Building a Healthy Community

Students and Researchers Hold the Key to Better Outcomes for All

Healthcare is not a one size fits all proposition. Culture, ethnicity, education, socioeconomic status, age and gender can all play roles in how we access and use healthcare.

The UCLA School of Nursing is committed to building a healthy community for all. Whether it’s down the street or around the world, addressing health equality is key to better health for all. For example, numerous studies show that culturally sensitive approaches improve patient care. Through education and research, we are working to bridge the divide between the culture of healthcare and the beliefs and practices that make up a patient’s value system to improve the healthcare of our communities.

The City of Los Angeles, and the entire Southern California region, has long been defined by its ethnic diversity. There are more minorities in this region than anywhere else in the United States. This diversity allows us to work and engage with various populations through targeted research and education efforts, leading to improved preventive efforts and health outcomes.

Culturally Sensitive Research in the Korean Community

Among Asian-American immigrants, Korean American women have one of the highest mortality rates for breast cancer. Too often, due to low screening rates, the cancer is in an advanced state by the time it’s detected. Furthermore, studies suggest that the breast cancer incidence rate doubles among immigrants after they have lived in this country for 10 years and adopted Western lifestyles.

Eunice Lee, PhD., RN, Associate Professor, herself a Korean American immigrant, was looking for ways to improve mammogram screenings. “We introduced a culturally sensitive and spouse-based educational program called KIM-CHI (Korean Immigrants & Mammography: -Culture-specific Health Intervention,” said Lee. “By creating an acronym based on a healthy staple that is eaten almost every day in Korea, we believed Korean-American women would be encouraged to develop a habit of receiving a routine mammogram every year just as they have a routine habit of eating kimchi every day.”

Because the women have limited English proficiency and a general reluctance to pursue preventative medicine, they prioritize the care of family members over themselves, sacrificing their own needs to meet those of their husbands and children. Lee found that most Korean-American men didn’t know about the importance of breast cancer screening so they also developed the spouse-based educational intervention that they tested with almost 500 Korean-American couples recruited through Korean religious organizations. Half of the couples, the control group, took part in presentations and discussions about a healthy diet. Another group viewed a specially produced Korean-language DVD about breast cancer and screening, which included correcting common beliefs such as “No screening is needed if a woman doesn’t have symptoms.” Following the film the couples viewed a Power Point presentation and participated in a group discussion. Each couple also had a homework assignment to write down two things they learned about breast cancer as well as two things the husband could do to be supportive of his wife getting breast cancer screenings.

In a 15-month follow-up to the intervention, Lee and her colleagues found that women in the KIM-CHI group were twice as likely as women in the control group to get a mammogram — a very significant difference. They theorized that spousal support motivated the women in a number of ways, such as understanding that getting breast cancer screenings regularly helps women maintain wellness and, ultimately, better care for their families.

Lee is now preparing to test the paradigm of including spouses of Thai, Vietnamese and Mexican women for breast as well as cervical and colorectal cancer screenings.

Another faculty researcher working with the Korean community is Associate Professor Sarah Choi, PhD., RN. Her research focuses on identifying and understanding the biological, psychological, social, and cultural factors associated with chronic disease self-management among ethnic minority immigrants. Dr. Choi has been particularly interested in the role of family and social support in disease self-management among Korean immigrants with type 2 diabetes mellitus. Her study interests have since broadened to include the self-management of risk factors among seniors in the areas of coronary heart disease and stroke prevention. Dr. Choi continues to develop and test community-based culturally tailored interventions focused on behavioral and lifestyle changes.

“I became interested in studying diabetes self-care while I was working as a family nurse practitioner in Central California. Many of my diabetic patients were ethnic minority immigrants and it was difficult for them to manage their diabetes well because of language, cultural practices, and limited resources. Because I speak Korean and am an immigrant myself, I am very aware of the important cultural factors that influence diabetes self-management behaviors in Korean immigrant adults and seniors, including social support. I am now working on developing an effective and practical diabetes self-management program for Korean immigrants addressing these cultural factors.”

Talking Circles and Social Support Improve Health Outcomes forNative Populations

Professor Felicia Hodge, Dr. PH, an American Indian, has clinical expertise in cultural competencies, health disparities, and health care among American Indians and is committed to removing barriers to care for the native populations. Continuously funded by the NIH since 1990, she conducts research on chronic health conditions among American Indian and Alaska Native populations. Her goal is to improve knowledge of preventive measures, improve access to health care services and make American Indians better health consumers. She has looked at the problems of cervical cancer, breast cancer, HPV, smoking cessation, nutrition, diabetes and cancer symptom management.

“My studies document that American Indians and Alaska Natives have had the poorest health, with cancer, heart disease, and suicide being among the top causes of death,” said Hodge. “Cultural interventions are long overdue and are critical to community wellness. We see so many issues of treatment noncompliance, compounded by illness belief differences in the social constructs of illness and understanding of why they are ill – these constructs need to be understood by providers.”

Many native populations are challenged in accessing treatment. Many live in rural areas where it is not easy to get to the doctor, to get ongoing physical therapy or cancer treatments or even ask follow-up questions. They have work to do to support their families and don’t want to burden anyone to take them for a doctor appointment so they keep their illness a secret.

“So they just keep working, suffering with horrible pain, until they die,” said Hodge.

Hodge also found that messages targeting non-native populations don’t always work for American Indians. “For example the American Cancer Society uses the term “fight against cancer” and that people won by ‘fighting the cancer.’ But American Indians don’t want to fight, they want to find out how to live their life, so the concept of fighting cancer doesn’t work for them.”

Some health issues are relatively new to American Indians, and that presents its own challenges. “While cancer has been prevalent among AI/ANs for generations – we’ve seen it in old bones – diseases such as type 2 diabetes didn’t make an appearance until the late 1940s. So the communities don’t understand the illness, how it is presented, or what they need to do to address these issues.”

Hodge uses talking circles to facilitate the message because “one head is not above another, one voice is not stronger than another, each individual’s questions are equal and should be heard. You sit in a circle so you all learn together.” In using this method, Hodge has often found herself an observer, listening to others in the circle tell an individual ‘oh you should try this treatment or you should see a doctor.’ They work as a community and help one another.”

But to influence the best outcomes, Hodge has found that a strong social and family support is needed. “If you don’t have people who care for you and provide you support, then you become marginalized and you become lost.”

Preparing Our Students to Care for Our Communities

During their Public Health rotation, prelicensure students do more than just sit in the classroom. Working with community organizations, the students learn to assess and diagnose a problem in an underserved community, developing projects they hope will improve the quality of life for its residents. Many students are not from Los Angeles, so exposure to these neighborhoods has been quite an eye opener. And because the focus of their studies has been clinical practice, getting into the community really expands their knowledge base and provides them a much better understanding of the role that community health and prevention play in keeping people healthy. Not just observers, the students develop projects that could be implemented by the partnerships and organizations with which they work.

Highland Park is a historic neighborhood in Northeast Los Angeles that has been experiencing some gentrification with long-time businesses and trendy shops and restaurants creating a culturally unique neighborhood. One group of bachelor’s students, working with Professor Dorothy Wiley, Ph.D., RN, completed a community assessment of housing changes and walkability. Working with various community members and business owners, they assessed physical characteristics of streets and walkways, and evaluated traffic patterns in the community. The students used the CDC Walkability Assessment to determine if the neighborhood provided a safe and healthy environment for walking. On a walk through one tree-lined side street, the students pointed out large cracks, tree roots that had buckled pavement and other hazards that could cause falls. Once the students have completed their assessment – they plan to present their findings to business and community leaders.

In the heart of Skid Row, Lecturer Elizabeth Dixon, PhD., RN, worked with another group of students to conduct a “nutritional resources” assessment project to understand the issue of food access and food insecurity. Walking through a predetermined area in Skid Row, students surveyed about 120 homeless individuals over a two-week period asking questions such as “Did you worry that you would not have enough food? In the past month did you have to eat a limited variety of food due to a lack of money, community meals or other resources? Did you have to eat food you did not want to eat because of a lack of resources? Did you have to eat a meal smaller than you wanted because there was not enough food?” Students were surprised to learn that there were a lot of resources and that there is food available, yet there still are problems. Oftentimes people didn’t eat because they disliked the food, the environment was unpleasant or they lacked money. Once the students analyzed the data, they created a plan, which set a goal to reduce food insecurity from 54 to 36 percent among homeless individuals in the area by 2026 through changing the environments to make them more pleasant and welcoming. Their plan will be shared with the SRO Corporation, hoping that in turn it will be shared with a larger group of homeless advocates.Hope Street Family Center, located in downtown Los Angeles, is a community health, education and recreation resource of California Hospital Medical Center that provides in-home and on-site education, health, wellness, behavioral health and social services to educate children and transform the community and improve health outcomes among children at high risk for poverty-related poor health outcomes. Over the past several years, Lecturer Inese Verzemnieks, Ph.D., RN and her students have developed population-based programs to support the needs of this valuable program, including a number of obesity prevention efforts. For these projects, students created an interactive, hands on event where the children rotated through a series of activities that helped them understand the value of exercise and encouraged healthy snacks and drinking water.

For the past three years, the Master’s Entry Clinical Nurse students have visited one of the PACE (Program of All-Inclusive Care for the Elderly) senior care centers affiliated with AltaMed Health Services, to give students exposure to gerontology care. PACE provides medical, social, nutritional and rehabilitative services for aging Latinos and Asians on the eastside of Los Angeles. Projects have included a survey of residents on their knowledge of end-of-life care and advanced directive issues and education programs for fall prevention.

This year, AltaMed and the School received a grant from HRSA which pairs MECN students with nurses at one AltaMed’s primary clinics to help achieve better health outcomes for patients with diabetes and heart failure. The students will develop health education programs that the nurses can deliver to patients to help increase the skill set of the nurses who work in the clinic. By moving this education program into the community, the hope is that patient health will improve and they can be kept out of the hospital.

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