# Presentation: 724629

## Addressing Health Disparities: Using a culturally relevant community partnered mobile clinic to provide health care to high-risk women in an urban setting

- Rita Singhal, MD, MPH
- Ellen Eidem, MS; Amy Y. Chan, MPH; Lucie McCoy, MPH
- Los Angeles County Department of Public Health:
- Office of Women’s Health
- Office of Health Assessment & Epidemiology

**Notes:**
Good Morning. Thank you Dr. Jones. Today I am presenting research on Addressing Health Disparities, using a culturally relevant community partnered mobile clinic to provide health care to high risk women in an urban setting. This work comes from the Los Angeles County Office of Women’s Health with statistical support from our office of health assessment & epidemiology.

## The Need for a Mobile Clinic

- Health of women in Los Angeles County
- Women living in poverty 3X more likely to have fair to poor health than women >200%FPL
- Racial/ethnic disparities
- Barriers to accessing care among uninsured
- 60% difficulty accessing services
- 44% w/o regular source of care
- 42% could not afford it
- Transportation, child-care, long wait times
- Language & culture
- Lack of preventive care among ‘at risk’ women

- Source: Women’s Health Status and Access to Health Care Services, L.A. Health
-             Los Angeles County Department of Health Services

**Notes:**
To begin with some background – why was there a need for a mobile clinic in LA County? In May of 1999, a report was released from the Los Angeles County Department of Health detailing the health disparities apparent among women in LA
They found that women living in poverty were three times more likely to report fair to poor health compared with women living at greater that 200% FPL
There were also disparities found by ethnicity with Latinas and African American women having a poorer health status then Caucasian women
Numerous barriers were identified that uninsured women face in accessing care when they need it. (31%)
Of the almost one million uninsured women in the county at that time, 60% reported difficulty accessing health care services, 44% reported not having a regular source of care and 42% reported difficulty paying for health services which resulted in a delay in seeking care.
Other barriers included transportation, childcare and long wait times in an overburdened health care system.
Language and cultural differences also served as prominent barriers in the diverse LA population.
Last, receipt of preventive care among uninsured women was much lower compared to the general population.
(40% had not received appropriate cervical cancer screening and 47% of the women had not received an annual clinical breast exam.)

## Mobile Clinic Outreach Program

- Preventive screening provided via a mobile van to underserved women in Los Angeles County
- Services provided at no cost
- 1-3 times a week, usually weekends
- ~ 25 women served per event
- May 2002-September 2006
- 3,436 women screened
- 175 sites visited

**Notes:**
As a result of this report, the OWH launched the Mobile Clinic Outreach Program in May of 2002; This program provides preventive screening via a mobile van to underserved women in Los Angeles County. Services are provided at no cost to the women. Events are held 1-3 times a week, usually on weekends and anywhere from 20 to 25 women are served at each event.  As of September 2006, 3,436 women have been screened at 175 sites in the county.

## Program Goals

**Improve the health of ‘at risk’ women in Los Angeles County**
- Improve access to care
- Overcome barriers of cost, transportation, childcare, language & culture
- Establish a regular source of care for women requiring ongoing health care
- Provide preventive health screenings
- To detect dormant disease at an earlier and preventable stage
- Increase awareness of the importance of prevention

**Notes:**
The main goal of the program is to improve the health of the ‘at risk’ women in the County by:
Improving access to health care by overcoming identified barriers
 And by assisting women in establishing a regular source of care when ongoing care is required
2. Providing preventive health screenings which will allow detection of dormant disease at an earlier and preventable stage
3. Increasing awareness of the importance of prevention including what screening tests that women should be receiving and the lifestyle changes they can make to improve their health

## Target Population

- ‘At risk’ women in Los Angeles County
- Uninsured
- <200% FPL
- Live in underserved areas
- Recent immigrants
- Age 40-64 years
- Ethnic groups
- African American, Armenian, Chinese, Korean, Latina and Vietnamese

**Notes:**
This target population, the ‘at risk’ women in the County –includes the uninsured, women living in families at <200% of the FPL, women that live in underserved areas and specific health districts where there have been County clinic closures, recent immigrants, 
We also Targeted women in the 40 to 64 yrs age group given these women had the most difficulty accessing services and are at higher risk of developing preventable chronic diseases.
Last we targeted 6 specific ethnic groups secondary to the multicultural and multilingual capacity of the OWH– I will discuss this further a little later in the presentation.

## Services Provided

- Comprehensive preventive health assessment
- Hypertension
- Diabetes
- Hyperlipidemia
- Body Mass Index
- Breast cancer screening – clinical breast exam
- Cervical cancer screening
- Preventive health education
- Chronic disease prevention
- Mobile mammography

**Notes:**
The clinical services provided was a comprehensive preventive health assessment:
Screening for HTN, diabetes, hyperlipidemia
Height and weight measurement for a Body Mass Index calculation
Breast cancer screening in the form of a clinical breast exam and a referral for mammography
Cervical cancer screening with a gynecological exam and Pap test

Also education was provided on the importance of chronic disease prevention through lifestyle change

We partner with agencies that provide mobile mammography so all women 40 yrs of age and older can receive their mammogram the same day

## Community Involvement

- 300 Community Partners
- Request clinic and provide site for event
- Recruit women for screenings
- Publicize event
- Venues
- Health fairs
- Community centers
- Religious institutes
- Consulates
- Festivals
- Adult schools

**Notes:**
Community involvement is a vital component to the program. 
Over the years, the OWH has built a network of 300 community partners consisting of clinical, educational and advocacy agencies that work within their communities to improve health care access. These agencies play several key roles in the program:
	They request the services of the mobile clinic in connection with an event that is being organized by them for their constituency.
	They also provide the site for the event
	They then recruit clients from their organizations for screenings and refer them to the Office of Women’s Health for appts
	And they are responsible for publicizing the event to ensure a good turn out.

Examples of venues or events that the mobile clinic has visited include:
Health fairs, community centers, such as the Armenian Relief Society
Korean and AA churches, Mexican consulates
Festivals such as Buddha’s birthday celebration for the Chinese and Vietnamese population
And Adult schools

## Culturally & Linguistically Appropriate Staff

- Patient Resource Workers
- Community liaisons
- Schedule appointments
- Interview clients
- Patient information
- Medical history
- Translate as needed at events
- Make follow-up appointments after the event
- Clinician & Nurse/Educator
- Serving African American, Armenian, Chinese, Latina, Korean and Vietnamese communities

**Notes:**
Another unique aspect of the program is the use of cultural and linguistically appropriate staff – all services are provided in the primary language of the participants by Office of Women’s Health staff and members from the community

The office of women’s health has 8 Patient Resource Workers that speak 7 different languages – these PRWs serve as community liaisons, working closely with the community agency that is holding the event; they also schedule appointments for the mobile clinic events and interview the clients to collect patient information and basic medical history
At the events they help with translation and interviewing any walk-ins and after the event, they contact the women that were identified to have abnormal results to schedule a follow-up appointment

In addition, we have built an extensive multi cultural list of county employees that are willing to work on the mobile clinic in the capacity of a nurse/educator or clinican – we try to match the culturally and linguistically appropriate providers with each event depending on the community that is being served

In this manner we are able to serve many communities– including the AA, Armenian, Chinese, Latina, Korean and Vietnamese communities 

## Follow-Up

- Conducted by nurse and physician at OWH
- Follow-up appointments scheduled for women with detected abnormalities
- Attempt to establish a medical home for women with any abnormal results
- Results sent to client
- In language satisfaction survey distributed within 1 week of mobile clinic visit

**Notes:**
Follow up for all women seen on the mobile clinic is conducted by the nurse and physician on staff with the OWH. Follow-up appointments are scheduled within county and community clinics for women with detected abnormalities by the office staff with the intent of establishing a medical home for these women.
Results of tests and information on the follow-up appointment is mailed to the client with a letter in their preferred language. 
An in language satisfaction survey is distributed within 1 week of the mobile clinic visit

## Research Aims

- Demonstrate target population was reached
- Evaluate prevalence of major preventable diseases in an underserved population
- Describe disparities in disease prevalence based on demographics and access to care

**Notes:**
Data was collected from the mobile clinic clients with these specific aims: 
To demonstrate that the target population was reached
To evaluate the prevalence of major ...

## Data Collection & Analysis

- Questionnaire Design
- Demographics**: **age, zip code, marital status, birthplace, ethnicity, preferred language, FPL
- Access**:** insurance status, regular source of care, last physician visit, last preventive screenings
- Clinical outcomes
- BP, HbA1c, direct LDL, BMI, Pap test, breast exam, GYN exam
- Analysis
- Chi Square
- Logistic regression

**Notes:**
Data is collected via a questionnaire administered by the Patient Resource Worker in the clients preferred language either over the phone prior to the event or in person at the event. Variables include the clients’ demographics and access to health care
There is also data on the clinical outcomes of the screenings provided.
For the statistical analysis we preformed chi square tests and for variables showing significant association, logistic regression modeling was done.

Cutoffs – BP 140/90; HgbA1c – 6.0; LDL – 160 if BP and HbA1c normal, 130 if either abnormal

## Demographics

- 2,597 women seen at 130 events over 3 years

|  | MC
(n=2,597) | LAC*
(n=4,682) |
| --- | --- | --- |
|  |  |  |
| Born outside of the US,% | 82.4 | 43.2 |
| Preferred language other than English,% | 75.4 | 28.9 |
| Ethnicity,% |  |  |
|     Caucasian |  3.2 | 35.1 |
|     Armenian |  7.6 |   --- |
|     African American | 12.3 | 10.3 |
|     Asian | 35.1 | 14.9 |
|     Latina | 41.3 | 39.7 |

- *Source: 2002-03 Los Angeles County Health Survey

**Notes:**
The data presented here covers results for participants seen from the start of the program in May 2002 to June 2005 - 2,597women were seen at 130 events over this 3 year time period.
Here I have basic demographic results for the MC clients in the column labeled MC and for comparison there is data from the 2002-2003 LACHS that provides information on the general LAC population. 
Over 82% of MC clients are born outside of the US and 75% prefer a language other than English compared to 43% and 29% in the general LA population.
The ethnicity breakdown for MC clients shows that all the minority groups were oversampling including the Armenian, AA, Asian and Latina

NOTE: The % for the ethnicity categories add up to 99.6%. The additional 0.4% is ‘other’ which includes native american (1) and other (5).

## Access to Care

- *Source: 2002-03 Los Angeles County Health Survey

|  | MC
(N=2,597) | LAC*
(N=4,682) |
| --- | --- | --- |
| Federal Poverty Level (FPL) ≤ 200% | 93.8% | 49.6% |
| No health insurance | 93.8% | 20.8% |
| No regular source of care | 76.9% | 15.8% |
| Last physician visit > 2 yrs | 34.0% | -- |
| Last mammogram ≥ 2 yrs (women ≥ 40 yrs) | 47.8% | 27.2% |
| Last Pap smear ≥ 3yrs | 30.9% | 10.7% |

**Notes:**
Next there is data on the access to care variables – again the results from the MC clients is in the first column and data from the general LAC population in the last column
94% of MC clients reported living at less than 200% of the FPL having no health insurance and 77% reported no regular source of care; these numbers are significantly higher than the general LAC data
In addition 34% of MC clients had not seen a physicisn in over 2 years, 48% had not had a mammogram in 2 yrs or more and 31% had not had a Pap smear in 3 year sor more. highlighting the low receipt of preventive care in this population

## Outcomes and Ethnicity

- * p<0.05

|  |  | High Blood Pressure | Diabetes | High Cholesterol | Abnormal Pap Test | Abnormal Breast Exam |
| --- | --- | --- | --- | --- | --- | --- |
| Overall, % |  | 23.1 | 18.8 | 26.0 | 5.3 | 3.9 |
| White |  |   |   |   |   |   |
|     Caucasian, % |  | 22.1 | 7.4 | 21.1 | 3.2 | 5.8 |
|     Armenian, % |  | 26.7 | 12.8 | 45.0* | 4.7 | 1.8 |
| African American, % |  | 28.0* | 24.1* | 27.6 | 6.8 | 2.3 |
| Asian |  |   |   |   |   |   |
|     Chinese, % |  | 18.2 | 16.9 | 17.6 | 3.9 | 4.2 |
|     Korean, % |  | 25.5 | 14.8 | 20.7 | 3.8 | 1.3 |
| Latina |  |   |   |   |   |   |
|    Mexican, % |  | 20.1 | 18.6 | 23.9 | 4.1 | 5.1 |
|    Central American, % |  | 22.5 | 28.6* | 36.5* | 10.6* | 6.6 |

**Notes:**
Results of the outcomes of the screening tests performed.
in the first row we have the overall results and then it is broken down by ethnic group 
Highest rates of high blood pressure found in AA which is consistent with what we know. Highest rates of Diabetes was in AA and Central American latina and the highest rates of high cholesterol were by far in the Armenian women with CA women also having statistically significantly higher disease. Rates of abnormal Pap tests was twice as high in CA then the overall rate.
Looking at the data by each ethnic group – the CA women had the most disease. 

Bivariate analyses were done to examine differences in outcomes by ethnic group. Several findings were statistically significant – highlighted in yellow. 

## Outcomes and EthnicityAdjusted Odds Ratio

|  | Adjusted OR | 95% CI | p-value |
| --- | --- | --- | --- |
| High Cholesterol |  |  |  |
|      Armenian | 4.26 | 2.93,6.17 | 0.0001 |
|      All others | 1.00 |  |  |
|      Central American | 1.48 | 1.03,2.13 | 0.0358 |
|      All others | 1.00 |  |  |
| High Blood Pressure |  |  |  |
|      African American | 1.47 | 1.06,2.03 | 0.0221 |
|      All others | 1.00 |  |  |
| Diabetes |  |  |  |
|      Central American | 1.70 | 1.14,2.52 | 0.0088 |
|      All others | 1.00 |  |  |
|      African American | 1.55 | 1.03,2.31 | 0.0336 |
|      All others | 1.00 |  |  |

**Notes:**
Here we have adjusted odds ratios for the associations that were significant after controlling for confounding variables:
For high cholesterol, Armenians were 4x more likely to have it then all others and CA were 50% more likely to have high cholesterol

AA for almost 50% more likely to have HBP compared to all others

And for diabetes, CA and AA women had adjusted OR of 1.7 and 1.55 compared to all others.

Confounding variables: age, FPL, regular physician, last cholesterol check, last visit with physician

## Body Mass Index

|  | Overweight or Obese BMI |
| --- | --- |
| Overall, % |  56.9 |
| White |  |
|  Caucasian, % | 66.7 |
|  Armenian, % | 67.0 |
| African American, % |  75.4 |
| Asian |    |
| Chinese, % | 22.7 |
|  Korean, % |  24.4 |
| Latina |    |
|  Mexican, % |  75.9 |
| Central American, % |  79.1 |

- Note: Began calculating in year 2  (data not representative of entire sample; N=1,717 instead of 2,597)

**Notes:**
We began calculating the body mass index in the second year of the program – 
Compared to an overall rate of 46% of overweight and obesity in LA County, we had a rate of 57%
Rates were much higher in the Latina populations and AA women
The Asian populations showed much lower rates of overweight/obesity

## Conclusions

- Reached target population
- Overall rates of disease was high is this population
- Specific ethnic groups were at higher risk for certain diseases
- Central Americans – diabetes, high cholesterol, abnormal Pap test
- Armenian – high cholesterol
- African American – diabetes, high blood pressure

**Notes:**
In conclusion,
The program did reach its target population
Overall rates of preventable diseases was high in this population
Specific ethnic groups were identified to be at higher risk for certain diseases
There is a great need for innovative programs that address groups with high prevalence of disease

## Strengths

- Builds grassroots connections between the OWH and the women, community and CBOs
- Increases access to care for high-risk women
- Promotes early detection of disease
- Mobile clinic is the first step into ongoing care

**Notes:**
Some of the strengths of the MCOP are:
That helps build connections between the OWH and women in the community and CBOs
 It increases access to care for high risk women by overcoming key barriers
It promotes early detection of disease
Last, the clinic serves as a stepping stone for ongoing care for these women

## Challenges

- Mobile services are expensive
- Extensive administration and coordination required to work with community partners
- Detecting disease is not enough – getting women to change behaviors is much more difficult

**Notes:**
Some of the challenges we have faced include:
Mobile clinic is expensive to run – the upkeep and personnel costs due to overtime salaries for weekend events
There is extensive administration and coordination required to make each event work with the community partners
Third, detecting disease is not enough – it is harder to get the women to follow through with making changes that will make a difference in their health

## Opportunities

- Shift focus from service delivery to maximizing client education
- Changed to Point-of-Service testing with on-site results
- Further build network of CBOs and partners
- Follow-up survey to determine whether women have established a medical home

**Notes:**
There are also many opportunities that have developed for the program
Recently we have shifted the focus from service delivery to maximizing client education
Part of this change has been using point of service testing with the availability of on-site results which enable tailored education depending on the disease identified
Also, we continue to build our network of partners to ensure we are reaching the population most in need
And last we are administering a follow-up survey of women with abnormal screening results on the mobile clinic to determine if they have established ongoing care