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  • Improving the Health Status of African American Males

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    By Wayne T. Harris, Ph.D.
    Project Director and Contact Principal Investigator
    Hampton University Minority Men’s Health Initiative

    It gives me great pleasure to contribute to the National Institute on Minority Health and Health Disparities (NIMHD) blog, NIMHD Insights. While the health status of all groups in the United States has improved over the past century, significant gaps remain between the health status of African Americans and other minority groups, and that of the general population. For example, in 1950,1 the life expectancy of an African American male at birth was 59, while that of a Caucasian male was 68. In 2014,1 the life expectancy at birth for an African American male increased to 72.0 while that for a Caucasian male increased to 76.5. Similar gaps exist in the health status and health outcomes of minority populations using a variety of measures, and clearly more work needs to be done.

    The Hampton University Minority Men’s Health Initiative (MMHI) exists to contribute to the achievement of one of the overarching goals of Healthy People 2020: “to achieve health equity, eliminate disparities, and improve the health of all groups.” Research has consistently shown that disease management and prevention efforts related to chronic diseases such as diabetes, cardiovascular diseases, cancer, and asthma lead to long-term improvement in outcomes.2 But these research findings have not been translated into sustainable, community-based programs. Furthermore, violence prevention efforts are clearly needed to reduce the significant loss of life due to homicide – the eighth leading cause of death among African Americans in 2014, and the fifth leading cause of death among African American males in 2014.1 MMHI is a program based on collaboration between selected regional Historically Black Colleges and Universities (HBCUs) to leverage resources in order to increase research into the causes and solutions for health disparities, increase community outreach and education, and promote effective prevention and/or treatment activities. As part of the National Institutes of Health and NIMHD’s efforts to advance engaged and transdisciplinary research, MMHI serves as a Transdisciplinary Collaborative Center (TCC) for research on minority men’s health.

    Through this collaboration, and using the expertise of faculty, administration, staff, and community partners, MMHI supports ongoing research projects in cancer, cardiovascular disease (CVD) risk reduction, diabetes, and violence prevention. MMHI also supports 1-year research seed projects and 2-year research pilot projects aimed at improving health outcomes among minority males. Two specific examples of activities conducted by MMHI are the Promis Program, which is focused on violence prevention, and the Heart Strong Program, which focuses on CVD risk reduction in African American men in rural southern Virginia.

    In 2016 and 2017, 49 young men ages 12 to 18 were enrolled in the Promis Program. This program provides meetings and workshop sessions facilitated by male volunteers who serve as mentors. MMHI provides training for workshop facilitators, co-facilitators, and peer mentors, and conducts ongoing evaluation using mentor, retention, and engagement surveys.

    The Heart Strong Program uses a community-based, participatory research approach to design and test a behavioral intervention to reduce cardiovascular disease (CVD) risk. Secondarily, the project seeks to understand barriers and facilitators to healthy lifestyle (e.g., physical activity and diet) and to develop a culturally, contextually, and gender-sensitive intervention to improve healthy eating and physical activity. In 2017, 40 African American men ages 21 to 74 from the Brunswick and Greensville/Emporia areas were enrolled in the program. As part of the program, the men receive monthly memberships at local exercise facilities; weekly personal training; nutrition and cooking health classes; and CVD health education in a large group setting. Individuals can also participate in smaller social support groups.

    The results of these and other MMHI activities will be used to develop future long-term and expanded research studies, inform health policy decisions, and initiate sustainable community-based activities aimed at reducing and ultimately eliminating health disparities.

    References

    1. National Center for Health Statistics. (2016). Health, United States, 2015: With special feature on racial and ethnic health disparities. Hyattsville, MD: U.S. Department of Health and Human Services.

    2. Parekh, A. K., Goodman, R. A., Gordon, C., Koh, H. K., & The HHS Interagency Workgroup on Multiple Chronic Conditions. (2011). Managing multiple chronic conditions: A strategic framework for improving health outcomes and quality of life. Public Health Reports, 126(4), 460–471.

  • Stroke Ready: Partnering to Increase Acute Stroke Treatment Rates in Flint, Michigan

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    By Lesli Skolarus, M.D., M.S.
    Associate Professor, Neurology, University of Michigan

    Sarah Bailey, M.A.
    Executive Director, Bridges into the Future, Flint, MI


    Dr. Leslie Skolarus (left) and Elder Sarah Bailey (right)May is Stroke Awareness Month, and we would like to share some information about stroke and our research with you. Each year, about 800,000 people in the United States have a stroke. Disability is the greatest challenge facing survivors and their families. About two thirds of stroke survivors are left with a disability.

    Post-stroke disability is substantially reduced by acute stroke treatments, which include intravenous tissue plasminogen activator (tPA) and intra-arterial treatment. Unfortunately, these treatments are underutilized—administered to less than 5 percent of U.S. stroke patients. Treatment with tPA must be given in the emergency department (ED) within 4.5 hours of the start of stroke symptoms. 1 The main reason stroke patients do not receive tPA is that they wait too long to call 911. 2 Think of tPA like Drano® for your brain: We want to get the plugged pipe—in the case of stroke, the plugged artery—open as soon as possible. The less time the artery is plugged, the lower the chance of brain damage, so it is extremely important that a person who is experiencing stroke symptoms calls 911 right away.

    Compared with non-Hispanic Whites, African Americans are less likely to receive acute stroke treatment, largely due to their greater delays in seeking medical attention 3-7 Thus, the ability to recognize stroke symptoms and respond immediately by calling 911 is crucial to reducing racial disparities in post-stroke disability. 8 In Flint, Michigan, a predominantly African American community, the rate of acute stroke treatment is half the national rate. 9 In fact, Flint has the lowest treatment rate of any region of its size in the country.


    Dr. Lesli Skolarus and Elder Sarah Bailey distributing water

    For the past 7 years, neurologists and health behavior and health education experts from the University of Michigan have partnered with Bridges into the Future, a faith-based community organization dedicated to improving Flint’s health, to increase stroke preparedness. During our pilot study, “Stroke Ready,” which was funded by the National Institute of Neurological Disorders and Stroke, we learned through local focus groups that it would be important to address factors such as outcome expectations (i.e., the belief that strokes can be treated) and cost and anxiety barriers when developing stroke preparedness interventions for the Flint community. Using a community-based participatory research (CBPR) approach, we developed and tested a faith-based, theory-driven, peer-led behavioral intervention that increased stroke preparedness among youth and adults in three predominantly African American churches. 10-11 With support from the National Institute on Minority Health and Health Disparities, we are now testing a multilevel intervention to optimize acute stroke care in the ED and to improve community stroke preparedness, with the primary goal of increasing acute stroke treatment city-wide.

    African Americans experience significantly worse post-acute stroke outcomes. Our goal is to reduce this disparity by developing accessible, effective stroke preparedness programs with the communities that are most in need. By combining theory-based public health approaches to address neurological disease, we hope to provide neurologists and community partners with a framework for approaching neurological disease and, ultimately, improving the lives of our patients.


    References

    1. Hacke W, Donnan G, Fieschi C, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363:768-74.
    2. Kleindorfer D, Kissela B, Schneider A, et al. Eligibility for recombinant tissue plasminogen activator in acute ischemic stroke: a population-based study. Stroke. 2004;35:e27-29.
    3. Schwamm LH, Reeves MJ, Pan W, et al. Race/ethnicity, quality of care, and outcomes in ischemic stroke. Circulation. 2010;121:1492-501.
    4. Johnston SC, Fung LH, Gillum LA, et al. Utilization of intravenous tissue-type plasminogen activator for ischemic stroke at academic medical centers: the influence of ethnicity. Stroke. 2001;32:1061-8.
    5. Hsia AW, Edwards DF, Morgenstern LB, et al. Racial disparities in tissue plasminogen activator treatment rate for stroke: a population-based study. Stroke. 2011;42:2217-21.
    6. Lichtman JH, Watanabe E, Allen NB, Jones SB, Dostal J, Goldstein LB. Hospital arrival time and intravenous t-PA use in US Academic Medical Centers, 2001-2004. Stroke. 2009;40:3845-50.
    7. Messé SR, Khatri P, Reeves MJ, et al. Why are acute ischemic stroke patients not receiving IV tPA? Results from a national registry. Neurology. 2016;87:1565-74.
    8. Burke JF, Freedman VA, Lisabeth LD, Brown DL, Haggins A, Skolarus LE. Racial differences in disability after stroke: results from a nationwide study. Neurology. 2014;83:390-7.
    9. Skolarus LE, Meurer WJ, Shanmugasundaram K, Adelman EE, Scott PA, Burke JF. Marked Regional Variation in Acute Stroke Treatment Among Medicare Beneficiaries. Stroke. 2015;46:1890-6.
    10. Skolarus LE, Zimmerman MA, Murphy J, et al. Community-based participatory research: a new approach to engaging community members to rapidly call 911 for stroke. Stroke. 2011;42:1862-6.
    11. Skolarus LE, Zimmerman MA, Bailey S, et al. Stroke ready intervention: community engagement to decrease prehospital delay. Journal of the American Heart Association. 2016;5:e003331.

  • Contradicting the Myth of the Model Minority Through a Population Health Equity Approach

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    Diabetes management class participants perform group exercises


    By Chau Trinh-Shevrin, DrPH
    Principal Investigator, NYU Center for the Study of Asian American Health
    Associate Professor, Departments of Population Health and Medicine
    Vice Chair for Research, Department of Population Health
    Director, Section for Health Equity
    NYU School of Medicine

    Asian Americans do not need an apple a day to keep the doctor away. Research suggests that doctors are less likely to follow evidence-based guidelines and meet standards of care with their Asian American patients compared with other racial groups in preventing and managing chronic conditions.1,2Asian Americans, however, face just as many health challenges, including an increasing rate of diabetes and certain cancers.

    This neglect seems to be linked to the “model minority” stereotype of Asian Americans, promoted in American culture and media, which portrays them as uniformly hardworking, affluent, and healthy. Yet, Asian Americans are not all alike: There are substantial differences in language, migration, and social experiences across Asian subgroups whose ancestral heritages hail from East, South, and Southeast Asia, and health concerns and risks vary across and within these communities.3

    The model minority myth systemically influences how health care is provided to Asian Americans. In fact, the evidence suggests the following:

    • Aggregated data mask important differences—such as diet and health risks—that may affect health outcomes among more than 30 Asian ethnic subgroups.
    • Diabetes rates are strikingly high for South Asians and Filipinos.4
    • Suicide is one of the leading causes of death among Korean American males,5 suggesting difficulties in accessing and seeking mental health services.

    For these reasons, the Center for the Study of Asian American Health at NYU School of Medicine’s Department of Population Health was established in 2003 and is the only National Institute on Minority Health and Health Disparities Center of Excellence devoted to Asian American health in the United States. Our center seeks to counter the model minority stereotype by employing a population health framework to advance the health of Asian Americans in New York City and nationally.6–8 We have focused on three key development areas:

    • Data Disaggregation: We have led data collection and analyses efforts to support the disaggregation of data on Asian Americans into subgroup to better understand the nature and prevalence of certain health conditions.9
    • Community and Clinical Linkages: Our studies prioritize patient-centered care that aims to bridge communities with poor access to care to doctors and clinics. The DREAM (Diabetes Research, Education, and Action for Minorities) Project, a culturally tailored intervention for Bangladeshi Americans with uncontrolled type 2 diabetes, has demonstrated efficacy in reducing HbA1c and increasing physical activity.10 Community health workers (CHW) lead sessions on diabetes management in Bengali and work with community members to overcome a range of barriers, such as how to use the subway to get to doctor’s appointments and how to ask the right questions. One study participant said, “I only knew [previously] that if I was feeling bad, I should go to the doctor. Now, I have my own doctor—myself.”
    • Multi-level Strategies: We are developing multi-level strategies that integrate health information technology as well as policy, systems, and environmental changes to address major disparities that Asian Americans experience. One focus area of our work is on developing culturally adapted interventions with CHWs and electronic health records in safety net clinical settings to improve adherence to preventive treatments against stomach cancer in high-risk Asian American communities.

    Korean American community screening event at a church in Queens.

    As we celebrate Asian American and Pacific Islander Heritage Month, health care systems increasingly face the challenges of ensuring culturally and linguistically relevant care. We hope more resources will be dedicated to the health of Asian Americans—the fastest growing minority population in the United States11—and meaningful evidence-based strategies will inform policy and practice. As patients and medical professionals, we must mindfully approach Asian Americans as we would any other population—with the intention of addressing complex health challenges and risks experienced by all Americans.

    References

    1. Tung, E.L., Baig, A.A., Huang, E.S., Laiteerapong, N., & Chua, K.P. (2017). Racial and ethnic disparities in diabetes screening between Asian Americans and other adults: BRFSS 2012–2014. Journal of General Internal Medicine 32(4), 423–429. doi: 10.1007/s11606-016-3913-x

    2. Islam, N.S., Kwon, S.C., Wyatt, L.C., Ruddock, C., Horowitz, C.R., Devia, C., & Trinh-Shevrin, C. (2015). Disparities in diabetes management in Asian Americans in New York City compared with other racial/ethnic minority groups. American Journal of Public Health, 105(Suppl. 3), S443–S446. doi: 10.2105/AJPH.2014.302523

    3. Yi, S.S., Kwon, S.C., Sacks, R., & Trinh-Shevrin, C. (2016). Commentary: Persistence and health-related consequences of the model minority stereotype for Asian Americans. Ethnicity and Disease, 26(1), 133–138. doi: 10.18865/ed.26.1.133

    4. King, G.L., McNeely, M.J., Thorpe, L.E., Mau, M.L., Ko, J., Liu, L.L., . . . Chow, E.A. (2012). Understanding and addressing unique needs of diabetes in Asian Americans, native Hawaiians, and Pacific Islanders. Diabetes Care, 35(5), 1181–1188. doi: 10.2337/dc12-0210

    5. Hastings, K.G., Jose, P.O., Kapphahn, K.I., Frank, A.T., Goldstein, B.A., Thompson, C.A., . . . Palaniappan, L.P. (2015). Leading causes of death among Asian American subgroups (2003–2011). PLoS One, 10(4), e0124341. doi: 10.1371/journal.pone.0124341

    6. Trinh-Shevrin, C., Sacks, R., Ahn, J., & Yi, S.S. (2017). Opportunities and challenges in precision medicine: Improving cancer prevention and treatment for Asian Americans. Journal of Racial and Ethnic Health Disparities. Advance online publication. doi:10.1007/s40615-016-0334-9

    7. Trinh-Shevrin, C., Islam, N.S., Nadkarni, S., Park, R., & Kwon, S.C. (2015). Defining an integrative approach for health promotion and disease prevention: A population health equity framework. Journal of Health Care for the Poor and Underserved, 26(Suppl. 2), 146–163. doi: 10.1353/hpu.2015.0067

    8. Trinh-Shevrin, C., Kwon, S.C., Park, R., Nadkarni, S.K., & Islam, N.S. (2015). Moving the dial to advance population health equity in New York City Asian American populations. American Journal of Public Health, 105(Suppl. 3), e16–e25. doi: 10.2105/AJPH.2015.302626

    9. Islam, N.S., Khan, S., Kwon, S., Jang, D., Ro, M., & Trinh-Shevrin, C. (2010). Methodological issues in the collection, analysis, and reporting of granular data in Asian American populations: Historical challenges and potential solutions. Journal of Health Care for the Poor and Underserved, 21(4), 1354–1381. doi: 10.1353/hpu.2010.0939

    10. Islam, N.S., Wyatt, L.C., Patel, S.D., Shapiro, E., Tandon, S.D., Mukherji, B.R., . . . Trinh-Shevrin, C. (2013). Evaluation of a community health worker pilot intervention to improve diabetes management in Bangladeshi immigrants with type 2 diabetes in New York City. Diabetes Educator, 39(4), 478–493. doi: 10.1177/0145721713491438

    11. Colby, S.L., & Ortman, J.M. (2014). Projections of the size and composition of the U.S. population: 2014 to 2060. Washington, DC: U.S. Census Bureau.

  • Addressing Mental Health in African Americans Through FAITH

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    February 21, 2017

    By Tiffany Haynes, Ph.D.
    Assistant Professor, Department of Health Behavior and Health Education
    Fay W. Boozman College of Public Health
    University of Arkansas for Medical Sciences, Little Rock, AR University of Arkansas for Medical Sciences

    Dr. Tiffany HaynesDr. Tiffany Haynes Rural African Americans are disproportionately exposed to numerous stressors, such as poverty, racism, and discrimination,1-5 that place them at risk for experiencing elevated levels of depressive symptoms.6 Elevated levels of depressive symptoms can lead to a host of negative outcomes, including poor management of chronic illnesses (e.g., hypertension, diabetes), poor social and occupational functioning, and development of clinical depression.7 Although effective treatments for decreasing depressive symptoms exist, structural barriers (e.g., lack of available services, transportation) and perceptual barriers (e.g., stigma, fear of misdiagnosis) impede the use of traditional mental health services within these communities, resulting in a significant unmet psychiatric need. Failure to develop culturally appropriate strategies to provide adequate, timely care to rural African Americans can result in a significant public health crisis.

    African American churches have been identified as potential venues for providing depression education and treatment for rural African Americans.8 Within the African American rural community, churches represent a key portal through which as much as 85% of the community can be reached.9 Churches have been used to address physical health outcomes in those communities, but few have focused primarily on addressing mental health outcomes10-11. Through the NIMHD-funded project entitled “Faith Academic Initiatives to Transform Health (FAITH) in the Delta,” our partnership, consisting of faith community leaders and University of Arkansas for Medical Science researchers, conducted formative work in the Arkansas Delta. Data suggested that community members consider elevated depressive symptoms to be a significant unmet need. Furthermore, community members suggested that attempts to improve depressive symptoms should do the following:

    1. Provide education about depressive symptoms. Recognizing when depressive symptoms become a clinical problem is the first step toward receiving adequate treatment. However, rural African Americans report difficulties in differentiating between normal sadness and clinically significant depressive symptoms. Providing education about depressive symptoms allows rural African Americans to make informed treatment decisions.
    2. Address the role that stress from social inequities plays in the development and maintenance of depressive symptoms. Rural African Americans correctly realize that prolonged exposure to stress caused by social inequities is a significant factor in the development and maintenance of depressive symptoms. Treatments that conceptualize depressive symptoms as normal reactions to stress are more culturally acceptable in rural African American communities.
    3. Find ways to increase social support for those experiencing depressive symptoms. Stigma is a significant concern in rural communities. Rural African Americans experiencing depressive symptoms tend to socially isolate themselves, which, in turn, can worsen depressive symptoms.
    4. Provide mental health interventions in community-based settings. Residents suggest that offering mental health services in community settings, such as churches, would allow residents to receive treatment in less stigmatizing places and improve access to mental health care.


    (From left to right): Pastor Johnny Smith, Community PI; Dr. Tiffany Haynes, Academic PI; Dr. Karen K. Yeary, Academic Co-PI; and Pastor Jerome Turner, Community PI.


    Using this data as a base, researchers worked closely with the faith community to culturally adapt an evidence-based behavioral activation intervention for use with rural African American churches. This eight-session behavioral activation intervention, REJOICE (Renewed and Empowered for the Journey to Overcome in Christ Everyday), was adapted to include faith-based themes, scripture, and other aspects of the rural African American faith culture (e.g., Bible studies, interweaving faith-based messages throughout the intervention materials).

    Currently, we are testing the effectiveness of REJOICE and obtaining pilot data about the best ways to implement this intervention in rural African American churches. Collecting data from this project is the first step in providing timely and appropriate care to high-need and underserved communities.

    References

    1. Harris, R. P., & Worthen, D. (2003). African Americans in rural America. In D. L. Brown & L. E. Swanson (Eds.), Challenges for rural America in the twenty-first century (pp. 32-42). University Park, PA: The Pennsylvania State University Press.
    2. U.S. Department of Agriculture, Economic Research Service (2016). Rural Poverty and Well-Being: Geography of Poverty. Retrieved from https://www.ers.usda.gov/topics/rural-economy-population/rural-poverty-well-being/
    3. Fitchen, J. M. (1992). On the edge of homelessness: rural poverty and housing insecurity. Rural Sociology, 57, 173-193.
    4. Kusmin, L. (Ed.). (2012). Rural America at a glance, 2012 edition. Washington, DC: U.S. Department of Agriculture, Economic Research Service.
    5. Odom, E. C., & Vernon-Feagans, L. (2010). Buffers of racial discrimination: links with depression among rural African American mothers. Journal of Marriage and the Family, 72, 346-359.
    6. Kusmin, L. (Ed.). (2011). . Rural America at a glance, 2011 edition. Washington, DC: U.S. Department of Agriculture, Economic Research Service.
    7. Mays, V. M., Cochran, S. D., & Barnes, N. W. (2007). Race, race-based discrimination, and health outcomes among African Americans. Annual Review of Psychology, 58, 201-225.
    8. Taylor RJ, Chatters LM, Levin J. Religion in the Lives of African Americans: Social, Psychological, and Health Perspectives. Thousand Oaks, CA: Sage Publications, 2004.
    9. Reeves RR, Adams CE, Dubbert PM, Hickson DA, Wyatt SB. Are Religiosity and Spirituality Associated with Obesity Among African Americans in the Southeastern United States (the Jackson Heart Study)? J Relig Health. 2011.
    10. DeHaven MJ, Hunter IB, Wilder L, Walton JW, Berry J. Health programs in faith-based organizations are they effective? Am J Public Health. 2004; 94(6): 1030-6. 1448385
    11. Hankerson, Sidney H., and Myrna M. Weissman. “Church-based health programs for mental disorders among African Americans: a review.” Psychiatric Services 63.3 (2012): 243-249.