At Jamaica Hospital Medical Center in Queens, N.Y., Dr. Alan Roth oversees care delivery operations for one of the most diverse patient populations in the country, serving people from 130 countries speaking more than 160 languages.
During the 30 years Roth has worked at Jamaica Hospital, Queens County has doubled in size from a population of 1.2 million to 2.4 million with the increase almost entirely made up of immigrants, including an estimated 400,000 individuals with undocumented resident status.
Roth acknowledged there is a challenge to serving people from so many different backgrounds and understanding their cultural religious beliefs. But the dynamic has also provided opportunities for the hospital to learn effective ways of building relationships with various cultures that goes beyond providing language translation services or hiring a more diver clinical staff.
"Translation is the easiest," Roth said. "You need to have an understanding of their customs and beliefs, and in general, their distrust of the American healthcare system and what we do (to) people rather than what we do for people."
Jamaica Hospital's navigators
The hospital has opened clinic sites throughout the community to expand access and has a team of patient navigators hired from the community to help educate patients on better health. Roth said navigators are an important part of the health system's effort to better understanding how it can promote wellness by respecting, rather than disregarding, the customs and practices of their patients.
That approach has involved learning about community healers and their use of herbs and alternative remedies to understand how the hospitals can work alongside them as part of an overall care plan. Roth said Jamaica Hospital partners with many of the neighborhood bodegas that sell alternative remedies by linking them to local farmers who help them replace less healthy food options with more fruits and vegetables.
"We work with them as opposed to going against them and have them as part of the team," Roth said.
Efforts like the ones being employed at Jamaica Hospital are requiring providers to take on a certain level of cultural openness not traditionally associated with healthcare providers and Western medicine more broadly.
But Roth credits such approaches as important toward laying a foundation of trust between the hospital and community members. Having that kind of relationship has taken on an even greater importance during the COVID-19 pandemic.
Like many diverse communities, a disproportionate share of Jamaica Hospital's patients live in multi-family dwellings, rely on public transportation, and have jobs that require them work outside of their home, all of which contributes to a higher risk of exposure to the virus than most other communities.
The disproportionate impact the COVID-19 pandemic has had on marginalized communities like those with large racial and ethnic minority populations has highlighted the need for healthcare providers to do more to connect with their most vulnerable patients.
While development of two coronavirus vaccines and the prospect of more becoming available in the coming months marks a significant step toward ending the pandemic, the real challenge will come in vaccinating the 70% of the population experts say is needed to achieve herd immunity and control the disease spread.
And as hospitals prepare to conduct mass vaccinations to the general public, it remains unclear how those plans will address overcoming issues of mistrust of the new vaccines and of the medical field more broadly within many marginalized communities.
A recent survey conducted by the Associated Press and NORC Center for Public Affairs Research found 47% of American adults reported they planned to get a COVID-19 vaccine. Yet only 24% of Blacks and 34% of Latinos reported they would get vaccinated compared with 53% of white adults, despite higher rates of death and hospitalizations from COVID-19 within Black and Brown communities.
Experts say healthcare providers will need to embrace cultural competency to build the kind of trust with communities that will be crucial toward helping them to achieve both the necessary rates of vaccine adherence as well as address the longer-term health needs of patients once the pandemic ends.
"The term people have been using more is cultural humility," said Dr. Laurie Zephyrin, vice president of health care delivery system reform for the Commonwealth Fund. "It's about being able to self-reflect and self-critique about one's own beliefs and their culture and how that reflects when someone with another culture comes along."
Zephyrin said healthcare providers have gotten better in terms of reaching the "low hanging fruit" when it comes to cultural competency with actions like expanding access to language translators, implicit bias training, creating a more patient-friendly environment, and hiring a more diverse clinical staff. While those efforts are important basic steps, she said achieving cultural humility involves trying to understand how a patient's life experiences have impacted their health and how it has influenced the way they interact with the healthcare system.
Using partnerships at UW Health
Toward the end, Shiva Bidar-Sielaff, vice president and chief diversity officer at Madison, Wis.-based UW Health system, said the health system has partnered with local minority community organizations, churches and businesses in an education campaign designed to raise awareness about taking proper safety measures to reduce their risk of infection. UW Health has provided $225,000 to fund the effort, which she said has included educating community members on the safety and efficacy of taking the COVID-19 vaccines. Additionally, UW Health plans to contract with community health workers who will connect one-on-one with Black, Latinx and Hmong primary care patients to provide education about COVID vaccines as well as help them with scheduling appointments, transportation assistance, appointment reminders and follow visits.
Bidar-Sielaff said having an education campaign led by community stakeholders helps to serve as a bridge between the health system and residents by establishing trust that she hopes can be leveraged to build a stronger, more direct relationship moving forward.
Efforts to build a more direct relationship with communities of color was one of the key tenets of UW Health's recruiting campaign for participants in a phase 3 clinical trial study the health system conducted for the COVID-19 vaccine candidate being developed by AstraZeneca and the University of Oxford. Much like the outreach effort to promote COVID-19 safety measures, the health system again worked with local community groups to ensure Black, Latinx, Asian and Indigenous populations were informed about the opportunity to participate in the clinical trial and provided participants with transportation assistance to and from the trial site.
People of color, in particular Black Americans, have traditionally been underrepresented in clinical trial studies. Past incidents of medical experimentation, including the Tuskegee Syphilis Study, which observed the untreated progression of the disease in 600 men from 1932 to 1972 despite the use of penicillin as a treatment by 1947, have contributed to mistrust of the medical system. Other factors including appointment conflicts and a lack of awareness about trial studies have also contributed to low participation among Black individuals.
Around 10% of participants for the clinical trial for the first approved vaccine from Pfizer and BioNTech were Black and 13% were Latino. Trials for the recently approved Moderna vaccine were similar, with Black people making up 10% of study participants while Latinos were higher, accounting for 20%. Previous studies have estimated the average participation rate of Black patients in clinical trials was less than 4%.
"People of color are a vital population to making this study a success," Bidar-Sielaff said in September. "We want to make sure those who have been disproportionately affected by COVID-19 will have access to the safest, most effective vaccine possible."
Loyola Medicine targets education
Shawn Vincent, president and CEO of suburban Chicago-based, Loyola Medicine health system, said it began an education campaign geared toward people in underserved areas about the benefits of taking the vaccine weeks prior to the first drug being approved. He said much of that work has been led by their satellite clinic sites located within communities of color.
Like UW Health, Loyola is working with community groups to help with their education effort on the taking the vaccines. Dr. Richard Freeman, regional chief clinical officer at Loyola, said their vaccination plan initially involves the use of five clinic sites. As the effort evolves, Freeman said less vaccinations will take place in brick-and-mortar sites and more will be carried out in neighborhoods with the possible use of mobile units set up at churches and other community centers for vaccination drives.
"That is definitely on the horizon when we get to the phase where we're doing mass vaccinations," Freeman said.