Nicole Rakhmanova, OMS-III, highlights the importance of tailoring preventative medicine approaches and interventions to community and cultural beliefs, while providing suggestions for ways to overcome mistrust and misinformation.
Nicole Rakhmanova, OMS-III | New York Institute of Technology College of Osteopathic Medicine
2022 Namey/Burnett Preventive Medicine Writing Award Submission
Sponsored by the ACOFP Foundation, with winners selected by the ACOFP Health & Wellness Committee, the Namey/Burnett Preventive Medicine Writing Award honors the memory of Joseph J. Namey, DO, FACOFP, and John H. Burnett, DO, FACOFP—dedicated advocates for osteopathic medicine—and recognizes the best preventive medicine blog posts submitted by osteopathic family medicine students and residents.
The purpose of preventative medicine is to prevent disease prior to its occurrence. This is especially true when addressing diabetes and cardiovascular diseases, which have modifiable risk factors that can be mitigated, such as quitting smoking, losing weight, incorporating daily exercise and improving diet. Lifestyle improvements often start in a family physician’s office, where patients ask their physician(s) questions about daily actions and their consequential impacts on health. This is also where physicians assess the need for cholesterol screening, hemoglobin A1c testing, blood pressure readings, vaccinations and other preventative care, which is especially true with osteopathic physicians because they are trained to promote the body’s natural tendency toward self-healing and health. One could argue that preventative medicine does just that, by improving the biomechanical structure and body function and by making the body more capable of health maintenance.
However, one barrier to preventative medicine is posed by healthcare disparities. The very communities that often need prevention in a family physician’s office are those who lack primary care physicians. This is why cultural competency and cultural proficiency—evidenced by understanding and respect of cultural differences, followed by actions and advocacy for different cultural groups—are essential components of preventative medicine. Therefore, healthcare disparities can be effectively confronted with culturally appropriate community-based programs and preventative healthcare programs, tailored to the faith, language and/or cultural beliefs of specific communities.
Tailoring Interventions to Culture and Community
There are countless ways in which culture overlaps with health care. For instance, many Chinese ethnic groups have a long history of holistic medicine, which may include acupuncture, herbs and massages.1 Due to these approaches not being common practices in the United States, Western providers may overlook the herbal approaches a Chinese patient had utilized for treatment and may find that the treatment or medication they prescribe interferes both psychosocially and physiologically with those herbal treatments. This is a great example of how culture affects attitudes toward types of acceptable interventions that may include medications, vaccinations, blood transfusions and abortions, in addition to disease response. In addition to understanding the effects of culture directly on health care and to craft a care plan, it is important to consider these factors, as well as physician-patient communication.
Although English is the language technically predominant in the United States, according to 2011 Census Data, only 56% of people who speak a language other than English at home reported that they spoke English “very well.”2 Individuals who do not speak English well enough to communicate effectively in a health setting have a right to free interpretation and translation services. However, there has not been an effective measure of how many limited English speakers actually receive translation services in hospitals, especially in non-urban areas with low resources. Language barriers can result in misdiagnoses, medication errors and potentially fatal mistakes that are costly for both patients and providers. Providers who are culturally competent and proficient understand this barrier and act to ensure appropriate resources are accessed.
In the last two decades, there have been efforts to structure community-tailored preventative health care—largely in the form of screening health fairs hosted in urban areas. However, even limited efforts have proved to be successful thus far. One such campaign is the Heart-to-Heart Community Outreach free screening program carried out in New York City’s underserved and minority communities. Screening days are hosted in community centers and faith-based organizations, where patrons are assessed for height, weight, blood pressure, blood glucose, hemoglobin A1c and lipid panel. They then meet with a healthcare professional to review their results and receive follow-up information, such as an insurance screen and a medical appointment referral that may be at local free or low-cost clinics. This campaign is screening-based, but it empowers communities by providing people with knowledge of their health status and by helping facilitate access to medical care to further address health risk factors.
Most patrons are uninsured or do not have primary care physicians but feel comfortable attending this type of screening within their communities, where they are provided personalized health education and resources. For instance, nutritionists are trained on the diet of the particular cultures they may be seeing that day, whether their daily diet consists of rice, vegetarian meals or spices. Screenings revealed that 56.9% of patrons had undiagnosed hypertensive blood pressures, 4.7% had elevated HbA1c and 49.2% had dyslipidemia. The key to the success of this campaign was culturally proficient training of the healthcare professionals, as well as the community-based approach.3
A similar intervention—Supporting South Asian Taxi Drivers to Exercise through Pedometers (SSTEP)—served as a pilot exercise intervention study to reduce the risk of cancer and cardiovascular disease among South Asian taxi drivers in New York. The SSTEP intervention resulted in an increase in step counts and thus an increase in exercise among participants.4 In the years since, that research team has been developing broader plans with this population, including screening initiatives that are tailored to the locations these taxi drivers frequent and focus groups in their native languages to identify their knowledges of cardiovascular disease risk.5,6
Preventative Interventions During Childhood
Preventative health care starts during childhood. In the United States, the overall incidence of type 2 diabetes has significantly increased in children and adolescents (10–19 years old) between 2002 and 2015. Although the changes in incidence of type 2 diabetes remained stable among non-Hispanic white populations, it increased for all other racial and ethnic groups, particularly in non-Hispanic Black children and adolescents.7 It makes sense that promoting physical activity in schools is a way to target risk factors for obesity and diabetes. Healthcare disparities have been implicated in adverse health outcomes as ethnic minority groups have been found to be less physically active and have higher obesity rates, often due to lack of access to safe recreational spaces in their neighborhoods or access to healthy food.
Project SMART was a project focused on children’s health that created an online, cooperative game aligned with educational standards while incorporating physical activity. The community-centered approach entailed several community events, such as wellness fairs, town halls and parent/teacher focus groups. It also addressed obstacles reported by students such as lack of materials for physical activity. This community approach proved to be the key to the program’s success although children still faced barriers.8 The “citizen science” approach engaged the entire community and motivated efforts.
Another study exhibiting the importance of culturally appropriate and community-specific programs was Vida Saludable, a nine-month intervention program for Hispanic mothers with 3–5-year-old children that employed a community engagement approach with qualitative methods, including focus groups and individual interviews, to culturally adapt the intervention.9 Program goals were to decrease children’s consumption of sugary beverages and increase consumption of water, as well as increase maternal walking (step counts) to role model and engage children in physical activity. Conflicts with beliefs were avoided by using cultural perceptions. For example, plump children are perceived as healthy within many Hispanic cultures, so instead of focusing on obesity (which may be culturally inappropriate and offensive), the study focused on raising strong and healthy children.
Promotoras—Hispanic community members trained to provide basic health education—were introduced to study participants as ethnically similar individuals who know the language and culture. The organizers also incorporated social services and childcare for low-income participants. Children’s consumption of soda declined significantly by 82% and of other sugary drinks by 73%, while water consumption increased significantly by 46%. At six months post-intervention, children maintained improvement in consumption levels for sugary drinks and water. Maternal BMI also decreased.9
The cultural tailoring of this program is likely responsible for the promising results due to high participant satisfaction, engagement and retention. After learning the safe walking routes during the program, mothers reported they liked walking in the community and formed their own walking groups, excited to compare their step counts. They also reported satisfaction with the promotora support received during the program. With the use of ethnically similar educators, exercises that were sensitive to the culture and beliefs, and intermingling culturally similar individuals, there was a positive change in healthy behaviors of both children and mothers, and it is likely that such programs could be expanded and adapted to fit different cultures and target different health concerns.
Mistrust and Misinformation
In addition to diabetes and cardiovascular disease, the COVID-19 pandemic has uncovered health disparities when it comes to prevention of virus spread and immunization, especially as curative measures may not be enough. Racial and ethnic minority groups are disproportionally affected by COVID-19 infection. There is also disproportionate infection rate of people whose preferred language is not English, indicating that our healthcare system—which is centered on English speakers—creates a barrier.10
Vaccine hesitancy is delay or refusal of vaccination when a vaccine is proven safe and widely accessible.11 The reality of the disparities COVID-19 has exposed is that they can also likely be attributed to lack of resources—not just vaccine hesitancy, which may be attributed in part to medical mistrust and misinformation. Centuries of racism within the medical field have contributed to medical mistrust. For Black Americans, considerable impacts were made by the Tuskegee Study and unauthorized use of Henrietta Lacks’ cells. There is also contemporary implicit bias that adversely affects healthcare outcomes of Black Americans, notably Black mothers.
In addition to historic impacts, it is important to consider that there is misinformation coming from social media and media networks, which is especially impactful when trusted community-specific media sources provide misinformation, in addition to mass media. Many communities are close-knit and rely on trusted peers and messengers for information that influences their decisions. When focusing on misinformation and mistrust, using the same lens of community-tailored intervention may be helpful, including:
- Providing communities information from diverse sources, as well as partnering with well-trusted sources and messengers,
- Providing transparency by detailing both COVID-19 infection and vaccination narratives, and
- Encouraging education and awareness campaigns within communities and media.
People need to hear from others who are from their culture and/or community, which may mean faith-based leaders, physicians or simply peers. They need to hear it in a language that they understand and in a culturally relevant way.12
Driving culturally appropriate community-based programs and preventative healthcare programs tailored to the faith, language and/or cultural beliefs of specific communities is a social means of improving access to health care and diminishing healthcare disparities. Culture has a profound effect on health care. Thus, cultural proficiency in action is the key to ensuring that underserved communities have access to preventative medicine, whether it is a childhood physical activity intervention, vaccination, screening or free/low-cost resource.
Confronting disparities in the very communities where those affected live and work in a way that is conscious of their beliefs, customs and language is essential. The next step would be to plan how these programs would be funded. The COVID-19 pandemic provides the opportunity for state and federally funded programs to flourish, but it may be worthwhile to consider such preventative interventions in school curriculums, as well as community- and faith-based organizations.
- Ryan C. Language use in the United States: 2011. American Community Survey Reports. 2013. Accessed December 20, 2021. https://www2.census.gov/library/publications/2013/acs/acs-22/acs-22.pdf
- Do H. Chinese. Ethnomed. Published June 1, 2000. Accessed December 20, 2021. https://ethnomed.org/culture/chinese/
- Bales ME, Zhu J, Aboharb F, et al. 56326 Heart to heart: An interdisciplinary community collaboration to address health disparities through cardiovascular disease risk assessments in underserved urban neighborhoods. J Clin Transl Sci. 2021;5(s1):135–135. doi:10.1017/cts.2021.745
- Gany F, Gill P, Baser R, Leng J. Supporting South Asian taxi drivers to exercise through pedometers (SSTEP) to decrease cardiovascular disease risk. J Urban Health. 2014;91(3):463–476. doi:10.1007/s11524-013-9858-z
- Gany F, Bari S, Gill P, et al. Step on it! Workplace cardiovascular risk assessment of New York City yellow taxi drivers. J Immigr Minor Health. 2015;18(1):118–134. doi:10.1007/s10903-015-0170-8
- Gany FM, Gill PP, Ahmed A, Acharya S, Leng J. “Every disease…man can get can start in this cab”: Focus groups to identify South Asian taxi drivers’ knowledge, attitudes and beliefs about cardiovascular disease and its risks. J Immigr Minor Health. 2012;15(5):986–992. doi:10.1007/s10903-012-9682-7
- Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020 Estimates of Diabetes and Its Burden in the United States. U.S. Department of Health and Human Services; 2020. Accessed December 20, 2021. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
- Jung Y, Burson SL, Julien C, Bray DF, Castelli DM. Development of a school-based physical activity intervention using an integrated approach: Project SMART. Front Psychol. 2021;12. doi:10.3389/fpsyg.2021.648625
- Bender MS, Clark MJ, Gahagan S. Community engagement approach: developing a culturally appropriate intervention for Hispanic mother-child dyads. J Transcult Nurs. 2014;25(4):373–382. doi:10.1177/1043659614523473
- Cohen-Cline H, Li H-F, Gill M, et al. Major disparities in COVID-19 test positivity for patients with non-English preferred language even after accounting for race and social factors in the United States in 2020. BMC Public Health. 2021;21(1):2121. doi:10.1186/s12889-021-12171-z
- Hildreth JEK, Alcendor DJ. Targeting COVID-19 vaccine hesitancy in minority populations in the U.S.: Implications for herd immunity. Vaccines (Basel). 2021;9(5):489. doi:10.3390/vaccines9050489
- CDC. Health Equity Considerations and Racial and Ethnic Minority Groups. Centers for Disease Control and Prevention. Published April 30, 2020. Accessed December 20, 2021. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html