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August 24. 2014 1:41AM

Community health workers bridge culture gap


Manchester Community Health Center Community Health Worker Jazmin Miranda (right) explained the importance of exercise to patient Maria Arce (left), who suffers from diabetes, and who now tries to ride her exercise bicycle on a daily basis to improve her health. (COURTESY)

Hayat Wali recently cut the umbilical cord of a newborn, but it was not her own child.

Wali, a community health worker (CHW) with Manchester Community Health Center (MCHC), had this magical experience with the baby of a family she works with through a pilot project to help refugees and immigrants from two different cohorts - Spanish and Arabic speaking - manage their health care.


Manchester Community Health Center Community Health Worker Jazmin Miranda (right) spends a great deal of time working with patient Maria Arce (left) to ensure she understands her medication and how to take it. (COURTESY)

In the case of Wali, her client, Ashwak A Al Nomany, an Iraqi refugee, doesn't even look at her as someone doing a job. "I never feel like she's a worker. We think of her like one of our family members. We love her," said Al Nomany, explaining her decision to have the CHW with her during her labor and delivery.


The bond that forms between Manchester Community Health Center Community Health Workers and patients they see in their homes allows for the best overall care to be provided. Community Health Worker Jazmin Miranda (right) and patient Maria Arce (left) share friendship and smiles on the visits. (COURTESY)

Maria Arce, who left the Republica Oriental del Uruguay 11 years ago to come to the United States, feels the same way about her CHW, Jazmin Miranda of MCHC. "For me, Jazmin is a little angel fallen from the sky," she said.

The relationships the MCHC patients have with their CHWs is not surprising, given that these public health professionals are working hard to promote full and equal access to necessary health and social services by applying their own unique understanding of the experiences, language and culture of the populations they are serving. Wali is also an Iraqi refugee and Miranda is from Costa Rica.

Neither Al Nomany or Arce speak English. Al Nomany speaks Arabic while Arce speaks Spanish. Both have significant health concerns, and both have experienced barriers to receiving care, in large part because of the challenges they face due to their inability to speak English.

Grant-funded pilot project

Manchester Community Health Center is looking to break down the barriers. The Community Health Worker initiative is just one of the programs under the broader umbrella of the Center of Excellence for Culturally Effective Care being created by MCHC in response to the growing and spreading diversity in Manchester and throughout the state.

MCHC has been blazing a trail in serving patients from underserved, diverse and underinsured communities in the Greater Manchester service area and is undertaking this project, funded through a grant, to further develop its ability to provide culturally effective care and target health disparities. MCHC also hopes to model best practices to be shared with other health and human service providers to ensure quality health care for all.

CHWs work directly with patients in their own homes in a supportive and empowering fashion, so that the patients improve their health literacy, increase their capacity to navigate the health system, learn self-management, and become engaged and informed patients who work well with their health care providers, manage their chronic illness, and ultimately improve their health outcomes.

Duties include maintaining regular ongoing contact with patients including biweekly telephone contacts, in-person meetings every month, accompanying patients to appointments as needed, facilitating referrals, conducting home visits, monitoring health status, acting as a patient advocate and educating patients in self-management.

According to Health Equity Coordinator Selma Tarahija who directs this program, two cohorts of 75 people each have been selected for the pilot project, one for those speaking Spanish and the other for those speaking Arabic.

The CHWs are specifically targeting diabetes, hypertension, childhood obesity and individuals with one of these conditions and a co-occurring mental health issue, particularly depression. They are working to establish short- and long-term goals with the clients, attacking challenges on multiple fronts, recognizing the cultural barriers that may be inhibiting success.

"As has been said and is so true, having health insurance and access to care doesn't mean healthy," said Tarahija. "Listening and understanding are two different things, and what we are finding is that many of our patients who come from other countries and don't speak English are overwhelmed and struggling to comply with what the doctors are telling them to do."

Helping Arce manage her diabetes

Such has been the case with Arce, whose home visits by Miranda have literally been a lifesaver. Said Arce, "I was very angry about the diabetes. I had no real understanding about it before. Now I do, and I am starting to feel better because of the help."

"I help to educate patients and, little by little, they trust me more and more," said Miranda. She has worked to help Arce take her medication as directed and learn to call ahead when her medicine is starting to run out. She has also taught her about the importance of eating well and exercising.

And while she started working with Arce to assist with her diabetes, she quickly came to see that meant more than just the typical methods of care. She is now helping her work through some of the stress in her life, and seeking dental care for a serious tooth problem that has been ongoing, and, as a result, has derailed their diabetes control efforts.

"You're there for one thing, but you don't know what you are going to find," said Miranda.

Improving Al Nomany's blood pressure, diet

What Wali found when she started working with Al Nomany on her high blood pressure was that she didn't understand how diet was affecting her health. In her country of Iraq, the culture revolved around large meals that often included bread and foods high in calories but low in nutrition.

And while Al Nomany and her family, which includes her husband and five children, loved vegetables, in the United States, they found it expensive to get fresh vegetables and fruits, so they turned to less nutritious fare.

Wali has taught Al Nomany and her family how to read labels and the importance of exercise, even if it is just walking outside around her apartment building multiple times. And she has also helped her overcome other barriers inhibiting her progress that have resulted because of her inability to speak English.

"She was missing medical appointments because she couldn't understand the calls coming in because they were in English," said Wali. "Obtaining medicine at the pharmacy was difficult because if there was an issue, she wasn't able to understand what was being asked of her and basically would just give up and leave." Wali said she has found different ways to help her and to make processes easier, thus enabling her to help achieve her health goals.

Overcoming cultural barriers

Al Nomany and Arce's challenges are not unique. In fact, these types of issues are exactly the reason for the CHW initiative and the building of the Center of Excellence for Culturally Effective Care. "Coming from a different culture and language can have real health impacts in ways people don't think about," said Tarahija. "For example, when I came here, I had never had peanut butter, so when offered a peanut butter sandwich to provide me with protein, I didn't want to eat it. For many cultures, things like peanut butter or pasta sauce or other foods are simply not part of their understanding, culture and habits."

Nor, in many cases, is the concept of asking for help, or knowing how to do it. As Miranda explains, she has been helping patients with diabetes only to find that they aren't taking their medicine because it makes them sick to their stomachs, but saying that they are in fact doing so.

Others have candy hidden in their bedrooms, again not understanding that the CHWs are simply there to help them improve their health. "I tell them I need to know everything," said Miranda. "I ask them to 'pinky swear,' and then I realize they don't know what 'pinky swear' is, and we laugh when I explain it to them."

MCHC is well prepared to provide culturally effective care. The health center serves a highly vulnerable population with disproportionately large numbers of low-income, uninsured and minorities. In calendar year 2012, MCHC provided 37,809 health care visits for 7,886 patients from Manchester and surrounding communities, of whom:

. 93 percent lived at or below 200 percent of the federal poverty level.

. 42 percent were uninsured, 39 percent had Medicaid and 9 percent had Medicare.

. 43 percent were best served in a language other than English.

Today, MCHC's number of active patients is 12,061, with over 5,150 patients requiring an interpreter at visits.

Almost 50 percent of MCHC's staff (including provider and management staff) come from diverse communities and the organization employs six foreign language interpreters on staff, 20 contract interpreters, and over 70 of the most common handouts and forms have been translated into the top eight languages besides English.

With more than 20 years of experience in providing integrated care to a very diverse population, the health center is excited to see that its newest initiatives are already proving successful.

Success stories

For Al Nomany, that means blood pressure readings that have gone from a very unhealthy 148/100 to a reading in July of a perfect 120/80. The 38-year-old has also begun to lose weight.

She has gone from someone who was rightfully fearful of dying a year ago of a heart attack or stroke, to seeing positive improvements not only in her life, but in the life of her family. "This program has helped to save my life so that I can take care of my family," said Al Nomany.

Arce has lost 67 pounds over the course of the past year, lowered her blood pressure and her blood sugar, and is a lot more active and, as a result, happier. "I would not be where I am were it not for Jazmin coming into my home and helping me with everything, teaching me what I should eat and how to exercise," said Arce. "Jazmin is professional and loves what she's doing. You can see it. She has a good heart."

"We're at the forefront of health care right now," said Tarahija, adding that while they still have a ways to go and lots to learn, they must be doing something right. "We had one family come to Manchester Community Health Care after a Community Health Worker visited their home to see if the program was for real. They just couldn't believe this type of help was available."

Manchester Community Health Center (MCHC) is a nonprofit 501(c)(3) federally qualified health center offering high quality, comprehensive, and family-oriented primary health care and support services since 1993.


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