TAG: "Health disparities"

Culturally tailored intervention may help reduce obesity in Latino children

Study finds meaningful improvements in child weight and BMI.

By Linda Anderberg, UC Berkeley

A recent collaborative study between UC Berkeley School of Public Health and Contra Costa County researchers evaluated the efficacy of a culturally tailored obesity intervention for Latino children, Familias Activas y Saludables, or Active and Healthy Families (AHF). The study results were published online in Academic Pediatrics.

The randomized controlled trial found that child body mass index (BMI) decreased in the AHF group and increased in the control group over a 10-week period. Children in the AHF group also had reduced triglyceride levels (a type of fat measured in blood), but no significant improvement in blood pressure. This randomized trial is the first to date to show a significant impact on BMI of a culturally tailored primary care program addressing obesity in Latino children.

“Latinos represent the largest minority ethnic group in the United States and suffer disproportionately from childhood obesity and type 2 diabetes,” says Jennifer Falbe, a postdoctoral research fellow at the school and lead author of the study. “Given the unique barriers some Latino communities face regarding diet and physical activity, there is an urgent need for culturally and linguistically tailored programs to address childhood obesity in these communities.”

AHF is a family-based group medical appointment program of Contra Costa County Public Health Clinic Services. It consists of five two-hour sessions that teach healthy eating and exercise habits, as well as parenting skills. AHF sessions were delivered in Spanish by a multidisciplinary team including a registered dietitian, a physician and a promotora — a community health worker who engaged families and facilitated understanding of the content of the sessions. The promotoras called families twice to check on progress, bridge communications gaps and remind families about the next session.

“We found that AHF resulted in meaningful improvements in child weight and BMI,” says Falbe. “AHF was unique in its delivery by a provider triad and its cultural relevance. Furthermore, unlike many interventions, the program is financially sustainable for the publicly funded health centers in which it was delivered.”

The U.S. Preventive Services Task Force has called for studies that address weight management in minority children and investigate efficient, primary care feasible interventions using allied health professionals. This study makes a valuable contribution to that evidence gap.

Co-authors of the study include Kristine Madsen, associate professor at the UC Berkeley School of Public Health; Nicole K. Tantoco, research assistant at the UC Berkeley School of Public Health; Hannah R. Thompson, research scientist at the UC Berkeley School of Public Health; and Annabelle A. Cadiz, Contra Costa Public Health, Contra Costa Health Services.

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California children with health insurance, regular dental care show big gains

UCLA research shows significant increases over past decade, but disparities persist.

Photo by Elena Zhukova

By Venetia Lai, UCLA

An impressive 3 in 4 California children ages 2 to 5 had a regular dental checkup in 2012, including those from poorer households, according to a new policy brief by the UCLA Center for Health Policy Research.

A decade earlier, just half the children in low-income households made an annual visit to the dentist, along with 60 percent of those from higher-income households.

The findings are part of a comprehensive new study that tracked young children’s health in California from 2003 to 2012. The study found gains in many areas, including health insurance coverage and dental care, but showed a drop in preschool participation, perhaps because of the associated costs.

“These are really encouraging trends for the health and well-being of children in California,” said Sue Holtby of the Public Health Institute, who is lead author of the study. “But some beneficial services remain out of reach for low-income families. The challenge for policymakers is to continue to improve access to, and quality of, the care children receive.”

Using data from 10 years of California Health Interview Survey from 2003 to 2012, the report assessed trends in the health of young children in areas linked to health and school readiness. The report focused on Latino, white, Asian and African-American children ages 5 and younger. According to CHIS, more than 3 million children in that age range lived in the state in 2012.

The safety net expands

Much of the time period covered by the study took place during the recession from 2008 to 2012, when many families lost access to employer-funded health coverage. As more low-income families gained health coverage through two public programs — Medi-Cal and Healthy Families —  ––the share of children ages 5 and younger who had private health insurance plummeted, from 57 percent in 2003 to 44 percent in 2011–12. The change meant a bigger share of young children relied on public coverage: 1 in 2 overall, compared to 1 in 3 a decade earlier.

The dramatic improvements in dental care for young children during the time period may be attributable, in part, to expanded public support.  Specifically, the study notes that a $7 million grant from First 5 California, which funded the study, provided preventive dental health training and education for dental and medical providers at Women, Infants and Children and Head Start programs from 2004 to 2008, the same time period in which annual child dental visits increased. In addition, Medi-Cal and Healthy Families promoted greater awareness of dental benefits.

More parents reading to their children

Another bright spot: More families participated in activities that promote social skills and brain development in young children. The percentage of parents who sang or played music with their child every day rose from 64 percent in 2003 to 68 percent in 2011–12, and those who took their children out on an excursion increased from 32 percent to 37 percent. The biggest jump was in the share of parents who read to their children daily: from 53 percent in 2003 to 62 percent a decade later.

However, the report found the proportion of 3- and 4-year-olds going to preschool at least 10 hours a week dropped over the decade, from 37 percent to 30 percent.

“Parents have gotten the message that there’s a lot they can do for their children’s development at home,” said Elaine Zahnd, a faculty associate at the Center for Health Policy Research and co-author of the study. “But there is more work to do to help parents who want their children to go to preschool.”

Other findings from the report:

  • More young children had access to health care. Access to health care improved for poor children as the decade progressed: the rate of uninsured poor children dropped from 13 percent in 2003 to 8.9 percent in 2012.
  • There are disparities in the sources of medical care. In 2012, far more young Latino children (40 percent) obtained care at community clinics or public hospitals compared to white (14.6 percent) and Asian (20.1 percent) children. However, the share of white children who visited a private doctor’s office or an HMO declined 5.3 points over the decade to 82 percent.
  • Almost all young children (97 percent) had a usual source of medical care in 2012, with two-thirds being treated by private practice doctors and HMOs and the rest at community clinics and hospitals.

“Parents are getting coverage for their children, but can they access health care for their children when they need it?” asked David Grant, director of the California Health Interview Survey and co-author of the report. “As more children rely on the safety net, policymakers must ensure that the clinics and public hospitals that serve them are adequately funded.”

The report found noteworthy improvements in young children’s health over the decade — especially in closing the income gap in dental and health care. But authors say continued monitoring and further research are needed to understand what prompted negative changes in private insurance coverage and preschool enrollment.

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UCSF, San Francisco community partner to address oral health epidemic

Plan aims to move toward making the city cavity-free.

A UCSF dental resident gives a free dental screening to a child during a Sunday Streets fair in the Bayview, one of several annual outreach events for the local community. (Photo by Cindy Chew)

By Scott Maier, UC San Francisco

In San Francisco, nearly 40 percent of children have experienced tooth decay by the time they reach kindergarten, and low-income kindergartners are eight times more likely to have untreated tooth decay, reports the San Francisco Children’s Oral Health Collaborative (SF COH).

Oral health disparities are specific to local neighborhoods, with the highest rates in Chinatown, where more than 50 percent of all kindergarteners suffer from cavities.

To inform and elicit community feedback about the importance of children’s oral health – and continue to learn why some ethnicities are more at-risk – the SF COH, which includes UC San Francisco, the SF Department of Public Health and community health providers and advocates, hosted a community stakeholder meeting on April 30 in Chinatown.

Attendees at the two-hour meeting at the Chinatown YMCA included San Francisco Supervisors Julie Christensen and Scott Wiener, and Health Commissioner Ed Chow.

“Good oral health is critical to the well-being of our city, and we need to expand access to dental care as well as healthy and nutritious food, particularly in our low-income communities,” Wiener said.

Similar stakeholder meetings are planned for Latino and African American communities in San Francisco.

“Because of this meeting, we were able to raise the level of awareness of children’s dental caries that is disproportionately affecting the Chinatown neighborhood,” said Lisa Chung, D.D.S., M.P.H., associate professor in the UCSF School of Dentistry Department of Preventive and Restorative Dental Sciences and SF COH co-director. “We were able to bring together local health and child care providers and organizations and engage in a spirited discussion about what could be causing these Chinatown disparities, existing barriers to addressing them, and how we can collaborate and move forward.”

A silent epidemic

Tooth decay and periodontal disease are the two biggest threats to oral health and among the most common chronic diseases in the United States. In fact, former U.S. Surgeon General Regina Benjamin called oral diseases a “silent epidemic.”

Children with untreated cavities may experience pain, dysfunction, school absences, difficulty concentrating and low self-esteem, according to the SF COH.

“It is better to prevent tooth decay than to provide extensive dental treatment for a very young child,” said Dr. Steven Ambrose, director of dental services for the San Francisco Department of Public Health, a co-leading agency of the Children’s Oral Health Collaborative. “If we can help parents understand how to keep their babies’ teeth healthy, we can prevent unnecessary disease and pain, and promote and protect our children’s oral health in a far easier and cost effective manner.”

Dental caries is largely preventable through dental sealants, fluoride varnish, healthy eating habits, daily oral care at home and routine dental visits. However, many parents, medical providers and even dental providers do not fully understand their critical roles in preventing this disease.

Plan to make San Francisco cavity-free

A cross-sector initiative designed to improve the health and wellness of all San Franciscans, the San Francisco Children’s Oral Health Collaborative coordinated the San Francisco Children’s Oral Health Strategic Plan 2014-2017 toward making the city cavity-free. The plan identifies the most effective, evidence-based actions each group can take to make the most impact. Target groups are children under 10, pregnant women, low-income communities of color, recent immigrants and other populations most at risk.

“Involving the community and collaborating with its members are essential in efforts to improve public health, and is at the core of SF HIP’s Children’s Oral Health Collaborative,” Chung said. “We prioritized this first meeting in Chinatown on public and private health professionals and Chinatown program planners, community leaders, and school administrators as they are working closest with the target population – young children and their caregivers. We look forward to working to have similar community briefings throughout San Francisco.”

The San Francisco Children’s Oral Health Collaborative is supported by the Hellman Foundation. The Chinatown community stakeholder meeting was sponsored by the Chinatown YMCA, the Asian Pacific Islander Health Parity Coalition, APA Family Support Services, NICOS Chinese Health Coalition and API Council.

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New program targets next generation of physicians to advance Latino health

UC Davis, Permanente Medical Group launch Prep Médico.

By Charles Casey, UC Davis

The University of California, Davis, and The Permanente Medical Group today (May 4) launched a new initiative at UC Davis School of Medicine dedicated to building the next generation of physicians committed to advancing Latino health.

The program, called Preparando Estudiantes Para Ser Medicos, or Preparing Students to Be Physicians, (“Prep Médico” for short) is a multifaceted initiative that will provide scholarships, mentorship and internship opportunities, a residential program, intensive language training, volunteer service opportunities, and hands-on clinical experiences for pre-med and medical students. The goal is to expand diversity in medicine and ultimately increase the number of Latinos who choose to become physicians.

“With the growing demographic of the Latino community in California, it is imperative that we be proactive in educating a future workforce that is both skilled and culturally responsive to and respectful of the community we serve,” said UC Davis Chancellor Linda P.B. Katehi. “Launching innovative and scholarly initiatives such as Prep Médico helps UC Davis better serve our local and global community and represents a tangible way we are breaking new ground to meet society’s most pressing challenges and leading the way for higher education in the 21st century and beyond.”

UC Davis expects to serve approximately 100 students annually through the new program, which begins with scholarship support for medical school admissions testing this year and will be fully implemented by 2018.

“There is an urgent need for California and the nation’s health care providers to have a workforce of culturally competent physicians who can help address health inequities in underserved communities,” said David Acosta, associate vice chancellor of diversity and inclusion at UC Davis, who will serve as director of the new program.

“Our partnership with The Permanente Medical Group can be transformative, not just for UC Davis, but for California and the nation as well. Prep Médico will enable us to encourage and train more young people to become physicians and serve the rapidly growing Latino community.”

“The Prep Médico program will provide a holistic, comprehensive and longitudinal approach to supporting diverse students at key stages in their educational experience,” said Julie Freischlag, dean of the School of Medicine and vice chancellor for human health sciences at UC Davis. “It will encourage and support students from their first days in college all the way through medical school to help ensure that we can increase the number of Latino physicians practicing in California and around the nation.”

The growing importance of Latino health

According to the U.S. Census, Latinos are the largest single racial/ethnic group in California, making up 39 percent of the state’s population. However, only 4.7 percent of physicians in California are Latino. Having a diverse workforce is a key component in the delivery of quality, competent health care. Studies by the U.S. Department of Health and Human Services and the Institute of Medicine have indicated that race concordance between patients and physicians can result in improved patient satisfaction, trust with better adherence to medical treatment, health literacy, and patient safety. Expanding the Latino physician workforce could play a significant role in reducing health care disparities in those underserved communities.

“This program is part of The Permanente Medical Group’s commitment to meeting the needs of all patients throughout California, including the rapidly growing Latino community,” said Robert Pearl, executive director and chief executive officer of The Permanente Medical Group. “As the nation’s largest medical group with more than 8,000 physicians, we understand how important it is  to provide care that is culturally responsive and respectful. To do that, California and the nation will need high quality, well-trained physicians who are knowledgeable about Latino culture and fluent in Spanish. Prep Médico will help us meet that very important need.”

A new model for increasing the physicians pipeline

Prep Médico emphasizes both undergraduate and medical school elements in its program design.

Undergraduate/pre-medical school components:

  • Navigating Your Path Into Medicine: A six-week residential program for freshman and sophomore undergraduates consisting of science and math intensive sessions, clinical immersion experiences, technical skills development, community immersion opportunities and mentorship from both UC Davis Health System and The Permanente Medical Group physicians. The program will enroll its first class of 40 students in 2016 with plans to grow to 60 students participating annually.
  • Pre-Med Internship, Mentorship & Research: A four-month program, where junior and senior undergraduates receive in-depth clinical and research experiences in a range of medical and surgical specialties. It includes a six- to 12-month internship, where student scholars receive mentoring and assistance in preparing for the medical school application process. This program will enroll its first class of 10 scholars in fall 2016 and will expand to 30 students annually.
  • MCAT Scholarship: Starting this year, 10 scholarships will be awarded to cover the expense of preparation and registration fees for the Medical College Admission Test (including travel and lodging expenses if needed.)

Medical school components:

A certification program at UC Davis School of Medicine for students focusing on health care delivery for Latino communities.

  • Clinical Rotations: In addition to those rotations that currently exist, medical students enrolled at the UC Davis School of Medicine will have the opportunity to do two-to-four week clinical rotations with TPMG physicians from diverse specialties and in Kaiser Permanente medical centers and ambulatory care offices that provide health care services to large Latino communities. These rotation opportunities will target third- and fourth-year medical students.
  • Student-Run Clinics: Students will volunteer at a pair of community health clinics run by School of Medicine students and UC Davis undergraduates that are dedicated to serving predominately Latino communities: Clínica Tepati and Knights Landing Clinic.
  • Medical Spanish Intensive Program: In collaboration with TPMG’s existing Medical Spanish Intensive Program for physicians, UC Davis medical students and residents will have the ability to access workshops in the Bay Area designed to enhance medical Spanish language proficiency. An intensive program in Mexico is also being considered for inclusion in this component of the program.

In addition to launching the Prep Médico program, The Permanente Medical Group also announced today its renewed commitment to UC Davis’ Accelerated Competency-based Education in Primary Care (ACE-PC) program. The ACE-PC initiative is a unique medical education program that allows a select group of eligible students to complete medical school in three years, one year earlier than traditional programs, and then directly enter into their primary care residency. The UC Davis program eliminates summer vacations and electives, and is designed for students who know they want to become primary-care physicians.

Kristina Rodriguez, a Healdsburg native who is a first-year student at UC Davis School of Medicine, already has started her clinical rotations with TPMG physicians through the ACE-PC program. She said the experience has reinforced her childhood dream of becoming a physician and providing medical care to the Latino community.

“Having support and resources are everything to people who sometimes don’t have anything,” said Rodriguez, who is the first person in her family to go to college or medical school. “It is so important to have these programs to bridge those gaps for people who have a passion, but don’t have the resources, help and support to pursue a medical education. These programs are going to be essential.”

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Women, regardless of backgrounds, seek help for ‘got to go’ feeling

Study shows importance of providers discussing urinary incontinence with patients.

By Phyllis Brown, UC Davis

Regardless of their racial, ethnic, educational or socioeconomic background, women seek help for a frustrating — and ubiquitous — feature of becoming “a woman of a certain age:” the need be close to the women’s room.

Those are the findings of a large study by UC Davis of urinary incontinence in menopausal women, based on data from the Study of Women’s Health Across the Nation (SWAN), a nine-year investigation of diverse menopausal women from six sites across the United States. The study is published online today (April 7) in Obstetrics and Gynecology.

The study, of more than 3,302 study participants from such diverse locations as Oakland, Pittsburgh and Detroit, found that most women, regardless of their backgrounds, talked with their health care provider about urinary urgency incontinence — leaking with the immediate need to reach the restroom — or stress incontinence — leaking with “coughing, laughing or sneezing” — over the nine years they were followed.

All of the participants were transitioning through menopause. Some 68 percent of women reported monthly or more frequent urinary incontinence, either leakage with urgency or with coughing, sneezing or exercising.

Earlier studies have suggested that African-American women and women of lower socioeconomic backgrounds were less likely to seek treatment.

“Our study results do not support previous findings that black women or women with lower socioeconomic circumstances are either less likely to seek care only at a higher level of bother of urinary incontinence frequency than white women or women of higher socioeconomic resources,” said Elaine Waetjen, UC Davis professor in the Department of Obstetrics and Gynecology and lead study author.

Rather, Waetjen said, the strongest associations with seeking care were worsening and persistence of symptoms. That is important, Waetjen said, because urinary incontinence is readily treatable.

“By discussing their urinary incontinence with a health care provider, women can learn about the variety of treatment options available to them, from behavioral changes to medications and surgery,” she said.

Other study authors include Guibo Xing, Joy Melnikow and Ellen Gold, all of UC Davis and Wesley O. Johnson of UC Irvine.

The study was funded by the National Institutes of Health, including the Institute of Diabetes and Digestive and Kidney Disease, Office of Research on Women’s Health, Institute on Aging, and Institute of Nursing Research, including grants number DK092864, U01NR004061, U01AG012505, U012535, U01AG02531, U01AG02531, U01AG012539, U01AG012546, U01AG012553, U01AG012554, U01AG012495.

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Income inequality affects who get an underutilized test for breast cancer

UCLA-led study shows that economic factors may influence adoption of new technologies.

The study, led by UCLA’s Ninez Ponce, found that communities with greater gaps between high-income individuals and low-income individuals also had larger gaps in testing. (Photo by Shweta Saraswat, UCLA)

By Venetia Lai, UCLA

Wealthier women who live in communities with the greatest income divide between rich and poor had better access to a new genetic test that can determine the most effective form of treatment for early-stage breast cancer, according to a new study (link is password-protected) by the UCLA Center for Health Policy Research, Harvard Medical School’s Brigham and Women’s Hospital and Aetna. The study, published in the April issue of the journal Health Affairs, also indicated that only a small minority of women with breast cancer received the test at all.

“Our study shows that even among women who have insurance, where they live and how income is distributed in their community were closely linked to their chance of getting access to an effective innovation in the early years of its diffusion,” said Ninez Ponce, associate director of the UCLA Center for Health Policy Research and lead author of the study.

The Gene Expression Profiling test is an early example of a “precision medicine” genomic test that estimates a patient’s risk of having a recurrence of a disease. According to current medical evidence, a woman with early-stage, estrogen-receptor–positive, lymph-node–negative breast cancer with a low-risk GEP test score may not benefit from adding chemotherapy to her treatment plan, while a woman with a high-risk score would benefit and should consider including chemotherapy in her treatment. More than 100,000 women are diagnosed with this type of breast cancer every year.

The study is based on a survey of 1,847 women between the ages of 35 of 64 who were insured through an Aetna health plan and were newly diagnosed with breast cancer in 2006 and 2007. Of those, 235 (12.7 percent) had the GEP test.

The study found that the greater the gap between high-income individuals and low-income individuals within a community, the larger the gap in testing. In communities where there was greater equality in income — whether poorer or wealthier — the adoption and use of the tests was slower than in communities with unequal income levels.

“Income inequality is at an all-time high right now,” said Dr. Jennifer Haas, a co-author of the study and associate professor at Harvard Medical School’s Brigham and Women’s Hospital. “That it should have a bearing on who gets an innovative test and who doesn’t could lead to more social disparities in cancer care.”

The authors point to the need for more research to address the socioeconomic and other barriers that may prevent women from accessing GEP and other medical innovations.

The TRANSPERS Center for Translational and Policy Research on Personalized Medicine, the National Institutes of Health, Harvard Catalyst, the Harvard Clinical and Translational Science Center, and the National Research Service Award Primary Care Research Fellowship and Aetna supported this study.

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UCSF professor appointed to expert panel for precision medicine

Esteban Burchard will help shape President Obama’s precision medicine plan.

Esteban Burchard, UC San Francisco (Photo by Cindy Chew)

UC San Francisco’s Esteban Burchard, M.D., M.P.H., has been appointed to an expert panel advising the National Institutes of Health (NIH) on how to develop President Barack Obama’s Precision Medicine Initiative.

The $215 million initiative, announced by Obama earlier this year, aims to gather and analyze vast amounts of genetic and other patient data to develop more targeted, personalized therapies for treating diseases in the future.

The panel, composed of medicine, technology and policy leaders, will guide the NIH in its efforts to build a group of at least 1 million American volunteer research participants who will confidentially share their genetic, environmental, lifestyle and behavioral information with qualified researchers.

Burchard, whose specialty is how genetic ancestry affects drug response, said he was asked to be on the panel because of his expertise in applying precision medicine to minority children with asthma. He has recruited the largest pediatric gene-environment study of asthma in minority children in the U.S. Since 2004, more than 95 percent of all NIH funded clinical research has been performed in populations of European origin, even though it’s well known that ancestry affects both disease susceptibility and drug response.

“There are scientific advantages that can be gained by studying diverse populations,” Burchard said. “There are going to be some drugs that work really well for African Americans, and there are going to be some drugs that work really well for everybody.”

Treatments tailored to a patient’s genes

Burchard, professor of bioengineering in the UCSF School of Pharmacy has been conducting genomic research for more than a decade, completing the most comprehensive study of asthma in the United States, collecting the genetic, socioeconomic and environmental information of more than 10,000 patients.

Beyond simply finding which genes are associated with severe asthma, Burchard is studying the role a person’s genes play in determining how he or she responds to existing asthma medications.

He’s finding that genetic factors are the strongest predictor of drug response – more influential than air pollution or social factors – and some of the most severe asthma sufferers don’t respond well to common asthma drugs. Using this genetic knowledge to develop better, more targeted drugs to an individual’s specific disease profile is the promise of precision medicine.

“Forget notions of race and ethnicity. When you know specific genes involved in disease and can genetically test each individual, that’s the most effective way to identify the risk factor and the treatment,” said Burchard.

Gathering expert and public input

The working group panel will deliver a preliminary report in September to accelerate the launch of this national study of individual differences that influence health and disease outcomes. The group will gather input from patients and the scientific community through public workshops on precision medicine topics, including privacy, electronic health records, mobile health technologies, existing research cohorts, participant preferences, and inclusion of minority and underserved populations.

The plan is the outgrowth of a 2011 report from a National Academy of Sciences expert committee recommending the creation of a biomedical “knowledge network”  that would allow scientists to gather and mine vast amounts of patient data, with the goal gaining insights into the genetic and molecular basis of disease.

The committee was co-chaired by then-UCSF Chancellor Susan Desmond-Hellmann, M.D., M.P.H., and also included two other members of the UCSF faculty – Keith Yamamoto, Ph.D., vice chancellor for research, and Bernard Lo, M.D., professor of medicine emeritus and director emeritus of the Program in Medical Ethics at UCSF.

Desmond-Hellmann, now CEO of the Gates Foundation, is also serving on the president’s prestigious working group.

“I’m confident that we’ve pulled together the best of the best in this working group to put us on the right path forward,” said NIH Director Francis S. Collins, M.D., Ph.D.

“Establishing a 1 million person cohort is an audacious endeavor, but the results from studying such a large group of Americans will build the scientific evidence necessary for moving precision medicine from concept to reality.”

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Public health researchers go to church to promote hepatitis B screening

UCLA team held small group discussions in more than 50 L.A.-area Korean churches.

To reach a vulnerable population largely unaware of the health risks, a team from the Fielding School for Public Health held small group discussions in more than 50 Los Angeles-area Korean churches. (Photo by UCLA-Kaiser Permanente Center for Health Equity)

By Dan Gordon, UCLA

For the large Korean American-community in Los Angeles, chronic infection with the hepatitis B virus looms as a significant — and too often unspoken — health threat, associated with the highest rates of liver cancer for any ethnic group in Los Angeles. Knowing one’s hepatitis B status can be critical — it allows those who test HBV-negative to be immunized against the virus while pointing the way toward early treatment as well as more vigilant efforts to prevent transmission for those who are positive. But most adults in L.A.’s Korean-American community have never been screened and are unaware of whether they carry the virus.

In an effort to change that, a research team from the UCLA Fielding School for Public Health’s Kaiser Permanente Center for Health Equity and Center for Cancer Prevention and Control Research, working in partnership with leaders of Los Angeles’ Korean-American community, set out to increase HBV screening in the population through small group discussions led by trained community members. For their study testing the impact of this strategy, they chose unlikely venues: 52 Korean churches in Los Angeles.

“When we started, people questioned the feasibility of having discussions about a sexually transmitted virus at church,” said Roshan Bastani, the Fielding School professor with leadership roles in both centers who headed the study. “But if you want to target a general population of Koreans in Los Angeles, you have to go where they tend to gather. We learned that most Koreans go to church, and that it’s not just religious but also a social experience where non-religious services are delivered to members. In talking with church leaders and other members of the community, we were encouraged to pursue what they saw as an important project.”

If not treated, chronic HBV infection can lead to liver cirrhosis in as many as 1 in 4 carriers, which can ultimately progress to liver cancer. HBV is also highly infectious — spread not only via sexual contact and sharing needles, but also through household items such as razors or toothbrushes, or from an infected mother to her child during birth.

Because it is so common in many Asian countries, HBV disproportionately affects Asian Americans, particularly newer immigrants. The problem is particularly serious among Korean Americans. In Los Angeles, an estimated 12 percent of the Korean-American population is infected — and because the virus causes no symptoms until the liver damage becomes severe, the majority of them doesn’t know it. Although routine HBV vaccination of children has been implemented in the United States and much of Asia for two decades, most adults were born before childhood HBV vaccination became commonplace and can benefit from immunization only once they are tested and found to be HBV-negative. The potential for uninfected adults to get vaccinated, and for carriers to receive early treatment and monitoring while taking measures to prevent transmission to others, all point to the public health benefits of promoting HBV screening.

The Fielding School team relied heavily on the wisdom of its Korean-American community partners for both the design and implementation of an intervention aiming to increase screening. A seven-member community advisory committee included two church pastors, a pastor’s wife, a church elder, a church health leader, a physician and a representative of a Korean-American, nonprofit, faith-based organization. Fifty-one bilingual community members were hired as staff members for the study and trained to administer surveys and facilitate the small group discussion sessions with the churches — ensuring that the intervention could be sustained beyond the three-year study period.

One member hired for the study team with deep roots in the Los Angeles Korean community, Hosung Kim, was assigned the task of inviting the participation of pastors and other church leaders. “My role was to convince them that our project could improve the lives of their members through health care awareness,” said Kim, who covered the activities of Korean churches as a reporter working for a Korean newspaper chain. “I explained that because the overwhelming majority of Korean immigrants participate in Sunday services, this would provide the best opportunity to recruit participants … Most of the responses were very positive.”

Of the 52 Korean churches that participated, half were randomly assigned to the study’s intervention arm, which featured small group discussions on hepatitis B among Korean adults who had either not previously been tested or couldn’t recall their results; the other half, which served as the control group, discussed nutrition and physical activity. The HBV discussions provided facts about hepatitis B and liver cancer, the risk for Koreans, and the rationale for testing. Through scripts and role-playing, participants were guided on how to bring up the topic with their doctors and encouraged to discuss HBV with family and friends. Testing and vaccination were framed within Korean medicine concepts of keeping the body healthy.

The project identified and addressed factors that prevent many Koreans from getting tested, even when they are aware of the HBV risk. Many participants expressed fear about the consequences of learning they were infected, or the potential for bringing shame to their family if they tested positive. There was also concern about the cost of the test — 57 percent of the study participants reported lacking health insurance. In an effort to overcome that barrier, the project staff provided a list of clinics offering low-cost or free HBV screening.

In the end, the discussions proved highly effective: Participants in the intervention group were three times more likely to get a hepatitis B test than those who were in one of the groups that discussed nutrition and physical activity.

“Few previous studies have attempted to identify effective strategies to promote hepatitis B screening among Koreans,” said Beth Glenn, associate professor of health policy and management and a member of the study team. “We were excited to see that a one-time, small-group discussion intervention produced a meaningful increase in hepatitis B screening in a population at high risk for hepatitis B and liver cancer.”

Any concerns the Fielding School team had about testing the intervention in Korean churches were quickly eased.

“For some of our projects, even when we are actively recruiting, it can be hard to find people to participate,” said Alison Hermann, project director for the study. “In this case we would simply go to the churches, set up a table with our banner, and people would come to us. Part of it had to do with the sense of community in the churches, where if something was going on, members wanted to know about it. But we also found that the interest in health-related issues was tremendous.”

This story originally appeared in the UCLA Fielding School of Public Health magazine’s Fall 2014 issue.

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Insuring undocumented residents could help solve multiple health care issues

UCLA health policy care analysis finds four key problem areas for Latinos under ACA.

Alex Ortega, UCLA

By Mark Wheeler, UCLA

Latinos are the largest ethnic minority group in the United States, and it’s expected that by 2050 they will comprise almost 30 percent of the U.S. population. Yet they are also the most underserved by health care and health insurance providers.

Latinos’ low rates of insurance coverage and poor access to health care strongly suggest a need for better outreach by health care providers and an improvement in insurance coverage. Although the implementation of the Affordable Care Act of 2010 seems to have helped (approximately 25 percent of those eligible for coverage under the ACA are Latino), public health experts expect that, even with the ACA, Latinos will continue to have problems accessing high-quality health care.

Alex Ortega, a professor of public health at the UCLA Fielding School of Public Health, and colleagues conducted an extensive review of published scientific research on Latino health care. Their analysis, published in the March issue of the Annual Review of Public Health, identifies four problem areas related to health care delivery to Latinos under ACA:

  • The consequences of not covering undocumented residents.
  • The growth of the Latino population in states that are not participating in the ACA’s Medicaid expansion program.
  • The heavier demand on public and private health care systems serving newly insured Latinos.
  • The need to increase the number of Latino physicians and non-physician health care providers to address language and cultural barriers.

“As the Latino population continues to grow, it should be a national health policy priority to improve their access to care and determine the best way to deliver high-quality care to this population at the local, state and national levels,” Ortega said. “Resolving these four key issues would be an important first step.”

Insurance for the undocumented

Whether and how to provide insurance for undocumented residents is, at best, a complicated decision, said Ortega, who is also the director of the UCLA Center for Population Health and Health Disparities.

For one thing, the ACA explicitly excludes the estimated 12 million undocumented people in the U.S. from benefiting from either the state insurance exchanges established by the ACA or the ACA’s expansion of Medicaid. That rule could create a number of problems for local health care and public health systems.

For example, federal law dictates that anyone can receive treatment at emergency rooms regardless of their citizenship status, so the ACA’s exclusion of undocumented immigrants has discouraged them from using primary care providers and instead driven them to visit emergency departments. This is more costly for users and taxpayers, and it results in higher premiums for those who are insured.

In addition, previous research has shown that undocumented people often delay seeking care for medical problems.

“That likely results in more visits to emergency departments when they are sicker, more complications and more deaths, and more costly care relative to insured patients,” Ortega said.

Insuring the undocumented would help to minimize these problems and would also have a significant economic benefit.

“Given the relatively young age and healthy profiles of undocumented individuals, insuring them through the ACA and expanding Medicaid could help offset the anticipated high costs of managing other patients, especially those who have insurance but also have chronic health problems,” Ortega said.

The growing Latino population in non-ACA Medicaid expansion states

A number of states opted out of ACA Medicaid expansion after the 2012 Supreme Court ruling that made it voluntary for state governments. That trend has had a negative effect on Latinos in these states who would otherwise be eligible for Medicaid benefits, Ortega said.

As of March, 28 states including Washington, D.C., are expanding eligibility for Medicaid under the ACA, and six more are considering expansions. That leaves 16 states who are not participating, many of which have rapidly increasing Latino populations.

“It’s estimated that if every state participated in the Medicaid expansion, nearly all uninsured Latinos would be covered except those barred by current law — the undocumented and those who have been in the U.S. less than five years,” Ortega said. “Without full expansion, existing health disparities among Latinos in these areas may worsen over time, and their health will deteriorate.”

New demands on community clinics and health centers

Nationally, Latinos account for more than 35 percent of patients at community clinics and federally approved health centers. Many community clinics provide culturally sensitive care and play an important role in eliminating racial and ethnic health care disparities.

But Ortega said there is concern about their financial viability. As the ACA is implemented and more people become insured for the first time, local community clinics will be critical for delivering primary care to those who remain uninsured.

“These services may become increasingly politically tenuous as undocumented populations account for higher proportions of clinic users over time,” he said. “So it remains unclear how these clinics will continue to provide care for them.”

Need for diversity in health care workforce

Language barriers also can affect the quality of care for people with limited English proficiency, creating a need for more Latino health care workers — Ortega said the proportion of physicians who are Latino has not significantly changed since the 1980s.

The gap could make Latinos more vulnerable and potentially more expensive to treat than other racial and ethnic groups with better English language skills.

The UCLA study also found recent analyses of states that were among the first to implement their own insurance marketplaces suggesting that reducing the number of people who were uninsured reduced mortality and improved health status among the previously uninsured.

“That, of course, is the goal — to see improvements in the overall health for everyone,” Ortega said.

Other authors of the study were Arturo Vargas Bustamante of UCLA and Hector Rodriguez of UC Berkeley. Funding was provided by the National Heart, Lung, and Blood Institute (P50 HL105188).

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Welltopia: A new online resource for California

Comprehensive website aims to reduce health disparities.

By Carole Gan, UC Davis

Welltopia, a new website launched today (Feb. 25) by the California Department of Health Care Services (DHCS) and the UC Davis Institute for Population Health Improvement (IPHI), offers a wide range of essential resources to help Californians, especially those on limited incomes, build healthier lives and communities.

Designed to complement the popular Welltopia by DHCS Facebook page, the new website serves as a comprehensive resource connecting individuals, families and communities to credible information that addresses the social determinants of health and other leading causes of preventable death.

Many studies have shown that access to health care, education, employment, housing, nutritious foods and physical activity are among the fundamental drivers of health for individuals and their communities. Making reliable information and resources available for people of all ages is key to creating healthy environments.

“We developed Welltopiato be a convenient and trusted source of information covering all three aspects of health — physical, mental and well-being,” said Neal Kohatsu, DHCS medical director. “We’ve made every effort to ensure that the resources are both accurate and accessible to consumers.”

The Welltopia site organizes information into five categories — Well Body, Well Mind, Jobs & Training, Health Insurance, and Basic Needs. It includes information on nutrition, physical activity, smoking cessation, alcohol- and drug-abuse prevention, stress management, health insurance, residency, and social services, among others. The site also contains videos, photos and graphics with information about health-related programs. There are free applications, such as fitness trackers, women’s health information, recipes and food journals to track daily calorie intake, and links to CalFresh, education, job placement resources and other social services.

“Welltopia should be the first stop for persons seeking reliable information about the many determinants of health,” said Kenneth W. Kizer, IPHI director. “Its friendly format quickly guides users to practical and trustworthy sources.”

The Department of Health Care Services manages California’s form of Medicaid, known as Medi-Cal, which helps millions of low-income Californians obtain access to affordable, high-quality health care, including medical, dental, mental health, substance use disorder services, and long-term services and supports. DHCS aims to preserve and improve the health of all Californians.

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Undocumented farmworkers use Medicaid half as often as documented farmworkers

UC Davis study finds that greatest predictor of farmworker use of Medicaid is having children.

J. Paul Leigh, UC Davis

By Karen Finney, UC Davis

Undocumented farmworkers are half as likely as those who are documented to use Medicaid, the federal health insurance program available to low-income individuals and families, according to a new study from UC Davis Health System. The research also shows that the greatest predictor of farmworker use of Medicaid, which provides coverage for prenatal, pediatric and emergency care regardless of documentation status, was having children.

“Undocumented agricultural workers are using Medicaid at about half the rate of documented immigrants and citizens, and they appear to be using it in accordance with the law,” said J. Paul Leigh, senior author of the study, professor of public health sciences and researcher with the Center for Healthcare Policy and Research. “There’s a perception that undocumented farmworkers are overusing Medicaid resources, but our findings indicate the opposite.”

In conducting the study, which is published online in the Journal of Occupational and Environmental Medicine, Leigh analyzed records from the U.S. Department of Labor’s National Agricultural Workers Survey (NAWS) on 41,324 farmworkers from 1993 through 2009, about half of whom were migrants working without residency, citizenship or visas.

Because the NAWS database is the only nationally representative sample of undocumented workers, it is a rare source of information on demographics and income at both individual and household levels for this often elusive group. Given that almost 50 percent of Medicaid recipients are children, the data on households rather than individual adults was particularly relevant to the current study.

Leigh found that undocumented farmworker heads of household were 52 percent less likely to use Medicaid than their documented counterparts: 22.6 percent of documented farmworker heads of household and only 12.2 percent of undocumented farmworker heads of household reported that one or more family members received Medicaid services over two-year intervals during the 16-year study period.

The odds of receiving Medicaid benefits for documented heads of household with one child were 6.57 times greater than that of documented heads of household with no children. One-child undocumented heads of household were 8.4 times more likely to utilize Medicaid than childless documented heads of household.

“Simply having children is the best determinant of Medicaid use,” said Leigh. “Use by undocumented, unmarried males appears to be extremely rare.”

The seemingly disproportionate effect of children on undocumented versus documented heads of household may be explained by access to non-government health insurance options, according to Leigh. Documented workers are much more likely than undocumented workers to have employer-sponsored health insurance, which families typically prefer over Medicaid. Undocumented heads of household, even those with children who are U.S. citizens, rarely have that choice.

“Undocumented workers don’t have any other place to go for health insurance,” Leigh said. “As soon as they have a child in the family, undocumented workers are much more likely to use Medicaid.”

Higher income, either for individuals or families, was associated with lower odds of Medicaid use for both documented and undocumented heads of household. There were also variations by region, with California having the highest odds of Medicaid use.

This is one in a series of studies of health care utilization prepared by Leigh, an expert in economics and occupational illnesses. Next in the pipeline is a study of those who use food stamps and the U.S. Department of Agriculture’s Special Supplemental Nutrition Program for Women, Infants and Children, which provides supplemental foods, health care referrals, and nutrition education for low-income women and young children who are deemed at nutritional risk.

“Medicaid Use by Documented and Undocumented Farm Workers” was co-authored by Yoon-Kyung Chung of the Korea Energy Economics Institute in Seoul and Ph.D. graduate of the UC Davis Department of Economics. It was supported by the National Institute for Occupational Safety and Health (grant number 2U54OH007550-11). The study is available online.

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Hispanics develop alcoholic liver disease at younger ages than others

The difference is between four and 12 years earlier than Caucasians or African Americans.

Valentina Medici, UC Davis

By Karen Finney, UC Davis

Hispanics develop alcoholic liver disease (ALD), a common cause of liver-disease death, between four and 12 years earlier than whites/Caucasians or African Americans, according to a new study from UC Davis Health System.

While previous research indicated that Hispanics tend to have more severe ALD than other populations, the new study — published online in the journal Alcoholism: Clinical and Experimental Research — is believed to be the first to pinpoint racial and ethnic disparities in the ages at which symptoms first appear.

“Clinicians typically evaluate older patients for liver disease when moderate or heavy alcohol use has been long term,” said senior author Valentina Medici, associate professor of internal medicine. “We should be more aggressive in counseling patients about the importance of sobriety and testing them for ALD at younger ages, especially our Hispanic patients.”

An expert on liver metabolism and physiology, Medici and the study team reviewed records of nearly 800 UC Davis Medical Center patients diagnosed between 2002 and 2010 with one of the three, progressive stages of ALD caused by alcohol consumption — alcoholic fatty liver, alcoholic hepatitis or alcoholic cirrhosis.

The team also assessed patients’ drinking patterns, laboratory data, body mass indexes and additional health conditions such as metabolic syndrome and diabetes. Patients who had diseases such as hepatitis B or who were HIV-positive were excluded from the study to avoid potential confounding effects on ALD onset and severity.

The results showed that the most striking differences were in the average ages of onset of alcoholic fatty liver: 41 for Hispanic patients, 51 for whites/Caucasians and 53 for African Americans. This is the first stage of ALD and the point at which intervention can be most successful at reversing liver damage.

The average ages of onset for alcoholic hepatitis were 41 for Hispanic patients, 47 for whites/Caucasians and 48 for African Americans. For alcoholic cirrhosis, the average ages of onset were 49 for Hispanics, 53 for whites/Caucasians and 54 for African Americans.

The team also found that Hispanics who had end-stage ALD were more likely to be obese and diabetic than White/Caucasian and African American patients in the study.

“Our findings suggest that alcoholic liver disease is caused by more than chronic alcoholism,” said Charles Halsted, a study co-author and professor emeritus of internal medicine. “Future research should focus on genetic, metabolic and environmental factors that may increase the susceptibility of Hispanics to this disease.”

Funding for the study was provided by grants to Medici from the National Institutes of Health (numbers K08DK084111 and R03DK099427) and the UC Davis Division of Gastroenterology and Hepatology. Additional contributors to the research were lead author Robert Levy, Blythe Durbin-Johnson and Andreea Catana of UC Davis.

The study — titled “Ethnic Differences in Presentation and Severity of Alcoholic Liver Disease — is available online at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1530-0277/earlyview.

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