Faculty Bibliography

Eliminating health disparities in racial/ethnic minority and underserved populations requires a paradigm shift from biomedical approaches that are disease-focused to a health equity framework that aims to achieve optimal health for all by targeting social and structural determinants of health. We describe the concepts and parallel approaches that underpin an integrative population health equity framework and present the experience of NYU Center for the Study of Asian American Health (CSAAH) in applying the framework to guide its work. Applying an integrative framework has deepened our community engagement efforts, our understanding of the multi-level contextual factors that influence health, and our capacity to advance health equity for Asian American communities through action-oriented research and policy. This framework and experience is applicable to researchers and community members working with other underserved populations.

Community health workers (CHWs) are frontline health workers who often serve socially and linguistically isolated populations, including Asian American, Native Hawaiian, and Pacific Islander (AA and NHPI) communities in the United States (U.S.) and U.S. territories. We conducted a systematic review of the peer-reviewed literature to assess the characteristics of CHW programs for AA and NHPI communities in the U.S. and U.S. territories, generating a total of 75 articles. Articles were coded using eight domains: ethnic group, health topic, geographic location, funding mechanism, type of analysis reported, prevention/management focus, CHW role, and CHW title. Articles describing results of an intervention or program evaluation, or cost-effectiveness analysis were further coded with seven domains: study design, intervention recruitment and delivery site, mode of intervention delivery, outcomes assessed, key findings, and positive impact. Results revealed gaps in the current literature and point towards recommendations for future CHW research, program, and policy efforts.

According to national estimates, obesity prevalence is lower in Asian Americans compared to other racial/ethnic groups, but this low prevalence may be misleading for three reasons. First, while a lower body mass index (BMI) cutoff as proposed by the World Health Organization may be more appropriate to use in Asian populations, evidence is limited to substantiate the potential costs and burden of adopting these cutoffs. Increasing BMI in Asians (as in other racial/ethnic groups) should be considered across the spectrum of BMI, with a minimum awareness of these modified cutoffs among healthcare researchers. Second, the need for disaggregated data across Asian American subgroups is illustrated by the higher obesity (and diabetes) prevalence estimates observed in South Asian Americans. Third, prevalence of obesity should be placed in the larger context of immigration and globalization through cross-national comparisons and examination of acculturation-related factors. However these types of studies and collection of salient variables are not routinely performed. Data from a metropolitan area where many Asian Americans settle is presented as a case study to illustrate these points. Clear evidence that incorporates these three considerations is necessary for program planning and resource allocation for obesity-related disparities in this rapidly growing and diverse population.

CONTEXT: The Patient Protection and Affordable Care Act's (PPACA) emphasis on community-based initiatives affords a unique opportunity to disseminate and scale up evidence-based community health worker (CHW) models that integrate CHWs within health care delivery teams and programs. Community health workers have unique access and local knowledge that can inform program development and evaluation, improve service delivery and care coordination, and expand health care access. As a member of the PPACA-defined health care workforce, CHWs have the potential to positively impact numerous programs and reduce costs. OBJECTIVE: This article discusses different strategies for integrating CHW models within PPACA implementation through facilitated enrollment strategies, patient-centered medical homes, coordination and expansion of health information technology (HIT) efforts, and also discusses payment options for such integration. RESULTS: Title V of the PPACA outlines a plan to improve access to and delivery of health care services for all individuals, particularly low-income, underserved, uninsured, minority, health disparity, and rural populations. Community health workers' role as trusted community leaders can facilitate accurate data collection, program enrollment, and provision of culturally and linguistically appropriate, patient- and family-centered care. Because CHWs already support disease management and care coordination services, they will be critical to delivering and expanding patient-centered medical homes and Health Home services, especially for communities that suffer disproportionately from multiple chronic diseases. Community health workers' unique expertise in conducting outreach make them well positioned to help enroll people in Medicaid or insurance offered by Health Benefit Exchanges. New payment models provide opportunities to fund and sustain CHWs. CONCLUSION: Community health workers can support the effective implementation of PPACA if the capacity and potential of CHWs to serve as cultural brokers and bridges among medically underserved communities and health care delivery systems is fully tapped. Patient Protection and Affordable Care Act and current payment structures provide an unprecedented and important vehicle for integrating and sustaining CHWs as part of these new delivery and enrollment models.

Although the New York City Chinese population aged >/=65 years increased by 50% between 2000 and 2010, the health needs of this population are poorly understood. Approximately 3,001 Chinese individuals from high-density Asian American New York City areas were included in the REACH U.S. Risk Factor Survey; 805 (26.8%) were aged >/=65 years and foreign-born. Four health-related quality of life and three behavioral risk factor outcome variables were examined. Descriptive statistics were conducted by gender, and logistic regression models assessed sociodemographic and health factors associated with each outcome. Few women were current smokers (1.3% vs. 14.8% of men), 19% of respondents ate fruits and vegetables more than or equal to five times daily, and one-third of individuals received sufficient weekly physical activity. Days of poor health were similar to the national population aged >/=65 years, while self-reported fair or poor health was much greater among our Chinese sample; over 60% of respondents rated their health as fair or poor. Lower education and lower obesity were significantly associated with cigarette smoking among men, and older age was significantly associated with insufficient physical activity overall. Female gender was significantly associated with all poor health days; older age was significantly associated with poor days of physical health, and lower income was significantly associated with poor days of physical health and fair or poor self-reported health. This study provides important health-related information on a rapidly growing older population and highlights future research areas to inform culturally appropriate health promotion and disease prevention strategies and policies within community-based settings.

India has one of the highest burdens of diabetes worldwide, and rates of diabetes are also high among Asian Indian immigrants that have migrated into the United States (U.S.). Sikhs represent a significant portion of Asian Indians in the U.S. Diabetes prevention programs have shown the benefits of using lifestyle intervention to reduce diabetes risk, yet there have been no culturally-tailored programs for diabetes prevention in the Sikh community. Using a quasi-experimental two-arm design, 126 Sikh Asian Indians living in New York City were enrolled in a six-workshop intervention led by community health workers. A total of 108 participants completed baseline and 6-month follow-up surveys between March 2012 and October 2013. Main outcome measures included clinical variables (weight, body mass index (BMI), waist circumference, blood pressure, glucose, and cholesterol) and health behaviors (changes in physical activity, food behaviors, and diabetes knowledge). Changes were significant for the treatment group in weight, BMI, waist circumference, blood pressure, glucose, physical activity, food behaviors, and diabetes knowledge, and between group differences were significant for glucose, diabetes knowledge, portion control, and physical activity social interaction. Retention rates were high. Findings demonstrate that a diabetes prevention program in the Sikh community is acceptable, feasible, and efficacious.

BACKGROUND: New York City (NYC) is currently home to the largest Bangladeshi population in the United States (US) at approximately 62,000 individuals. The high prevalence of Type 2 diabetes mellitus (T2DM) among Bangladeshis has been well documented in Bangladesh, as well as in Canada and the United Kingdom (UK). However, little is known about the diabetes prevalence and management practices of US Bangladeshis. This paper describes the protocol for a Community Health Worker (CHW) intervention to improve diabetic management and control among Bangladeshis with diabetes in NYC. METHODS/DESIGN: For a two-arm, randomized controlled trial (RCT), investigators will recruit a sample of 256 participants, all of whom are 1) of Bangladeshi descent, 2) residing in NYC, 3) diagnosed with T2DM and a recent Hemoglobin A1c (HbA1c) of >/= 6.5, and 4) between the ages of 21-85. The treatment group receives a six-month CHW-led intervention consisting of five monthly group educational sessions, two one-on-one visits, and follow-up phone calls as needed from a CHW. The control group receives an introductory educational session only. Primary and secondary outcomes include clinical and behavioral measures, such as HbA1c and weight change, access to and utilization of care (i.e. appointment keeping and use of specialty care), and knowledge and practice of physical activity and healthful eating. Additionally, information regarding CHW characteristics, the processes and mechanisms for influencing healthful behavior change, and fidelity of the intervention are collected. Outcomes are measured at Baseline, 3-Months, 6-Months for both groups, and at 12-Months for the treatment group. DISCUSSION: To our knowledge, this study represents the first attempt to document the efficacy of T2DM management strategies in the NYC Bangladeshi population. Thus, future qualitative and quantitative findings of the submitted protocol will fill an important gap in the health disparities literature. TRIAL REGISTRATION: NCT02041598.

OBJECTIVE: The purpose of the pilot study was to assess the feasibility and efficacy of a 4-month community health worker (CHW) intervention to improve hypertension management among Filipino immigrants in New York and New Jersey. DESIGN: Single-arm CHW pilot intervention using a pre-post design delivered by 5 CHWs. SETTING: New York City, NY and Jersey City, NJ. PARTICIPANTS: Of 88 Filipino individuals recruited for the study, 39 received the full pilot intervention, 18 received a partial intervention, and 31 dropped out; 13 Filipino participants, 10 CHW Trainers, and 3 Filipino CHWs were interviewed for qualitative analysis. INTERVENTION: Individuals participated in 4 workshops related to hypertension management and cardiovascular disease (CVD) risk factors and received monthly in-person visits, and twice monthly phone calls individually from a CHW. MAIN OUTCOME MEASURES: Primary outcomes included blood pressure (BP) reduction and control, appointment keeping, and medication adherence; secondary outcomes included weight, body mass index (BMI), self-efficacy related to diet, exercise, and medication taking, CVD knowledge, and nutrition (salt/ sodium and cholesterol/fat). RESULTS: A mixed method analysis was used to assess the intervention, utilizing quantitative and qualitative methods. By the end of the intervention, significant changes were exhibited for systolic and diastolic BP, weight, and BMI (P<.01). Significant changes were not seen for medication adherence and appointment keeping, however, CVD knowledge and self-efficacy related to diet and weight management all improved significantly (P<.01). Qualitative findings provided additional information on the acceptability, feasibility, and efficacy of the intervention. CONCLUSIONS: This pilot CHW intervention showed evidence of feasibility, as well as efficacy, in improving hypertension management and reducing CVD factors in Filipino Americans.

BACKGROUND: Because health disparities among Asian Americans are understudied, a partnership program between the Charles B Wang Community Health Center and the Center for the Study of Asian American Health was created to increase awareness and interest in Asian American research. PURPOSE: To evaluate the process, outcome, and impact of a health professionals' research training program. METHODS: Mixed research methods were employed to collect data from online surveys administered to mentors and trainees of the program. RESULTS: Although many trainees did not continue to pursue Asian American health disparities research, results indicate that the program has positive impacts on trainees in their preparedness to conduct CBPR, work within the Asian American community, and network with public health professionals and researchers. DISCUSSION: This evaluation adds to the current literature of research training programs but more research on Asian American health disparities is needed. TRANSLATION TO HEALTH EDUCATION PRACTICE: Although the program has helped raise awareness in Asian American health disparities research, more Asian American specific research training programs are needed to stimulate a true generation of researchers.