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Service Delivery Innovation Profile

Community Health Workers Offer Culturally Tailored Interactive Workshops and Counseling to Filipino Americans, Leading to Improvements in Medication Adherence and Cardiovascular Risk Factors


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Snapshot

Summary

Based on a community assessment and input from groups serving the Filipino American community, the Center for the Study of Asian American Health at New York University School of Medicine and the Kalusugan Coalition developed a program in which trained community health workers help Filipinos who are at high risk for cardiovascular disease take charge of their cardiovascular health. Over a 4-month period, the community health workers led interactive workshops using storytelling and other culturally tailored techniques and also regularly met with participants one-on-one to address specific health issues and barriers to care and to connect them to culturally competent providers for needed medical care. Compared with similar individuals receiving only written information, participants adhered more closely to their medication regimens, were more likely to attend medical appointments, and achieved better blood pressure control and greater reductions in body mass index.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial comparing medication adherence, attendance at appointments, and changes in blood pressure control and body mass index between program participants and a control group of similar individuals receiving only one brief educational session with a community health worker and written educational materials.
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Developing Organizations

Center for the Study of Asian American Health; New York University School of Medicine
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Date First Implemented

2007
A pilot was conducted from 2007 to 2010. The full program ran from 2010 to 2013. begin pp

Patient Population

Race and Ethnicity > Asian; Vulnerable Populations > Immigrants; Racial minoritiesend pp

Problem Addressed

A large and growing segment of the immigrant population in New York City and the United States, Filipino Americans face a higher risk of cardiovascular disease than do Caucasians and other Asian groups. Cultural factors, along with a lack of insurance, low income levels, and immigration concerns, often prevent Filipino Americans from accessing needed health care services. In addition, in most Filipino communities, relatively few providers or programs focus on this population's specific health needs.
  • Large, growing population: Filipino Americans make up the second largest subgroup of Asian Americans and are the one of the fastest growing immigrant groups in the United States.1 Between 2000 and 2010, the Filipino American population in New York and New Jersey grew by 33 percent.2 In 2011, more than 1.8 million Filipino immigrants lived in the United States, with the largest concentrations being in Los Angeles, San Francisco, and the New York metropolitan area.3
  • High risk of heart disease: Cultural traditions can increase the risk of heart disease among Filipinos, including a diet high in fat and sodium and high rates of alcohol and tobacco use (particularly among Filipino men).1 Heart disease causes nearly a third of deaths among Filipino Americans, compared to a quarter of deaths for Americans overall and 19 to 29 percent of deaths for other Asian American groups. Roughly 60 percent of Filipinos have hypertension, and relatively few have the condition under control. Many Filipinos also have coexisting conditions that increase the risk of heart disease, such as diabetes or obesity.4,5
  • Cultural barriers to accessing preventive care and treatment: Cultural traditions and challenges related to the immigrant experience often make it difficult for Filipinos to access needed preventive care and treatment. Many Filipinos who have recently come to the United States have limited social support. In addition, a stigma exists in the Filipino community with respect to seeking health care, particularly among men (for whom seeking care is associated with weakness). Filipino women often work full time and take primary responsibility for the home and family, leading to stress that increases cardiovascular risk and a lack of time available to seek care.1
  • Unrealized potential of culturally competent programs: Despite the high need, relatively few health care organizations in communities where many Filipino Americans live have programs specifically designed to serve this population. The scarcity of programs likely stems in part from the relatively low level of cohesiveness in many Filipino communities, compared with other minority groups.1

What They Did

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Description of the Innovative Activity

The Center for the Study of Asian American Health (CSAAH) at the New York University (NYU) School of Medicine and the Kalusugan Coalition developed a program in which trained community health workers (CHWs) helped Filipino Americans at high risk for cardiovascular disease take charge of their health. During a 4-month program, the CHWs led interactive workshops using storytelling and other culturally tailored techniques and also regularly met with participants one-on-one to address specific health issues and barriers to care and to connect them to culturally competent providers. Key program elements include the following:
  • Enrollment through screenings at community-based organizations: Community-based organizations (e.g., churches) and businesses that serve Filipinos held screening events to identify those with hypertension or other risk factors for cardiovascular disease. Such screenings also took place at community events frequented by Filipinos. The screenings included measurement of blood pressure, blood glucose, cholesterol, height, and weight. 
  • Series of culturally tailored workshops: Trained CHWs presented a series of four culturally tailored educational workshops over a 4-month period. The workshops covered a variety of health topics, including general background on heart disease, signs of a heart attack, diabetes, healthy eating, physical activity, and smoking cessation. Sessions were tailored to the Filipino community in the following ways:
    • Adaptation of existing curriculum: Staff at CSAAH adapted the National Heart, Lung, and Blood Institute (NHLBI) Healthy Heart, Healthy Family curriculum to the local Filipino community in New York and New Jersey. (CSAAH served as a test site for the curriculum.) The NHLBI series already included culturally appropriate information in both English and Tagalog (the primary language spoken by Filipinos), including recipes for traditional Filipino foods and how Filipino culture may affect diet, exercise, and other health-related behaviors. Staff added information about local resources, such as affordable exercise classes, and tailored the curriculum to the demographics of the area and the specific participants. For example, an individual participant's daily commute could be altered to incorporate exercise by suggesting a farther subway or bus stop.  
    • Addition of storytelling, role playing, and other interactive techniques: As part of their training (described in the Planning and Development Process section), CHWs learned to use storytelling, role playing, and other interactive techniques (also known as “theater-of-the-oppressed” techniques) designed to empower disadvantaged groups to effect social change. For example, participants acted out how the blood flows through the chambers of the heart in a normal heart and in one clogged with cholesterol. They also demonstrated the functions of the different types of cholesterol, throwing wads of paper on the ground to signify "lousy" (low-density lipoprotein) cholesterol and picking them up to designate "happy" (high-density lipoprotein) cholesterol. 
    • Convenient locations and times: Classes took place in areas where many Filipinos live (often at community organizations familiar to participants) and at times that accommodated participants’ work and family responsibilities.
  • Regular one-on-one coaching: CHWs worked one on one with participants to address individual health issues and health-related behaviors and to provide referrals to culturally competent providers for needed services (see details below). Each CHW had a caseload of about 20 participants, often matched according to age, gender, and other demographics so that CHWs and participants could easily relate to each other. CHWs met with participants in person once each month and talked with them by phone twice a month. During these sessions, CHWs discussed strategies for overcoming individual health challenges (including how to adhere to an appropriate diet and physical activity regimen and form other good health-related habits), answered questions, and provided information about local health resources.
  • Referrals to culturally competent providers: Using a directory of culturally competent providers in the local community, CHWs provided referrals for needed services, such as physician care, home health, and other services. As necessary, CHWs scheduled these appointments and accompanied participants to them.

Context of the Innovation

Established in 2003 with funding from the National Center for Minority Health and Health Disparities (NCMHD), the CSAAH conducts research and training focused on evaluating the health of Asian Americans and addressing the health disparities they face. CSAAH works with a broad network of community organizations locally and across the country to build and strengthen public–private partnerships and train health professionals in community-based approaches to understanding and addressing health disparities in Asian American communities. In 2007, NCMHD designated CSAAH as a National Research Center of Excellence. CSAAH is currently the only Research Center of Excellence focused solely on Asian American populations. With support from the Centers for Disease Control and Prevention, CSAAH recently established the Prevention Research Center, focused on cardiovascular disease and diabetes disparities, as well as a Racial and Ethnic Approaches to Community Health (REACH) Center of Excellence in the Elimination of Hepatitis B Disparities.

The CHW program is part of Project AsPIRE (which stands for Asian American Partnership in Research and Empowerment), a multiyear, community-based research program that consists of three phases: planning (3 years) and testing and evaluating interventions (5 years). Project AsPIRE currently focuses on addressing disparities in Filipino communities in New York and New Jersey.

Did It Work?

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Results

Compared with similar individuals receiving only written information, participants adhered more closely to their medication regimens, were more likely to attend medical appointments, and achieved better blood pressure control and greater reductions in body mass index (BMI).
  • Better medication adherence and attendance at appointments: More than half (52 percent) of the participants achieved 100-percent adherence to their medication regimen, up from 28.9 percent at baseline. In comparison, only 39.3 percent of the control group (who received one brief educational session with a CHW and written educational materials) achieved perfect medication adherence, up from 26.9 percent. Both control and intervention groups improved attendance at medical appointments, but the level of improvement was greater among program participants.6
  • Greater improvement in blood pressure control and BMI: Over an 8-month period (spanning the period between the program's launch and 4 months after it ended), participants achieved greater reductions in blood pressure than did those in the control group, with systolic blood pressure falling 24.3 mm Hg and diastolic pressure falling 10.6 mm Hg among participants, well above the corresponding 7.9 mm Hg and 2.6 mm Hg improvements seen in the control group. In addition, participants reduced their average BMI by 0.37, compared with 0.25 in the control group.6

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial comparing medication adherence, attendance at appointments, and changes in blood pressure control and body mass index between program participants and a control group of similar individuals receiving only one brief educational session with a community health worker and written educational materials.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Seeking Filipino community input on social determinants of health: Starting in February 2004, CSAAH convened a series of meetings with representatives from the Filipino community. The group discussed health issues facing Filipino residents and potential strategies for addressing them.
  • Building community ties: CSAAH hired a Filipino staff member and a graduate research assistant to build ties with Filipino organizations. A prominent Filipino physician acted as a champion for the project, introducing it to leaders and staff at community organizations.
  • Conducting a community health needs assessment: Using formative and qualitative research, CSAAH conducted a community needs assessment to identify concerns, available resources, and the best approaches to meeting the health needs of Filipino residents. As part of this effort, program staff administered a 22-item survey to Filipino men and women between the ages of 13 and 80. The survey was based on existing instruments available from NHLBI and the New York City Department of Health and Mental Hygiene. The survey found that 71 percent of respondents felt that cardiovascular disease and stroke were major concerns for the community. Other concerns focused on poor health habits, including lack of exercise and unhealthy diets, and on various issues facing Filipino immigrants, such as separation from family, feelings of alienation, loss of self-esteem, discrimination, and challenges related to immigration status.
  • Establishing a coalition: The meetings and assessment process led to the formation of a community-wide advisory committee known as the Kalusugan Coalition. (Kalusugan means "health" in Tagalog.) Coalition participants came from different organizations representing the social services, cultural, educational, and professional sectors of the Filipino community.
  • Securing funding: In partnership with the Kalusugan Coalition, CSAAH applied for and received a community-based research project grant from National Center for Minority Health and Health Disparities to address high rates of cardiovascular disease through a CHW-based program. 
  • Developing and adapting a curriculum: CSAAH staff tested and adapted the aforementioned NHLBI curriculum on heart disease. Working with members of the coalition, they added an interactive component using techniques designed to empower disadvantaged groups (also known as "theater-of-the-oppressed" techniques).
  • Recruiting and training CHWs: Organizations involved in the coalition took charge of hiring seven CHWs, choosing candidates based on their skills and experience in community outreach rather than their background in health care. The coalition developed a 100-hour training program that focused on heart health and related issues, such as obesity, diabetes, high blood pressure, high cholesterol, and medication adherence. During the training, CHWs also learned the basics of community-based research projects, the history of CHWs and their role on the health care team, communication strategies, cardiopulmonary resuscitation for adults and children, effective strategies for communicating with enrollees, and available resources for Filipino immigrants in the local community. The training curriculum also covered the interactive techniques described earlier, teaching CHWs how to incorporate them into their teaching and other interactions with participants. 
  • Conducting a pilot study: Prior to undertaking the randomized control trial (RCT) with 170 participants, the organization conducted a pilot study with 99 participants. Based on the success of this study, program leaders decided to conduct an RCT using a control group that received only one educational session with a CHW and written educational materials.

Resources Used and Skills Needed

  • Staffing: At any given time, 4 CHWs worked as part of the program, with each having a caseload of roughly 20 individuals. Additional program staff included a project director and project coordinator who helped with data collection and CHW recruitment and retention. Outside consultants and experts led the training sessions; some donated their services.
  • Costs: Planning (including community-based research), implementation, evaluation, and dissemination of findings totaled roughly $375,000 per year; major expenses for the intervention itself included compensation for the CHWs and other staff, training, transportation for participants and staff, workshop materials, and data collection and evaluation, totaling approximately $212,000 per year. 
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Funding Sources

National Heart, Lung, and Blood Institute (U.S.); New York University School of Medicine; National Institute for Minority Health and Health Disparities
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Tools and Other Resources

More information on the use of CHWs in Filipino American communities can be obtained from the Alliance for Filipino Community Health Workers, available at: http://filamchw.org/. (The Spreading the Innovation section provides more information on this alliance.)

Adoption Considerations

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Getting Started with This Innovation

  • Involve community members: CSAAH had several Filipino staff who lived in neighborhoods with high concentrations of Filipino Americans. These individuals offered an insider’s perspective on the community. Staff also attended events at community-based organizations that serve Filipinos, which demonstrated their support of the community and helped to build trust and cohesiveness among coalition partners.
  • Recognize diversity within community: By asking Filipinos of different ages, genders, backgrounds, and skills to be part of the coalition, staff gained insight into the different situations and issues encountered by members of the Filipino American community. This approach also helped address social determinants of health within the Filipino community related to age, gender, income, immigration status, employment, education, neighborhood, and length of time in the community.
  • Choose intergenerational leaders: The Kalusugan Coalition has two co-chairs: an older established leader in the community and an emerging leader from the next generation. This structure builds in mentoring opportunities and recognizes the importance of considering the perspectives of those from different generations.

Sustaining This Innovation

  • Match participants with CHWs of similar background: Participants tend to feel more comfortable with CHWs of the same gender and age. Hiring a mix of CHWs helped facilitate this matching.
  • Professionalize role of CHWs: CHWs who receive extensive training and who are treated with respect are more likely to have a professional attitude toward their work and to remain in the position for long periods of time.
  • Recognize potential to build capacity and gain visibility: By conducting the program as part of a research project, the Kalusugan Coalition was able to build capacity in local organizations. These organizations gained credibility and influence, while the coalition itself gained visibility within the wider Filipino community and in the media. This credibility and visibility led to additional opportunities to advocate for the Filipino community and to spread the program to other parts of the country. (The Spreading the Innovation section provides more information on this topic.)

Spreading This Innovation

As part of the dissemination component of the NHLBI grant, CSAAH and the Kalusugan Coalition developed the Alliance of Filipino American Community Health Workers. This Alliance promotes the CHW model in Filipino communities in other parts of the country. To date, the model has been adopted in the following areas: 
  • San Francisco, CA (through the Filipino Community Cancer Collaborative)
  • Hudson County, NJ (through the Pan-American Concerned Citizens Action League)
  • San Diego County, CA (through Kalusugan Community Services)

More Information

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Contact the Innovator

Chau Trinh-Shevrin, DrPH
Principal Investigator
NYU Center for the Study of Asian American Health
550 First Avenue, VZN 8th Floor
New York, NY 10016
(212) 263-3072
E-mail: trinhc01@nyumc.org

Innovator Disclosures

Dr. Trinh-Shevrin reported having no financial interests or business/professional affiliations relevant to the work described in the profile.

References/Related Articles

Aguilar DE, Abesamis-Mendoza N, Ursua R, et al. Lessons learned and challenges in building a Filipino health coalition. Health Promot Pract. 2010;11(3):428-36. [PubMed]

Ursua R, Aquilar DE, Wyatt LC, et al. A community health worker intervention to improve management of hypertension among Filipino Americans in New York and New Jersey: a pilot study. Ethn Dis. 2014;24(1):67-76. [PubMed]

Ursua R, Aquilar DE, Wyatt LC, et al. Awareness, treatment and control of hypertension among Filipino immigrants. J Gen Intern Med. 2014;29(3):455-62. [PubMed]

Footnotes

1 Aguilar DE, Abesamis-Mendoza N, Ursua R, et al. Lessons learned and challenges in building a Filipino health coalition. Health Promot Pract. 2010;11(3):428-36. [PubMed]
2 Ursua R, Aquilar DE, Wyatt LC, et al. A community health worker intervention to improve management of hypertension among Filipino Americans in New York and New Jersey: a pilot study. Ethn Dis. 2014;24(1):67-76. [PubMed]
3 Stoney S, Batalova J. Filipino immigrants in the United States. Migration Information Source [Internet]. 2013 Jun 5. Available at: http://www.migrationpolicy.org/article/filipino-immigrants-united-states.
4 Hypertension among Filipinos. NYU Langone Medical Center fact sheet [Internet].  Available at: http://asian-health.med.nyu.edu/research/aspire/hypertension-among-filipinos.
5 Heart disease facts. Centers for Disease Control and Prevention fact sheet [Internet]. Available at: http://www.cdc.gov/heartdisease/facts.htm.
6 Ursua R, Aquilar DE, Wyatt LC, et al. Impact of community health worker intervention for Filipino Americans with hypertension: a randomized control trial in New York. To be presented to the American Public Health Association, 2014.
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Original publication: July 16, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 16, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.