Bridging the Gap: The End of the Beginning

As I near the completion of the semester and approach a milestone in the project, I am left with several acquired lessons, a broadened perspective and an array of novel thoughts and ideas.

Prior to joining this project team, my goal was simply to improve health outcomes in this underserved community. I sought to extend health care access to a population that is known to face inequities not only in healthcare, but in essentially all other major systems. That is my purpose. Although this purpose has not changed, I have developed more specific intentions relating to how my purpose is fulfilled.

One significant lesson that I’ve learned from this project is the importance of self-efficacy and motivation. I realized that regardless of how important my patients’ health is to me, there will not be progress unless the patients themselves acknowledge the importance of health promoting behaviors. A realization that was equally as important is that lack of existing motivation or action can be the result of numerous factors that healthcare professionals may not be aware of. Some of these factors may include decreased health literacy, the burden of other stressors, lack of access and even fear. With this insight, I have instilled addressing these specific factors into my overall purpose. For me, this requires approaching people with a holistic mindset. It means really getting to know the person that I am seeking to help. It means increasing my emotional intelligence and developing the capacity to step into another person’s shoes and anticipate their needs. Lastly, it means encouraging others to make the same efforts.

As you absorb these words, you may become inquisitive about how, if at al,l this could relate to you. So you’re not a healthcare worker? Are you a teacher who can ensure that young Black children develop literacy skills that exceed their statistical low averages? Are you a corporate business owner who can offer affordable health insurance benefits? Are you a law enforcement official who can advocate against racial profiling and stand as an example in an effort to ease the burden of health-deteriorating stressors? Yes, this blog is intended to illustrate my journey throughout this project and relate it to my purpose but affecting change in others aligns with my purpose, too. Engaging with this community and providing mechanisms for blood pressure control for these men was a huge win, but it was only the beginning.

Change is the product of consistency. Consistency can undoubtedly be challenging, especially with the introduction of barriers. During this project, I struggled with maintaining communication with patients because of their financial inability to pay their phone bills. I struggled with overwhelming emotions as I realized how complex my patient’s needs were and how limited I was with resources that I could offer. I faced losing multiple patients to death. What I gained from these challenges, however, is the drive to be more consistent. I was constantly reminded of the reasons for my purpose and why it’s so significant. I was encouraged to view each failed attempt as the end of something that was just an introduction; something that created space for more progress and success, the end of what was only the beginning.

Bridging the Gap: Open Dialogue

When developing my partnership with Lincoln Community Health Center (LCHC) the concept of patient collaboration was identified as an essential foundation. As I continued to construct my hypertension education intervention, I remained grounded in this foundation and sought to gain a deeper sense of the needs of the population.

I began with anticipating likely barriers to access. According to the Durham County Department of Public Health, approximately 4,551 African American or Black families live below the poverty line. These statistics represent a key contributor to decreased healthcare access. As telehealth becomes increasingly popular, especially in a global pandemic, it is important to recognize arising barriers. Health Affairs acknowledges the absence of technology, digital literacy, and reliable internet coverage as major contributors to the digital divide that disproportionately affects individuals living in poverty. These factors have undoubtedly increased the difficulty of developing a successful intervention. Nevertheless, I started my approach with reaching out to my patients via phone. During these conversations, I assessed potential technology-related social determinants. In summary, I gauged that digital literacy and absence of technology were dominant barriers for my patient population. Examples included some individuals having only a cellular device without smart functions, not having computers or similar alternatives, and inadequate knowledge about how to do things such as access internet links. After gaining this insight, my approach shifted to the idea of placing access on two central platforms – the LCHC website and affiliated YouTube page. The thought behind this methodology was to ensure that access was as uncomplicated as possible. The patients would not have to search for and access their links through emails, both platforms were smartphone-friendly, and both platforms were familiar to most if not all of the patients.

As my team and I worked to establish the educational class links, we made the decision to initiate a test-run. In an effort to maintain the foundation of patient collaboration, we invited two individuals deemed “hypertension heroes” to be present for the test-run and provide feedback. Our hypertension heroes are individuals of the Durham and LCHC communities who have participated in previous hypertension-related interventions and now voluntarily act as awareness advocates for their peers. This collaborative experience yielded open dialogue that has been extremely valuable as we continue to craft our intervention.

The first insightful lesson came as one of the heroes detailed his difficulty with joining the meeting. In alignment with the aforementioned barrier of digital literacy, the hero explained that he had trouble accessing the zoom link on his smartphone. He further shared having to walk to his neighbor’s house to get assistance with access. When evaluating this example, I am able to get a stronger grasp on the implications related to this disparity. What if the hero did not have a helpful neighbor? What if he was also disabled and would not leave his house to seek help? What if he simply became too discouraged by the lack of ease in accessing the class so he gave up? This is how social factors are able to so drastically act as health determinants. However, without engaging in dialogue with patients and hearing stories such as the one of this hero, myself and other healthcare providers can not fully understand the daily struggles that patients face.

Additionally, this lack of understanding leads healthcare providers to view patients as “non-compliant” or not being actively involved or interested in their health.

The open dialogue continued after I completed the mock educational presentation. When prompting the heroes for feedback, they mentioned that it was helpful to simply have the information reiterated even if it had been delivered to them in the past. This provokes the idea of continuity of care. As mentioned in my previous posts, many of the patients that LCHC services are uninsured. Due to this barrier, it is likely that many have experienced a lapse in established primary care at some point which can prevent follow up and repetition of education. This further highlights the significance of my intervention and other voluntary partnerships.

Following this mock experience, I am increasingly motivated to start implementation. In the following few weeks, my team and I will establish an educational platform that we hope can be maintained by LCHC professionals and continue to benefit the community.

Bridging the Gap: Finding Middle Ground

It is no secret that the COVID-19 pandemic has tainted the functionality of healthcare. Frontline workers have succumbed to physical and mental distress, facilities are exceeding volume capacity, and patients with non-emergent conditions are experiencing barriers to accessing treatment. My local community partner, Lincoln Community Health Center and the population that it serves has similarly been impacted. When my team and I began our research and quality improvement endeavors, we had a plan to engage with participants face to face for at least a portion of our involvement. As we brainstormed different modes of virtual and other non-contact interventions, impediments of social determinants of health became more evident. While attempting to modify our efforts to include telehealth, I’ve learned that while the burden of requiring transportation to receive care has been somewhat relieved for this population, it has only highlighted other imposing social factors.

Since my last post, I have been submerged in the process of developing a hypertension education class to supplement the medical care that my participants receive from providers at Lincoln. The first phase involved reaching out to the participants to obtain a sense of their perceived needs. In doing so, I found that the overwhelming number of daily stressors that a large amount of this population faces greatly affects the amount of attention and effort that they dedicate to health promotion.

For example, when attempting to recruit one of my previous participants as an attendee for my class, he detailed multiple other aspects of his life that were seemingly more prioritized. He described his struggle to care for his uneducated, unemployed son and his mandate to attend consequential virtual rehabilitation classes. In this case, the potential impact of socioeconomic status on the health of both this individual and his generational offspring are evident. As I continued to converse with him, I found that his story seemed all too familiar. His words triggered my reflection of my own mother’s circumstances. She too suffers from uncontrolled hypertension but struggles to devote time and energy to implement beneficial behavioral change – not because it is not important, but because the stress of fighting an uphill battle against poverty, mental anguish and ineffective coping mechanisms, limited employment opportunities, etc. can outweigh an intangible health condition. As I gain this new perspective, I have learned the significance of meeting individuals where they are. In nursing school, I was taught to assess for readiness to change prior to intervening and to treat the patient using a holistic approach. I have learned that applying these principles to our project can increase the chances of achieving our goal.

While the previous anecdotes represent common circumstances experienced by this population, our efforts have yielded differing perspectives as well. I have noted that after relieving the barrier of obtaining resources such as blood pressure home monitoring systems (our previous intervention), many of our participants have taken the strides to improve their blood pressure. I have found that not only have many acquired the habit of daily quantitative monitoring, but they have also begun to distinguish patterns relating to their health. For example, I recently followed up with a participant who was surprised to find that he obtained higher blood pressure readings when he did not get adequate amounts of sleep and when he consumed fatty meals. Initially, I felt a huge sense of joy, pride and gratification – the work that I was doing was working! However, the unfortunate thought associated with this milestone is that this awareness was established following the development of unfavorable conditions, surpassing opportunities for prevention. Nonetheless, our goal is to continue to educate, improve health literacy and optimize health.

In the next phase of my hypertension education class development, I will be utilizing obtained feedback and data to develop a presentation that will be most effective and appropriate for this population. Health literacy is defined by the U.S. Department of Health and Human Services as the degree to which individuals have the ability to obtain, process, and understand basic health information and services needed to make appropriate health care decisions. Furthermore, research by Du et al., has found that low health literacy is recognized as a major risk factor in blood pressure control and has adverse effect on health outcomes. With this knowledge, it is anticipated that this class can have a strong impact on the health of this community.

Bridging the Gap: A new partnership with historical ties

Unique will be developing interventions to increase healthcare access to minorities with high risk cardiovascular disease, who report to Lincoln Community Health Center for reduced-cost medical care.

“Of all the forms of inequity, injustice in health is the most shocking and inhumane” – Martin Luther King Jr.

I reflect on this quote often. It fuels my passion as a Black healthcare provider to treat and heal all individuals, but especially those whose unmodifiable circumstances yield a lower quality of life. It drives my motives to do meaningful work that will make a difference. Heart disease has consistently remained the leading cause of death in the United States. Center for Disease Control (CDC) research shows that African Americans are 20% more likely than their non-Black counterparts to account for these deaths. Social determinants of health serve as well-known culprits of this disparity. My current research and quality improvement measures, in partnership with the Lincoln Community Health Center (LCHC) and American Heart Association (AHA) focus on addressing and eliminating this disparity. Before providing further details of my work, I’d like to more descriptively introduce my Durham community partner.

The original Lincoln Hospital located in Durham, North Carolina, was established in 1901 as the first non-religion affiliated hospital for Blacks in North Carolina. Lincoln served as one of the only options in the area where Black patients could be treated, Black physicians could practice and receive training, and Black women could attend nursing school. Lincoln Hospital has since undergone several modifications but continues its legacy as Lincoln Community Health Center, which was officially founded in September of 1971. LCHC proudly stands as a center for preventive and primary healthcare for all members of the Durham community regardless of race, religion, or socioeconomic status. However, in an effort to provide a more specific and accurate illustration of the average individual to receive care at Lincoln, I’d like to highlight the following statistics from a 2019 North Carolina Primary Care Conference: 71% of patients at LCHC are at or below 100% poverty level, 89% of patients are of racial or ethnic minorities, 55% of adult patients are uninsured, and 49% of patients report they are best served in a language other than English. You should be under the impression that LCHC is exceedingly vital to a particularly vulnerable community.

My first encounter with LCHC was during the summer of 2019, just a few months before I would relocate from my hometown in Southern California to attend Duke University School of Nursing (DUSON). As a Health Equity Academy II Scholar, I was presented with the opportunity to participate in a pre-immersion nursing (PIN) program during which I was exposed to the Durham community and other aspects of what my future life as a DUSON student would resemble. During the PIN program, I was escorted on a tour of the LCHC facility where I initially became educated on its rich history. It was during this unique experience that I became aware of four things: 1) life experiences for all people, especially minorities, were drastically different here than in my west coast city 2) social determinants of health contribute significantly to health disparities 3) equal is not synonymous with equitable 4) I wanted to be involved with LCHC and make a positive impact on the community that it served. A few months later, I was offered the position as a Graduate Student Leader on the Bass Connections’ “Closing the Gap on Health Disparities and Treatment Outcomes in Hypertension” project team, which launched my collaborative partnership with LCHC and the AHA.

Our work began with the knowledge base that only 48% of individuals with hypertension were able to effectively control their disease. Additionally, 42% of Durham County residents suffer from hypertension, with an exacerbation of this burden being prevalent among minorities. In the past few months, our team has concentrated on developing a sustainable plan involving the incorporation of evidence-based guidelines, comprehensive blood pressure monitoring and data collection, and patient contribution. Our primary intervention involved distribution of home blood pressure monitoring systems, consistent virtual patient follow-up, and healthcare education. Thus far, our efforts have allowed us to extend healthcare access to at least 71 African American men in the Durham community and encourage consistent and effective management of their hypertension. Why is this significant? Hypertension is the most substantial risk factor for stroke, a condition responsible for more than 140,000 yearly deaths with the majority of those deaths being African American men. 120 mmHg systolic over 80 mmHg diastolic is the identified ideal blood pressure range. Increases in these numbers are directly proportional to heightened stroke risk. Among the men that received our intervention, about 41 were recognized as high risk with systolic measurements titrating up to 218 mmHg. Get the picture? As my team and I continue our program, it is our intention to build on our previous efforts while also implementing newly developed interventions. In order to incite an upsurge in community participation our first additional intervention will consist of organizing virtual hypertension related education classes. As I venture through this ongoing experience, I hope to deepen the impact that I have on this population. My goal is to continue to identify and mitigate social determinants of health, improve health literacy and ultimately promote optimal health for these burdened individuals. Simply put, the combat for equity continues on.