-relevant community resources. The CHW intervention component includes a randomized controlled trial consisting of group education sessions on diabetes management, physical activity, and diet/nutrition. South Asian individuals with type 2 diabetes are recruited from 20 PCPs throughout NYC and randomized at the individual level within each PCP site. A total of 886 individuals will be randomized into treatment or control groups; EHR data collection occurs at screening, 6-, 12-, and 18-month. We hypothesize that individuals receiving the multi-level diabetes management intervention will be 15% more likely than the control group to achieve ≥0.5% point reduction in hemoglobin A1c (HbA1c) at 6-months. Secondary outcomes include change in weight, body mass index, and LDL cholesterol; the increased use of community and social services; and increased health self-efficacy. Additionally, a cost-effectiveness analysis will focus on implementation and healthcare utilization costs to determine the incremental cost per person achieving an HbA1c change of ≥0.5%. DISCUSSION: Final outcomes will provide evidence regarding the effectiveness of a multi-level, integrated EHR-CHW intervention, implemented in small PCP settings to promote diabetes control among an underserved South Asian population. The study leverages multisectoral partnerships, including the local health department, a healthcare payer, and EHR vendors. Study findings will have important implications for the translation of integrated evidence-based strategies to other minority communities and in under-resourced primary care settings. TRIAL REGISTRATION: This study was registered with clinicaltrials.gov: NCT03333044 on November 6, 2017.

Exploring the Link Between the Hazards and Value of Work, and Overcoming Risk for Community-Based Health Interventions for Immigrant Latinx Low-Wage Workers.

Few studies integrate work and immigration as intersecting social determinants of health. We synthesize data from 12 focus groups (N = 97) originating from two separate community-engaged studies that originally centered on exploring barriers to health and hazards of work among immigrant Latinx women and men to explore the role of work in their overall health and well-being. The three major interrelated themes we drew from this research-hazards of work, value of work, and building agency to overcome risk-provide insights that can help to reframe and begin to operationalize how community-based health promotion practice might better incorporate workplace issues for Latinx low-wage workers. The value of work, and its subtheme, pride in performing well specifically, could be engaged by workers to actively change conditions for themselves and others. We discuss findings in light of previous occupational health research and implications for community-based intervention design and practice.

Determinants of Depression Risk among Three Asian American Subgroups in New York City.

Objective: Although the fastest growing minority group, Asian Americans receive little attention in mental health research. Moreover, aggregated data mask further diversity within Asian Americans. This study aimed to examine depression risk by detailed Asian American subgroup, and further assess determinants within and between three Asian ethnic subgroups. Methods: Needs assessment surveys were collected in 16 Asian American subgroups (six Southeast Asian, six South Asian, and four East Asian) in New York City from 2013-2016 using community-based sampling strategies. A final sample of N=1,532 completed the PHQ-2. Bivariate comparisons and multivariable logistic models explored differences in depression risk by subgroup. Results: Southeast Asians had the greatest depression risk (19%), followed by South Asians (11%) and East Asians (9%). Among Southeast Asians, depression risk was associated with lacking health insurance (OR=.2, 95% CI: 0-.6), not having a provider who speaks the same language (OR=3.2, 95% CI: 1.3-8.0), and lower neighborhood social cohesion (OR= .94, 95% CI: .71-.99). Among South Asians, depression risk was associated with greater English proficiency (OR=3.9, 95% CI: 1.6-9.2); and among East Asians, depression risk was associated with ≤ high school education (OR=4.2, 95% CI: 1.2-14.3). Additionally, among Southeast Asians and South Asians, the highest depression risk was associated with high levels of discrimination (Southeast Asian: OR=9.9, 95% CI: 1.8-56.2; South Asian: OR=7.3, 95% CI: 3.3-16.2). Conclusions: Depression risk and determinants differed by Asian American ethnic subgroup. Identifying factors associated with depression risk among these groups is key to targeting limited public health resources for these underserved communities.

A Culturally Adapted Diabetes Prevention Intervention in the New York City Sikh Asian Indian Community Leads to Improvements in Health Behaviors and Outcomes.

INTRODUCTION: Sikh Asian Indians are an underserved, minority group demonstrating high rates of diabetes. Community health workers (CHWs) are effective in addressing health disparities by reaching socially and linguistically isolated populations. There are no culturally-adapted programs for diabetes prevention among Sikh Asian Indians, thus, this study tests the efficacy of a culturally-tailored CHW intervention to improve diabetes prevention-related outcomes among Sikh Asian Indians at-risk for diabetes. METHODS: A quasi-experimental two-arm intervention among Sikh Asian Indian adults at-risk for diabetes and living in New York City (n=160) was conducted in 2013-2014. The treatment group received six monthly CHW group education sessions and ten follow-up phone calls; the control group received the first session. Main outcomes included weight, body mass index (BMI), blood pressure (BP), physical activity (PA), diet, and health self-efficacy. RESULTS: Positive and significant changes in weight, BMI, and diabetes prevention-related indicators were seen among both study groups. However, only treatment group participants showed significant changes over time for weight, BMI, PA self-efficacy, and health-related self-efficacy. Significant between-group differences were seen in adjusted analyses for weight, BMI, systolic BP, total weekly PA, PA self-efficacy, PA social interaction, portion control, barriers to healthy eating, and health self-efficacy. At 6-months, treatment participants were more likely to lose ≥5% and ≥7% of their weight compared to control participants (p=0.071, and p=0.015, respectively). CONCLUSIONS: Findings demonstrate that a culturally-adapted CHW diabetes prevention program in the Sikh community is efficacious, adding to the growing literature on CHWs' capacity to address health inequity among underserved populations.

A Faith-Based Intervention to Reduce Blood Pressure in Underserved Metropolitan New York Immigrant Communities.

Minority populations, including Asian Americans, face disparities in hypertension compared with non-Hispanic whites. This underscores the need for culturally adapted programs in settings that reach Asian American communities, such as faith-based organizations. We worked collaboratively with community partners to culturally adapt and implement an evidence-based community blood pressure monitoring program for Asian Americans (Asian Indians, Koreans, Filipinos, and Bangladeshis) in metropolitan New York during 2015 and 2016. The program included regularly scheduled volunteer-led screening and counseling events with congregants at faith-based organizations. Among participants with complete 6-month data (n = 348), health-related self-efficacy significantly improved after 6 months, and systolic and diastolic blood pressure was significantly reduced in some subgroups; reductions were highest in participants who self-reported a previous diagnosis of hypertension. Among Asian Americans, faith-based programs may be a replicable, low-cost, sustainable way to increase health-related self-efficacy and decrease blood pressure, specifically among individuals with self-reported hypertension.

Innovations in Payer-Community Partnerships: The EmblemHealth Neighborhood Care Program.

Comprehensive and innovative strategies are needed to address and manage chronic diseases and conditions and to reduce health disparities. EmblemHealth Neighborhood Care (EHNC) sites provide community-based linkages across payers, health providers, and delivery systems and underserved communities using culturally sensitive methods tailored to meet the needs of the community. This article describes this novel initiative and early indicators of its feasibility. Three EHNC sites were established in New York City: Harlem, Cambria Heights, and Chinatown. Each site provides core health and customer services to members and the community. In addition, sites provide tailored services to meet the unique needs of each community. Preliminary data suggest that program and community members are utilizing the sites and returning for follow-up visits. Sites also demonstrate success in cross referral between EHNC teams. The EHNC program is both feasible from the payer's perspective and acceptable to diverse patient populations and settings.

Defining an integrative approach for health promotion and disease prevention: a population health equity framework.

Eliminating health disparities in racial/ethnic minority and underserved populations requires a paradigm shift from biomedical approaches that are disease-focused to a health equity framework that aims to achieve optimal health for all by targeting social and structural determinants of health. We describe the concepts and parallel approaches that underpin an integrative population health equity framework and present the experience of NYU Center for the Study of Asian American Health (CSAAH) in applying the framework to guide its work. Applying an integrative framework has deepened our community engagement efforts, our understanding of the multi-level contextual factors that influence health, and our capacity to advance health equity for Asian American communities through action-oriented research and policy. This framework and experience is applicable to researchers and community members working with other underserved populations.

Characteristics of Asian American, Native Hawaiian, and Pacific Islander community health worker programs: a systematic review.

Community health workers (CHWs) are frontline health workers who often serve socially and linguistically isolated populations, including Asian American, Native Hawaiian, and Pacific Islander (AA and NHPI) communities in the United States (U.S.) and U.S. territories. We conducted a systematic review of the peer-reviewed literature to assess the characteristics of CHW programs for AA and NHPI communities in the U.S. and U.S. territories, generating a total of 75 articles. Articles were coded using eight domains: ethnic group, health topic, geographic location, funding mechanism, type of analysis reported, prevention/management focus, CHW role, and CHW title. Articles describing results of an intervention or program evaluation, or cost-effectiveness analysis were further coded with seven domains: study design, intervention recruitment and delivery site, mode of intervention delivery, outcomes assessed, key findings, and positive impact. Results revealed gaps in the current literature and point towards recommendations for future CHW research, program, and policy efforts.

Physical activity, fruit and vegetable intake, and health-related quality of life among older Chinese, Hispanics, and Blacks in New York City.

OBJECTIVES: We explored the relationship between health-related quality of life (HRQOL) and adequate physical activity (PA) and fruit and vegetable (F&V) intake among racial/ethnic minority groups aged 60 years or older living in New York City (NYC). METHODS: Survey data from 2009 to 2012 targeted minority groups in NYC ethnic enclaves; we analyzed 3594 individuals (Blacks, Hispanics, and Chinese) aged 60 years or older. Descriptive statistics were run; unadjusted and adjusted logistic regression evaluated the relationship of HRQOL with PA and F&V intake. RESULTS: Hispanics were most likely to engage in sufficient PA and eat recommended F&Vs and had significantly worse HRQOL. After multivariable adjustment, significant associations were found between PA and self-reported health, activity limitation and physical health days for all groups, and PA and mental health days for Hispanics. Significant associations were found between F&V intake and physical health days for Hispanics and F&V intake and self-reported health for Chinese. CONCLUSIONS: Findings indicated variations between HRQOL and PA by racial/ethnic subgroup. Despite being highly insured, recommendations for PA and F&V intake were not met. There is a need to promote healthy living behaviors among aging NYC racial/ethnic populations.

Moving the dial to advance population health equity in New York City Asian American populations.

The shift toward a health equity framework for eliminating the health disparities burden of racial/ethnic minority populations has moved away from a disease-focused model to a social determinants framework that aims to achieve the highest attainment of health for all. The New York University Center for the Study of Asian American Health (CSAAH) has identified core themes and strategies for advancing population health equity for Asian American populations in New York City that are rooted in the following: social determinants of health; multisectoral, community-engaged approaches; leveraging community assets; improved disaggregated data collection and access to care; and building sustainability through community leadership and infrastructure-building activities. We describe the strategies CSAAH employed to move the dial on population health equity.

Health-related quality of life and health behaviors in a population-based sample of older, foreign-born, Chinese American adults living in New York City.

Although the New York City Chinese population aged ≥ 65 years increased by 50% between 2000 and 2010, the health needs of this population are poorly understood. Approximately 3,001 Chinese individuals from high-density Asian American New York City areas were included in the REACH U.S. Risk Factor Survey; 805 (26.8%) were aged ≥ 65 years and foreign-born. Four health-related quality of life and three behavioral risk factor outcome variables were examined. Descriptive statistics were conducted by gender, and logistic regression models assessed sociodemographic and health factors associated with each outcome. Few women were current smokers (1.3% vs. 14.8% of men), 19% of respondents ate fruits and vegetables more than or equal to five times daily, and one-third of individuals received sufficient weekly physical activity. Days of poor health were similar to the national population aged ≥ 65 years, while self-reported fair or poor health was much greater among our Chinese sample; over 60% of respondents rated their health as fair or poor. Lower education and lower obesity were significantly associated with cigarette smoking among men, and older age was significantly associated with insufficient physical activity overall. Female gender was significantly associated with all poor health days; older age was significantly associated with poor days of physical health, and lower income was significantly associated with poor days of physical health and fair or poor self-reported health. This study provides important health-related information on a rapidly growing older population and highlights future research areas to inform culturally appropriate health promotion and disease prevention strategies and policies within community-based settings.