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  • Optimizing Health for Immigrant Populations: When One Thing Stands, Another Thing Stands Beside It

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    By Yewande Oladeinde, Ph.D.
    National Institute on Minority Health and Health Disparities
    Posted June 10, 2024

    Dr. Yewande OladeindeMost immigrants have frames of reference or ways of knowing based on their immigrant experience that confer certain health advantages in positive and unique ways, often known as the “healthy immigrant effect” or the “immigrant paradox.” To better understand the rationale behind why and how immigrants seek care, we need to know “what are those things that stand and what are the other things that stand beside them," as immigrants try to navigate a fragmented health care system that was not built for them.

    The quote referenced above by Nigerian novelist Chinua Achebe refers to the "reality of a cultural multiverse rather than a cultural universe." As public health professionals, we often think about developing and implementing sustainable interventions that will lead to improved health outcomes. As noble as this may sound, many public health professionals design interventions that fail to consider the cultural contexts within which the behaviors and practices they are trying to change are formed and from which they thrive. Failure to do so leads to interventions that are unsustainable at best and, at worst, ineffective.

    Dr. Yewande Oladeinde wearing traditional Nigerian gele head wrap made with aso-oke fabric and dress made with ankara fabricDr. Yewande Oladeinde wearing traditional Nigerian gele head wrap made with aso-oke fabric and dress made with ankara fabric.

    Highlighting Cultural Assets

    Immigrant Heritage Month is about celebrating diversity and one's cultural heritage. It’s also about highlighting the cultural assets people bring to their health that can then be used to develop programs that end disparities while optimizing health for all people.

    Take the story of Kemi, for example, a first-generation immigrant woman rooted in the Yoruba culture of Nigeria and an American anchored in the African American experience. Kemi has lived in the United States for over two decades despite spending her formative years in her home country of Nigeria. To remain connected to her Nigerian roots, she and her family are active members of a cultural organization for Nigerians in her community. Even though Kemi has lived in the United States for over two decades, she is very much rooted in her Yoruba culture.

    Kemi was experiencing symptoms of extreme fatigue, a feverish feeling, and other flu-like symptoms. At the time when she was experiencing these symptoms, she wanted to see a doctor, but she heard the news of how nobody was allowed to accompany loved ones to the hospital. People were asked to literally drop off their loved ones to an unknown fate and leave them there. Because of this rule, Kemi decided to stay home and have her loved ones care for her.

    Kemi called her mother in Nigeria to inform her about her symptoms and to ask for the agbo, a Yoruba term for a medicinal herbal remedy that is commonly used for feverish conditions. Her mother gave her the names of the herbs she needed, the specified quantities, and the preparation instructions. Her husband tried to purchase the medicinal herbs recommended, but many of them were unavailable in the United States. Kemi’s mother shipped the agbo remedy from Nigeria. Kemi drank a 4- to 8-ounce cup of the medicinal herbs each day. After about two weeks, her symptoms abated.

    Prior to this incident, Kemi used Western allopathic medicine often. However, when she was in a dire health situation, and some of the allopathic treatments recommended to her were not working, she knew she had to rely on “those other things that seek to stand beside that one thing,” such as traditional cultural practices and values related to healing that sustained prior generations, and reliance on the wisdom and divine power of one’s mother.

    When Kemi’s friends spoke to her about possibly seeking care as her symptoms got serious, she stated, ”What is the point of going to the hospital and being subjected to trial-and-error treatment when I can rely on what mothers and grandmothers in my culture have used for several generations that worked for them?” She relied on her cultural identity and the value of what had worked for previous generations. This is one of the reasons why it is important to build and maintain trust with the medical community and between people from other racial and ethnic minority communities, as cultural factors may influence their perceptions of health and uptake of recommended guidelines of care.

    As we continue to celebrate our diversity and cultural heritage this month, we must remember to:

    • Pay attention to the perceptions that feed people’s beliefs and the broader contexts where these perceptions emerge and from which they thrive. People’s perceptions, be they sociocultural, political, or historical, do not emerge from a vacuum.
    • Keep indigenous ways of knowing, which have helped our ancestors thrive. Chinua Achebe's quote speaks to the essence of multiple ways of knowing, which often coexist within an individual and may sometimes complement or oppose more popular views.
    • Understand that there is no singular worldview or universal belief that resides within an individual, and trying to silence other narratives or beliefs would be detrimental to addressing pressing health challenges faced by immigrants in the United States.
    • Encourage and empower alternate perspectives of people from other cultures, the things they value, and the unique qualities they acknowledge while leveraging their assets for optimal health.

    Yewande Oladeinde, Ph.D., is a social and behavioral science administrator in the Division of Clinical and Health Services Research at NIMHD. Her research focuses on understanding the role culture plays in shaping people’s perceptions of health and illness, and how it influences their choices and their behaviors, with a goal of implementing culturally and contextually appropriate interventions. Dr. Oladeinde was born and raised in Lagos, Nigeria, and she is from the Yoruba ethnic group.

    Dr. Oladeinde writes periodically for a local Maryland newspaper and aspects of this story were previously published there.

  • Confronting the Legacy of Medical Misinformation - Let's Start With Race-Based Medicine

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    By Keisha Bentley-Edwards, Ph.D., Olanrewaju Adisa, Kennedy Ruff, and Catherine Kiplagat
    Samuel DuBois Cook Center Health Equity Working Group
    Posted May 30, 2024


    Authors, clockwise from top left: Dr. Keisha Bentley-Edwards, Catherine Kiplagat, Olanrewaju Adisa and Kennedy Ruff

    Throughout the COVID-19 pandemic, the health community was alerted to the proliferation of medical misinformation, particularly messages related to vaccines and treatment. For me, Dr. Bentley-Edwards, I became alerted to the dangers of medical misinformation in the early 1990’s from my father’s annual physical. My father’s new primary care provider (PCP) asked him what medication he was taking to control his hypertension. My father was confused. He wasn’t taking antihypertensive medication because his blood pressure was normal. However, his medical records revealed his blood pressure was well above the hypertension level cut-offs for several years. In past years, my father’s prior doctors had been telling him that his blood pressure was “high-normal” or that his levels were “normal for a Black man.” This misinformation allowed his blood pressure to be uncontrolled for an unnecessarily long time, heightening his risk for cardiovascular disease, stroke, and kidney disease. Upon learning all of this, my father’s new PCP, a young Black doctor, immediately prescribed him the appropriate medication, and he has taken care of his health since then.


    Loud and Wrong

    Dr. Keisha Bentley-Edwards and her fatherHypertension is often called the “silent killer,” but in this case, my father’s physicians’ reliance on race-based medicine to guide diagnosis and care rang loud and wrong. Race-based medicine relies upon biological distinctions between racial groups that are integrated into practice, training, and health algorithms and represents a systemic form of medical misinformation. As such, medical misinformation cannot be reduced to error-filled social media campaigns. As researchers, providers, and other members of the health community, we must reflect on how we generate, share, and sustain medical misinformation so that we can bring it to an end. To be clear, race-based medicine is not to be confused with personalized care or precision medicine.

    In the past, providers were taught to provide Black patients with a specific class of antihypertensive medication, narrowing their medication options early in their treatment course from those that may be more effective and reduce the risk for progression to chronic kidney disease.  These race-based assumptions do not exist in a vacuum. They inform the development of critical assessments and risk predictors. This history calls into question the goal of algorithms to save time, money, or lives. If the goal of an algorithm is to save lives and reduce health disparities, an over-reliance on race-based medicine can get in the way of its success.

    Important Steps

    Prior to 2021, kidney function was determined by a calculation that considered multiple biological indicators and included a coefficient accounting for patient race. The use of this formula systematically overestimated kidney function for Black patients, reduced the chances of patients meeting the threshold for end-stage kidney disease, and increased the wait times for Black patients to get on the transplant list or receive other appropriate care such as dialysis. However, the National Kidney Foundation and the American Society of Nephrology revised the eGFR recommendations to exclude Black race as a biological factor. In 2023, researchers  estimated that roughly 70,000 Black adults could move higher up in the matching system and decrease their wait time for a kidney transplant as a result of the improved algorithm. As evidenced by the pre-2021 eGFR recommendations and the lack of evidence supporting race-based antihypertensive treatment, race-based medicine is not the solution. The Organ Procurement and Transplantation Network took an important step to push policy that has helped nearly 2,500 Black patients receive a kidney who would not have if the old algorithm were still in use. More needs to be done to improve the health of Black Americans.

    Race vs. Genetic Ancestry

    Eliminating confusion by understanding race versus genetic ancestry is fundamental to addressing and redressing health inequities. Although structural racism is the most undeniable factor of disparate outcomes for Black patients with hypertension and kidney disease, ancestral genetic variation can partially explain differential experiences with kidney disease.  APOL1 is a genetic marker present in all people; however, certain Black Americans (up to 10-15%) inherited a genetic high-risk allele combination (G1 and G2) that has evolved over 10,000 years beyond the original function in protection against African sleeping sickness (trypanosomiasis). This combination correlates with an increased risk of kidney diseases like kidney failure. Similar to sickle cell disease, there is an increased incidence of these alleles where the disease is prevalent (e.g., West Africa).  APOL1-mediated kidney disease (AMKD) may accelerate the progression to kidney failure, but it is not the single cause of progression. Even with the help of ancestry studies, physicians must resist jumping to conclusions about how to use these findings to serve their patients.

    Thoughtful Engagement

    Studies about AMKD hold promise for personalized and genetically informed care for millions of Americans in the wake of precision medicine. Up against an extensive history of medical untrustworthiness by the U.S. health care and research systems, my team and I have argued that we must thoughtfully engage and include communities impacted by health disparities throughout the research enterprise.

    Discussions of structural racism and medical misinformation do not diminish the relevance of personal agency and health behaviors. Yet, our personal agency is informed by the options that are available to us. When our choices are clouded by misinformation, so is our personal agency. Although I can’t decisively say that my father’s eventual progression to chronic kidney disease was the result of medical racism and structural racism, I can confidently say that it was contributing factor.

    In the Health Equity Working Group for the Samuel DuBois Cook Center on Social Equity at Duke University, we study the causes and consequences of racism and sociocultural indicators on health outcomes. Does race matter in understanding health disparities? Yes, but we argue that when you recognize race as a social construct, you realize that social conditions should be an integral area of study for resolving racial health disparities. In our NIMHD-funded project, we examined Black people’s religiosity for its effect on cardiovascular disease risk factors, including hypertension. Our findings showed that Black religious and cultural experiences in America are diverse and important in understanding cardiovascular disease risks. Additionally, we are members of the recently formed ERASE-KD consortium (Eliminating Racism And Structural inEquities in Kidney Disease) dedicated to mitigating structural racism’s impact on kidney disease.

    We, as members of the health community, must have the humility to recognize that we are not immune to the allure of medical misinformation, even when it is rooted in systemic racism. How this form of racism is reproduced and disseminated as medical misinformation is neither isolated nor benign.

    Keisha Bentley-Edwards, Ph.D., is an associate professor of medicine, Co-Director of the Center for Equity in Research, and associate director of research for the Samuel DuBois Cook Center (Cook Center) on Social Equity at Duke University.

    Olanrewaju Adisa is a medical student at Duke University.

    Kennedy Ruff is an associate in research at the Cook Center and graduate student at North Carolina State University’s Clinical Mental Health Counseling Program.

    Catherine Kiplagat is a 2nd year undergraduate student at Duke University.

    Dr. Bentley-Edwards leads the Cook Center’s Health Equity Working Group, and Adisa, Ruff, and Kiplagat are all members.

  • Be the Source for Better Health

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    By CAPT Tarsha Cavanaugh, Ph.D., M.S.W., LGSW
    Office of Minority Health
    Posted April 26, 2024

    CAPT Tarsha Cavanaugh

    We are nearing the end of National Minority Health Month (NMHM), an annual observance led by the U.S. Department of Health and Human Services (HHS) Office of Minority Health (OMH). NMHM is a time for us all to reflect on the role we can play in advancing health equity and eliminating health disparities in racial and ethnic minority and American Indian/Alaska Native populations.

    This year the theme Be the Source for Better Health: Improving Health Outcomes Through Our Cultures, Communities, and Connections, emphasizes the role social determinants of health (SDOH), cultural competency, and humility play in advancing health equity.

    At OMH we are committed to furthering this effort by providing resources that support federal and community-based partners’ provision of quality, equitable, and respectful care and services that acknowledge the diverse cultural beliefs, practices, and linguistic preferences among the populations we serve.

    But let’s talk more about what health disparities are and how you can Be the Source for Better Health in your community.

    Understand Health Disparities

    Social Determinants of Health graphic formed by 5 sections, Education access and quality, Health care access and quality, Neighborhood and built environment, Social and community context, and Economic stability, circling a person icon. Healthy People 2030 logoHealth disparities among minority communities are persistent and multifaceted. We define them as “differences in health that are closely linked to the social determinants of health (SDOH).” SDOH are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

    One of the many ways OMH works to address these disparities is through the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. The Standards are a roadmap for improving the quality of care by providing equitable, understandable, and respectful care and services that pay keen attention to diverse cultural health beliefs and practices, preferred languages, health literacy, and communication styles.

    By tailoring services to an individual's cultural and language preferences, you can help bring about positive health outcomes for diverse populations.

    Be a Wellness Champion

    A Black woman with a stethoscope around her neck holds a Black man’s index finger. A glucose testing stick is in her other handWellness Champions are federal and community partners committed to addressing the root causes of health disparities while advancing holistic approaches to achieve optimal health within racial and ethnic minority and American Indian/Alaska Native communities. Through education, outreach, and policy advocacy, they serve as trusted messengers empowering individuals to take charge of their health and navigate healthcare systems effectively.

    One type of Wellness Champion OMH supports is Community Health Workers (CHWs). CHWs often live within the communities they serve and broaden community connections to valuable health resources. They advocate for specific population needs (i.e., housing, food security), coordinate care at all levels, provide basic health screenings, and much more.

    While CHWs are a great example of Wellness Champions, it is important to remember that anyone can be a Wellness Champion committed to promoting good health habits with your friends, family, and local community.

    Embrace Self-Care and Self-Compassion

    Encouraging self-care and self-compassion in both the populations we serve but also for ourselves is also an important element of achieving health equity. But equally as important is understanding that we all have unique health needs when it comes to these practices. Each person’s ‘healthiest self’ is different and influenced by SDOH.

    A row of 4 racially, ethnically diverse people of different genders and generations who are laughing. 3 other smiling people are in the backgroundTake the time to reflect on your personal wellness in areas such as your lived environment, relationships, and emotional health. Utilize resources like the NIH Your Healthiest Self: Wellness Toolkits to embrace self-care while navigating your whole-health journey and encourage others to do the same. Better understanding the knowledge gaps in our own health empowers us to seek out resources or trusted partners that can help improve our health status.

    Embracing self-care or compassion practices, through activities such as mindfulness, exercise, or creative expression has the potential to nurture resilience and improve your well-being.

    Conclusion

    National Minority Health Month calls upon us to recognize the intersecting factors that contribute to poor health outcomes and work to overcome these barriers. When all receive quality, equitable, and respectful care and services that are responsive to our cultural health beliefs and practices, preferred languages, economic and environmental circumstances, and health literacy levels, the health and well-being of our families, communities and nation will soar.

    Let’s keep working together in NMHM and beyond to Be the Source for Better Health for populations we serve by advancing sustainable policies, programs, and practices that work towards eliminating health disparities and prioritize the achievement of health equity.

    Resources

    U.S. Department of Health and Human Services. Healthy People 2030.

    Office of Minority Health. National CLAS Standards. U.S. Department of Health and Human Services.

    Bureau of Labor Statistics. Community Health Workers. U.S. Department of Labor.

    National Institutes of Health. Your Healthiest Self: Wellness Toolkits. U.S. Department of Health and Human Services.

    CAPT Tarsha Cavanaugh, Ph.D., M.S.W., LGSW, is Principal Deputy Director at the Office of Minority Health.


  • Moving From Willingness to Vaccination Uptake: Strategies for Promoting Health Through Vaccines

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    By Deborah E. Linares, Ph.D., M.A. and Vanessa Marshall, Ph.D.
    National Institute on Minority Health and Health Disparities (NIMHD)
    Posted March 7, 2024

    Moving from willingness (to take a vaccine) to vaccination uptake remains a public health challenge, because there are multiple factors driving vaccine hesitancy. Vaccine hesitancy occurs when there is a reluctance to receive a vaccine despite its availability. Developing strategies to build trust with people from racial and ethnic minority communities and the medical community are essential to effectively promoting health.

    NIMHD supports research in this area to eliminate health disparities and incorporate strategies to address:

    • Social determinants of health that create barriers to accessing vaccines.
    • Sustainable collaborations in communities disproportionately affected by illnesses.

    NIMHD continues to invest in community-engaged research among populations experiencing health disparities to promote wellness and protect health through vaccines. We held an NIH extramurally funded grantee meeting on COVID-19 vaccine uptake in 2022 where several insights were shared. In this blog post, we share these insights and a brief overview of how applying knowledge, steadfastness, and collaboration can help promote vaccine uptake. While we know some people are reluctant and may be unsure about being vaccinated, hopefully this blog will help to inform them.

    What are the benefits of vaccines?

    Vaccines provide multiple benefits for the prevention or reduction of disease, serious illness, or death while also protecting against disease transmission. The Centers for Disease Control and Prevention (CDC) recommends vaccinations across the lifespan for protection against many diseases.

    For example, influenza or the flu is an infection of the respiratory system that can cause serious complications for children ages 2 or younger, pregnant people, adults over age 65, and people with chronic health conditions. The flu causes more than 400,000 hospital stays and 50,000 deaths each year in the United States, with the highest rates among Black and African American and American Indian and Alaska Native (AI/AN) populations. Yet less than 43% of Latino and Hispanic, AI/AN, and Black and African American adults and less than 54% of Latino and Hispanic and Black and African American children receive the flu vaccine.

    U.S. Food and Drug Administration-approved vaccines are critical for reducing infection rates and slowing the spread of infectious diseases. Despite the CDC’s recommendations and the overwhelming benefits of vaccination, disparities exist in the acceptance and uptake of vaccines (e.g., COVID-19, flu, pneumococcal, hepatitis B, pertussis, measles, and human papilloma virus) among populations experiencing health disparities. These disparities also occur for many routine immunizations for all ages.

    What drives vaccine hesitancy?

    The COVID-19 pandemic showed us that vaccine hesitancy is complex; context specific; and changes across time, place, and type of vaccine, as well as in the timely completion of a vaccine series (i.e., receiving all vaccines within a series). It can also be influenced by factors such as complacency, convenience, and confidence.

    Pathways of vaccine hesitancy vary and are subject to change over time. For instance, parental vaccine hesitancy for childhood vaccines is growing within the United States for diseases such as measles, despite measles being declared eliminated in the United States in 2000 due to a prior robust vaccination program.

    Racial and ethnic minority populations may be more likely to experience skepticism about the trustworthiness of the source(s) of vaccination recommendations due to prior experiences of marginalization and mistreatment within the medical community. Cultural and religious factors may also influence vaccine uptake and low risk perceptions of disease.

    Other factors such as limited knowledge, limited information on vaccines, concerns about perceived safety, parental perceptions of vaccine safety, public uncertainty, low health literacy, considering immunization a low priority, and exposure to misinformation or disinformation via social media channels play a role in vaccine uptake.

    Getting protected: What you need to know

    Winter months are critical times for vaccines, especially COVID-19, flu, and respiratory syncytial virus (RSV). People may also be behind on other vaccines due to health care closures and accessibility issues during COVID-19. So how can we encourage the people around us to get vaccinated? Community-based organizations and health care providers can do the following:

    • Engage others in meaningful, authentic communication when you discuss vaccines.
    • Identify and address the needs, preferences, and concerns of a group in discussions about vaccines.
    • Provide targeted messaging that meets people where they are, in terms of their decision to vaccinate and the places where they receive care.
    • Give understandable communication that comes from a trusted source (e.g., health care provider or community leader).
    • Provide different modalities for messaging about vaccines (e.g., text message, face-to-face interactions, social media, videos).

    These strategies can be helpful to increase vaccine uptake within your community. In addition to getting vaccinated, please continue to use evidence-based mitigation strategies to reduce the risk of spreading infectious diseases, such as mask wearing and frequent hand washing. Persistence to these strategies and drawing on community-based collaborations can help promote health among populations experiencing health disparities.

    On-going NIMHD vaccine related funding opportunities and initiatives:

    Want to know more about how NIH is addressing vaccine hesitancy, uptake, and implementation among populations experiencing health disparities in the United States and its territories?

    To locate vaccines near you: www.vaccines.gov

    Deborah Linares, Ph.D., M.A., is a Health Scientist Administrator (Program Official) at NIMHD. She focuses on promoting research to understand behavioral and interpersonal factors contributing to resilience and susceptibility to adverse health conditions among disadvantaged and underserved populations. She provides expertise in conducting minority health and health disparities research in the areas of behavioral health, women’s health, child development, healthy aging, eHealth, and cancer control.

    Vanessa Marshall, Ph.D., is a Social Behavioral Scientist Administrator (Program Officer) in the Division of Community Health and Population Science at NIMHD. She manages and conducts research to advance public health prevention science. Her research focuses on improving health outcomes and promoting research to understand and address the multilevel determinants of factors that play a role in health disparities. She provides expertise in key research areas including minority health, health disparities, health services research, community engaged research, clinical trials, public health, quality improvement, implementation, dissemination and evaluation.